1 Introduction

The United Nations Population Fund (UNFPA) publishes annually the State of World Population (SWOP) report to highlight trends in population change and associated factors. The 2022 report had the theme, “Seeing the Unseen: The case for action in the neglected crisis of unintended pregnancy” (UNFPA, 2022). The report compiled the latest evidence on unintended pregnancy and its impact on societies, countries, and global development. This particular theme is timely and resonates with most countries in East and Southern Africa as the region witnessed a soaring increase in the numbers of unintended pregnancy linked to the hard, highly restrictive lockdown measures that were instituted to control the spread of COVID-19 from early 2020 up to 2021. Most publications on the effects of the hard lockdown measures focused on teenage pregnancy (Partridge-Hicks, 2020; Save the Children, 2021; World Vision, 2020; Davis, 2021; Olukya, 2021), but we emphasise that such humanitarian crises have an even more severe effect on the risk of unintended pregnancy among marginalized populations, particularly female sex workers (FSWs).

Recent experiences from other health crises such as the Ebola epidemic in West Africa and Zika Epidemic in South America have clearly shown that vulnerable populations are more likely to experience unique difficulties in accessing quality sexual and reproductive healthcare during a crisis (Catterson, 2020). While the 2022 SWOP report recognises that certain populations of young women and girls are at a higher risk of unintended pregnancy, it did not adequately address the grave situation of FSWs, who experience the worst sexual and reproductive health outcomes ( Gichuna, et al., 2020 ; Platt, et al., 2020). FSWs have a higher unmet need for contraception than women in the general population (Ippoliti et al., 2017). A scoping review of literature published since 2010 revealed that unintended pregnancy among FSW in different settings ranged from 24 to 91%, and abortion from 11 to 48% in the East and Southern Africa region (Macleod et al., 2022). A similar picture has been painted in Asia (Ippoliti et al., 2017) and North America (Zemlak et al., 2020). The unmet need for contraception and high risk of unintended pregnancy are mirrored in HIV infection rates, with the risk of acquiring HIV among FSWs estimated at 30 times higher than in adult women globally (Joint United Nations Programme on HIV/AIDS (UNAIDS), 2022).

The high unmet need for contraception and risk of unintended pregnancy among FSWs calls for improved access to quality contraceptive information and services ( Beckham, et al., 2021; Twizelimana & Muula, 2021; Long, et al., 2019; Bowring, et al., 2020). Sex workers’ overall higher vulnerability to negative sexual and reproductive health outcomes relative to the general female population is influenced by complex and interrelated factors, some of which may be aggravated by humanitarian crises such as the COVID-19 pandemic. First is the occupational risk. Sex workers have more partners and sexual contacts than the average population (Lafort et al., 2017) and a significant proportion are unlikely to use condoms consistently (Steen, 2019), which increases their risk for unintended pregnancy, HIV infection and other sexually transmitted diseases.

Second, sex workers are generally exposed to high levels of stigma and discrimination (Orchard et al., 2020). This is pervasive in both their private and public life, including in health settings. The unfavourable attitude of health workers in many settings is partly explained by the incorrect public health framing of sex workers as “vectors of diseases” (Global Network of Sex Work Projects (NSWP), 2018). This can negatively affect health seeking behaviour of sex workers (Ryan & McGarry, 2022).

Third, the incorrect framing of sex workers has resulted in a narrow public health response, which focuses primarily on HIV and sexually transmitted infections (STIs), hence limiting the range of sexual and reproductive health (SRH) information and services accessible to them in both the private and public health system (Dhana et al., 2014; Global Network of Sex Work Projects (NSWP), 2018).

Fourth, the operational environment, characterised by criminalization and policing of sex work compromises health outcomes by limiting access to and use of health services by sex workers ( (Krüsi et al., 2021). It is common in many countries in East and Southern Africa for sex workers to be arrested for suspicion of soliciting sex by simply being found with condoms. Similarly, violence by the police against sex workers is aided by the unfriendly legal environment (Human Rights Watch, 2019). Other structural factors that exacerbate sexual and reproductive health and rights (SRHR) outcomes among sex workers include poverty, violence, human rights violations, low community cohesion, heavy episodic drinking, high levels of mobility, illegal immigration status, lack of familiarity with locally available health services and unsuitable opening hours for health facilities (Argento et al., 2021). While these factors existed prior to the COVID-19 outbreak, the highly restrictive lockdowns magnified the challenges and exposed the already marginalized populations to an even higher risk of unintended pregnancy and unsafe abortions.

