Punitive and non-protective sex work laws are associated with prevalent HIV infection among female sex workers in countries across sub-Saharan Africa. The prevalence of stigma is high among female sex workers and consistently associated with prevalent HIV infection, highlighting the importance of structural determinants alongside more proximal individual-level characteristics. The degree of the relationship between stigmas and HIV varies by legal status of sex work, suggesting that stigmas and legal status of sex work may operate jointly in increasing individual HIV burden. This study further demonstrates the persistence of certain types of stigmas across differing legal contexts and suggests that the potential impact of stigmas on HIV risk and ultimately burden may be greatest in punitive and non-protective settings. Finally, these results suggest the complexity of HIV risks among sex workers across sub-Saharan Africa transcending individual-level sexual practices, highlighting the need to continue to measure and address stigmas to inform a more effective and efficient HIV response.

The magnitude of the relationship between the legal status of sex work and individual HIV infection is highest among individuals in fully criminalized settings, followed by settings where the legal status of selling sex is not specified. These results are consistent with prior findings from ecological studies19 and highlight how laws serve as a structural determinant that contribute to individual-level health outcomes. Findings suggest that written laws, independent of enforcement practices, influence HIV outcomes and that explicit legality serves in protecting sex workers. Moreover, these results suggest that punitive and non-protective laws may contribute to an environment that perpetuates HIV risks among sex workers. These findings are consistent with earlier mathematical models that demonstrated that across generalized and concentrated HIV epidemics, decriminalization of sex work could have the largest effect on the course of country-level epidemics, averting one-third to almost one-half of incident HIV infections over the next decade10. This reduction would be through combined effects on violence, harassment by uniformed officers, and safer work environments collectively mediating HIV transmission pathways10. Despite these consistent results, the number of countries decriminalizing sex work has not increased over the last 5 years2,11.

The relationship between stigmas and HIV varies across different legal contexts of sex work, suggesting that stigmas and sex work laws interact in increasing HIV risks and ultimately burden. Sex workers living in settings with criminalized and non-specified laws generally show a stronger relationship between stigmas and HIV compared with partially legalized settings. Existing evidence suggests that sex workers living in punitive and non-protective settings may experience greater burdens of stigmas than women living in partially legalized settings37. However, in this study, women reporting any lifetime history of stigma is not clearly or consistently higher in criminalized or non-protective settings compared with partially legalized settings, highlighting that sex workers across legal environments experience stigmas. Although sex workers may still experience a greater frequency of stigmas over the course of their lifetime in punitive and non-protective settings, the periodicity of stigma experiences among women is not measured in this study. Given the near universality of stigmas affecting sex workers, the mechanisms associated with increased HIV burden may act by amplifying the barriers to safety, as well as efficacious health services. Specifically, sex workers in punitive and non-protective environments may be more susceptible to the harms related to stigmas affecting overall safety in society and in access to HIV prevention and treatment services. Furthermore, sex workers in partially legalized or more protective environments have been shown to have higher levels of social capital, resiliency, and options for support that can mitigate the impact of stigmas on HIV risks38. Ultimately, the mechanisms underpinning the synergies of stigmas and sex work laws in the burden of HIV among sex workers likely vary by the specific type of stigma. The consistency in the findings of the interaction between laws and stigma in especially punitive legal settings reinforce the importance of HIV prevention and treatment intervention strategies tailored for sex workers that consider the legal context during implementation.

Uptake of HIV testing, prevention, and treatment services remains low among sex workers across sub-Saharan Africa and globally, in part due to healthcare-related stigmas2,10,39. In these analysis, higher HIV burden among sex workers was associated with anticipated and perceived stigmas relating to seeking care in criminalized settings. Harmful effects of stigma are reinforced by the experience of intersecting stigmas among sex workers living with HIV attributable to both sex work and HIV status, as participants who reported to be aware of living with HIV prior to enrollment report higher levels of sex work-related stigmas. The combined or compounded effect of multiple stigmas may further influence uptake of services and health outcomes40,41,42. Leveraging innovative approaches to provide services outside of health facilities while working to mitigate observed individual and intersecting stigmas may facilitate improved service coverage. In this context, decentralized services have been able to serve sex workers who were not accessing traditional services and therefore may provide an avenue to increase coverage and access43,44,45. To date, few studies have evaluated stigma mitigation approaches for people living with HIV and even fewer have aimed to study stigma reduction for sex workers in healthcare settings across sub-Saharan Africa24. These results suggest the importance of protective structures within healthcare systems, such as the enforcement of anti-discriminatory policies and accountability mechanisms to ensure culturally and clinically competent services for all.

