Current HIV/AIDS Reports

, Volume 10, Issue 1, pp 65–78

HIV/STI Risk Among Venue-Based Female Sex Workers Across the Globe: A Look Back and the Way Forward


    • Division of Global Public Health, Department of MedicineUniversity of California San Diego, School of Medicine
  • Seth C. Kalichman
    • Center for Health, Intervention, and PreventionUniversity of Connecticut
  • Lisa A. Eaton
    • Center for Health, Intervention, and PreventionUniversity of Connecticut
  • Steffanie A. Strathdee
    • Division of Global Public Health, Department of MedicineUniversity of California San Diego, School of Medicine
  • Thomas L. Patterson
    • Department of PsychiatryUniversity of California San Diego
The Science of Prevention (S Kalichman, Section Editor)

DOI: 10.1007/s11904-012-0142-8

Cite this article as:
Pitpitan, E.V., Kalichman, S.C., Eaton, L.A. et al. Curr HIV/AIDS Rep (2013) 10: 65. doi:10.1007/s11904-012-0142-8


Female sex workers (FSWs) continue to represent a high-risk population in need of targeted HIV prevention interventions. Targeting environmental risk factors should result in more sustainable behavior change than individual-level interventions alone. There are many types of FSWs who operate in and through a variety of micro- (eg, brothels) and macro-level (eg, being sex-trafficked) contexts. Efforts to characterize FSWs and inform HIV prevention programs have often relied on sex work typologies or categorizations of FSWs by venue or type. We conducted a systematic search and qualitatively reviewed 37 published studies on venue-based FSWs to examine the appropriateness of sex work typologies, and the extent to which this research has systematically examined characteristics of different risk environments. We extracted information on study characteristics like venue comparisons, HIV/STI prevalence, and sampling strategies. We found mixed results with regards to the reliability of typologies in predicting HIV/STI infection; relying solely on categorization of FSWs by venue or type did not predict seroprevalence in a consistent manner. Only 65 % of the studies that allowed for venue comparisons on HIV/STI prevalence provided data on venue characteristics. The factors that were assessed were largely individual-level FSW factors (eg, demographics, number of clients per day), rather than social and structural characteristics of the risk environment. We outline a strategy for future research on venue-based FSWs that ultimately aims to inform structural-level HIV interventions for FSWs.


Female sex workHIVRisk environmentsSocial factorsStructural interventionsHIV prevention


Women who engage in sex work are considered a high risk group for transmitting HIV and other sexually transmitted infections (STIs). Estimates of the proportions of female sex workers (FSWs) among women in different regions around the world range from 0.2 % to 2.6 % in Asia, 0.4 % to 4.3 % in sub-Saharan Africa, and 0.2 % to 7.4 % in Latin America [1]. Further, data from 77 countries suggest that the number of HIV-infected FSWs is the strongest predictor of countrywide HIV prevalence in the general population [2]. Not only do female sex workers frequently engage in high risk sexual behavior, they are exposed to multiple harms [3] including illicit drug use [4, 5], violence [6, 7], stigma and discrimination [8, 9], and exploitation [10]. Thus, comprehensive social interventions must continue to focus on the multiple needs of this vulnerable population. While risk reduction interventions targeted at FSWs have focused on individual-level factors [11, 12], more recently efforts have been made to address the social and environmental factors that may influence HIV risk [13, 14•, 1517, 18•, 19].

Women who sell sex work in a variety of environments. They solicit sex from different venues (eg, brothels, bars, streets) or through different mediums (eg, pimps, classified ads, telephone-service) and have sex with clients in different places (eg, motels, homes, bars, vehicles, public places, alleyways). In recent years, prevention scientists have demonstrated the effectiveness of targeting structural factors, or factors exogenous to the individual, in HIV risk reduction interventions [13, 14•, 18•]. In doing so, interventions are argued to result in more sustainable behavior change. Given the broad spectrum of types of venues and risk environments in which FSWs operate, an organizing conceptual framework will inform harm reduction and intervention efforts.

One organizing approach has been to create typologies of female sex work. Harcourt and Donovan reviewed the literature on female sex work and differentiated between “direct” and “indirect” sex work [20]. They described ‘direct’ sex work as sexual services in which the primary purpose of the interaction is to exchange sex for a fee; women involved in direct sex work typically rely on this as their primary source of income. Working in a brothel is the most common and well known example of involvement in direct sex work. In contrast, women in ‘indirect’ sex work often have legitimate occupations providing non-sexual services to patrons in places like bars and massage parlors, and through this occupation they also solicit sex to clients. It is often the case that for women in indirect sex work selling sex is not always the sole or primary source of income for the women. While this direct vs indirect typology provides an important step towards guiding research and intervention efforts, Harcourt and Donovan emphasize that there remains great variability in the social context and potential harms within both types of sex work.

