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Work environments and HIV prevention: a qualitative review and meta-synthesis of sex worker narratives Goldenberg, Shira M; Duff, Putu; Krusi, Andrea Dec 16, 2015

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RESEARCH ARTICLE Open AccessWork environments and HIV prevention:a qualitative review and meta-synthesis ofsex worker narrativesShira M. Goldenberg1,2*, Putu Duff1,3 and Andrea Krusi1,3AbstractBackground: Sex workers (SWs) experience a disproportionately high burden of HIV, with evidence indicating thatcomplex and dynamic factors within work environments play a critical role in mitigating or producing HIV risks insex work. In light of sweeping policy efforts to further criminalize sex work globally, coupled with emerging calls forstructural responses situated in labour and human-rights frameworks, this meta-synthesis of the qualitative andethnographic literature sought to examine SWs’ narratives to elucidate the ways in which physical, social and policyfeatures of diverse work environments influence SWs’ agency to engage in HIV prevention.Methods: We conducted a meta-synthesis of qualitative and ethnographic studies published from 2008 to 2014 toelucidate SWs’ narratives and lived experiences of the complex and nuanced ways in which physical, social, andpolicy features of indoor and outdoor work environments shape HIV prevention in the sex industry.Results: Twenty-four qualitative and/or ethnographic studies were included in this meta-synthesis. SWs’ narrativesrevealed the nuanced ways that physical, social, and policy features of work environments shaped HIV risk andinteracted with macrostructural constraints (e.g., criminalization, stigma) and community determinants (e.g., sexworker empowerment initiatives) to shape SWs’ agency in negotiating condom use. SWs’ narratives revealed theways in which the existence of occupational health and safety standards in indoor establishments, as well asprotective practices of third parties (e.g., condom promotion) and other SWs/peers were critical ways of enhancingsafety and sexual risk negotiation within indoor work environments. Additionally, working in settings where negativeinteractions with law enforcement were minimized (e.g., working in decriminalized contexts or environments in whichpeers/managers successfully deterred unjust policing practices) was critical for supporting SWs’ agency to negotiateHIV prevention.Conclusions: Policy reforms to remove punitive approaches to sex work, ensure supportive workplace standards andpolicies, and foster SWs’ ability to work collectively are recommended to foster the realization of SWs’ health andhuman rights across diverse settings. Future qualitative and mixed-methods research is recommended to ensure thatHIV policies and programmes are grounded in SWs’ voices and realities, particularly in moreunder-represented regions such as Eastern Europe and Sub-Saharan Africa.Keywords: Sex work, HIV, Sexual risk, Structural determinants, Work environment, Meta-synthesis, Criminalization,Occupational health, Peer support, Third parties* Correspondence: gshi@cfenet.ubc.ca1Gender and Sexual Health Initiative, British Columbia Centre for Excellencein HIV/AIDS, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z1Y6, Canada2Faculty of Health Sciences, Simon Fraser University, 8888 University Drive,Burnaby, BC V5A 1S6, CanadaFull list of author information is available at the end of the article© 2015 Goldenberg et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Goldenberg et al. BMC Public Health  (2015) 15:1241 DOI 10.1186/s12889-015-2491-xBackgroundGlobally, sex workers (SWs) experience a disproportion-ately high HIV burden across epidemic settings (i.e., inboth concentrated and generalized epidemics). A globalreview of female SWs in 50 countries recently estimatedthat SWs globally face 13.5-fold higher odds of HIV in-fection, compared to the general population of womenof reproductive age [1]. Studies of male and trans* SWsare scarce, although existing data suggest they also facea greatly elevated HIV burden compared to the generalpopulation [2, 3].Previous work has illustrated that HIV vulnerabilityand prevention in sex work represent the product ofintersecting factors operating at multiple levels of influ-ence. Our team recently published a comprehensiveframework for understanding structural determinants ofHIV in sex work, in which the role of social, policy, andphysical features of work environments (e.g., policing,peer interactions, managerial policies and practices, typeof work venues); community organization (e.g., commu-nity empowerment, sex work collectivisation); and macro-structural determinants (e.g., criminalisation) in shapingHIV epidemics is explicitly highlighted and acknowledged[4, 5]. Such structural determinants interact dynamicallywith interpersonal (e.g., condom use, types of sexualexchanges, sexual networks), individual behavioural(eg, drug use or duration in sex work), and biological(eg, sexually transmitted disease co-infection) factorsto shape vulnerability to HIV acquisition, preventivepractices, and transmission risk among SWs [4–7]. Inaddition to drawing on this structural determinantsframework, this review was also underpinned by theconcept of structural vulnerability, which has previ-ously been useful in framing HIV vulnerability andviolence experienced by SWs [8–11]. This includesconsideration of how social and structural forces embed-ded in the organization