A systematic review reveals how tailored health services are failing a key population, and what it will take to fix the system.
When we talk about public health in Africa, the conversation often centers on broad epidemics and system-wide challenges. Yet beneath these overarching narratives lies a more hidden crisis: the systematic exclusion of female sex workers (FSWs) from the sexual and reproductive health services they desperately need. These women experience HIV rates three times higher than the global average for sex workers, yet the health initiatives designed to protect them are often too narrow, too fragmented, and too temporary to make a lasting difference 1 .
This article explores the findings of a systematic review of facility-based health services for sex workers across Africa, a research effort that synthesized data from 149 articles describing 54 different projects. The results paint a startling picture of well-intentioned programs failing to connect with the complex realities of women's lives, and point toward a more compassionate, effective path forward 1 .
The systematic review uncovered several critical gaps in how healthcare reaches female sex workers across Africa. These aren't simple failures of execution, but fundamental flaws in the design and delivery of essential services.
Services were found in only 28 of Africa's 58 countries, leaving vast regions without dedicated support 1 .
Most programs were small-scale, isolated to single "hot spots" for sex work, with little national or regional coordination 1 .
An overwhelming majority focused exclusively on HIV prevention and STIs, ignoring other critical health needs 1 .
Scant provision of family planning, cervical cancer screening, and support for gender-based violence 1 .
The research identified structural problems that undermined these health initiatives from their foundation:
Source: Systematic review of 149 articles describing 54 projects across Africa 1
Most programs operated with "scanty government support," relying instead on a patchwork of international donors. This funding model often prioritizes short-term research over sustainable, long-term service delivery 1 .
In countries like Zimbabwe, simply carrying condoms could be used as evidence of sex work, leading to harassment and arrest. This criminalized environment drives sex workers away from health services for fear of exposure 3 5 .
To understand both the challenges and potential solutions, researchers conducted an in-depth study of the Sisters with a Voice programme in Zimbabwe, which provides comprehensive HIV and sexual health services for sex workers 5 .
The program noticed a troubling pattern: many women attended services only once or disengaged after repeated visits. To understand why, they launched a meticulous tracing study 5 .
Source: Sisters with a Voice programme study 5
The results revealed a population in constant motion, navigating complex life circumstances that made consistent healthcare difficult 5 :
Source: Sisters with a Voice programme study 5
Perhaps most strikingly, the research found that women living with HIV were significantly less likely to re-engage with services, despite arguably needing them most. The study also confirmed what sex workers had long reported—the criminalization of their work and the constant threat of police harassment created overwhelming barriers to consistent care 5 .
The systematic review revealed that the most successful programs recognized a crucial truth: providing clinical services alone is not enough. The most meaningful interventions also addressed the social and structural factors that make sex workers vulnerable in the first place 2 .
Researchers applied a four-stage framework developed by Ashodaya, an Indian sex worker organization, to assess how African programs fostered community empowerment 2 :
Initial contact with sex worker community. Most programs achieved this
Community participates in targeted activities. Most stopped here (primarily peer education)
Community controls project direction. Rarely achieved
Action continues beyond initial project. Exceptionally rare
Source: Based on Ashodaya framework applied to African programs 2
The findings were sobering: while most programs successfully engaged sex workers as peer educators, few progressed to genuine community ownership or sustainable, long-term impact 2 .
One notable exception showed what's possible when programs tackle structural barriers directly. A project that facilitated meetings between sex workers and police led to a marked reduction in violence and harassment, demonstrating how addressing power dynamics can create healthier environments 2 .
Understanding these research findings requires familiarity with several key concepts that shape interventions for sex workers:
Approaches that address "macro-level" forces like laws, policies, and social norms that shape health outcomes, rather than focusing solely on individual behavior change 2 .
"A collective process through which the structural constraints to health, human rights and well-being are addressed by sex workers to create social and behavioural changes, and access to health services" 2 .
Programs that train and employ sex workers to educate and support their peers, proven effective in enhancing engagement with health services 5 .
A systematic approach where peer educators maintain "hotspot" lists, conduct risk assessments, and tailor support to individual needs, helping address common barriers like stigma and mobility 5 .
The evidence points toward clear solutions for creating more effective, compassionate health services for sex workers in Africa:
Combine HIV prevention with family planning, cervical cancer screening, and violence support to address women's complete health needs 1 .
Implement active tracing and re-engagement strategies that acknowledge the mobility and changing circumstances of sex workers' lives 5 .
Move beyond token peer education to involve sex workers in program design and decision-making 2 .
Reduce reliance on unpredictable donor funding by building government-led services of high quality and scale 1 .
Building "Government-led FSW services of high quality and scale" that would markedly reduce health vulnerabilities for sex workers across Africa 1 .
The health of female sex workers is not a marginal issue—it's a barometer of our broader commitment to health equity. When we design systems that work for the most marginalized, we create systems that work for everyone. The research shows us both how far we have to go, and the path to get there.
The systematic review this article is based on was published in Global Health and included 149 articles describing 54 projects across Africa 1 .