Another approach to understanding structural factors relating to HIV risk is the risk environment framework developed by Rhodes and colleagues [21, 22••]. This framework gives primacy to the social and environmental context in influencing HIV-related risk behaviors. It encourages a focus on interactions between risk factors exogenous to the individual, and posits that physical, social, economic, and political factors operate at both micro-environmental and macro-environmental levels to confer risk or protection from HIV/STIs. Originally developed to understand HIV risk among injection drug users, this framework has also been successfully applied to understanding HIV risk among FSWs, as well as their male clients [14•, 23, 24].

Sex work typologies, or at least distinctions between various types of sex workers, are often used in research on FSWs. For example, studies may examine categories of venues as an independent variable predicting HIV infection or sexual risk behavior. In addition, survey research on FSWs will often take typologies into account as part of the sampling strategy [25•]. Categorization of sex workers into different types or venues have also been relied upon in the development of HIV prevention strategies and programs. Given this reliance, it is important to examine the extent to which sex work typologies provide meaningful and reliable information on HIV risk [25•]. These typologies should not only reliably predict levels of HIV risk, they should also examine the characteristics of the different risk environments across venues. Not doing so limits the understanding of the underlying factors that may account for differential levels of HIV risk between the types of venue-based FSWs.

In this paper, we review the body of literature that has explicitly identified types/venues of sex workers and has examined HIV/STI prevalence across venues. Our primary aim was to examine the extent to which researchers have done work to characterize risk environments, as opposed to solely relying on the categorization of venues as an independent variable predicting HIV/STI risk. That is, we aimed to examine whether researchers are systematically assessing differences between venues/types along various factors related to the FSW (eg, age, cost per sex act, mean number of clients per day), the clients (eg, SES of typical clientele), or to the venues themselves (eg, condom availability). In so doing, this review evaluates the appropriateness of using sex work typologies to inform HIV prevention programs for FSWs. We also have secondary aims to examine the extent to which researchers have been clear about labeling venues with regards to both solicitation of clients and the location where sexual transactions take place, a distinction that has important implications for the development of prevention programs. Finally, we also pay attention to the sampling strategies employed by the studies included in this review, as FSWs represent a hidden and difficult-to-reach population.


Inclusion Criteria

Studies were included in this review if they met all of the following criteria: (1) Studies of FSWs; (2) Quantitatively examined prevalence of HIV and/or other STIs (either through biological samples and/or self-report); (3a) Explicitly identified venue/type(s) of FSW (eg, brothel-based, entertainment venues, streetworkers), and (3b) If the study recruited FSWs from multiple venues, provided comparisons between those venues in HIV/STI prevalence. Because one secondary aim of this review was to examine the extent to which authors define whether the venue label refers to the place where FSWs solicited clients or where FSWs had sex with clients, we did not eliminate studies that only recruited from 1 venue (eg, the study included only brothel-based women).

Search Strategy

In our review we followed the accepted guidelines outlined by the PRISMA (preferred reporting items for systematic reviews and meta-analyses) statement [26]. We searched PubMed and PsycInfo by cross-referencing multiple search terms including “female sex work,” “commercial sex,” “sex industry,” “sell sex,” “exchange sex,” “sex trafficked,” “prostitution,” with “HIV risk,” “HIV infection,” “HIV prevalence,” “sexually transmitted infection” for citations available in these electronic databases through March 2012. We also searched the World Health Organization public databases. Following PRISMA recommendations, our process for determining eligibility of inclusion is depicted in Fig. 1.
Fig. 1

Elimination process for the current review

This search strategy yielded a total of 1649 records (1354 PubMed records and 295 PsycInfo records). We reviewed titles of all of these records for relevance for this review. For example, we scanned titles for phrases like “HIV prevalence” or “HIV infection among sex workers.” This resulted in 343 abstracts to review after duplicate records were removed. The first and the third author reviewed these abstracts independently. Of the 343 abstracts, 141 were removed because they provided commentaries and no data, or were randomized controlled trials, or alternate research designs. Another 56 qualitative studies, 29 studies that examined male or transgender sex workers, and 30 that did not provide sufficient descriptions of the sample (eg, did not explicitly identify venues or types of sex workers, or when this was identified, did not provide comparisons between the venues on HIV/STI) were excluded. This resulted in 87 full-text articles that were assessed for eligibility. From these 87, we removed 41 articles that reported behavioral data (eg, condom use) only and not HIV/STI infection, 4 articles that did not provide data on venue differences in HIV/STI prevalence, and 5 articles that used duplicate samples to other articles included in the final review (we included more recent and/or studies that had a larger sample size). In the end, 37 studies were included in this review.

