Interventions to improve health and the determinants of health among sex workers in high-income countries: a systematic review

Abstract

Many sex worker populations face high morbidity and mortality, but data are scarce on interventions to improve their health. We did a systematic review of health and social interventions to improve the health and wider determinants of health among adult sex workers in high-income countries. We searched MEDLINE, Embase, PsycINFO, CINAHL, the Cochrane Library, Web of Science, EthOS, OpenGrey, and Social Care Online, as well as the Global Network of Sex Work Projects and the Sex Work Research Hub for studies published between Jan 1, 2005 and Dec 16, 2021 (PROSPERO CRD42019158674). Quantitative studies reporting disaggregated data for sex workers were included and no comparators were specified. We assessed rigour using the Quality Assessment Tool for Quantitative Studies. We summarised studies using vote counting and a narrative synthesis. 20 studies were included. Most reported findings exclusively for female sex workers (n=17) and street-based sex workers (n=11). Intervention components were divided into education and empowerment (n=14), drug treatment (n=4), sexual and reproductive health care (n=7), other health care (n=5), and welfare (n=5). Interventions affected a range of mental health, physical health, and health behaviour outcomes. Multicomponent interventions and interventions that were focused on education and empowerment were of benefit. Interventions that used peer design and peer delivery were effective. An outreach or drop-in component might be beneficial in some contexts. Sex workers who were new to working in an area faced greater challenges accessing services. Data were scarce for male, transgender, and indoor-based sex workers. Co-designed and co-delivered interventions that are either multicomponent or focus on education and empowerment are likely to be effective. Policy makers and health-care providers should improve access to services for all genders of sex workers and those new to an area. Future research should develop interventions for a greater diversity of sex worker populations and for wider health and social needs.

Figure 1

Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram

Figure 2

Harvest plot of evidence for interventions to improve health and wider determinants in sex workers by intervention category The harvest plot is a supermatrix showing the direction of effect for outcome categories across different categories of intervention. Each bar represents an intervention and is labelled by a footnote, which can be identified below. Taller bars represent interventions from studies with a moderate-quality assessment; shorter bars are interventions from studies with a low-quality assessment. Darker purple bars are static interventions. Lighter purple bars are outreach. Striped bars are interventions that involved peer design, delivery, or both. Solid bars had no peer involvement. *Murnan et al (2018)—home intervention. †Murnan et al (2018)—office intervention. ‡Surratt and Inciardi (2010)—sex worker-focused intervention. §Surratt and Inciardi (2010)—National Institute on Drug Abuse intervention. ¶Surratt et al (2014)—professional–peer intervention. ||Decker et al (2017). **Wong et al (2019)—resilience programme. ††Burnette et al (2009). ‡‡Cigrang et al (2020). §§Park et al (2020). ¶¶Ward and Roe-Sepowitz (2009)—prison group intervention. ||||Ward and Roe-Sepowitz (2009)—community group intervention. ***Litchfield et al (2010). †††Sherman et al (2006). ‡‡‡Bowser et al (2008).