Table 2 Characteristics of primary studies pertaining to sex work and HIV, STIs, and SRH in conflict-affected settings

Alemayehu et al. (2015) [32]

Mekelle City, Ethiopia

Cross-sectional

SWs (N = 250)

Post-conflict

STI history: 17% reported history of an STI, gonorrhea (45.8%) syphilis (41.7%), and chancroid (12.5%)

STI testing: 9.6% of those with an STI reported having sought treatment

Reproductive health: 27% of SWs reported a history of at least one elective abortion, with 35.3% of these women reporting more than one pregnancy termination.

Contraceptive use: 69% of SWs acknowledged any type of contraceptive use

Violence: Prevalence of sexual violence among SWs = 75.6%, correlates included lower education, sex work duration, and drug use. SWs with lower monthly income were the most likely to experience sexual violence.

Bing et al. (2008) [50]

Angola

Cross-sectional (Behavioural surveillance study)

Military personnel (N = 1710)

Post-conflict

Combatants as sex buyers: 9% of combatants reported having sex with a SW in past 12 months

Condom use: 54.2% of military personnel reported using a condom at last sex with a SW

STIs: Combatants who had casual sex partners or who had sex with a SW during the past year were significantly more likely to report STI symptoms than those without such sexual partners.

Dupas et al. (2012) [43]

Kenya

Retrospective study

- SWs (N = 248)

- Self-employed entrepreneurs (N = 230)

- Shopkeepers (N = 325)

Active and post-conflict comparison

Influence of political violence on unprotected sex: SWs engaged in higher risk (unprotected vaginal or anal) sex both during and after the post-election crisis, to make up for income shortfall. Overall levels of higher risk sex declined during the crisis, but women responded to the negative income shock by significantly increasing the amount of unprotected sex they had, conditional on being able to find clients.

Erickson et al. (2015) [31]

Gulu, Uganda

Cross-sectional

SWs (N = 400)

Post-conflict

HIV/STI prevalence: 22.3% SWs reported HIV infection and 40.3% reported STIs

Contraceptive use: 45.0% of SWs used male condoms and non-barrier family planning methods.

Policing: Having to rush sexual negotiations owing to police presence was negatively associated with dual contraceptive use (AOR 0.65, 95% CI 0.42–1.00; P = 0.050).

HIV testing: Dual contraceptive use was positively associated with HIV testing (AOR 5.22, 95% CI 1.75–15.57; P = 0.003), suggesting the potential importance of better integration of HIV/SRH services.

Goldenberg et al. (2015) [11]

Gulu, Uganda

Cross-sectional

SWs (N = 400)

Post-conflict

HIV infection: 33.75% of SWs were HIV-seropositive (compared to 8.51% of women of reproductive age in general pop); of whom 33.3% were new/previously undiagnosed HIV infections.

Abduction by rebels: War-related abduction was associated w/HIV (AOR: 1.62, 95% CI: 1.00–2.63).

Criminalization: Incarceration (AOR: 1.93, 95% CI: 1.17–3.20) associated w/ HIV

Harrison et al. (2009) [45]

Oruchinga and Nakivale refugee settlements, Uganda

Cross- sectional (Standardised behavioural surveillance survey (BSS))

- Settlement refugees who sold sex in last 12 months (N = 93)

- Ugandans in surrounding

settlement area who sold sex in last 12 months (N = 47)

Post-conflict

Sex work following displacement: More refugees than nationals reported exchanging sex for money, drugs or other goods (10% versus 6%; p < 0.01), which mostly occurred post-displacement. Sex work engagement higher in the refugee population vs. Ugandan nationals (4.7% vs. 2%).

Condom use: Condom use was low in both populations, but lower among refugees. Condom use at last sex with all types of partners (non-regular, paid, and higher risk) four-times higher among the nationals than refugees, but confidence intervals overlapped.

Sexual violence: Percentage of women aged 15–59 forced to have sex in the past year was roughly the same for refugees (1.3%) as nationals (1.2%).

