Section 6-7: Canadian Guidelines on Sexually Transmitted Infections – Specific populations – Sex workers

Section 6 - Specific Populations

Sex Workers

Definition

Sex workers are female, male or transgendered adults or young people who receive money, shelter or goods in exchange for sexual services, either regularly or occasionally, and who may or may not consciously define those activities as income-generating.Footnote 1 There are no reliable verbal or visual clues as to whether a patient is a sex worker or not. Where appropriate, patients should be asked whether they ever receive money, shelter or goods in exchange for sexual services.

Epidemiology

Sex workers are vulnerable to sexually transmitted infections (STIs), including HIV, because of the following factors:

  • Lack of control (e.g., condom use, refusing clients).
  • Lifestyle risks, such as violence, substance use and mobility.Footnote 1
  • Stigmatization and marginalization.
  • Limited economic options.
  • Limited access to health, social and legal services.
  • Limited access to information about and the means of prevention.
  • Gender-related differences and inequalities.
  • Sexual abuse and exploitation, including trafficking and child prostitution.
  • Legislation and policies affecting the rights of sex workers.
  • Mental health problems.
  • Incarceration.
  • Lack of family and social support.

Because of high rates of partner change, sex workers play an important role in the transmission of STIs. Studies from developed and developing countries have shown increased STI and HIV incidence and prevalence among sex workers.Footnote 2Footnote 10 Sex workers tend to use condoms less often with regular partners, even though these individuals are often at high risk for STIs and HIV themselves. Adolescents and children who work in the sex trade are especially vulnerable to STIs due to the cellular immaturity of the female vagina and cervix, as well as an inferior ability to negotiate for safer sex and higher risk of violence and abuse.Footnote 11

Prevention and Control

Successful STI/HIV prevention focuses on the promotion of safer sexual behaviour through female and male condom availability and correct usage; improved negotiating skills; and supportive policies and laws.Footnote 1Footnote 3 Peer education, outreach work, accessible services, advocacy, community development, program coordination and sex worker involvement are all important prevention principles and strategies.Footnote 1Footnote 3,Footnote 12Footnote 15

Lubricants have been associated with a reduced risk for STIs.Footnote 16 Spermicides such as nonoxynol-9 have been linked to enhanced susceptibility to infection and have not been shown to enhance the protective effect of condoms.Footnote 17 Hepatitis B vaccination should be available to sex workers, since they are at increased risk for infection.Footnote 18 Hepatitis A vaccination should be available to sex workers at high risk, such as male sex workers who engage in oral-anal contact with male customers.

Evaluation

Sex workers presenting for STI care or a routine medical examination should have an STI/HIV history taken and undergo a physical examination focusing on the genital area, including a speculum exam for women and a throat and rectal exam if indicated.Footnote 19 Privacy and confidentiality must be assured. STI/HIV evaluation of sex workers cannot always be performed in ideal clinic conditions; it may need to be adapted to less structured settings, such as mobile clinics. In addition to the standard STI/HIV evaluation, it is important to ask about current or past drug use, whether there is a regular partner and whether there is condom use with both customers and partners.Footnote 19

Specimen Collection and Laboratory Diagnosis

History, examination and setting should determine specimen collection. With counselling and informed consent, sex workers should receive regular laboratory screening for syphilis, HIV infection (unless known to be HIV-positive), gonorrhea, chlamydia, vaginitis/vaginosis and HPV infection (if available).Footnote 19 Regular cervical screening for dysplasia and/or HPV infection is important. Persons at risk for hepatitis C should be counselled and tested.

Because of the nature of sex work and the social situation of many sex workers, urine-based laboratory testing, rapid point-of-care testing and self-collected specimens are especially relevant.

Management and Treatment

Sex workers should be able to access standard STI and HIV/AIDS management and treatment recommendations.Footnote 20 Curing a single sex worker of gonorrhea can result in fewer secondary cases and reduce the risk of HIV, thereby saving 120 disability-adjusted life years (DALYs) at a cost below US$1 per DALY.Footnote 21 Single-dose, oral therapies for STIs should be available to sex workers who are unable to complete a longer course of treatment. Epidemiological or syndromic treatment without a full evaluation or laboratory testing may sometimes be necessary.Footnote 1,Footnote 19

Education and counselling is a vital component of STI/HIV management for sex workers, as well as for other patients.Footnote 1,Footnote 19 It is especially important that sex workers know how to use condoms, how to negotiate for safer-sex and why they should use condoms with regular partners. Clinicians need to understand the specific circumstances of risk for each patient and develop an individualized risk reduction plan for him/her.

Reporting and Partner Notification

STI/HIV surveillance is important, and accurate and prompt reporting is the basis of effective STI surveillance and case management. Sex workers and other marginalized populations often rely on publicly funded STI/HIV services, so to facilitate case management and cooperation with patient reporting, trust, respect and confidentiality should be emphasized in these situations.

Sex worker partners (both regular and commercial) need to be notified in a confidential manner and offered treatment in the same manner as non–sex workers. The possibility that partner notification may result in violence toward the index sex worker should be explored and mitigated where possible. In this instance, notification by the health department or a health care worker (keeping the identity of the sex worker anonymous) is often preferable.

Follow-up

Sex workers should be encouraged to have a regular monthly STI evaluation.Footnote 19 Children and youth who may have been exploited should be reported to the relevant youth protection agency (see Sexual Abuse in Peripubertal and Prepubertal Children chapter). Sex workers with mental health, social service, housing or legal issues need to be referred to appropriate agencies or practitioners.

References

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