of society, such as for example,laws, policing, welfare and immigration policies, urbanzoning and stigma, render particular groups of peoplesuch as SWs, and in particular those living in poverty,disproportionately vulnerable to harm and gives focus tohow various structural forces intersect to shape experi-ences of violence and poor health among SWs [12].Epidemiological literature highlights the significantvariability in HIV risks faced by SWs across differentwork environments (e.g., indoor versus outdoor venues),yet is often limited in its capacity to elucidate thecomplex, intersecting and potentially context-specificimpacts of work environment features on HIV preven-tion. Physical features of the work environment (e.g.,working in indoor venues, such as brothels, lodges,entertainment venues, hotels, or private homes, versusoutdoor spaces such as the street) have often been ex-amined in relation to HIV risk, however this relationshiphas been found to vary significantly by context. For ex-ample, our recent review of the epidemiological litera-ture found that street-based sex work was linked tohigher HIV prevalence [13–17] and inconsistent condomuse [18–22] in most contexts, while operating in indoorenvironments such as entertainment venues (e.g., bars,nightclubs, karaoke) was associated with higher HIVrisks in some studies [17, 23, 24], but was protective inothers [25–31].Heterogeneity in the relationship between work venueand HIV risks in sex work is likely due to the diversityof working conditions characterizing such environments(e.g., the intersecting influences of policy or social fea-tures within different workspaces) – dynamics which arenot well captured by epidemiological research designsalone [4, 5, 32]. For example, over 16 studies identifiedby our recent review of the epidemiological literature in-dicate that the relationship between venue typology andHIV risk is complex, potentially context-dependent, andgreatly heterogeneous, with a need for qualitative re-search examining the nuanced and intersecting influ-ences of policy, social, and physical features of the workenvironment [5]. As an example of how qualitative re-search may be useful in elucidating these intersections, amixed-methods study among SWs’ clients found thatsexual transactions in entertainment venues (i.e., bars,nightclubs) were more likely to be characterized bybinge drinking and offers of increased pay for unprotectedsex – a finding in seeming contradiction to previous re-search identifying sex work within indoor venues as moreconducive to HIV prevention than outdoor spaces. Inmixed-methods analysis, participant narratives character-ized indoor entertainment venues as higher-risk than thestreet due to social norms promoting alcohol use in bars,perceptions of managerial exploitation of bar-basedworkers, and negative consequences of the enforcement ofpublic health regulations surrounding sex work in bars[33]. These complexities highlight the importance of quali-tative research in “unpacking” and elucidating the complexways in which intersecting work environment featurescan shape HIV prevention – information that remainsessential for informing appropriate occupational healthinterventions.Despite a growing body of research showcasing theoverall influence of work venue in shaping SWs’ risk ofHIV and violence, less is known about the specificfeatures of these environments and the dynamic negoti-ation of sexual risk and safety across different work envi-ronments. Additionally, it remains critical to ensure thatpolicies and programmes aimed at curbing the HIV epi-demic are grounded in the voices and lived experiencesof SWs across diverse settings and work environments.To gain a better understanding of these lived experi-ences and to tease out the intersecting influences ofGoldenberg et al. BMC Public Health  (2015) 15:1241 Page 2 of 15physical, social and policy features of work environ-ments, we conducted a synthesis of the qualitative litera-ture on sex work environments and HIV risk andprevention. Given sweeping efforts to further criminalizesex work globally, coupled with emerging calls for struc-tural responses situated in a labour and human-rightsframework [5, 7, 34], we reviewed and synthesized quali-tative studies published between 2008 and 2014 to de-scribe the nuanced and often intersecting ways in whichphysical, social, and policy features of work environ-ments (e.g., the ways in which venue policies or man-agerial practices influence condom use across differenttypes of indoor workspaces) shape SWs’ lived experi-ences and capacity to mitigate HIV risks.MethodsWe reviewed and synthesized peer-reviewed qualita-tive literature published from 2008 to 2014 pertainingto the influence of sex work venues on HIV vulner-ability and risk mitigation among SWs (e.g., condomuse). Our review and synthesis was informed byguidelines for meta-synthesis of qualitative literature[35] as well as PRISMA guidelines for systematic re-views [36]. We systematically searched the followingdatabases: Pubmed, EMBASE, Science Citation Index,BIOSIS Previews, PsycINFO, CINAHL (CumulativeIndex to Nursing and Allied Health Literature), SocialSciences Citation Index, Sociological abstracts, andCAB Direct (CAB Abstracts & Global Health) forstudies assessing determinants of HIV or condom useamong female sex workers. We used search termspertaining to sex work (e.g., sex work*, prostitut*),drivers of risk/protective factors (e.g., risk*, context*,vulnerability), and HIV/condom use (e.g., HIV*, AIDS*,condom*, unprotected sex) to retrieve peer-reviewedpapers published in any language from January2008-December 2014. The search was supplementedby cross-referencing and hand-searching key data-bases (e.g., google scholar).We initially screened the abstracts and titles for eligi-bility. All studies among cis- and transgender womenSWs were considered for inclusion. Studies focusedsolely on adolescent SWs (<18 years old), transgender ormale SWs, or transactional sex (exchange of sex fornon-monetary goods) were excluded. Next, two re-viewers (SG and PD) screened the abstracts and full-textpapers to assess eligibility for inclusion. Qualitative stud-ies published between 2008 and 2014 that examinedphysical, social, or policy work environment features inrelation to HIV prevention (e.g., condom use) amongSWs were eligible for inclusion. We excluded studiesthat were solely epidemiological (e.g., quantitative ana-lyses) and non-primary research (e.g., reviews, modelingstudies, commentaries). Studies in which physical, social,or policy features within the work environment were nota primary focus (e.g., studies focused on community em-powerment, macrostructural issues, or individual risks)or which did not present supporting data (e.g., quotes orfield note excerpts) were also excluded.Three independent reviewers extracted data from thedifferent studies, using a standardized form to recorddetails regarding study information (year, setting, studydates), and design (sample size, data collection methods,aim) (Additional file 1: Table S1). Key findings (relation-ships between work environment features and HIV pre-vention) were also collected (see Table 1 for summary ofkey findings ). We also noted major limitations whererelevant (e.g., where validity could be impacted by thestudy design or missing information). The first authoroversaw the extraction process, collating and synthesiz-ing the data extracted by each reviewer, and reviewingthe included studies and data extractions to ensureconsistency across the extraction process. Cases where alack of clarity or potentially conflicting/inconsistent find-ings were identified were discussed between the re-viewers and the original source was reviewed to verifythe information.We adopted a meta-synthesis approach to systemat-ically integrate and synthesize the results of the 24 ar-ticles. Drawing on theoretical principles of structuralvulnerability and a structural determinants of HIV insex work conceptual framework, we used an inductiveprocess to extract key themes of salience to our aimthat emerged in each study. Representative quoteswhich articulated the ways in which physical, social,or policy features of work environments shape SWs’agency in mitigating HIV risk were explicitly soughtand collected for each theme (Table 2). During thesynthesis, we considered inconsistencies and potentialdiscrepancies within each theme (e.g., potential formanagement policies and practices to promote pre-vention as well as risk), as well as across contexts(e.g., criminalized versus decriminalized policy set-tings) and regions (e.g., high-income countries (HIC)vs. low- and middle- income countries (LMIC)). Asthe synthesis progressed, the themes were refined andregrouped, until they yielded a core set of themeswhich represented key topics identified across studiesand settings [35].ResultsOf 1514 articles screened for eligibility, we identified24 eligible qualitative studies that elucidated the nu-anced and often intersecting ways in which featuresof work environments (e.g., establishment managerialpractices, access to security, peer roles, policing)shape SWs’ capacity to engage in HIV prevention. Ofthe 24 studies, 19 were from LMICs, primarily AsiaGoldenberg et al. BMC Public Health  (2015) 15:1241 Page 3 of 15(n = 14) (e.g., China, India) and Sub-Saharan Africa (n = 5);five studies were from HICs (e.g., Canada, New Zealand).Characteristics of the studies included are described inAdditional file 1: Table S1.Although most of the studies emphasized work envir-onment features that undermined HIV prevention (e.g.,working in isolated, outdoor spaces; negative interac-tions with police; workplace violence), SWs’ narrativesalso highlighted key work environment features that en-hanced their agency to successfully negotiate condomuse (Tables 1 and 2). SWs’ narratives revealed the criticalinfluence of occupational health and safety standards inindoor establishments, as well as the extent to whichthird parties engaged in protective practices (e.g., sup-port for condom use; intervening in violent encounters)within such venues. Occupational health and safety wasoften perceived as most effectively facilitated in work-places where there was access to SW/peer support (e.g.,ability to share advice on condom use, strategies fordealing with difficult clients), as well as in contextswhere negative interactions with police were minimized(e.g., working in decriminalized contexts or environ-ments in which peers/managers successfully deterredunjust policing practices).Table 1 Emergent themes on work environment influences on HIV prevention from sex worker narratives, 2008–2014(n = 24 studies)Theme Features that support HIV prevention Features that undermine HIV preventionOccupational health &safety standards inindoor venues• Where occupational health & safetyare provided in formal indoor spaces,SWs experience enhanced power tonegotiate condom use, less violence,access to care, sharing of informationand advice [37, 39, 40, 49, 53, 57]• Operating in isolated, informal spaces oftenlinked to greater susceptibility to violence,barriers to sexual risk negotiation [39, 10]• Enhanced vulnerability in isolated, informalsettings can impede sexual health and enhancevulnerability to violence [38, 40, 10, 45–47]Influence of thirdparties• Manager support/policies for HIVprevention promotes condom norms,access to information [38, 49]• Protection against client violence bythird parties in some indoor venues(e.g., security guards, manager policieson violence) can assist in preventingviolence and enables sexual negotiation[37, 41, 42]• Close relationships between managersand workers in managed indoor spacesfacilitate condom promotion and accessto HIV/STI and health information [56].