Study Characteristics

We coded various study characteristics. Specifically we extracted information on publication date, location of study/sample, type of FSWs included in the sample, comparison groups of FSWs being evaluated in the study, whether the categorization or labeling of venue defined where clients were being solicited or serviced (ie, where sex took place), HIV/STI prevalence differences between venues, how HIV/STI was assessed, whether and what venue differences were assessed apart from HIV/STI prevalence, and sampling strategy used.

Overview of Review

The primary aim of this study was to assess the appropriateness of sex work typologies, or the categorization of types of FSWs in understanding HIV risk. To investigate this, we assessed the validity of findings regarding differential HIV/STI prevalence as a function of venue. Specifically, we examined the extent to which seroprevalence was found to be reliably higher or lower among “direct” FSWs compared to “indirect” FSWs across the studies, and the extent to which seroprevalence was found to be reliably higher or lower among brothel-based vs other FSWs.


A total of 37 studies spanning 2 decades (1992–2012) were included in this review (Table 1). Eight (21.6 %) of the studies were published in the last 2 years (ie, through 2010–2012), and 3 (8.1 %) were published prior to 1996 and the advent of highly active antiretroviral therapy. Seventeen different countries were represented. The studies were primarily conducted in Asia (Vietnam, India, China, Cambodia, Thailand, and Singapore; n = 23, 62 %), South America (ie, Bolivia, Guyana, and Mexico; n = 5, 14 %), North America (ie, the United States and Canada; n = 2, 5 %), Western Europe (ie, Scotland and England; n = 2, 5 %), Eastern Europe (ie, Uzbekistan and Estonia; n = 2, 5 %), and sub-Saharan Africa (ie, Democratic Republic of Congo and Ghana; n = 2, 5 %).
Table 1

Summary of studies reviewed (n = 37)

Study Authors, Date

City, Country


Venue/type of sex work

Venue defines place where clients solicited or serviced

HIV/STI prevalencea

Venue Differences Assessedb

Sampling method

McKeganey et al. (1992) [48]

Glasgow, Scotland

206 street-based FSWs from Glasgow red light area

Street-based only


2.5 % HIV + (out of 159)



Rehle et al. (1992) [49]

Khon Kaen, Thailand

356 FSWs in Khon Kaen

Direct (ie, brothel) vs indirect (ie, massage parlor)

Solicited and serviced

12 % HIV + among direct >2 % among indirect

Age; Age first sold sex; education; total year in sex work; Total years of sex work in Khon Kaen; avg. no. of clients per night; international clients per month; condom use; anal sex; oral sex


van Griensven et al. (1995) [50]


800 FSWs in Northern and Southern Thailand

Direct (eg, brothels) vs Indirect (eg, bars, massage parlors, karaoke clubs)

Direct = solicited and serviced; indirect = solicited

31.7 % HIV + among direct >6.4 % among indirect

Age; Age started sex work; condom use; geographic origin


Thuy et al. (1998) [51]


968 FSWs in Southern Vietnam from “education centers” (ie, have been arrested)

Brothel vs other (street, entertainment establishments, home)

Undefined (“working place” of participant)

8.4 % HIV + among brothel-based > other (Total seroprevalence = 5.2 %)

brothel-based > other (total seroprevalence = 5.2 %) condom use; Client characteristics (ie, SES, frequency of use of commercial sex, occupation)


Levine et al. (1998) [52]

La Paz, Bolivia

508 Brothel-based sex workers attending an STI clinic in La Paz

Brothel-based only

Solicited and serviced

9.9 % gonorrhea, 8.7 % syphilis, 1.3 % genital ulcers, 10.9 % chlamydia,16.3 % trichomoniasis



Limpakarnjanarat et al. (1999) [53]

Chiang Rai, Thailand

500 FSWs from the Chiang Rai provincial STI clinic

Brothel vs. Other (eg, massage parlors, music clubs, bars, restaurants, barber shops, etc.)

