Optimising the public health benefits of sex work regulation in Senegal: A formative study

Globally, there is strong evidence that reducing the transmission of STIs among female sex workers (FSWs) is a cost-effective strategy to reduce the spread of HIV/AIDS. In West Africa, the HIV epidemic is concentrated among FSWs since 75% of HIV infections among men are attributable to sexual intercourse with FSWs. In Senegal, FSWs are up to 9 times more likely to be infected than the general population.

In 1969, in order to limit the spread of STIs, the Senegalese government legalised prostitution and regulated sex work activities. As part of this policy, which is unique on the African continent, FSWs over 21 years old are compelled to register with a health centre and to attend monthly health visits to test for and treat STIs. An official registration card is issued with the FSW's photograph in order to keep a record of the visits made to the appointed health centre. An up-to-date card gives FSWs the right to solicit clients and non-registered FSWs or registered FSWs who did not comply to their monthly health checks may incur a prison sentence of up to six months.

Despite its legal status, sex work is morally condemned by society members in Senegal and keeping sex work secret is a central preoccupation of Senegalese FSWs. Carrying the registration card puts FSWs at risk of social exclusion if their sex work activity is discovered by their relatives and as a result, 80% of FSWs in Senegal and 57% in the capital city, Dakar, are not registered. The low proportion of registered FSWs limits the impact of this public health policy on HIV transmission and explains why FSWs are still a main contributor in this concentrated HIV epidemic. In addition, registered FSWs have very low level of well-being because of the stigma attached to the current design of the registration policy.

Because the stigma attached to this policy is counterproductive to HIV prevention efforts, an intervention is needed to reframe registration in ways that better meet preferences of FSWs in order to achieve higher rates of registration and improved well-being of FSWs.

The early phase study will aim to define a policy change that will allow to address the main barriers to registration and that will increase benefits of registration. The early phase study will also provide evidence on the feasibility to evaluate the effectiveness and cost-effectiveness of this policy change in a future study.

In previous research funded by a UK Medical Research Council fellowship, we provided the first causal evidence of the effect of the registration policy in Senegal. We used advanced matching technique in order to reconstruct the counterfactual.

Our results confirm that the registration policy in Senegal is effective to improve physical health since registration led to a reduction in STIs by 38%. However, our results also confirm that carrying a registration card and, hiding it from relatives and friends causes psychological distress and leads to a reduction in wellbeing: registered FSWs were 29% and 36% more likely to declare that they are unhappy and unsatisfied with their life in general, respectively. Those results justify that the stigma attached to this public health policy is counterproductive to HIV prevention efforts and reinforce the urgent need to reframe registration in ways that better meet FSWs' preferences.

At the moment, there is evidence to support that (1) changes in the registration policy (e.g. removal of physical card, integration of health visits to reproductive health services, suppression of information on police record when FSWs leave sex work, free STI test, respect of human rights by police officers), (2) better information regarding the registration policy and (3) increased benefit of registration (e.g. package of free services available to registered FSWs) are likely to be effective to encourage registration and well-being of FSWs. However, many questions remain regarding the effectiveness and acceptability of those interventions. The early phase study will aim to define feasible and effective policy changes in order to make registration more attractive to FSWs.

To reach academic audiences, the project will produce working papers and seek to publish articles in high-impact journals in the field of public health. Because publication of journal articles can sometimes be delayed by publishing cycles, we will endeavour to present the study findings at international meetings and invited seminars.

The project will also reach policy-makers and national stakeholders. Suggestion of recommended changes to the registration policy for FSWs will be facilitated by the involvement of the head of the HIV/STI division of the Ministry of
Health as a co-investigator of this operational research. In-country workshop with policy-makers and national stakeholders, including sex workers, will allow to disseminate and discuss the results of this research.

We expect that the results will also provide invaluable evidence informing discussions beyond the immediate research setting, to middle and low-countries targeting female sex workers with interventions to limit the spread of HIV/AIDS.

Overall, we expect that the research will ultimately result in improved health outcomes of FSWs and the general population in Senegal.