• Support from managers/supportiveestablishment policies available in someinformal indoor venues, but often dependedon type of relationship [50]• Lack of manager supports, particularly withincriminalized environments results in limitedsupport and a lack of access to condoms,HIV/STI prevention [46, 51, 52]• Manager pressure to service clients quickly/satisfy clients’ needs leads to pressure forunprotected sex. [39, 53]• Concern of manager exploitation or restrictionof autonomy relates to reduced control overHIV prevention, extortion for sex [46, 53]• In more informal settings, health protectionoften left to the individual worker, with a lackof managerial support [50]Sex worker/peersupport• Peer support within the workplace linked topositive outcomes including role modeling,sharing of HIV/STI information, condomnegotiation strategies, and support for dealingwith difficult clients [49, 56, 57]• Workplaces that promote cooperation, ratherthan competition, between workers enhancedworkers’ power to negotiate condom use andstrengthened condom use norms at a venuelevel [37, 39]• Peers support for HIV prevention also includedfacilitating access to HIV/STI testing and condoms(e.g., by purchasing in bulk to have available inthe venue, lending condoms) [56]• Lack of social support at work or ability to workwith peers related to social isolation, less exposureto advice or information on condom negotiationand sexual health, violence, and enhancedsusceptibility to exploitation at work promotedworkers’ vulnerability [41, 46, 58]Interactions with police • Access to police protections and the ability towork without criminalization fostered the creationof trusting relationships with police, ability toreport violence, and ability to negotiate sexualtransactions without fear of negativeconsequences [39]• Harassment, raids, arrest, or detention by policelinked to displacement and undermines sexualnegotiation [57, 59]• Fear of police harassment, abuse, and arrest andconfiscation of harm reduction equipment posedcritical barriers to accessing/carrying condoms andother HIV prevention supplies [10, 44]• Direct impacts of police harassment, abuse, andarrest included HIV/STI risks as a result of sexualviolence, rape, and sexual abuse by police [45, 46]Goldenberg et al. BMC Public Health  (2015) 15:1241 Page 4 of 15“I like being in a parlour because it is safe”:Occupational Health and Safety Standards in IndoorWorkspacesAcross settings, indoor workspaces (e.g., in-callvenues, managed spaces such as massage parlours)characterized by workplace health and safety stan-dards often featured prominently in participants’ nar-ratives as critical for condom negotiation and accessto HIV prevention (e.g., condoms, HIV/STI testing).SWs’ narratives elucidated how condom use with cli-ents could be more safely and effectively negotiatedin indoor workspaces where occupational standards,policies and protections were in place [37, 38]. InIndia, Canada, and New Zealand, formal indoor work-spaces typically offered a greater degree of protection(e.g., safety mechanisms; the presence of otherworkers, managers, madams, or other staff who coulddeter or assist in the removal of violent or unco-operative clients). Where such protections were of-fered, workers generally experienced enhanced agencyand opportunities for safer sex negotiation [37–40].As the narrative of a parlour-based worker from NewZealand highlighted:The street just doesn’t appeal to me, because of thewhole security safety issues. You know, I like being in aparlour because it is safe. Yeah, sure, you don’t makeas much, they take a big cut, but that’s the price youpay, you know, for your health and life.(Sex worker, Indoor parlour, New Zealand) [37]While working in informal indoor spaces such as en-tertainment venues (e.g., bars, nightclubs, beer gardens)was often perceived as safer than outdoors, this variedwidely due to the lack of occupational standards andsubstantial diversity of informal venues [39, 40]. In com-parison to more formal and managed spaces, operatingout of unfamiliar and informal settings was often linkedto reduced control over clients, the terms of transac-tions, substance use, and condom use [39, 40]. An emer-gent theme in entertainment venues related to alcoholuse with clients, which was a common feature of the so-cial environment. While this was perceived by mostentertainment-based workers as having some benefits interms of providing opportunities to observe and screenclients prior to negotiating a transaction (e.g., as anentertainment-based worker in Laos noted, “Clients pre-fer to spend hours talking and drinking before taking agirl for sex…we observe and consider the clients andcheck references with friends”) [41], working in alcohol-serving venues was