• sexually transmitted diseases
• condom use
• sex workers
• intervention programme

The introduction of market capitalism into the countries of the former Soviet Union, eastern Europe, and China has been associated with a social revolution. This is reflected in changes to employment, the family, mobility, state institutions, and culture. Many people face a precarious economic situation following the closure of state industries, the ending of food subsidies and declining welfare provision. Women have been harshly affected and sex inequalities have increased. Eastern Europe is the only area of the world where there has been a recent decline in the proportion of women in formal employment,¹ and a decline in the proportion of girls going to school in two thirds of the countries.² With these economic conditions it is inevitable that there will be an expansion in the informal economy, including trade in sex as a temporary survival strategy or, for some, a medium term strategy out of poverty.

These sex workers are vulnerable to HIV, STIs, and other risks of sex work related to violence and exploitation. The risks are heightened by the increase in sexually transmitted infections in many of these states.^3,4 Shaojun Ma and colleagues in this issue of STI (p 110) report the impact of a short term intervention for sex workers in Guangzou, China.⁵ The team provided screening and treatment for infections along with health promotion and condom distribution. Reported risk behaviours declined along with the incidence of bacterial STIs. This confirms once again that the provision of services and advice to sex workers is very effective. While this has not previously been reported in China, the key message is not new and has been shown in a wide variety of settings.^6–8 However, this intervention was short term, and it is equally clear that sustained action is necessary if the changes are to be maintained.⁹ Sex workers are very mobile within and between countries, new women enter the business constantly, and therefore ongoing programmes are needed.

What then are the obstacles to sustained effective interventions? The fundamental obstacle is the hypocrisy that surrounds sex work. In most countries sex work is not legal, workers are repressed, stigmatised, and denied human rights. In China, sex work is illegal, and workers are arrested and detained for “re-education.” This is not only an abuse of human rights, it is also going to facilitate the spread of HIV and other infections in the population. But China is not alone. In the United Kingdom, sex workers and clients are arrested and fined. In Sweden, clients are arrested and “re-educated.” In the United States sex workers are arrested and imprisoned. This repression is an obstacle to health and safety.

The fundamental obstacle . . . to effective interventions . . . is the hypocrisy that surrounds sex work

In contrast, where sex work is legal—for example, in New South Wales, Australia, workers have been able to insist on health and safety policies that protect themselves, their clients, and new entrants into the business.¹⁰ Brothels have policies on condom use, access to health care is guaranteed, and workers have recourse to the law if they are abused and exploited. However, where sex work is not legal but criminalised, more pressure is placed on the individual sex worker and client to determine whether condom use occurs, and in many places this cannot happen. Condoms may not be available or be too expensive. Sex workers may lack the knowledge, the negotiating skills, or control to insist on condom use. Sex workers who are being abused and exploited, who are underage, or who are working against their will are unable and generally unwilling to seek help for fear of being turned into criminals.

Where sex work occurs without adequate safety, the consequences can be devastating, particularly in the early phase of an epidemic. In sub-Saharan Africa, sex workers were extremely vulnerable to HIV infection because of lack of safety in the early 1980s. Once the prevalence of infection in the wider population rises above a certain level, it is more difficult for limited increases in condom use to protect individuals and the broader population.

The sex industry is growing, fuelled on the one hand by globalisation and the free market increasing the “supply” of potential workers, and on the other by massive demand. In London, for example, 9% of men have paid for sex in the last 5 years, compared with 5% 10 years ago.¹¹ Prostitution is not going to go away so we should try to shift attention from idealist attempts to abolish it towards practical efforts to make it safe. We know what kind of health interventions are effective, and that they need to be sustained, not short term.¹² We also know that decriminalisation is a key step in preventing epidemics of STI and widespread exploitation. In contrast, there are no published data supporting abolitionist policies as a way of promoting health and safety. Sex workers across the world are organising themselves for rights, an end to brutal oppression and exploitation, for quality health care, and for training and support for those who wish to leave the industry.¹³ The International Labour Organisation has correctly called for sex work to be recognised and for workers to be given rights as the best way of ending exploitation¹⁴ and, we should add, promoting health.