Brothel = solicited and serviced; Other = undefined

47 % HIV + among brothel >13 % among other (total seroprevalence = 32 %)

Age; education; marital status; children; age at first commercial sex; no. of sex partners and fee on most recent day worked


Uribe-Salas et al. (1999) [54]

Mexico City, Mexico

757 FSWs in Mexico City

Street vs bar vs massage Parlor

Undefined (“work site”)

78.9 % HSV-2 among street >55.4 among bar = 44.4 among massage parlor


Targeted sampling [55]

Persaud et al. (1999) [56]

Georgetown, Guyana

124 FSWs from the streets and two popular brothels in Georgetown

Brothel vs Street

Brothel = solicited and serviced; Street = undefined

45 % HIV + among brothel = 46 % among street

Age; children; marital status, education; other source of income; ethnicity; length of time in sex work; no. clients per work day; condom use with clients and regular noncommercial sex partners; substance use


Wong et al. (1999) [57]


444 free-lance FSWs arrested for illicit prostitution and randomly selected brothel-based FSWs)

Brothel vs freelance (i.e., solicit on streets, bars, nightclubs, karaoke lounges, or massage parlors or have pimps PR agents who solicit)

Brothel = solicited and serviced; freelance = solicited

34.8 % any STI among freelance >24 % among brothel

Nationality; race; age; duration of sex work in Singapore; education; no. clients per day; condom use

Convenience (for freelance) and random (for brothel-based)

Ohshige et al. (2000) [32]

Sisophon, Cambodia

237 FSWs in Sisophon

Direct (ie, brothel) vs Indirect (ie, legitimately employed in hotels, nightclubs or restaurants as maids, waitresses, dancing girls or beer promotion girls)

Indirect (ie, legitimately employed in hotels, nightclubs or restaurants as maids, waitresses, dancing girls or beer promotion girls) Brothel = solicited and serviced; Indirect = solicited

52.4 % HIV + among direct >22.3 % among indirect

Age; nationality; marital status; social support; age started sex work; duration of sex work, no. clients per day; earnings per client; condom possession; condom use; history of STI; HIV knowledge; post-coital hygiene; method of genital hygiene


Asamoah-Adu et al. (2001) [58]

Accra, Ghana

1013 FSWs from clinics for sex workers in Accra

Seaters (ie, work out of own home) vs Roamers (ie, find customers in bars, hotels, brothels, or on the street)

Seaters = solicited and serviced; Roamers = solicited

74 % HIV + among seaters >26 % among roamers

Age; Region of origin; ethnicity; marital status; children; price per intercourse; duration of sex work; average number of clients per day; sex work outside Ghana; condom use


Uribe-Salas et al. (2003) [59]

Soconusco, Mexico

484 FSWs from sex work-related bars in the municipalities of the Soconusco region

Bars only


0.6 % HIV+, 9.4 % T pallidum, 85.7 % HSV-2, 11.6 % N gonorrhea, and 14.4 % C trachomatis


Targeted sampling

Minh et al. (2004) [60]

Nha Trang, Vietnam

610 FSWs in Nha Trang

Direct (ie, street and beach) vs Indirect (ie, bars, restaurants, other facilities)


19 % self-reported prior STI among direct >16 % among indirect

Age; marital status; children; education; previous occupation; reasons for entering sex work; age entered sex work; time in sex work; expected further time in sex work; occupation of clients; HIV knowledge

Targeted sampling

Baltazar Reyes et al. (2005) [61]

Cuautla, Mexico

100 FSWs from the red-light district of Cuautla attending an STI clinic

Bars and night clubs only


11 % STI (syphilis and chlamydia)



Tran et al. (2005) [62]

Hanoi, Vietnam

400 Noninstitutionalized FSWs

Middle-class FSWs (ie, karaoke bars, hotels, massage parlors, guest houses, or dance clubs or stayed home and waited for calls from the above) vs lowerclass FSWs (ie, street or brothels)


Total seroprevalance = 12 %, HIV + lower class > middle class

Age group of clients; types of clients (eg, businessmen, laborers); ave. no. clients per day)

Two-stage cluster sampling

Sarkar et al. (2005) [63]

Kolkata, India

622 brothel-based FSWs in Kolkata

Brothel-based only

Solicited and serviced

9.6 % HIV+


Random (brothels) & convenience (participants)

Shannon et al. (2005) [64]

Vancouver, Canada

159 Women engaged in survival sex from a low-threshold drop-in centre servicing street level SWs in Vancouver



23 % Self-reported HIV + (self-reported HIV testing >95 %)



Kim et al. (2005) [65]


114 beer girls in Cambodia

Beer-girls only


26.1 % HIV+, 50 % any STI (gonorrhea, chlamydia, trichomonas) and/or bacterial vaginosis



Inciardi et al. (2006) [66]

Miami, United States

586 drug involved, Inner city, street sex workers in Miami

Street-based only

Solicited and sometimes serviced

22 % HIV+, 53 % HBV, 30 % HCV


Targeted sampling

Sarkar et al. (2006) [67]

West Bengal, India

2076 sex brothels of West Bengal

Brothel-based only

Solicited and serviced

5.9 % HIV+



Todd et al. (2006) [68]