also noted to undermine SWs’agency to negotiate condoms within the context of clientintoxication or pressure to use alcohol themselves[42, 43]. As an entertainment-venue based SW inCambodia explained, “When the alcohol gets in, he al-ways requests me not to use condom” [42].SWs’ narratives suggested that outdoor settingswere often the least conducive to HIV prevention,with street-based workers reporting being pushed tothe margins due to fear of policing and violence[42, 10]. Operating in dark, isolated areas typicallyundermined SWs’ access to security while working[10], leading to an increased risk of physical andsexual violence [38, 40, 10–47] and limiting opportunitiesfor effective condom negotiation with clients [38, 39]. Asthe narratives of SWs from New Zealand and Canadahighlighted the dangers of outdoors and how this lim-ited opportunities to ensure safety and use condomsconsistently:The street’s way too dangerous. It’s just so easy forpeople to do anything they want. Like we’ve lostabout, lost two lovely ladies from the street, andyou know, just like that, you could just, yeah, justthere’s nothing you can do about it when you’restanding out on a corner or any part of the street,there’s nothing much you can do about it. Theremay be a lot of traffic, but not many people pullover to help.(Sex worker, Street/Independent, New Zealand) [37]Out there [street/public location] you’re like a hostagealmost. You feel almost that bad if you were out there.You’re going to settle, or you’re going to put yourself ina bad position maybe. If it’s not going good, you’restuck, and that’s not a good feeling. You don’t want tobe isolated…(Sex worker, Unsanctioned indoor workspace,Canada) [40]For those working outdoors, a lack of access to famil-iar and safe spaces to service clients was a key concern.For example, SWs’ narratives suggested that servicingclients in unfamiliar or isolated locations (e.g., clients’homes, hotels, vehicles) represented situations which el-evated the risk of violence (e.g., gang rape, forced unpro-tected sex, lack of payment) due to the lack of agencythis provided SWs in controlling the context and termsof a transaction: [40, 45, 46]Once you get into a guy’s house, they can just…That’s it, you know. You don’t know where you’regonna go. At a guy’s place, it’s more or less like,what he says you have to do, you know. Um. Iguess you just go with uh, risk.Goldenberg et al. BMC Public Health  (2015) 15:1241 Page 5 of 15Table 2 Sex worker narratives: Work environment influences on HIV prevention and risk, 2008–2014 (N = 24 studies)Theme Features that support HIV prevention Features that undermine HIV preventionOccupational health & safetystandards in indoor venuesThe street just doesn’t appeal to me, because of thewhole security safety issues. You know, I like beingin a parlour because it is safe. Yeah, sure, you don’tmake as much, they take a big cut, but that’s theprice you pay, you know, for your health and life.(Indoor parlour) [37]The street’s way too dangerous. It’s just so easy forpeople to do anything they want. Like we’ve lostabout, lost two lovely ladies from the street, andyou know, just like that, you could just, yeah, justthere’s nothing you can do about it when you’restanding out on a corner or any part of the street,there’s nothing much you can do about it. Theremay be a lot of traffic, but not many people pullover to help. (Street/Independent) [37][on the street] they [spotters] can take the license platedown and the car make, but once buddy gets you twoblocks away, how are they going to stop the guy fromshooting or stabbing you? They might prevent it fromhappening to the next girl, cause they got his plate number,but for you, there’s no protection. None at all. (Street) [10 ]He took me to the graveyard. . . There were 5–6 peopletotally drunk.They did like that only and did not even give me a rupee.They did without condom. (Street) [39]They took me by car to a guesthouse and they force meto have sex with four other men. [Do you know if theyused condoms?] No. Not used condom becauseit was a force. (Street) [47]Influence of third parties We meet the boss every Monday and each FEWattends the meeting. Our boss told us in themeeting that the ‘classes’ (intervention sessions)are worth attending. He is really supportive of ustaking the classes. After the classes, he oftenreminds us that health should be our priority andwe can make more money if we are healthy. Heeven jokes that the intervention saves us money tobuy condoms and reminds us that no one elseoutside might be this considerate of us.(Entertainment establishment) [49]I explain to the girls that they should use condoms.I emphasize the fact that these people from SHIPare giving us knowledge so that our lives are safe,and we can prevent ourselves from acquiring anysuch infection or disease. (Madam and SW) [38]It is important for my girls to enjoy good health.If she is sick then I need to ensure that she getsmedical attention either in our own clinic oroutside… I charge her room rent and that is tomy benefit; she is getting a room and healthcare—that is to her benefit. (Madam) [38][I] t is safer with a boss such as when there is aproblem, they deal with it. When policeman catchus, they pay for us … They protect us. Whenpeople fight us, they also protect us. (Brothel) [42]He [the lodge manager] says ‘use condom anddo’ but if he [the client] says it’s not fun, then themanager says ‘Take your money and go, we get100 other clients. (Indoor) [39]They [building staff] really pay attention: we getall the lists of all the offenders and stuff, and they’reput up [by the door] and staff study them. One ofthe staff caught one [a violent client]. He was avisitor in the house, and he came in as a date,and they called the police, and he got arrested.