A person-centred approach to preventing HIV among sex workers

By Clare Morrison

Clare Morrison is a support officer for influence at the Alliance.

On average, women, men, and transgender people who sell sex are up to ten times more at risk of acquiring HIV compared to the general population. Worldwide, many sex workers still cannot access a full range of HIV prevention, treatment, and care services.

Two condoms© Alliance

This is particularly true in South Africa, where restrictive legal environments, a lack of funding for HIV prevention programming, deep-seated stigma and discrimination, and high levels of gender-based violence continue to challenge sex workers’ abilities to protect themselves, their families, and their sexual partners from HIV.

Impressively, South Africa is now home to the largest antiretroviral treatment programme in the world. Yet sex workers are still experiencing very high rates of new infections and many of them are not accessing antiretroviral treatment. 

One organisation hoping to turn the tide on this epidemic is SWEAT (Sex Workers Education and Advocacy Task Force), a South African non-governmental organisation based in Cape Town, which supports and champions sex workers to speak out on issues of health and human rights.

Avoiding a ‘one-size-fits-all’ approach

The belief that sex workers have multiple, overlapping identities is at SWEAT’s core, and HIV prevention services should embrace this complexity.

You have to remember that sex workers are people, first and foremost.

Sex workers, like all people, are diverse. Although the majority are women who sell sex to male clients, there is also a sizable population of male and transgender sex workers, who need equal support.

Sex workers work in a variety of different contexts, some in safety, and some in difficult, challenging and often dangerous environments. While the majority work independently, either in their own homes or on the streets, others sell sex through third parties, formal establishments or brothels. Some enter the profession by choice, while others are coerced, either through poverty, drug use or gender-based violence.

Because of this diversity, a ‘one-size-fits-all’ approach to HIV prevention does not work.

During my visit to SWEAT, Sally Shackleton – SWEAT’s executive director, a passionate advocate with over 25 years’ experience working on the frontline of the HIV epidemic – said: "You have to remember that sex workers are people, first and foremost. Their lives are messy and complex.

"Instead of telling a service user 'this is how you prevent HIV' we try to open a constructive dialogue and find out what services are most useful to that individual."

Sally’s comment was a stark reminder about why implementing a person-centred approach to HIV programming is so important. Sex workers must be treated as people with diverse needs like anyone else; needs that extend far beyond those just related to their work.

A holistic package of services

SWEAT provides a range of services that are nonintrusive and non-judgmental. This can be as simple as providing a cooked meal and handing out condoms, or more complex interventions such as a 24-hour helpline, HIV counselling, and legal support services. 

One example of this diverse approach is their pioneering Mothers for the Future Programme, an initiative led and run by female sex workers, which supports them to be the best mothers they can be.

The programme provides access to a range of family planning and healthcare services. This includes supporting people to initiate and adhere to antiretroviral treatment, promoting self-testing and early infant diagnosis, home visits, broader psychosocial support, and care-giving skills to help women care for their children more effectively.

This innovative programme is pushing boundaries and challenging people’s perception of what it means to be a sex worker and a mother, two identities that are often seen as incongruous. SWEAT also works closely with the local community to challenge the stigma and discrimination that prevent these women and their children from accessing the services they need.

Removing structural barriers

Challenging the stigma around sex work is crucial. This is especially true in South Africa, where draconian laws and hostile policing practices continue to restrict sex workers access to vital HIV prevention services.

Our role is not about helping people ‘escape’ from the profession. We believe that sex work is a legitimate form of work.

Despite persistent efforts by SWEAT and others to advocate for changes in the law, it remains a criminal offence to buy or sell sex in South Africa. This drives sex workers further underground, creating conditions where exploitation, abuse, poor health and inequality can thrive.

SWEAT actively campaigns against the criminalisation of sex work. Their Advocacy and Law Reform Programme works closely with sex workers to help educate them on their legal rights and challenge potential legal infringements. SWEAT also has an in-house legal team, the majority of whom are sex workers themselves, who conduct legal case-work and feed into national advocacy campaigns.

A big part of this work is empowering sex workers to speak out on their own behalf and raise public awareness of the abuses being committed. This includes supporting sex workers to increase their visibility by engaging with parliamentarians and key decision makers on policy reform.

Sally described how “our role is not about helping people ‘escape’ from the profession. We believe that sex work is a legitimate form of work. Our role is about providing a safe, legal environment, where people can access the services and protection they require”.

However, achieving this goal requires a long-term approach. Only by building long-lasting relationships with people and communities can we reduce the number of new HIV infections among sex workers. That is why a person-centred approach that addresses both the biomedical, behavioural and structural drivers of HIV is so important.

By taking this approach, SWEAT encourages us to consider sex workers in a new light. Not as stereotypes or statistics, but as real people with families and the same rights as the rest of us.