A comprehensive review of HIV/STI prevention and sexual and reproductive health services among sex Workers in Conflict-Affected Settings: call for an evidence- and rights-based approach in the humanitarian response.

Background: While the conditions in emergency humanitarian and conflict-affected settings often result in significant sex work economies, there is limited information on the social and structural conditions of sex work in these settings, and the impacts on HIV/STI prevention and access to sexual and reproductive health (SRH) services for sex workers. Our objective was to comprehensively review existing evidence on HIV/STI prevention and access to SRH services for sex workers in conflict-affected settings globally.

Methods: We conducted a comprehensive review of all peer review (both epidemiological and qualitative) and grey literature published in the last 15 years (2000-2015), focusing on 1) HIV/STI vulnerability or prevention, and/or 2) access to SRH services for sex workers in conflict-affected settings. Five databases were searched, using combinations of sex work, conflict/mobility, HIV/STI, and SRH service terms. Relevant peer-reviewed and grey literature were also hand-searched, and key papers were cross-referenced for additional material.

Results: Five hundred fifty one records were screened and 416 records reviewed. Of 33 records describing HIV/STI prevention and/or access to SRH services among sex workers in conflict-affected settings, 24 were from sub-Saharan Africa; 18 studies described the results of primary research (13 quantitative, 3 qualitative, 2 mixed-methods) and 15 were non-primary research (e.g., commentaries, policy reports, programmatic manuals). Available evidence indicated that within conflict-affected settings, SWs' capacity to engage in HIV/STI prevention and access SRH services is severely undermined by social and structural determinants including widespread violence and human rights violations, the collapse of livelihoods and traditional social structures, high levels of displacement, and difficulties accessing already scant health services due to stigma, discrimination and criminalization.

Discussion/Conclusions: This review identified significant gaps in HIV/STI and SRH research, policy, and programming for conflict-affected sex workers, highlighting a critical gap in the humanitarian response. Sex worker-informed policies and interventions to promote HIV/STI prevention and access to HIV and SRH services using a rights-based approach are recommended, and further research on the degree to which conflict-affected sex workers are accessing HIV/STI and SRH services is recommended.A paradigm shift from the behavioural and biomedical approach to a human rights-based approach to HIV/STI prevention and SRH is strongly recommended.