(Indoor – supportive housing) [40]Last time, a client wanted oral sex without acondom. I could not persuade him to put one on.Then, I called Manager W from the guest room.The client argued with the manager and said hecan get the service in another brothel. Manager Winsisted that wearing a condom is regulation hereand asked the client to leave politely.(Spa) [50]Last time, I put on a condom for a client. But hetook it off under the table. Angry, I refused tocontinue sex with him. I put on my clothes andwent downstairs. I know the boss will protect andsupport me, so I dared to refuse him. (Roadside hotel) [50]I am always concerned with their health. I tell themto pay more attention to their personal hygiene.They should always wash their hands after massage,and I tell them to prepare condoms.(Massage Parlour) [55]I got raped and the guy just walked out the door. I wascrying and the manager came to me and all he said was,“As soon as you walk in the room, you are on your own.It’s not my problem or my responsibility for your safety.(Indoor parlour) [52]Usually, if a man is taking too long my madam starts toblame me and says that I have sat twice, so if he takes along time I take the condom off. With this customer Iconvinced him and he discharged quickly so there was notrouble. (Brothel) [53]If we sent any client back she used to get angry, sowe did not use[condoms] regularly”. (Brothel) [39]One day I was harassed by a client and when I toldthe bar manager,he demanded sex so that he can help me. (Bar) [46]Girls from the dalal bari (houses where pimps bringclients) rarely misbehave…The girls there are bound todo all kinds of sex…They rarely can protest or behavebadly. For us it is different. If I bring a customer I canmake him use a condom or drive him away — I can dothat — they cannot do that. (Indoor/Independent) [53]The boss never talks about condom use. He pretends hedoesn’t know [the sex business]. There is no talk aboutcondom use or HIV prevention among girls either. Nobodytalks about this. We only talk about which client is rich orwhich is decent (Massage Parlour) [55].It is better to train the girls. The boss doesn’t care about us.He has his business to take care of. He never talks aboutthis with us (Sauna) [55]Goldenberg et al. BMC Public Health  (2015) 15:1241 Page 6 of 15(Unsanctioned indoor workspace, Canada) [40]Sometimes when they went in a different direction, Iopened the door and jumped out of the car…when hetakes you in a different direction from the hotel, thereis a chance of gang rape.(Sex worker, Street, Thailand) [48]“I know the boss will protect and support me”: ThirdParties as Protective of SWs rightsThe extent to which indoor workspaces facilitated HIVprevention was greatly shaped by the extent to whichthird parties engaged in protective (vs. exploitative ormore 'hands-off') practices. In Cambodia, workers’ nar-ratives suggested that some, but not all brothel managersimplemented policies supportive of condom use [42],Table 2 Sex worker narratives: Work environment influences on HIV prevention and risk, 2008–2014 (N = 24 studies) (Continued)Sex worker/Peer support When I first came here to start working, it was[another SW] who taught me how to use condoms.She said that this was the hygienic way [57].In the waiting room, new FEWs will stay with old FEWs.We don’t feel as embarrassed to discuss these things(sex and condoms) in the venue compared to whenwe are outside. (Entertainment venue) [49]Clients prefer to spend hours talking and drinkingbefore taking a girl for sex…we observe and considerthe clients and check references with friends.(Entertainment venue) [41].Sometimes mammies would ask us to show pity fornew girls who were in the same room with us andteach them things they didn’t understand. In thiscase, we would tell them a lot of things and teachthem a lot. (Indoor) [49]When my friends [sex workers] knew when or wherethere were free services for HIV or STI testing andcounseling, they called me and asked me to gothere with them. (Indoor) [56]My friend [sex worker] encouraged me to use acondom when I had my first client. She told me touse condoms to protect myself from being infected.[Furthermore,] I was too shy to buy condoms at first.My friend [sex worker] bought them for me and taughtme how to use them. (Indoor) [56]My FSW friends advised me that using condoms couldprevent diseases (Indoor) [56].When I get into a conflict with clients, my colleagueswill come to mediate the conflict and persuade theclient to use a condom (Indoor). [56]I don’t talk to friends about my genital symptoms becausefriends who are jealous of me might disclose it to clients.Also I may be asked to stop working for a while, or evennot be allowed to work in this bar if the bar owner knowsabout this.I wait and quietly visit a health clinic alone.