Marlise Richter

This Open Forum records a conversation between three activists who have worked within the field of sex worker rights in South Africa for close to two decades. Drawing on our experiences of organising, movement-building, documenting, theorising and creating art and activism on the impact of apartheid-era criminal law on sex worker lives, we explore questions relating to feminism, gender, power and feminist ways of organising on the decriminalisation of sex work.

An ethical and forward-looking health sector response to sex work aims to create a safe, effective, and non-judgemental space that attracts sex workers to its services. Yet, the clinical setting is often the site of human rights violations and many sex workers experience ill-treatment and abuse by healthcare providers. Research with male, female, and transgender sex workers in various African countries has documented a range of problems with healthcare provision in these settings, including: poor treatment, stigmatisation, and discrimination by healthcare workers; having to pay bribes to obtain services or treatment; being humiliated by healthcare workers; and, the breaching of confidentiality. These experiences are echoed by sex workers globally. Sex workers’ negative experiences with healthcare services result in illness and death and within the context of the AIDS epidemic act as a powerful barrier to effective HIV and STI prevention, care, and support. Conversely positive interactions with healthcare providers and health services empower sex workers, affirm sex worker dignity and agency, and support improved health outcomes and well-being. This chapter aims to explore the experiences of sex workers with healthcare systems in Africa as documented in the literature. Findings describe how negative healthcare workers’ attitudes and sexual moralism have compounded the stigma that sex workers face within communities and have led to poor health outcomes, particularly in relation to HIV and sexual and reproductive health. Key recommendations for policy and practice include implementation of comprehensive, rights-affirming health programmes designed in partnership with sex workers. These should be in tandem with structural interventions that shift away from outdated criminalized legal frameworks and implement violence prevention strategies, psycho-social support services, sex worker empowerment initiatives, and peer-led programmes.

Sports mega-events have expanded in size, popularity and cost. Fuelled by media speculation and moral panics, myths proliferate about the increase in trafficking into forced prostitution as well as sex work in the run-up to such events. This qualitative enquiry explores the perceptions of male, female and transgender sex workers of the 2010 Soccer World Cup held in South Africa, and the impact it had on their work and private lives.

Characteristics, sexual behaviour and risk factors of female, male and transgender sex workers in South Africa

Sex work is a criminal offence, virtually throughout Africa. This criminalisation and the intense stigma attached to the profession shapes interactions between sex workers and their clients, family, fellow community members, and societal structures such as the police and social services.

Intersections between migration and sex work are underexplored in southern Africa, a region with high internal and cross-border population mobility, and HIV prevalence. Sex work often constitutes an important livelihood activity for migrant women. In 2010, sex workers trained as interviewers conducted cross-sectional surveys with 1,653 female sex workers in Johannesburg (Hillbrow and Sandton), Rustenburg and Cape Town. Most (85.3 %) sex workers were migrants (1396/1636): 39.0 % (638/1636) internal and 46.3 % (758/1636) cross-border. Cross-border migrants had higher education levels, predominately worked part-time, mainly at indoor venues, and earned more per client than other groups. They, however, had 41 % lower health service contact (adjusted odds ratio = 0.59; 95 % confidence interval = 0.40–0.86) and less frequent condom use than non-migrants. Police interaction was similar. Cross-border migrants appear more tenacious in certain aspects of sex work, but require increased health service contact. Migrant-sensitive, sex work-specific health care and health education are needed.

Important unanswered questions remain on the impact of international sporting events on the sex industry. Speculation about increased demand and supply of sex work often generates significant attention, but also additional funding for HIV programmes. This study assessed whether changes occurred in the demand and supply of paid sex during the 2010 Soccer World Cup in South Africa.

Sex work is highly stigmatised in South Africa. All aspects of sex work are currently a criminal offence. Sex workers’ stigmatised position in society, and the nature of their work-multiple, concurrent sexual partnerships, working within dangerous and violent spaces, and lack of services and legal protection-render them particularly vulnerable to HIV and other Sexually Transmitted Infections (STIs). No recent data on sex worker HIV prevalence in South Africa exists, but it ranged from 45%–69% in 1998. Sex work often occupies a much maligned – and often sensationalised or lurid – space in contemporary thinking and social change activism on feminism, health matters, policy-formation and human rights in Africa. Few individuals or institutions treat sex work or sex workers with seriousness or respect. Indeed, in areas of policy-formation, programme design or law reform, sex workers are often either overlooked, paid lip-service to, or they are let down during power-broking. South Africa's AIDS response has been no exception. This Briefing explores South Africa's 2007 and 2012 AIDS Plans and the South African National AIDS Council (SANAC) processes during 2007–2011 as a case study of sex work marginalisation at a critical time where their interests and demands should have been heeded: not only as it would recognise sex worker health, human rights and dignity, but as it would have significant public health effects.

Self-tests for HIV in South Africa are currently unregulated. Gaps in law and policy have created a legal loophole where such tests could effectively be sold in supermarkets, but not in pharmacies. At the same time, South Africa lacks an effective regulating mechanism for diagnostic tests, which brings the quality and reliability of all self- tests into question. The authors argue for greater access to, and availability of, quality HIV self-tests. This strategy will encourage regular HIV-testing, allay fears about stigma and confidentiality when testing in public facilities, and decrease the costs associated with traditional voluntary counselling and testing, and is likely to lead to earlier diagnosis and treatment of HIV.