Sex work: holding the knife on the sharpest edge

As countries around the world deal with a new global pandemic, sex workers are being left out in the cold trying to be heard in the cacophony of noise created by the worsening economic and health crisis.

Globally, sex workers are 13 times more likely to be living with HIV and 9% of new infections are related to sex work. This of course looks different depending on where you live – 50% of sex workers in five Southern African countries are living with HIV.

It is no accident that HIV infections are concentrated in this population, and in this part of the world. Sex workers are predominantly women, with about 4% identifying as trans women. Poverty, gender inequalities and high rates of gender-based violence add to the stigma and criminalisation that sex workers face.

This is not a new dilemma

In the past few months, COVID-19 driven lockdowns and restrictions have made life very difficult for sex workers. Many are facing impossible choices – work and risk getting or passing on COVID-19, or starve.

Sex work organisations have shown their resilience and commitment to their communities by adding food relief and other basic needs to their already overburdened services. Since sex workers are not recognised as workers and are excluded from any economic support measures states have made available to workers, this is a key need. Sex workers are responsible for an average of four dependants, most of whom are children – their inability to earn has a devastating impact on families already struggling to make ends meet.

For sex workers, this is not a new dilemma. While WHO and UNAIDS warn that COVID-19 could take us back to 2008 levels of HIV-related deaths, for sex workers, not much has shifted in a policy and legal sense in the past ten years anyway. Very few countries have made any real progress towards decriminalisation of sex work, and levels of stigma and discrimination remain high.

Moreover, studies show that HIV is still rapidly increasing among sex workers despite the improvement in availability of services. Investments in health services targeting sex workers are laudable and necessary, but the impact of these measures is slow. This is directly because failure to change laws and policies allows human rights abuse to flourish. Sometimes this contradiction is quite literal – with police confiscating condoms recently delivered to sex workers as evidence of engaging in sex work.

Overzealous policing

Making matters worse, the COVID-19 response has been weaponised in many countries, resulting in increased powers of police, deployment of the military and increased harassment and abuse of sex workers and other marginalised populations (observed in Uganda, South Africa and Zimbabwe).

Organisations are receiving and responding to reports of increased violence and overzealous policing. Their staff, many of whom are or have worked in sex work, are facing their own fears and health risks while fundraising and reporting (not to mention parenting and caring for their families).

It’s also likely that the routine abuse sex workers experience at the hands of their intimate partners exacerbated by lockdown, goes unreported over this time.

Sex workers lead the response

I spoke to Kholi Buthelezi from the Sisonke movement of sex workers in South Africa, who has been working 16-hour days.

Everything takes longer and is more complicated – our staff don’t have data or laptops to work from home, and many are struggling, but sex workers rely on us and we have to be there for them.

The truth is, organisations led by, and staffed by sex workers are the ones best positioned to deliver services to sex workers. They are closest to their service users; they have the best understanding of what is needed. NACOSA, a principle recipient in the Global Fund’s South African grant knows this, and partners with Sisonke to deliver services to sex workers. SWEAT – the Sex Workers Education and Advocacy Taskforce – another South African NGO, receives funding to undertake advocacy for sex workers rights.

Both organisations integrate human rights with service delivery on HIV because they know the two cannot be separated. In a country where at least one third of sex workers are living with HIV by the time they are 24, and four in five sex workers older than 25 are HIV-positive, an interruption in the HIV transmission rate is a critical and urgent task.

Increased vulnerabilities of sex workers

As many experts have pointed out – we are likely to see an increase in vulnerabilities of sex workers with COVID-19, which will impact on health systems. In addition, there will be increased numbers of women selling sex, given rising unemployment and a global economic recession. We will see this impact in the longer term in increased new HIV infections and poorer health outcomes for people who sell sex.

COVID-19 has shown us a future in which the current HIV trajectory among sex workers is fast-forwarded – we cannot afford to continue to be complacent. Now is the time to scale up support to community based and sex worker lead organisations around the word to address the human rights barriers to preventing HIV.

Now is the time for political leaders to support these efforts and address punitive laws that slow our progress to achieving a world free of AIDS.

Sally Shackleton is Lead: HIV Technical (Key Populations) at Frontline AIDS.

Holding the knife on the sharpest edge’ is the strapline for Mothers for the Future, a project in South Africa serving the needs of sex working mothers and their children – based on a local expression ‘mothers hold the knife on the sharper edge’.

Watch ‘Flowers of tomorrow’, our new film following the human rights of sex workers in South Africa

Download our Implementers’ Guide to programming aimed at removing human rights-barriers to HIV services