Background: The legal and policy environment has been established as a key structural determinant of HIV risk for female sex workers and has become a focus for HIV response. Ecological studies of country level data have observed a relationship between HIV and legal status of sex work. The majority of studies have examined legal status of sex work and health outcomes through ecological studies and systematic reviews, highlighting the need for empiric data. In response, the aims of this study are to use pooled individual-level data examine the relationship between HIV and legal environments.
Methods: Respondent driven sampling was used to recruit sex workers over the period of 2011-2018 across 10 countries: Burkina Faso, Cameroon, Côte d''Ivoire, Gambia, Guinea-Bissau, Lesotho, Senegal, eSwatini, South Africa, and Togo. Interviewer-administered socio-behavioral questionnaires and biological testing for HIV were conducted. Legal status of sex work for countries was defined and categorized based on the legal approach: Not specified; partially legalized; criminalized. Individual-level data were pooled across countries. Multivariable logistic regression was used to measure the association between legal status and HIV.
Results: HIV prevalence among sex workers in contexts with partial legalization was 11.6%(219/1908), 19.6%(248/1266) within contexts where selling sex is not legally specified, and 40.4%(1605/3985) within criminalized settings. Legal status of sex work was associated with HIV(p-value< 0.001). When compared to settings with partial legalization, criminalized status(aOR:7.6;95%CI:2.2,26.6), and not legally specified(aOR:2.5;95%CI:1.1,5.4) were associated with increased odds of HIV.
Conclusions: Consistently, the legal context of sex work was associated with prevalent individual HIV infection among sex workers. The magnitude of this relationship was highest among individuals in criminalized setting, followed by individuals in setting where the legal status of selling sex was not specified. These results highlight that laws contribute to individual level outcomes and decriminalization alongside supportive services should be established to effectively address the HIV epidemic.

Figure 1: HIV infection and country level legal status
[Figure 1: HIV infection and country level legal status]