Tashkent, Uzbekistan

448 FSWs in Tashkent (some attending a counseling center)

Telephone service vs Street-based vs Brothel/pimp


73.3 % HIV + among street >62.2 % among telephone service >4.4 % among brothel/pimp


Convenience and modified snowball sampling

O'Farrell et al. (2006) [69]


904 FSWs in five border provinces of Vietnam

Direct (ie, streets, parks, bus stops, boats, ferry piers, brothels and guesthouses) vs Indirect (ie, hotels, restaurants, massage parlors, cafes, karaoke lounges, bars and barbershops)

Undefined (“selling sex from”)

Direct > indirect, total HSV-2 = 27.7 %


Targeted sampling

Ruan et al. (2006) [70]

Southwest China

343 FSWs in a southwestern Chinese city located on a drug-trafficking route

High-end (ie, star hotels, big karaoke and dancing bars, saunas, and VIP clubs) vs low end (ie, hair salons, massage parlors, small hotels, streets)


20.1 % Syphilis among low-end >11.5 % syphilis among high-end



Vandepitte et al. (2007) [27]

Kinshasa, Democratic Republic of Congo

502 FSWs presenting for the first time in an STI clinic

Hotel vs home vs street vs phaseures (homeless people living and working on the street) vs masquées (women involved in clandestine or occasional sex work)

Hotel, Home, Street Solicited Phaseures, Masquées = Undefined

24.0 % HIV + among home-based >20.0 % among street >11.8 % among hotel >10.0 % among phaseures >6.6 % among masquées

Compared masquées to others in age; education; months in prostitution; age at sexual debut; steady partner; no. clients last working day/week; condom use; cost per sex act/night


Sopheab et al. (2008) [71]


1079 brothel-based FSWs in Cambodia

Brothel-based only

Solicited and serviced

Any STI 24.4 % (13 % gonorrhea, 14 % chlamydia, 2 % syphilis)


Two-stage cluster sampling

Uusküla et al. (2008) [72]

Tallinn, Estonia

227 FSWs in Tallinn

Street vs Brothel/apartment (ie, supervised by organized sex industry) vs other (ie, sex work entrepreneurs – “elf employed”, soliciting sex at alcohol vending venues or hotels, other)

Street = undefined, brothel = solicited and serviced, other = solicited

Street > brothel/apartment > other, total seroprevalance = 7.6 %


Multistage approach combining time location, community and respondentdriven sampling

Shahmanesh et al. (2009) [73]

Goa, India

326 FSWs in Goa

Street vs Establishment (ie, lodge/bar or brothel) vs home-based


Street > other, Total seroprevalance = 25.7 %


Respondent driven sampling

Wang et al. (2009) [74]

Kaiyuan City, China

China 737 FSWs in Kaiyuan City

Higher risk venues (ie., streetwalkers, temporary sublets, and beauty salons) vs. lower risk venues (saunas, karaoke, hotels, night clubs)


17.9 % HIV + among higher risk >5.7 % among lower risk

Age; nationality; education; marital status; tooth filling; tattoo; Blood transfusion; vaginal douching; drug use; duration in sex work; no. clients in previous week; condom use with clients and with regular non-commercial partners; earnings per client


Nguyen et al. (2009) [75]

Soc Trang province, Vietnam

406 FSWs in Soc Trang

Direct (ie, income only from selling sex, and working on the streets, in parks, at bus stops, on boats, on ferry piers, in brothels, at small cafés and at guesthouses) vs. indirect (ie, income from both selling sex and their employment in hotels, restaurants, massage parlors, karaoke lounges, bars, and barbershops)

Brothel = solicited and serviced, all else = solicited

6.5 % HIV + among direct >0.5 % among indirect, total seroprevalence = 3.3 %

Age; residence; education; living alone; early sexual debut; clients per month; withdrawal as contraceptive method; condom use; illicit drug use


Nhurod et al. (2010) [31]

Bangkok, Thailand

684 FSWs from 3 public STI clinics in Bangkok

Public STI clinics in Bangkok street vs other (ie, brothel, entertainment venue, others)


45.8 % HIV + among street-based >4.2 %

Age; place of birth; education; condom use with clients and with steady and casual noncommercial partners; history of injection drug use


Buzdugan et al. (2010) [25•]

Karnataka, India

2312 FSWs from 5 districts in Karnataka

Categorized by where FSWs solicited and where serviced clients: home, rented room, lodge, Dhaba (roadside resting place for truckers and other long-distance motorists), brothel, vehicle, street, other

Solicited and serviced (asked separately)

