Countries that have legalised some aspects of sex work have fewer sex workers living with HIV than countries that criminalise all aspects of sex work, according to an ecological analysis of 27 European countries. The association remained statistically significant after adjustment for countries’ economic development, HIV prevalence, antiretroviral therapy coverage and proportion of sex workers who inject drugs.
“Our findings suggest that the legalisation of some aspects of sex work might help reduce HIV prevalence in this high-risk group, particularly in countries where the judiciary is effective and fair,” say Aaron Reeves at the International Inequalities Institute, London School of Economics and Political Science, London, and department of sociology, University of Oxford, and colleagues.
Although the prevalence of HIV tends to be higher in sex workers than in the general population, prevalence varies between European countries, suggesting that structural factors might play a part.
Structural determinants of HIV risk include sex work policy, particularly laws that criminalise buying, selling, or procuring sex. They may increase HIV risk through recurrent police harassment, violence, and arrests or fear of arrests of female sex workers or clients, which can perpetuate unsafe working conditions, drug use risks, and physical or sexual violence against sex workers without recourse. Such insecurity can make it more difficult for sex workers to negotiate condom use, especially if condoms can be used as evidence in judicial proceedings.
The researchers say they are the first to take advantage of the diversity of legal frameworks between European countries “to test the hypothesis that legalisation of some aspects of sex work is associated with decreased HIV prevalence among sex workers when compared with countries that retain criminal laws”.
Data comes from 27 countries in which the European Centre for Disease Prevention and Control have an estimate of the proportion of sex workers living with HIV. Although two countries’ estimates do include male sex workers, their numbers are so small that the analysis essentially pertains to female sex workers.
In one group of countries, such as Lithuania and Romania, all aspects of sex work are criminalised. In another group of countries, including the UK, Italy and Bulgaria, the buying and selling of sex has been legalised, but procurement through brothels or pimping is criminalised.
In addition, two countries in the data set, Sweden and Norway, have legalised selling sex but have criminalised buying sex. Despite the intent of this ‘Nordic model’ to shift criminalisation from sex workers to customers, many advocates say that it continues to make sex workers vulnerable.
Finally, one country – Germany – has legalised most forms of sex work and regulated the industry.
The researchers also investigate whether more effective and fair law enforcement mediates the relation between sex work policy and HIV prevalence. They use a World Bank indicator of the rule of law in countries, which captures the confidence the general population has in the effectiveness and fairness of the judiciary and police. However, this indicator does not specifically measure sex workers’ experience of policing.
The researchers used ecological linear regression models to test the possible relationships.
In countries where sex work is partly legalised, sex worker HIV prevalence was lower than in countries where sex work is criminalised (β= -2.09). Specifically, the average prevalence in ten countries where the practice is illegal was 4.0%, compared to 0.5% in 17 countries where some aspects of sex work have been legalised.
HIV prevalence remained lower in countries that legalise some aspects of sex work after adjusting for gross domestic product (β= -1.86) and after adjusting for the prevalence of injecting drug use among sex workers (β= -1.93). Neither GDP nor the proportion of sex workers who inject drugs was associated with HIV prevalence after controlling for sex work policy.
Germany, the one country which has legalised all aspects of sex work had a lower prevalence (after adjustment) than countries with more restrictive policies, although it is hard to generalise on the basis of one case. It is also hard to draw specific conclusions about the two ‘Nordic model’ countries, especially as data were collected in Norway before the introduction of this law in 2009.
Effective and fair law enforcement did not make any difference to these associations in countries which criminalise all aspects of sex work. But effective and fair law enforcement was associated with a lower HIV prevalence in countries that have legalised some aspects of sex work (β= -0.63). This suggests that legalisation in a context of the effective rule of law makes the most difference to sex workers’ health.
To check that the findings were not skewed, a series of sensitivity analyses were done. The results did not qualitatively change.
Reeves and colleagues say that their findings are consistent with other studies that report that the removal of criminal laws protects sex workers, allowing them to enter the formal economy, to benefit from social insurance, and to receive protection from law enforcement. This may help increase access to condoms, reduce the risk of violence and empower sex workers in condom negotiation.
They also acknowledge the limitations of their study – in particular weaknesses in the data sources that can be analysed, including a lack of detailed data on how sex work laws and policies are implemented.
But in a linked comment article, Marie-Claude Boily, at Imperial College London and Kate Shannon at the University of British Columbia commend the researchers for attempting to disentangle the independent effects of the law and enforcement. “Despite its limitations, this study provides useful ecological-level data across many European countries that should raise caution for governments and policy makers considering criminalised or end-demand models,” they say.
Background: Sex workers are disproportionately affected by HIV compared with the general population. Most studies of HIV risk among sex workers have focused on individual-level risk factors, with few studies assessing potential structural determinants of HIV risk. In this Article, we examine whether criminal laws around sex work are associated with HIV prevalence among female sex workers.
Method: We estimate cross-sectional, ecological regression models with data from 27 European countries on HIV prevalence among sex workers from the European Centre for Disease Control; sex-work legislation from the US State Department’s Country Reports on Human Rights Practices and country-specific legal documents; the rule of law and gross-domestic product per capita, adjusted for purchasing power, from the World Bank; and the prevalence of injecting drug use among sex workers. Although data from two countries include male sex workers, the numbers are so small that the findings here essentially pertain to prevalence in female sex workers.
Findings: Countries that have legalised some aspects of sex work (n=17) have significantly lower HIV prevalence among sex workers than countries that criminalise all aspects of sex work (n=10; β=–2·09, 95% CI −0·80 to −3·37; p=0·003), even after controlling for the level of economic development (β=–1·86; p=0·038) and the proportion of sex workers who are injecting drug users (−1·93; p=0·026). We found that the relation between sex work policy and HIV among sex workers might be partly moderated by the effectiveness and fairness of enforcement, suggesting legalisation of some aspects of sex work could reduce HIV among sex workers to the greatest extent in countries where enforcement is fair and effective.
Interpretation: Our findings suggest that the legalisation of some aspects of sex work might help reduce HIV prevalence in this high-risk group, particularly in countries where the judiciary is effective and fair.
Aaron Reeves, Sarah Steele, David Stuckler, Martin McKee, Andrew Amato-Gauci, Jan C Semenza