HIV and Sex Work: Key Facts, Resources, and Prevention Methods

Sex work is the exchange of sexual services for some form of compensation, like money, shelter, or something else of value. People who engage in sex work do so for multiple reasons, which can include circumstance, choice, or coercion, according to the National Harm Reduction Coalition.

In the U.S., sex work involving physical contact is illegal almost everywhere, except for a few counties in Nevada. Maine decriminalized selling, but not buying, sex in 2023—which means that sex workers are not prosecuted, but their clients are, according to the Associated Press. “People are going to engage in consensual adult sex work; that is a reality. So the conversation needs to be: How do we keep people who are engaging in it safe, not how do we keep people from engaging in it,” said Ariela Moscowitz, the director of communications for Decriminalize Sex Work, an organization working to change U.S. laws around this profession.

The bottom line: Sex work is work, and sex workers deserve to be safe and informed. That includes being aware of the most current research, guidance, and information regarding the risks of HIV for sex workers and how to get access to important resources for prevention and care.

Are Sex Workers at Risk of Acquiring HIV?

In a word: yes. In principle, anyone who has sex with multiple partners is more vulnerable to acquiring HIV or another sexually transmitted infection (STI) than someone who is in a mutually monogamous relationship. In addition, sex workers face unique risks, including the risk of being arrested for prostitution when they carry condoms or HIV prevention medications, not knowing their clients’ HIV status, and sometimes living and working on the street.

Many people think of sex workers as cisgender women, but transgender people and cisgender men also work in this profession. However, the few existing U.S. studies on sex work and HIV have focused mainly on cisgender women.

How Common Is HIV Among Sex Workers?

In the U.S., sex worker statistics are rare. One analysis of studies conducted between 1987 and 2013 found that about 17% of women who are engaged in sex work are living with HIV. “Because of the nature of the activity, especially in countries that have criminalized the act, it is challenging to track the incidence rates of STDs and STIs among sex workers,” Ronni Benson, B.S.N., R.N., noted in Infection Control Today.

Globally, UNAIDS estimates that around 2.5% of sex workers are living with HIV, compared to about 0.7% of all adults. That number is even higher for transgender people and for people who inject drugs—groups that are disproportionately represented among sex workers.

Why Are Sex Workers at Increased Risk of Acquiring HIV?

A number of factors increase sex workers’ vulnerability to acquiring HIV:

• Having many clients
• Dangers involved with keeping condoms or HIV prevention medications on hand
• Substance use, which is more common among sex workers
• Risk of being a victim of sexual violence
• Homelessness, street work, and the risks of “survival sex” to get a bed for the night
• The ever-present threat of arrest while working on the street

Here’s some more detail on each of these risk factors:

Multiple Partners

Having sex with many people is inherent in the nature of the work. While an undetectable viral load prevents a person living with HIV from transmitting the virus to their sexual partners, there is no way for sex workers to be certain of their clients’ HIV status. Safer-sex practices can reduce the risk of acquiring HIV, but clients may insist on “risky” sex and/or pay more for it. Given the precarious income derived from what is an illegal activity in most of the U.S., sex workers may not be in a position to refuse client requests or additional income.

Condom Use Is Difficult

Beyond not always being able to insist on condom use, simply having these prophylactics in one’s purse or pocket can be dangerous. When police search a woman, they may use the fact that she carries condoms as a reason to arrest her for prostitution. A 2012 Human Rights Watch report documented sex workers’ experiences of police harassment and fear of carrying condoms. “People want to be able to use condoms, but if you are being put in the position by law enforcement of having to choose between your freedom and jail because you carry condoms to have safe sex, that puts people in a very compromising position,” noted Moscowitz.

Even the use of HIV prevention medications, such as pre-exposure prophylaxis (PrEP), can be tricky for sex workers. “In many countries, including the United States, police and courts already use the possession of multiple condoms as ‘evidence’ of intention to do sex work,” Rewire News Group reported in 2016. “Some fear that police could likewise make PrEP possession grounds for arresting and charging a person with intention to engage in sex work.”

