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

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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.