Kriitmaa et al. (2010) [54]

Hargeisa, Somaliland, Somalia

Cross sectional (Integrated bio-behaviouralsurveillance (IBBS))

SWs (N = 237)

Post-conflict

HIV infection: Heterosexual commercial sex suggested as dominant mode of HIV transmission

Condom use and access: 24.0% SWs reported using a condom at last SW transaction and only 4.3% reported consistent condom use with clients in the past month. Of the 24.0% who did use a condom at last sex with a client, 80.5% said it was suggested by the client. 29.5% didn’t use condoms with clients due to not knowing where to obtain condoms. Almost none (0.4%) received condoms through a clinic or outreach in the past year.

HIV testing: Only 2.6% SWs knew where to go for a confidential HIV test. 4% reported ever having had an HIV test, and none of them received their test results.

HIV prevention: 6.9% SWs correctly answered all 5 questions on HIV factual knowledge; only 38.4% had ever heard of an STI.

Larsen et al. (2004) [36]

Sierra Leone

Pre-post test intervention

- SWs (N = 202)

- Military (N = 205)

Post-conflict

HIV knowledge: Only 8.5% SWs and 22.8% military knew >3 modes of HIV transmission

Condom knowledge/access: 14.9% of SWs and 12.4% of military knew no sources to purchase condoms

International Office of Migration (2008) [35]

Hargeisa, Somalia

Cross-sectional (IBBS)

SWs (N = 219)

Active conflict

HIV knowledge: No SWs knew their HIV status, 93% SWs lacked correct HIV prevention knowledge.

Condom use: 28% SWs had never used a male condom

Migration: 69% SWs were migrants

Muldoon et al. (2015) [14]

Gulu, Uganda

Cross-sectional

SWs (N = 400)

Post-conflict

HIV seroprevalance: 33.8%

SW demographics: Sample was generally young, the majority between the ages of 19–25 yrs., many with dependent children. 65% of SWs had less than primary school education

Violence: 49.0% of SWs reported extreme physical and/or sexual workplace violence in the previous six months, including physical assault, rape, and gang rape. Among 196 SWs who reported client violence, the most common forms included being physically assaulted (58.7%), raped (38.3%), the client attempting sexual assault (18.4%), and being gang raped (15.8%).

Condom use: 84.0% SWs reported inconsistent condom use with regular or one-time clients.

Policing: Rushing negotiations due to police presence contributed to client violence (AOR: 1.61, 95% CI: 1.03–2.52). Highlights negative consequences of policing practices for conflict-affected SWs.

Ntumbanzondo et al. (2007) [44]

Kinshasa, Democratic Republic of the Congo (DRC)

Cross-sectional

SWs (N = 136)

Active conflict

Sexual decision making: 96.3% SWs felt they were able to negotiate safer sex with clients.

Condom use: 81.6% SWs always used a condom with clients, but 26.5% reported charging extra for unprotected sex with clients upon request.

Unprotected sex for more money: SWs who engaged in unprotected sex for more money were significantly more likely to live or work at non-downtown sites (OR = 3.07), and to have at least one child less than six years of age (OR = 2.95). They charged a median of 2.90 USD (IQR: 1.54 USD 4.61 USD) for protected intercourse. The median ratio of their charge for unprotected intercourse to their charge for protected intercourse was 3.5 (IQR: 2.5 5.0).

HIV Knowledge: ~75% of SWs feared contracting HIV as a result of unprotected intercourse.

Rowley et al. (2008) [49]

Tanzania

Cross-sectional

Refugees/IDPs aged 15–24 exchanging sex (N = 16)

Surrounding villagers aged 15–24 exchanging sex (N = 32)

Post-conflict

SW engagement among refugees: 40% of refugee/IDPs 15-25 yrs. reported exchanging sex for money, gifts, or favors during the last year, compared with 21% of village respondents (χ2 33.83, p = .000).

Condom use: Condom use at last sex with non-regular or paid/transactional partners amongst refugees/IDPs (40%), compared to village respondents (21%).

Todd et al. (2011) [53]

Afghanistan

Cross-sectional

SWs (N = 520)

Active conflict

SW demographics: 76.9% SWs had no formal education

Displacement/mobility: 37.7% SWs lived outside Afghanistan in the last five years.