Violence affecting sex workers is prevalent across legal contexts and is associated with HIV among sex workers in this analysis, consistent with findings from other settings46. Violence has been associated with HIV risks, such as inconsistent condom use, difficultly in condom negotiation, recent condom failure, client condom refusal, and high client volume47,48,49. In this analysis, the relationship between physical violence and HIV varies by legal context, with an increased association in criminalized settings. Increased legal restrictions on sex work has been shown to move activities to more hidden settings to avoid detection by uniformed officers, alongside increased vulnerability to violence and HIV-risk behaviors such as unprotected sex50. Even when enforcement efforts prioritize clients or third parties, violence affecting sex workers persists51. In contrast, the degree of the relationship between sexual violence and HIV does not vary across legal contexts. Aligning with findings from other studies, this suggests that partial legalization, such as the removal of only some aspects of criminal laws and regulation of sex workers is necessary, but not sufficient for reducing sexual violence as a risk factor for HIV52. This is consistent with previous modeling and empirical work, suggesting that only through full decriminalization, such as full removal of laws targeting sex industry; access to safer work environments; and prevention of violence and harassment by police could law reform as a structural determinant avert violence and HIV infections10,51. Finally, empirical research pre and post law reform has shown that in settings where clients and third parties are criminalized but not sex workers, rates of both sexual violence was unchanged from full criminalization53.

Sex workers reporting lack of protection from uniformed officers is prevalent in this analysis, and likely true in much of the world54. The lack of protection explains the persistent violence and blackmail observed among sex workers across legal contexts, likely due to impunity of offenders. There have been limited recent efforts among countries or regions to end impunity for crimes and abuses against sex workers2. In this study, the relationship between blackmail and HIV is highest in non-protective settings, followed by criminalized settings. In other settings, repressive police practice has been associated with violence, as well as HIV and sexually transmitted infections18. Perceived stigmas related to policing practices is prevalent and associated with HIV infection in this analysis, suggesting that legal protections as well as training and accountability of law enforcement may support improved HIV outcomes. Here, there is no assessment of enacted stigmas by uniformed officers specifically, however, this has been observed in other settings55. For instance, qualitative assessments have reported abusive practices by uniformed officers against sex workers, including blackmail, arbitrary arrest, and violence56,57. Women have also reported that sex or money are used as compensation for release after arrests56,57. Among sex workers in Côte d’Ivoire, Burkina Faso, and Togo who had experienced physical violence and forced sex, a large proportion reported perpetration by a uniformed officer55,58. In this study, fear of being in public places is negatively associated with HIV prevalence overall, prior to stratification across legal contexts. In part, the lower HIV risk may emerge from protective behaviors such as avoiding street-based sex work, which has been associated with increased violence, extortion by uniformed officers, and increased HIV-related risk behaviors18,59. Combined structural interventions with uniformed officers involving advocacy with senior uniformed officers, and crisis response mechanisms have been shown to reduce uniformed officers arrests and violence, and create a safer work environment for sex workers60,61.

Several limitations in this study should be considered. Although data are clustered by site and country to account for the non-independent nature of observations within each site and within each country, individual country and site differences may be lost in the aggregation of data. Legal status categories were determined based on country-specific legislation where available, but not necessarily the enforcement practices and justice systems. Although we are not able to assess causality through cross-sectional data and cannot account for the relationship between HIV prevalence and stigmas over time, laws were established prior to HIV introduction within countries. At a minimum, this limits the possibility that laws criminalizing sex work were a result of or influenced by the HIV epidemic. It is possible that unmeasured confounders preceding both sex work laws and country-level epidemics may exist and feed independently into both, thus resulting in uncontrolled confounding. There may also be unmeasured confounders that are associated with sex work laws and/or stigmas, as well as causally associated with HIV, but not on the casual pathway between these exposures and outcomes. None of the countries included in this analysis meet the criteria for decriminalized legal status, and therefore this legal context could not be evaluated. Data were collected over a period of 7 years, which should be considered in the interpretation of the results. Enforcement practices, program funding, and other external measures over time may have influenced stigmas, HIV status, or HIV risk. Female sex workers living with HIV may experience intersectional or compounded stigmas due to HIV status and engagement in sex work, and therefore there is a need to further evaluate these intersectional stigmas.

In the context of a slowing HIV pandemic, epidemics among sex workers in most settings across sub-Saharan Africa are stable or growing. Although others are benefiting from improved prevention and treatment interventions, these data highlight that both sex work laws and stigmas prevent the effective provision and uptake of interventions for sex workers across sub-Saharan Africa. Moreover, the unmet HIV treatment needs among sex workers results in onward HIV transmissions that are relevant even in the most generalized HIV epidemics. The data presented here collectively demonstrate the importance of punitive and non-protective laws in driving HIV risks among sex workers. Furthermore, stigmas and sex work laws appear to operate synergistically in increasing HIV burden, with stigmas having a greater impact on HIV risk in punitive and non-protective settings. In 2020, there will be more than three times the number of infections compared with the stated goal of 500,000 new HIV infections, highlighting the need to do things differently if there is to be a chance of achieving zero new infections by 2030. Thus, whether the path forward is driven by human rights or public health principles, achieving zero new HIV infections in the foreseeable future can only be realized if we meaningfully address the structural determinants that contextualize individual HIV risks among sex workers across sub-Saharan Africa.