34.0 % Among brothel to brothel, 29.6 % among street to lodge, 19.1 % among street to street, 15.7 % among street to home, 14.0 % among home to home, 12.7 & among street to rented room, 11.1 % among other

Monthly client volume; mean occasional and regular clients; condom breakage in last month; anal sex with clients; physical force to have sex; alcohol in past week; HIV tested

Conventional cluster and time-location cluster sampling

Couture et al. (2011) [76]

Phnom Penh, Cambodia

160 FSWs from Young Women’s Health Study in Phnom Penh

Brothels vs Entertainment vs Freelance (ie, outside of entertainment establishments, in private apartments, streets, and parks)


37.3 HIV + among freelance >19.2 % among multiple, 17.4 % among brothel, 9.8 % among entertainment



Kang et al. (2011) [77]

Qingdao, China

1187 FSWs in Qingdao

Street-based vs club/bar/sauna/hotel based vs hair/beauty salon-based


4.5 % syphilis among hair/beauty salon, 2.7 % among club/bar/sauna/ hotel, 2.5 % among street

Age; marital status; ethnicity; residency; education; age at sex debut; age at first sex work; duration of commercial sex; condom use with clients; no. clients in past week; condom use with regular noncommercial partners; substance use; HIV knowledge; uptake of HIV/STI services

Combined cluster and stratified sampling

Miller et al. (2011) [78]

Vancouver, Canada

255 Street-based youth engaged in survival sex in Vancouver

Street-based only


23 % HIV+


Time-location sampling

Platt et al. (2011) [79]

London, England

268 indoor FSWs in London

Bar/private/other vs escort agency vs flat vs sauna


23.5 % HIV/STI among bar/private/other, 11.9 % among escort, 7.7 % among flat, 5.6 % among sauna



Li et al. (2012) [80]

Liuzhou, China

583 FSWs in Liuzhou

Two ways: (1) Low-, Middle-, and high-paid categories based on 3 pricing ranges charged per vaginal sex, (2) KTV based (FSWs working at karaoke bars, night clubs, and bars) vs sauna/bathhouses vs massage/hair salons vs street-based vs telephone-based


3.5 % Active syphilis among high price, 1.4 % among middle, 25.4 % among low; 3.8 % among KTV-based, 1.0 % among sauna, 0.7 % among massage, 39.8 % among street, 17.0 % among phone

Age; education; ethnicity; marital status; duration of sex work; no. clients past week; condom use; injection drug use; HIV prevention activities at sex work location; known HIV status

Venue-based sampling method called “ LACE” (Weir et al., 2002) and respondent- driven sampling

Medhi et al. (2012) [81]

Dimapur, India

426 FSWs in the Dimapur district of Nagaland, India

Home vs hotel/lodge vs public places/street


59.6 % HIV + among hotel/lodge, 32.9 % among home, 7.5 % among public places/street


Respondent driven sampling

Total n (studies) = 37

aUnless otherwise noted, HIV/STI status was assessed with biological samples

bAll of the studies examined characteristics (eg, age, condom use) associated with HIV/STI, but not all assessed venue differences in these characteristics

--Not applicable because study only recruited 1 type/venue

> Statistically significant difference

STI sexually transmitted infection

HIV/STI Testing

All but 2 of the studies (Minh et al 2004 and Shannon et al 2005 used self-report) assessed HIV and/or STI using biological samples. Nine (25.7 %) of the 35 studies using biological data did not determine seroprevalence and instead tested different STI (eg, syphilis or HSV-2).


Various venues and types of FSWs were represented by the studies included in this review. Counting each “group” (eg, brothel-based, street-based, “direct,” and “indirect” FSWs) across the 37 studies, there were a total of 84 venues/typologies. Among these 84 categories, street-based FSWs represented the plurality (n = 15, 17.9 %), followed by brothel-based (n = 12, 14.3 %), an “other” category (n = 5, 6.0 %), home-based (n = 4, 4.8 %), bar (n = 3, 3.6 %), freelance (n = 2, 2.4 %), telephone-service (n = 2, 2.4 %), and sauna (n = 2, 2.4 %). Six (16.2 %) of the 37 studies compared “direct” with “indirect” FSWs. Other venues that were examined across the studies included FSWs in hotels, hair salons, and entertainment establishments (eg, nightclubs, karaoke bars) and other unique groups of FSWs included “beer-girls,” Dhaba, or roadside resting places for truckers and other long-distance motorists in Karnataka, India [25•], and Phaseures, or homeless people living and working on the street [27] and Masquées, or women involved in clandestine or occasional sex work in the Democratic Republic of Congo [27].