(Entertainment venue) [41]I felt tidak pantas (inappropriate). Even though I do whatthey [other sex workers] do, I will never associate myself withthem. I will not share anything with them; I just feel it isn’tappropriate. From day one I felt that someone here dislikedmy presence. (Brothel) [58]During my first weeks there, no one told me to use condomsor even offered me a condom. I didn’t know what condomslooked like, so when I had clients I just did it, simple andcrazy, really crazy. (Brothel) [58]Interactions with police On the corner, doing it in the car, I used to be scaredall the time, paranoid about cops, scared about gettingcharged… It’s a lot easier now. I can come and go,and cops actually say hi to me. (Indoor – supportivehousing) [40]It’s safer. I can just yell for help, and, you know, inthe alley you can’t really yell, you know? It’s hard torun away, and… you don’t know whether they’regoing to get violent or something. There’s a lot morechance of that outside than at my place. [If ithappened in my room] I’d run for the door. It’shappened before, and the staff have come, and theytold him to leave, or they even got the police to gethim to leave. They do that right away. It took 4 copsto get this guy to leave. Then they barred him [fromthe place]. (Indoor – supportive housing) [40]We faced many problems as we stood on the streets;mainly from the police and the local goons. Police used todump us in the vans, ask for Rs. 60,9 and used to have sexwith us. They used totake money as well as service. The local goons used to charge…They used to say, “You peoplestand here and earn well, so you have to give somethingto us.” If we said no, they would beat us up. See here, theyonce stabbed my hand with a knife [showing a large scaron her hand]. (Street) [38]They mistreat us so much. Even policemen rape us, andif you try to resist, they threaten you with arrest anddetention [59].[The police] look in your purse and if they find condoms,they put you in jail, but clients are released. (Street) [44]The difficulties were great, especially when we started.The local police dispatched people to drive us out. Theydidn’t understand. They would take our condoms andthrow them on the groun [57].They’re not out to get us, but they don’t really have anycompassion or concern about us. A lot of us girls startcarrying pepper spray or bear spray. But you have tobe careful too, because as soon as the cops search you,jack you up, they take away what you can to protectyourself with, even rigs. (Street) [10]Goldenberg et al. BMC Public Health  (2015) 15:1241 Page 7 of 15whereas SWs in entertainment venues rarely receivedcondoms from establishment managers [42]. In India,Canada, Cambodia and China, SWs highlighted theimportance of working in establishments where HIVprevention and education (e.g., provision of condomsat work, managers discussing and establishing normsfor condom use) were promoted, insofar as managerswere respectful of their agency and human rights, asopposed to taking a punitive or coercive approach[38, 39, 42, 49].For example, in Belgaum, India, brothel-based SWs op-erate as more permanent staff, with transactions controlledby a brothel madam. In this context, the policies and prac-tices put in place by the madam strongly determined SWs’earnings, types of clients, and services performed. SWs in-dicated that there was great variation in such practicesacross madams and brothels, with some reporting expos-ure to exploitative practices that undermined HIV preven-tion, whereas in cases where SWs’ autonomy wasrespected and positive occupational health policies wereadopted, this often enhanced SWs’ agency in HIV preven-tion [39]. In light of this, a key pillar of the community-ledSonagachi HIV/AIDS Intervention Program (SHIP) andsubsequent community-led initiatives of the large-scaleAvahan Project in India involved incentivizing brothelmadams to support HIV prevention (i.e., by ensuring thatbrothels were safe and viable workspaces) [38]. As brothel-based SWs and madams participating in the SHIP projectdescribed the positive effects of such an approach:No, I will never have sex without a condom. Not worthit. I kick them out, and if they don’t go, I call for help.(Sex worker, Brothel, India) [38]I explain to the girls that they should use condoms. Iemphasize the fact that these people from SHIP aregiving us knowledge so that our lives are safe, and wecan prevent ourselves from acquiring any suchinfection or disease.(Manager, Brothel, India) [38]SWs’ narratives revealed that when third parties engagedin protective practices, including practices to promotesafety (e.g., bad date sheets, security guards, cameras, man-agers intervening in situations of client violence), thiscould successfully reduce their vulnerability to violent en-counters while fostering opportunities to negotiate sexualrisk reduction with clients [37, 40–43, 50]. As SWs’ testi-monials from Cambodia, China and Canada highlighted:There’s cameras on each floor, they’re not allowed inunless they have ID, their name is written down, and,people have seen you with the guy, so he knows that hecan’t go and try to do something to me and get awaywith it.(Sex worker, Unsanctioned indoor workspace,Canada) [40][I]t is safer with a boss, such as when there is aproblem, they deal with it…They protect us. Whenpeople fight us, they also protect us.(Sex worker, Brothel, Cambodia) [42]Last time, I put on a condom for a client. But he tookit off under the table. Angry, I refused to continue sexwith him. I put on my clothes and went downstairs. Iknow the boss will protect and support me, so I daredto refuse him.