Beyond Stigma: The Case Against the Criminalization of Sex Work for HIV Prevention and Health Equity

• Published in: American journal of public health (1971) 2024-11, Vol.114 (11), p.e1-1178
• Main Authors: Cochran, Tyler, Smith, Leah, Ayers, Kara, van Stone, Maureen
• Format: Article
• Language: English
• Subjects: Acquired immune deficiency syndrome; Adults; Aggression; AIDS; Antiviral agents; Arrests; Clients; Condoms; Crime; Criminal law; Criminalization; Decriminalization; Disease prevention; Disease transmission; Exposure; Extortion; Females; Government employees; Health care access; Health disparities; Health education; HIV; Human immunodeficiency virus; Human rights; Identity; Imprisonment; Infections; Informed consent; Intersectionality; Jurisdiction; Law enforcement; Legislation; Mathematical models; Medical personnel; Medical tests; Medical treatment; Money; Occupational exposure; Offenses; People with disabilities; Police; Pornography; Prostitution; Public health; Public officials; Risk management; Sex crimes; Sex industry; Sexual assault; Sexual behavior; Sexual health; Sexually transmitted diseases; Social exclusion; Social interactions; Social networks; Social organization; Social support; Sociocultural factors; STD; Stigma; Support networks; Transgender persons; Violence; Workers; Working women
• ISSN: 0090-0036; 1541-0048; 1541-0048
• DOI: 10.2105/AJPH.2024.307782

Currently, more than one million new HIV infections are recorded annually.1 As world governments and policymakers mobilize to pursue this goal, evidence suggests that among the most impactful policy changes in reducing HIV incidence is the decriminalization of sex work,2 largely because of the disproportionate incidence of HIV infection among sex workers; for example, UNAIDS reports that female sex workers are 30 times more likely to become HIV-positive relative to the overall female population.3 However, a way forward remains: mathematical models from Imperial College London estimate that ending the criminalization of all aspects of sex work would prevent between 33% and 46% of global new HIV infections in sex workers and their clients-both of which are key populations particularly vulnerable to HIV infection4 Indeed, many experts argue that the total decriminalization of sex work would, "have a greater effect on the course of the HIV epidemic than any other structural intervention," by increasing key linkages to care and social support networks for sex workers living with HIV, as well as reducing the incidence of HIV infections for sex workers, their clients, and their clients'sexual networks.5(p356) Note that this essay will discuss evidence regarding both the decriminalization of sex work, meaning that consenting adults who are buying or selling sex are not committing a crime, and the legalization of sex work, which creates an affirmative regulatory scheme that creates rules governing the sale of sex between consenting adults6 For the purposes of this article, sex work will be defined broadly, using the working definition put forward by Decriminalize Sex Work, a national organization that advocates the human rights of sex workers: "Sex work is the exchange of sexual services (sex, erotic dancing, pornography, etc.) for money or something of value. Increased stigma leaves sex workers at a higher risk for contracting HIV, lowers their access to care and treatment, and leads to them being acutely vulnerable to violence and arrest.8 Violence as Key Driver of HIV Infection One key driver of the disproportionate HIV infection rates of sex workers is the disproportionate levels of violence that sex workers experience 8 A global systemic review of the relationship between legislation criminalizing sex work and HIV and other STIs outcomes points to the role of repressive policing in jurisdictions that criminalize sex work 9 Sex workers who were exposed to repre