Substance Use

Substance use—including injecting drugs—appears to be more common among sex workers than among the general population, although data is scarce. A 2018 analysis of studies from around the world found that 35% of sex workers had used street drugs, but researchers cautioned that the individual studies reported a wide range of percentages. In another study, 71% of women engaging in sex work in Baltimore reported injecting drugs within the past three months.

Some people engage in sex work to fund their substance use; others use substances to deal with stigma, trauma, and discrimination. Substances can impair judgment, leading to a lack of precautions. Sharing injection equipment can also transmit HIV and hepatitis C.

“When we criminalize drugs, when we criminalize sex work, when we criminalize homelessness, we disrupt people’s ability to protect themselves and keep themselves safe,” said Moscowitz. People who use substances depend on them. Making such use illegal does not address the underlying addiction.

Sexual Violence

Sex workers experience both sexual and physical violence at higher rates than the general population. A global 2012 analysis found that 32% to 55% of sex workers reported experiencing violence during the past year, while as many as 75% of sex workers had ever been subjected to violence.

Clients may force sex workers to perform acts that increase the worker’s vulnerability to acquiring HIV, may become violent, or may refuse to pay. In areas where sex work is illegal, they may threaten to have the worker arrested if they don’t get their way.

Moscowitz explained that because of stigma and discrimination, sex workers may not seek out medical care following an assault for a checkup or for HIV prevention treatment over the fear that they might be arrested.

Homelessness and Working on the Street

Some people who are experiencing homelessness turn to sex work to meet their needs, while others lose their housing after engaging in sex work. The Chicago Coalition for the Homeless reports that 84% of sex workers in that city said they were or had been without housing. Faced with sleeping in the street, some people may engage in “survival sex” to get a bed for the night. Soliciting or being approached by strangers on the street carries its own risks because it increases the chances of sexual violence and harm, according to Moscowitz.

Threat of Arrest

In areas where sex work is illegal, the possibility of arrest is a constant danger. In a recent study of women who exchange sex for money or goods in Baltimore, solicitation by police officers was common, and many participants said they were afraid of being arrested if they refused the officers.

Systemic Changes Needed To Reduce Sex Workers’ HIV Risk

Global health organizations advocate for the decriminalization of the work as a first step to reducing HIV risk. The World Health Organization, for example, notes that “modelling studies indicate that decriminalizing sex work could lead to a 46% reduction in new HIV infections in sex workers over 10 years.” The suggestions below address the U.S. context, including specific laws.

Decriminalization

“Decriminalization refers to the removal of all penalties for buying or selling sex,” explained Moscowitz. In contrast, “legalization imposes a set of rules, regulations, codes that people working within the sex industry would need to comply with in order to not be committing a crime.”

Legalizing the profession without decriminalizing it would result in a two-tier system. “People who are operating outside that system would be left out in the cold and still subject to all the dangers of criminalization,” Moscowitz said. “People see sex workers as lacking agency, lacking autonomy, and therefore disposable. People prey on those who are vulnerable. Criminalization makes them vulnerable,” she added.

Repealing Internet Censorship

The internet is “where a lot of people get their information as it relates to sexual and reproductive health. All these censorship laws … interfere with people’s ability to find information on HIV and keep themselves safe,” noted Moscowitz.

Of particular importance here is a pair of laws passed in 2018, FOSTA (Allow States and Victims to Fight Online Sex Trafficking Act) and SESTA (Stop Enabling Sex Traffickers Act). The laws’ stated goal was to combat sex trafficking. However, their result was that websites used by sex workers to get and vet clients were shut down, pushing them back out onto the street. In San Francisco, for example, street-based sex work increased threefold after FOSTA-SESTA was passed, noted Moscowitz. “All these laws work together to push people into dangerous situations and then punish them for being there,” she added.