In 2020, UNFPA undertook a rapid assessment to document the impact of COVID-19 pandemic on sex workers’ programmes in East and Southern Africa with a particular focus on sex workers’ livelihoods, human rights and health. The assessment identified lessons learnt from 14 out of 23 countries in the region that could be used to enable a more robust, risk-informed, rights-based and effective response in future. Although the scope of the rapid assessment was on the broad domains of livelihoods, human rights and health, the assessment elicited some data on sex workers’ exposure to unprotected sex, access to contraception, and unintended pregnancies, in the context of barriers to access to sexual and reproductive health and rights during COVID-19.

2 Methodology

This study used a mixed-methods approach consisting of a desk review, key informant interviews and an online survey. Key informants and survey respondents included representatives of sex worker-led organisations and networks, organisations providing services to sex workers, development partners, advocacy organisations and donors. Priority was given to key informants who had direct experience of providing services to sex workers during the COVID-19 pandemic. A deliberate effort was made to include the perspectives of organizations that work with sex worker sub-groups who experience intersecting vulnerabilities, such as migrants; transgender; lesbian, bisexual or gay; people who use or inject drugs; and young sex workers (ages 18–24). In total, 21 key informants were interviewed and 69 respondents participated in the online survey.

Data from the key informant interviews and online survey were then subjected to qualitative content analysis. During this process, interview and survey responses were coded/categorised according to the three domains which were the focus of the study (livelihoods, health and human rights), and the frequency of the different categories of responses to the survey questions quantified. Thereafter data from the key informant interviews and online survey were reviewed again to identify the most common themes. Less common themes were also included in the analysis, where they provided alternative viewpoints, or modifications of the main themes. Once the preliminary findings were generated, these were triangulated with sources from the literature, which enabled further interpretation, contextualisation and analysis of the findings. This was an iterative process over several rounds of analysis (Braun & Clarke, 2012).

3 Results

While the scope of the study was broader than that of the current paper, many of the findings have relevance to the understanding of factors that shape sex workers’ access to contraception and risk of unintended pregnancy during humanitarian crises. Predominantly, the widespread hardship, disruption and violations of human rights was attributed not to the pandemic itself, but rather, to the containment measures which governments put in place, including lockdowns, social distancing, curfews and quarantine. We highlight how such disruption to livelihoods and threats to human rights and health intersect with sex workers’ access to contraception and risk of unintended pregnancy in humanitarian situations and the response of sex worker organizations to the crisis.

3.1 Livelihoods

The greatest challenge to livelihoods, identified by the majority (78.3%) of participants in the online survey was loss of income. Respondents noted that loss of income was linked to both food insecurity for sex workers and their dependents (53.6% of respondents) and loss of housing (52.2% of respondents). Other livelihood impacts included exclusion from both government social protection schemes and other relief efforts (11.6% of respondents) and displacement or migration (4.4% of respondents). Due to the economic hardships, sex workers experienced difficulty negotiating payment rates for fear of losing clients or avoiding risky sexual behaviour that could result in unintended pregnancy.

In most countries, sex workers were excluded from social protection schemes, and sometimes from donor-provided humanitarian aid due to social stigma, with some even experiencing physical violence at service delivery points. Similarly, migrant sex workers could not easily access government social support due to lack of local and/or international identification documentation.

3.2 Human rights

The study revealed widespread concerns about violations of sex workers’ rights during COVID-19 related containment measures. The most prevalent concern that sex workers had experienced, or were aware of, was violence from police (including murder, assault, rape, harassment and extortion), mentioned by nearly half (49.3%) of survey respondents. To illustrate, a survey respondent from Kiambu Sex Workers Association, Kenya, listed “‘police arrests, assaults, rape, sex with no pay, lodges broken into by police while sex workers are selling sex, and in some cases sex workers have been killed’ as challenges which the sex worker community had experienced since the onset of COVID-19”. Other issues were stigma and discrimination towards sex workers in communities (42.0% of respondents) and increases in arrests of sex workers (36.2% of respondents).

3.3 Health care

The greatest health impacts experienced by sex workers were in accessing health care, not for COVID-19 itself, but for other conditions. In the survey, about half (49.3%) of respondents reported that sex workers had challenges accessing health facilities, specifically for HIV treatment services (52.2%), HIV prevention services (21.7%) and SRH services (21.7%).

Study participants reported widespread interruptions including: halting of community-based HIV prevention services; closure of antiretroviral (ARV) treatment clinics; medication stock-outs; halting of HIV, STI and cervical cancer screening and testing services; shortages in condoms and lubricants; and interruptions in family planning and termination of pregnancy services.

