We reviewed evidence from over 800 studies and reports on the burden and HIV impact of human rights abuses against sex workers across policy climates. Published research documents widespread abuses of human rights perpetrated by both state and non-state actors. Such violations facilitate HIV vulnerability, both directly and indirectly, and undermine effective HIV prevention and intervention efforts. Violations include homicide, physical and sexual violence from law enforcement, clients and intimate partners, unlawful arrest and detention, discrimination in accessing health services, and forced HIV testing. Abuses occur across all policy regimes, though most profoundly so where sex work is criminalized through punitive law. Protection of sex workers’ human rights is critical to respect, protect and fulfill human rights, and to improve their health and wellbeing. Findings affirm the value of rights-based HIV responses for sex workers, and underscore the obligation of states to uphold the rights of this marginalized population.

An ethical and forward-looking health sector response to sex work aims to create a safe, effective, and non-judgemental space that attracts sex workers to its services. Yet, the clinical setting is often the site of human rights violations and many sex workers experience ill-treatment and abuse by healthcare providers. Research with male, female, and transgender sex workers in various African countries has documented a range of problems with healthcare provision in these settings, including: poor treatment, stigmatisation, and discrimination by healthcare workers; having to pay bribes to obtain services or treatment; being humiliated by healthcare workers; and, the breaching of confidentiality. These experiences are echoed by sex workers globally. Sex workers’ negative experiences with healthcare services result in illness and death and within the context of the AIDS epidemic act as a powerful barrier to effective HIV and STI prevention, care, and support. Conversely positive interactions with healthcare providers and health services empower sex workers, affirm sex worker dignity and agency, and support improved health outcomes and well-being. This chapter aims to explore the experiences of sex workers with healthcare systems in Africa as documented in the literature. Findings describe how negative healthcare workers’ attitudes and sexual moralism have compounded the stigma that sex workers face within communities and have led to poor health outcomes, particularly in relation to HIV and sexual and reproductive health. Key recommendations for policy and practice include implementation of comprehensive, rights-affirming health programmes designed in partnership with sex workers. These should be in tandem with structural interventions that shift away from outdated criminalized legal frameworks and implement violence prevention strategies, psycho-social support services, sex worker empowerment initiatives, and peer-led programmes.