A common comparison in HIV/STI prevalence was between “direct” and “indirect” FSWs. These included older as well as more recent papers (ie, 1992 to 2009). All 6 of the studies that made this comparison found higher HIV/STI prevalence among direct than indirect FSWs. Of the 37 studies, 14 (37.8 %) compared brothel-based FSWs to some other group (eg, “other,” street-based, entertainment). Across these 14 studies, 7 (50 %) found a greater prevalence of HIV/STI among brothel-based FSWs, 6 (42.9 %) found a lower prevalence among brothel-based FSWs, and 1 (7.1 %) found an equal HIV/STI prevalence.

Assessment of Venue Differences

Eleven (29.7 %) of the studies recruited only 1 particular type of venue-based sex worker (eg, street-based or brothel-based only). Not all of the studies examined differences between venues beyond differences in HIV/STI prevalence. Of the other 26 studies that identified different types of FSWs in their study, 17 (65.4 %) tested differences in various characteristics between different types of FSWs. However, upon close examination of those 26 studies examining differences between venue-based FSWs, only 4 (15.4 %) measured characteristics exogenous to individual FSWs. Three of those 4 studies measured client characteristics (eg, age of clients, SES of clients, frequency of commercial sex used by clients, client occupation), and only 1 (Li et al 2012) of the 26 studies asked about a venue-level factor, namely whether there were HIV prevention activities at the participant’s sex work location. Finally, of the 14 studies that compared brothel-based FSWs with some other group, 4 (28.6 %) did not assess venue differences in FSW, client, or venue characteristics. Interestingly, these 4 studies were 4 of the 6 that found a lower prevalence of HIV/STI among brothel-based women to the other group(s), precluding examination of some potential reasons for why these differences were found.

Solicitation vs Place of Sex

In light of the risk environment framework, an important distinction with regards to HIV risk among venue-based FSWs is the location in which FSWs solicit clients vs the location in which the sexual transaction takes place. For example, a sex worker may solicit a client on a street, and she may have sex with him on the street corner or in a motel. These different contexts may have substantially different influences on HIV risk (eg, the FSW and client may be less likely to be caught by the police in a motel). In another example, different levels of risk may result from soliciting and servicing a client in a brothel, compared to soliciting and servicing a client in a bar, where alcohol use may compromise safer sex negotiation . Of the 37 studies in this review, 16 (43.2 %) were not explicitly clear about whether the venues defined the place where the client was solicited or serviced. One notable exception is Buzdugan et al. (2010); in this study the authors assessed place of solicitation and sex separately. In doing this they were able to categorize FSWs by both (eg, street-solicited and street sex vs street-solicited and motel sex).


The majority of the studies (n = 20, 54.1 %) relied solely on convenience sampling to recruit participants, whereas the other 17 (45.9 %) utilized either an entirely different sampling strategy (eg, cluster sampling, or respondent driven sampling) or some combination of convenience sampling and another method. Of the 8 studies published in the last 2 years, 37.5 % (n = 3) used only convenience sampling, whereas of the 29 studies published prior to 2010, 58.6 % (n = 17) relied solely on this method, suggesting a greater use of more advanced sampling methods in recent years.


We reviewed the literature on venue-based FSWs and HIV risk to examine the appropriateness of relying solely on categorization of types of FSWs as an independent variable predicting HIV and other sexually transmitted infections. We found that the “direct vs indirect” sex work typology appears useful for differentiating between samples of FSWs who had higher vs lower HIV/STI prevalence. Comparisons between brothel-based FSWs with other types or venues did not yield consistent results, suggesting that categorizing FSWs by venue or type may not always be meaningful for understanding HIV risk, without also examining contextual factors that might explain venue differences.

The risk environment conceptual framework has been shown to be useful in understanding HIV risk among high risk groups, including FSWs. Research that has systematically examined the risk environments of FSWs using quantitative methods has been conducted in Mexico and the Philippines [14•, 23]. Strathdee and colleagues studied FSWs from Tijuana and Ciudad Juarez, Mexico who injected drugs and found that risk environment factors (eg, police confiscation of syringes, injecting drugs with a client) were independently predictive of HIV infection rather than individual-level factors [14•]. Based on these findings, the authors suggested that interventions should target unjustified policing practices and clients’ risk behaviors, and not solely target individual-level risk behaviors of FSWs. Similarly, Urada and colleagues studied women who engaged in sex trade in entertainment venues in Manila, Philippines and also found that social and structural factors such as less manager contact and not following co-workers’ condom use advice were predictive of inconsistent condom use more so than individual-level risk behaviors [23].

