Around the world, many women rely on sex work to make a living for themselves and their families. Sex workers face large amounts of stigma and criminalization, which make enacting safety measures to prevent violence difficult. Beyond the increased risk of sexual violence, sex workers face a much higher risk of HIV, sexually transmitted infections, and bloodborne infections such as hepatitis. According to the World Health Organization, female sex workers are 30 times more likely to be living with HIV than other women of reproductive age.

SIS professor Maria De Jesus focused her recent research article on female sex workers in the Dominican Republic and Tanzania living with HIV. Her research examines how mobility impacts the sex worker’s ability to access HIV care and highlights the health sacrifices these women often make to sustain their livelihood. To learn more, we asked De Jesus some questions about her research, the research process, and her findings.

What made you pursue this specific type of research? How did you decide to focus your research on these two locations?

This research draws on a larger National Institutes of Health (NIH) longitudinal study that followed 400 female sex workers (FSWs) living with HIV in Santo Domingo, Dominican Republic, and Iringa, Tanzania, to examine the social and structural determinants of the women’s HIV outcomes. In this particular publication, the subsample consisted of women with a mean age of 40 and 28 in Santo Domingo and Iringa, respectively. All of them had children; some were living with a partner, others were single, and most had an elementary-level education. The women traveled to different parts of their country for sex work. This phenomenon, referred to in the literature as “sex work mobility,” was a key livelihood strategy, that allowed the women to provide for themselves and their family members by attempting to increase their income beyond what it would have been if they stayed in one location. In both settings, they strategically traveled to places where there was greater market demand, and they could potentially earn higher wages.

The Dominican Republic, with its tropical climate like other Caribbean islands, is a tourist destination for many travelers, particularly from North America and Europe. FSWs often travel from the capital to these more distant beach towns to meet tourists. Others travel to neighboring or distant smaller pueblos (towns) where clients are comprised mostly of local and seasonal workers. In the case of Iringa, similar to other settings in the sub-Saharan Africa region, mobility is influenced by the Tanzanian-Zambian highway, which is a source of clients, most of whom are truck drivers and seasonal migrant workers. Both these countries are epidemic settings, and evidence demonstrates that FSWs are at a heightened risk for HIV infection.

What methodology did you utilize for this research?

For this longitudinal mixed methods research study, we administered a survey and conducted two rounds of in-depth interviews in either Spanish (Dominican Republic ) or Swahili (Tanzania). The inclusion criteria included women at least 18 years of age with a confirmed HIV-positive diagnosis (using a single rapid test) who reported having exchanged sex for money in the last month prior to their enrollment in the study. We utilized a semi-structured interview guide, which was common to both settings and included country-specific questions. These questions were intended to purposefully probe their preparations before they traveled, their experiences during their travels and at their destination, their social relationships, and their HIV care-seeking and antiretroviral therapy (ART) adherence when they traveled.

You identified three ‘mobility paradoxes’ in your research. Briefly, can you explain what a mobility paradox is and what you found?

“Mobility paradoxes” refer to the fact that sex work mobility does not simply create disruptors in the lives, livelihoods, and HIV care and treatment experiences of Dominican and Tanzanian FSWs living with HIV, but also offers them important tangible and intangible benefits. For instance, sex work mobility meant that women were sometimes exposed to contexts of vulnerability where they experienced violence, exploitation, and human rights abuses by a wide spectrum of actors such as police officers, clients, and bar/hotel employees and owners. Paradoxically, sex work mobility also promoted a sense of autonomy and agency among the women. Participants often reported feeling empowered as they were able to make their own choices related to sex work, e.g., deciding where and when to go, where and for how long to stay, etc. By the same token, many participants described how sex work mobility allowed them to also gain more economic independence and power. For some, this meant the possibility to invest in a better future for themselves and their family members—for example, by investing the money they made through mobile sex work in other money-generating activities to increase their overall capital or by buying a plot of land to build a small house for themselves and their family members. However, across both geographical settings, mobile sex work was not always profitable and, in fact, sometimes led to economic insecurity. Women sometimes ended up making less money than expected due to exogenous factors such as having fewer clients than anticipated in a specific area or low harvest yields in rural areas during a particular season, which created poorer local economies and, in turn, lower demand and diminished profitability for these women.

Sex work is often stigmatized in many parts of the world, and there are few studies conducted on female sex workers. Why did you choose to focus on this population, and why is it important to include sex workers in research?

It is important to focus on this population and include sex workers in research to shed light on the experiences of these women as well as improve our understanding of sex work mobility. This information is critical in informing our efforts to successfully respond to the specific needs of these women. Our study findings highlight how mobile FSWs are not a monolithic group; they have multifaceted lives and experiences, and many of them are juggling multiple life roles. They are mothers, daughters, partners, and sisters who often simultaneously engage in several occupations ranging from sex work to developing and selling their own cleaning and beauty products. They are entrepreneurial women who are helping to support their families, and the research findings deconstruct the negative stereotypes often imposed upon these women.

Part of this research also focuses on the health aspects of the subjects’ lives and how mobility affects their HIV-related care. What were the key takeaways, health-wise, from your research?

Although one would assume that mobility is a major source of disruption for their HIV-related care and treatment—and it can be—what the research findings also showed is that the women found creative and strategic ways to reduce the interruption to their care. For instance, they shared experiences of how they would schedule their HIV appointments around their mobility plans to prevent interruptions in their HIV care. Others recounted how they proactively calculated the amount of ART medication they needed to obtain before traveling to ensure that they had enough for the entire duration of their trip.

The study findings have key takeaways for the development of strengths-based health intervention approaches that challenge the focus on deficits-based approaches. Adopting a strengths-based community empowerment health approach aims to map the benefits of mobility and leverage the existing individual and collective resiliencies and capabilities of mobile FSWs living with HIV. HIV services can be tailored to effectively meet the unique needs of this mobile population. Examples include mobile HIV treatment centers, virtual HIV support groups, more flexible hours for HIV care appointments to accommodate travel plans, long-acting (LA) injectable ART, or increased prescriptions for longer trips to avoid ART interruption.