Non-Stigmatizing Health Care

Fear of stigma and discrimination, as well as arrest, often keeps sex workers from accessing health care. Decriminalize Sex Work is trying to get a patient bill of rights passed that would prohibit discrimination based on how someone earns their income.

Harm Reduction and Sex Education

Safer-sex supplies need to be more widely available in many different settings. Beyond getting the supplies, people need to know how to prevent HIV and other STIs. A Baltimore study found that 21% of female sex workers started in the trade before age 18 and another 39% began between ages 18 and 25. Comprehensive sexual and reproductive health education in high school would equip these young women with the knowledge needed to keep themselves and their clients from acquiring or transmitting HIV or other STIs.

Another key facet of HIV prevention for sex workers is access to prescription HIV prevention medications, which are extremely effective. These come in the form of pre-exposure prophylaxis, or PrEP (for ongoing protection), and post-exposure prophylaxis, or PEP (for sex workers who very recently had a potential exposure). In the U.S., PrEP is available as either an oral medication that’s ideally taken daily or an injectable that a person receives at a clinic every two months. In many African countries, there is also a ring that a person can insert into their vagina that provides protection for about one month. (The ring has not yet been approved for use outside of Africa due to regulatory hurdles.)

Unfortunately, PrEP use can be difficult for many sex workers due to a mix of issues, including personal safety and challenges with finding safe, non-stigmatizing, affordable access to health care. A number of organizations and advocates are working to improve this access (see our listings below).

Creation of Safe Brothels

Moscowitz explained that street-based sex work in the U.S. exists because sex work is criminalized and there aren’t brothels or a place where people can go. In brothels in New Zealand, where sex work has been decriminalized, sex workers have the right to take legal action if they are assaulted by a client.

One of the provisions in that country’s 2003 Prostitution Reform Act specifies that brothels must display safer-sex information and must take steps to ensure that these practices are followed. However, even in New Zealand, also known by its Māori name, Aotearoa, people without work permits who turn to sex work to support themselves are criminalized.

Ending the Use of Stigmatizing Language

When talking about sex—and sex work in particular—a variety of slang expressions are often used. People refer to sex workers as “prostitutes,” “whores,” “hookers,” “hussies,” or “hoes,” among other terms. Those who use sex workers’ services are called “johns,” and people who get clients for a sex worker are called “pimps” or “procurers.” Sex workers may use some of these terms among themselves—and even “take back” a term in a way that empowers them.

However, in the general public, these terms carry negative connotations; they stigmatize and stereotype people involved in sex work. “Most sex workers themselves would much rather be referred to as a ‘sex worker’ versus as a ‘prostitute,’” explained Moscowitz. Stella, a community organization created and run by sex workers in Montreal, notes: “Sex workers’ rejection of the term is often based in how the public perceives prostitutes and prostitution rather than an inherent shame in the word itself.”

Takeaways

Sex work is often called “the oldest profession.” It is a fact of life that can be made safer for both the sex workers and their clients but cannot be legislated away. Many slang expressions for this work are demeaning to the people engaged in it. The term “prostitution” should be reserved for talking about laws related to this work, while “sex work” should be used in all other contexts.

HIV is more common among sex workers than in the general population. Some of the reasons for this include having sex with many people, fear of policing practices keeping sex workers from carrying condoms, substance use impairing judgment, criminalization and stigma resulting in sexual violence, fear of seeking medical care after being assaulted, and the dangers inherent in living and working on the street.

Organizations and health departments have provided a variety of information resources to help sex workers prevent HIV acquisition or transmission. Sex workers themselves are also organizing to keep each other safe and to fight discriminatory laws.

To reduce HIV risk, sex work must first be decriminalized. Other needed changes include repealing internet censorship laws that keep sex workers from safer client engagement, providing health care without stigma, making safer-sex supplies and HIV prevention medications widely available, educating young people accurately about sexual health, and establishing safe brothels.

By Barbara Jungwirth

This article was published Apr 16, 2025 on portal thebody.com