1975年6月2日,一群約100名性工作者佔領了法國里昂的聖尼齊爾教堂,抗議她們的生活條件和當局的待遇,並在教堂尖頂懸掛橫幅,宣稱「我們的孩子不想要他們的母親進監獄」。抗議者呼籲警察停止騷擾,重新開放他們所工作的飯店,並對一系列性工作者謀殺案進行適當調查。他們的事業引發了法國各地的進一步抗議,並引起了國際關注。從那時起,6 月 2 日就被定為國際性工作者日,藉此機會表彰性工作者對社會的貢獻,並倡導他們的權利、健康和福祉。這一天也是一個關注從事性工作的人面臨的許多挑戰的機會,包括恥辱、歧視、暴力和不成比例的愛滋病毒負擔。
聯合國愛滋病規劃署將性工作者視為特別容易感染愛滋病毒,並由於結構性障礙、恥辱和歧視而無法獲得服務的五個關鍵人群之一(其他人群是男男性行為者、注射藥癮者、跨性別者和被監禁的人)。根據聯合國愛滋病規劃署 2023 年的數據,在全球範圍內,性工作者的愛滋病毒感染率是一般人的四倍。在南部非洲一些愛滋病毒高發生地區,女性性工作者的愛滋病毒感染率高得驚人:南非部分地區為 62%,辛巴威為 50%。儘管估計數差異很大,且由於刑事定罪使得從事性工作的人被邊緣化,因而可能缺乏數據;對於男男性行為者或跨性別者來說,現有的數據可能非常地不可靠。聯合國愛滋病規劃署2021 年情況說明書《愛滋病毒和性工作》報告稱,2019 年,全球女性性工作者的愛滋病毒發生率高出30 倍,所有新感染愛滋病毒的8% 發生在任何性別的性工作者中。
有關性工作的立法尤其複雜。全球有 168 個國家將性工作的某些方面定為犯罪,包括銷售、組織和購買,但很少國家將性工作合法化或非罪刑化。由於刑事定罪的某些方面而受到當局起訴或歧視的風險可能會阻礙性工作者參與健康服務,包括專門針對愛滋病毒的服務。幾乎三分之一感染愛滋病毒的性工作者不知道自己的愛滋病毒狀況,並且擔心會因衛生工作者的恥辱和歧視而阻礙性工作者獲得愛滋病毒服務。一項針對撒哈拉以南非洲十個國家的研究發現,將性工作定為犯罪的國家相較於性工作部分合法化的國家,其感染愛滋病毒的風險比高出七倍多。
在世界各地,性工作者獲得愛滋病毒服務往往依賴社區參與,而不是傳統的健康服務。提供愛滋病毒服務的非政府組織經常依賴社區的貢獻來傳播檢測服務、幫助愛滋病毒感染者獲得照護服務並提供順從性支持。性工作者的貢獻會延伸擴增到其他人群,包括他們的顧客以及與他們有交叉和互動的其他的邊緣群體。 2016 年,Harsha Thirumurthy 及其同事報道了肯亞的一項舉措,其中女性性工作者向客戶分發愛滋病毒自檢單,有助於提高其顧客對感染狀況的意識並提升性工作者的安全。這是性工作者為世界各地愛滋病毒研究和服務之提供所做出貢獻的眾多例子之一。
為了解決全球性工作者中不成比例的愛滋病毒風險和負擔,聯合國愛滋病規劃署在2021 年情況說明書中提出了2025 年六項「全球推動目標」:國家中制定了將性工作之任何方面定為刑事犯罪的法律應少於10% 以下;性工作者中遭受恥辱或歧視者應少於10% 以下;衛生工作者和執法人員對性工作者持負面態度者應少於10% 以下;國家中缺乏舉報虐待和歧視性工作者的機制者應少於10% 以下;性工作者中無法獲得法律服務者應少於10% 以下;性工作者中曾遭受身體暴力或性暴力者應少於10% 以下。顯然,這些目標遠未實現,但仍充滿希望。
性工作者存在於每個時期、每個國家、地區、社會和文化中——無論從什麼定義上來說,性工作者都是關鍵人群。性工作就是工作,非罪刑化和社會包容對於承認從事性工作的人對整個社會的貢獻以及解決他們所面臨的不成比例的愛滋病毒負擔至關重要。 ■刺胳針人類免疫缺乏病毒
Sex workers are a key population in society
www.thelancet.com/hiv Vol 11 June 2024
On June 2, 1975, a group of about 100 sex workers took over the Saint-Nizier Church in Lyon, France, to protest their living conditions and treatment by authorities, hanging banners from the church spire declaiming “Our children do not want their mothers to go to jail”. The protestors called for an end to police harassment, reopening of hotels where they worked, and proper investigation into a series of murders of sex workers. Their cause sparked further protests across France, and garnered international attention. Since then, June 2 has been International Sex Workers’ Day—an occasion to acknowledge the contributions of sex workers to society and to advocate for their rights, health, and wellbeing. The day is also a chance to focus on the many challenges that people who engage in sex work face, including stigma, discrimination, violence, and a disproportionate burden of HIV.