Challenges related to an increase in stigma and discrimination in health services were reported by one in ten of online survey respondents. Akin to HIV-related stigma and discrimination, sex workers were labelled as vectors of the coronavirus and shunned by health service providers, resulting in missed opportunities for both drug refills and attendance to other conditions, including access to contraceptives and safe abortion services. For example, a survey respondent from Sisonke, a sex-worker led network in South Africa reported: “there have been remarks ‘Don’t bring you corona here’ when sex workers have gone to clinics”.

4 Response of sex worker organizations to the crisis

In response to the crisis, sex worker-led community-based organisations responded swiftly and creatively to ensure that sex workers’ human rights were protected and health services, particularly SRHR, continued. Such organisations, whose capacities have been strengthened during the HIV response, provided established and trusted mechanisms for reaching sex workers during their time of crisis. To maintain access to SRHR services, sex worker organisations mobilised peer educators to provide decentralised services, including home deliveries of ARV medicines and pre-exposure prophylaxis (PrEP) refills, condoms and lubricants and community-distributed contraceptives. Sex worker organisations maintained contact with their members and beneficiaries using digital technologies, particularly WhatsApp groups, to provide mutual support to each other and mobilize concerted efforts against human rights violations during the crisis.

Table 1 highlights some of the ways in which organizations led by and serving sex workers responded to sex workers’ needs, including continued access to SRHR services.

Table 1  A summary of responses by sex worker-led or –serving organizations to female sex workers’ needs during the stringent COVID-19 containment period
Full size table

5 Discussion

The findings from the study identified five key facilitators of effective response to sex workers’ SRHR needs during humanitarian crises. First, sex workers as a marginalized population mobilized better when organized in recognized groups or associations prior to crises. Sex worker community-based and/or community-led organizations are agile and can mount a multi-pronged response, tailored to the needs articulated by their constituents. The key approaches used by civil society organisations to address structural and social barriers to HIV prevention and care, such as taking services to the community level, ensuring that processes are participatory, protecting human rights, reducing stigma and discrimination and preventing and responding to violence, proved invaluable to the response to sex workers’ SRHR needs at the peak of the stringent COVID-19 containment measures.

Second, organizations which employed peer educators and applied micro-planning approaches were able to provide a person-centred response by maintaining contact with individual sex workers and ensuring continuity of services, even when sex workers had been displaced. Micro-planning is a method used in HIV key population programmes, which employs a set of tools that enable peer educators to collect and regularly update data on a cohort of community members for the purpose of providing tailored and individualised support (Bhattacharjee et al., 2018).

Third, partnerships established between sex worker organisations and governments, development partners and other civil society organisations as part of the HIV response enabled sex worker organizations to leverage resources and ensure continued access to services in ways that they would not have managed on their own, such as the reported partnership between KESWA and the International Red Cross in Kenya.

Fourth, the use of technology within such a marginalized and hard-to-reach population opened doors to new ways of service delivery that not only improved access but also reduced exposure to stigma and discrimination at service delivery points.

Finally, social capital, conceived of as networks of social relations characterised by trust, reciprocity and other norms and values (Putman, 2000; Wong & Kohler, 2020) may have mitigated at least some of the impacts of COVID-19 containment measures on sex workers’ SRHR outcomes.

6 Conclusions

Looking to the uncertain future of humanitarian crises, we conclude by outlining issues that need to be addressed to ensure resilience of SRHR services for populations in vulnerable positions, such as sex workers. Stable livelihoods are critical to SRHR choices among sex workers. Governments should support inclusive approaches to vulnerability assessments and design of social protection programmes that serve vulnerable groups, including sex workers. To this end, generation of data on the sizes and locations of vulnerable groups for timely delivery of services in humanitarian crises is a matter of priority.

Second, a human-rights based approach to SRHR should be institutionalized and practiced. Criminalisation of sex work, stigma and discrimination, and violence from law enforcement authorities and other perpetrators only serve to place sex workers at a greater risk of unprotected sex and limited access to services, ultimately leading to unintended pregnancy and other adverse SRHR outcomes.

Third, community-led responses should be adequately funded as they are able to provide critical support in times of emergency. The responses should build on a people-centred public health service system that provides SRHR services to all population groups as part of the minimum essential package of services during humanitarian crises.

Finally, the crisis precipitated by the COVID-19 pandemic has provided an opportunity for re-visioning social, technological, political and economic systems. The transformation of the health system towards an inclusive, people-centred service delivery and universal coverage assumes greater importance now than ever before!