Qualitative research has also been conducted to characterize the risk environments of FSWs in Canada and Serbia [28•, 29, 30]. For example, Krüsi and colleagues found that low-barrier, supportive housing for marginalized women who engage in sex work promoted women’s increased control over negotiation of sex work transactions. Environmental-structural factors such as support from staff and police in removing violent clients were associated with improved police relationships and the institution of informal peer-safety mechanisms which supports the notion that safer sex indoor sex work environments may improve FSWs’ health [28•]. In Serbia, Rhodes and colleagues interviewed female and transvestite sex workers and found that the experience of violence from both clients and police was normative and was linked to unprotected sex, suggesting the need for legal protections for sex workers in this country [30]. Similar methods and approaches may be used to understand HIV risk and inform HIV risk reduction programs for venue-based FSWs around the world.

For those particularly interested in studying venue-based FSWs, we put forth a conceptual framework for this type of research, depicted in Fig. 2. The model hypothesizes that HIV risk among FSWs is partly a function of venues or types of sex work, but also proposes that different structural characteristics explain such venue differences in HIV risk. For example, in 1 study, brothel-based FSWs in Thailand were shown to have a lower prevalence of HIV than street-based FSWs [31]; this difference may have been explained by the condom policies instituted in brothels, but this hypothesis was not formally tested. In another study, brothel-based FSWs in Cambodia had higher HIV prevalence than entertainment venue-based FSWs [32]; had it been assessed, this difference may have been explained by the client-perpetrated violence that may be more likely to occur in the privacy of brothels. As these examples illustrate, risk environment characteristics should be assessed in research on venue-based FSWs. The model we put forth is akin to predicting a mediated process in which venue-level factors are proposed to account for venue differences in HIV risk. By going beyond categorizing FSWs by venue or type, the assessment of characteristics of the FSW risk environment would provide valuable information for the development of HIV prevention programs targeted for this population. In addition, whereas sex work venues including streets may be considered as micro-environments in which FSWs operate, there is also a need to consider the larger, macro-level contexts surrounding women’s lives, including community and legal factors. For example, collective power and community mobilization in India [19, 33], community solidarity and safer sex government policy in the Dominican Republic [18•], social cohesion and mutual aid in the community of Rio de Janeiro, Brazil [34], and both residential instability and parenting challenges in Andhra Pradesh, India [35•, 36] have all been demonstrated as macro-level structural forces influencing HIV risk among FSWs.
Fig. 2

Proposed conceptual framework for HIV prevention research on venue-based female sex workers whereby macro- and micro-level risk environment factors are systematically assessed and hypothesized to explain venue differences in HIV risk

The clandestine and often illegal nature of sex work results in FSWs being a hidden and difficult-to-reach population. Consequently, studies of FSWs must often rely on convenience sampling (eg, from STI clinics or visible and well-known brothels). Unfortunately, however, evidence suggests that harder to access FSWs tend to have higher STI prevalence [37]. Results from this review suggest that these more advanced sampling methods have been utilized more in recent years. While efforts should be taken to de-stigmatize sex work, other methods different from convenience sampling may be used, like time-location sampling. Unfortunately, police sweeps and other logistical problems can complicate the ability to select venues at random [38]. While some studies have reported success in recruiting FSWs and/or female IDUs through respondent-driven sampling (RDS) [39, 40], others have not [4143], suggesting that RDS [4345] should be preceded by formative research to properly tailor this sampling method to the sociocultural context [46]. Altogether, more research is necessary to provide more information and guidance on proper sampling strategies to increase access to FSWs.


In this paper, we reviewed the literature on HIV and other sexually transmitted infections among venue-based FSWs. Overall, results suggest that without more meaningful and rich assessments of risk environments, the use of false dichotomies or categorizations of FSWs may mask associations by grouping together FSWs who have very different risk profiles. In addition to information gleaned from quantitative methods, more qualitative and mixed method research is required to adequately describe the context of risk environments. The use of both quantitative and qualitative methods would also allow for detection of measurement bias from a given method [47], and the data gathered from one method may be used to complement and aid interpretation of findings from the other, painting a more comprehensive and rich picture of the risk factors at play. Understanding the social, physical, economic, and physical factors surrounding and influencing risk behaviors among different FSWs around the world is essential for HIV prevention aims. Ultimately, the conceptual and methodological approach outlined here should aid the development of effective and sustainable tailored HIV prevention interventions targeting FSWs.


Preparation of this manuscript was supported by a National Institute on Drug Abuse training fellowship T32DA023356.


E. V. Pipitan: fellowship grant from National Institute on Drug Abuse; S. C. Kalichman: none; L.A. Eaton: none; S. A. Strathdee: none; T.L. Patterson: none.

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© Springer Science+Business Media New York 2012