UNAIDS considers sex workers as one of five key populations that are particularly vulnerable to HIV and lack access to services because of structural barriers, stigma, and discrimination (the others being men who have sex with men, people who inject drugs, transgender people, and people in incarceration). Worldwide, according to UNAIDS figures for 2023, prevalence of HIV is four times higher among sex workers than in the general population. In some areas of southern Africa with high burdens of HIV, the prevalence of HIV in female sex workers is eyewateringly high: 62% in parts of South Africa and 50% in Zimbabwe. Although estimates vary substantially and because criminalisation marginalises people involved in sex work, data are likely to be lacking; and for sex workers who are men who have sex with men or transgender people, data, where available, are potentially very unreliable. The 2021 UNAIDS fact sheet HIV and Sex Work reported that in 2019 incidence of HIV was 30 times higher in female sex workers globally and 8% of all new HIV infections were among sex workers of any gender.
Legislation around sex work is particularly complex. 168 countries worldwide criminalise some aspect of sex work, including selling, organising, and purchasing, and few countries have legalised or decriminalised sex work. The risk of prosecution or discrimination from authorities on the basis of some aspect of criminalisation can discourage sex workers from engaging with health services, including those dedicated to HIV. Almost a third of sex workers living with HIV do not know their HIV status, and fear of stigma and discrimination from health workers discourages sex workers from accessing HIV services. A study of ten countries in sub-Saharan Africa found that the odds of living with HIV were over seven times greater in countries that criminalise sex work compared with a country where sex work is partly legalised.
Around the world, access to HIV services for sex workers frequently relies on community engagement rather than conventional health services. Non-governmental organisations providing HIV services frequently rely on contributions from the community to disseminate testing services, help people living with HIV to link to care services, and to provide adherence support. The contributions of sex workers extend to other populations, including their clients and other marginalised groups with whom they intersect and interact. In 2016, Harsha Thirumurthy and colleagues reported on an initiative in Kenya in which female sex workers distributed HIV self-tests to clients, helping to increase status awareness and improve safety for sex workers. One of many examples of sex workers contributing to HIV research and service provision around the world.
To address the disproportionate risk and burden of HIV among sex workers worldwide, in the 2021 fact sheet, UNAIDS proposed six “global enabler targets” for 2025: less than 10% of countries to have laws criminalising any aspect of sex work; less than 10% of sex workers experiencing stigma or discrimination; less than 10% of health workers and law enforcement officers with negative attitudes towards sex workers; less than 10% of countries lacking mechanisms for sex workers to report abuse and discrimination; less than 10% of sex workers lacking access to legal services; and less than 10% of sex workers experiencing physical or sexual violence. Clearly, these targets are far from being met, but nonetheless remain aspirational.
Sex workers have existed in every time period, every country, region, society, and culture—a key population by any definition. Sex work is work, and decriminalisation and societal inclusion are essential to recognise the contribution of people who engage in sex work to all society and to address the disproportionate burden of HIV that they face. ■ The Lancet HIV