HIV knowledge: Only 17.4% SWs had comprehensive HIV knowledge.

Condom knowledge: <60% SWs heard of condoms; of those who had, only half had used a condom.Condom use: Consistent client condom use was reported by 11.5% SWs and was independently associated with having more clients per month.

Maclin et al. (2015) [37]

Goma, Bukavu and Kalehe, DRC

Focus group discussions

- Vulnerable women

- Males involved in community groups

Post-conflict

Post-conflict SW seen to break down traditional social structures/family dynamics: Discussants detailed how exchanging sex (i.e., commercial or transactional sex) post-conflict was linked to poverty. This was seen to undermine traditional social structures and family dynamics, and was portrayed as both a symptom of, and a catalyst for, changes within family dynamics resulting from conflict-related experiences in eastern DRC. Families were physically separated because of the conflict – from death, displacement and marriage dissolution, according to study participants.

Muhwezi et al. (2010) [38]

Katakwi and Amuria, Uganda

Focus group discussions

Key informant interviews

In-depth case study interviews

- FGD (4 men, 4 women)

- KI (16 men, 16 women)

- Case studies (8 men, 8 women)

Post-conflict

Sex work as a consequence of conflict: Breakdown of the social structure due to conflict resulted in economic destruction and a perceived soaring of vulnerable people whose propensity to engage in high-risk sexual behaviour was increased.

High risk sexual behavior due to refugee camp environment: High risk sexual behaviour (lifestyle or activity that places a person at increased risk of suffering or being infected with HIV/AIDS, a sexually transmitted disease and/or an unwanted pregnancy) was associated with concentration of people in camps where idleness and unemployment were the norm.

Nyanzi (2013) [23]

Kampala, Uganda

Repeat individualin-depth interviews

Repeat focus-group discussions

- 54 wacheche (SWs and same-sex-loving or gender non-conforming people)

Post-conflict

Criminalization perpetuates violence against SWs: Perpetrators of ‘hate-crimes’ against SWs, went unpunished numerous times because the victim refused to report the case.

Criminalization creates barriers in access to services: In criminalized states where SWs are policed, individuals may fail to access available services for fear of disclosing their so-called ‘non-conforming sexual practices’.

Displacement impedes legal knowledge: Displaced persons in Uganda found to have varying levels of awareness of the legal frameworks governing sexual conduct and relationships within their contexts of displacement.

Gazi et al. (2008) [47]

Teknaf, Bangladesh/ Myanmar

Cross-sectional survey & KI interviews

Boatmen (N = 433)

Active conflict

Migrants as sex buyers: 17% of Bangladeshi migrant boatmen reported having had sex with a SW while in Myanmar.

Prolonged displacement and sex buying: Significant correlation found between the number of nights spent away from home and engaging in paid sex.

Condom use: Condom use by migrants with SWs and other partners was rare (0–4.7% in the last month), and did not vary with types of sex partners.

International Office of Migration (2012) [48]

Somalia

HIV Hotspot Mapping

- SWs (N = 143)

- Male clients (N = 73)

Violence: SWs commonly reported assault, threats, violations, ill treatment, rape, and refusal to pay by clients, resulting in injury and damage to property, reduced ability to work, and loss of income.

Mobility: SWs reported high levels of mobility before and after engagement in paid sex. Many left home after losing parents/caregivers, or experiencing conflict and domestic violence. Transactional sex more prominent due to population movements: SWs in Somaliland and South-central more likely to report exchanging sex for gifts or favors rather than money.

SW entry linked to economic survival: SW initiation typically referred to as a means of survival during conflict.

HIV testing: Most SWs had never been tested for HIV and did not know their status; main barrier to testing was a lack of risk perception. Many doubted the confidentiality of VCT services. Those who sought to test were motivated by illness among a fellow SW.

HIV knowledge: Almost all migrant SWs had heard of HIV, but knowledge around prevention and transmission was mixed, with many misconceptions still present.

Migrants as sex buyers: Most common sex clients were truck drivers, seafarers, port workers, uniformed services, businessmen, traders and unemployed men.