Sex workers contributed 6.9% to new HIV infections

There are around 150,000 sex workers in South Africa. The National Strategic Plan on HIV identifies sex workers as a “key population” at high risk of HIV. HIV prevalence for female sex workers ranged from 48% to 72% in 2013/2014. This was much higher than for adult women in the general population, where prevalence was 14.4%. Reducing the prevalence of HIV among sex workers is prioritised as a critical national-level response to HIV.

But there are complex client–sex worker power relations that play a central role in HIV transmission in the sex industry in South Africa.

Research shows that sex between sex workers and clients contributed to 6.9% of the overall new HIV infections recorded in South Africa between 2010 and 2019. Sex between clients and their non-paying partners accounted for 41.9% of new infections over the same period.

Some men in South Africa do not want to use condoms, as “flesh-on-flesh” sex remains closely tied to conceptions of masculinity and pleasure. Sex workers in South Africa may face violence from clients for refusing demands for condom-less sex. In the face of abject poverty, some sex workers may accept their clients’ demands for condom-less sex and other risky sexual practices, or negotiate condom-less sex for a higher fee.

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New research shows that clients of sex workers may be key to reducing HIV transmission in South Africa. This study predicts that scaling up antiretroviral therapy among the clients of sex workers would avert almost one-fifth of new HIV infections in South Africa over the next decade. This constitutes the most influential population-level intervention possible. Why, then, do public health programmes and policymakers pay so little attention to sex work clients?

What we know about sex work clients

Sex work clients come from all walks of life. The limited research available on this group suggests that about 18% of men in South Africa report having had sex with a sex worker.

Many men who pay for sex never tell anyone about it, so the actual numbers are likely to be higher. Clients are not a homogeneous group and have diverse needs and experiences. There is evidence that clients can and do play an important role in supporting safe and respectful client–sex worker relations. However, some South African studies also report that clients can be particularly violent and misogynistic. Other studies suggest that men who buy sex contributed significantly to new reported adult HIV cases in 2018.

Surprisingly, sex worker clients have been almost completely ignored in public health or psychosocial interventions and education programmes. These typically target female sex workers. This symbolically reinforces stigmatising ideas that sex workers are disease-carriers and should be blamed for social ills like HIV. To some, it suggests that sex workers are to be held responsible for the violence and marginalisation they experience. As one policeman put it:

You are just whores — you can’t be raped.

These narrow, even unimaginative public health responses inhibit reducing HIV, exploitation and marginalisation within sex work. Greater innovation and closer collaboration with people who participate in the sex industry are needed.

During the last decade, important strides have been made in South Africa in designing sex-worker-friendly health programmes in consultation with sex workers. The South African National Sex Worker HIV Plan 2016-2019 provides for:

• peer education;
• healthcare and psychosocial interventions;
• human rights safeguards, and
• economic empowerment.

The plan includes an important call for the decriminalisation of sex work. Yet, like most other interventions on sex work, clients are barely mentioned. It is this silence around the role and responsibilities of clients that has motivated us to design client interventions.

Designing a client programme

In cooperation with sex workers, clients, and service organisations, we have produced a report on client intervention programmes. We have also designed a prototype training programme for sex worker clients in South Africa. We offer suggestions for interventions that include and target clients to foster safer, healthier, and more respectful sex work engagements. We build on colleagues’ work on demystifying sex work transactions. The “Secret Guide to the Business of Sex” encourages a health and safety approach to buying sexual services in the form of a booklet pitched at sex work clients.

In developing the training materials, we considered the current evidence available on client interventions worldwide. We found that South Africa is not unique in overlooking sex work clients – there are very few existing programmes internationally. Several sex work client interventions attempted to “re-educate” or “rehabilitate” clients, working from the assumption that the buying of sexual services is morally offensive and socially undesirable, and thus employed shaming techniques to “correct” people’s behaviour.

There is little evidence that interventions with clients that start from the position of sexual deviance and focus on re-education are effectual. In fact, the humiliation and stigma resulting from such programmes added to men’s emotional problems and distress. Conversely, evidence from client programmes in the Global South suggests that sex worker and peer-led programmes have the potential to influence clients’ awareness, knowledge, and behaviours around sexual health risks and safer sex practices.

Drawing on these lessons, our team drafted principles and strategies to inform the design of context-appropriate client interventions in South Africa, and included a model curriculum. Intervention programmes should be non-judgmental and aim to encourage clients of sex workers to share the responsibility for HIV harm reduction by practising healthy and respectful engagements with sex workers. Principles for practical client interventions include clear definitions of sex work, challenging stigma and judgment, emphasising elements of sexual consent, and considering risk perception and emotional distress.

The COVID-19 pandemic is rapidly eroding some of the gains made with HIV and AIDS programmes. Now more than ever, innovative and bold interventions are necessary to reach beyond social taboos and conventions. Sex worker clients are a neglected group who deserve respectful attention, political will, and programmatic resources, not sexual moralism.