(Sex worker, Roadside hotel, China) [50]Although the protections afforded by third parties in in-door workspaces were described as critical for supportingSWs’ health and safety, their implementation was oftenlimited by macrostructural constraints, including sex work-related stigma and criminalization (e.g., of third parties) inmost of the contexts studied. For example, stigma and con-cerns regarding frequent raids and fear of arrest withincriminalized settings often discouraged managers from en-gaging in protective practices, such as discussing condomuse in the workplace or keeping condoms onsite [51], andin some settings constrained management from interferingin situations of violence [52]. In these cases, managersoften preferred a ‘hands-off ’ management style to avoid im-plicating their establishment in illegal activities – whichwas perceived by SWs’ to constrain agency to refuse clientpressures for unprotected sex or to protect oneself from orreport client-perpetrated violence [51, 52]. As a CanadianSW explained:I got raped and the guy just walked out the door. I wascrying and the manager came to me and all he saidwas, “As soon as you walk in the room, you are onyour own. It’s not my problem or my responsibility foryour safety.”(Sex worker, Massage parlour, Canada) [52]Additionally, SWs in Asia and Sub-Saharan Africa fre-quently reported establishment practices and policiesthat prioritized profit over their workers’ health andsafety or that constrained workers’ autonomy, resultingin negative impacts on SWs’ health and working condi-tions [39, 46, 50, 53, 54]. For example, in a number ofstudies from India and China, participant narrativesGoldenberg et al. BMC Public Health  (2015) 15:1241 Page 8 of 15included experiencing pressure to accept client requestsfor unprotected sex due to managerial practices that pri-oritized client satisfaction and financial considerationsover occupational health: [39, 53–55]Usually, if a man is taking too long my madam startsto blame me and says that I have sat twice, so if hetakes a long time I take the condom off.(Sex worker, Brothel, India) [53]The boss does not care about condom use. She onlycares about earning money. She is very kind to sexworkers who do not use condoms because they bringher more clients.(Sex worker, Indoor venue, China) [56]Although norms supportive of condom use oftenexisted among managers in indoor settings, their role inshaping condom negotiation between workers and cli-ents was complex and varied substantially across venuesand contexts. For example, an ethnographic study in-volving SWs and managers in China highlighted the roleof managers as both intermediaries and protectors ofSWs, who can facilitate or impede agency depending onthe type of relationship they maintain with their workers[55]. Similarly, a qualitative study in three Chinese citieselucidated how although maintaining healthy workerswas often perceived to be important for the success ofmanagers’ businesses, to retain and attract clients, man-agers’ goal was to ensure their customers were satisfied,which could lead to contradictory practices with respectto HIV prevention [56]. Some studies indicated that inmore upscale indoor venues and venues where managersand workers maintain closer and more trusting relation-ships, managers may be more likely to develop policiesand practices to protect sexual health, even at the expenseof interfering with their business [50]; whereas in venueswhere employee turnover was high (e.g., due to highmobility of SWs and unfavorable working conditions),managers were often less invested in workers’ wellbeingand were less engaged in ensuring workplace health andsafety [55]. This dichotomy is illustrated below:I am always concerned with their health. I tell them topay more attention to their personal hygiene. Theyshould always wash their hands after massage, and Itell them to prepare condoms.(Manager, Massage Parlour, China) [55]The boss never talks about condom use. He pretendshe doesn’t know [the sex business]. There is no talkabout condom use or HIV prevention among girlseither. Nobody talks about this. We only talk aboutwhich client is rich or which is decent.(Sex Worker, Massage Parlour, China) [55]SWs’ narratives also indicated that managers could con-tribute to abusive practices that enhanced vulnerability toHIV (e.g., sexual abuse, exploitative working conditions)[46, 53]. For example, as a bar-based SW in Kenya sharedher experience: “One day I was harassed by a client andwhen I told the bar manager, he demanded sex so that hecan help me” [46]. Concerns of exploitation by managers,a desire for increased flexibility and autonomy, and a pref-erence to keep more of one’s earnings (rather than havingto pay a room/management fee) meant that in some con-texts, SWs described a preference to work independently.The following narratives highlight the nuances of inde-pendent versus managed indoor sex work in terms of theirrelative advantages and disadvantages:I don’t like having a boss. I don’t want to be undertheir control. They benefit from my sweat. If by myself,I can decide to do or not to do … If we areindependent, we can do anything we want. No-onecontrols us.(Sex worker, Street, Cambodia) [41]Yes, I have (thought of working in other sectors), but Ididn’t want to. I found the street more freely to work,but just it was just dangerous at the same time, but Iwas more free when I worked out on the, as a streetworker than what I would be inside, cause there’llbe rules and regulations, yeah, and I’m not reallyused to rules and regulations and people telling mewhat to do.(Sex worker, Street, New Zealand) [37]“We stand up for each other”: Access to Sex Worker/Peer SupportSWs’ narratives across the diverse settings studied artic-ulated the ways in which SW/peer support within theworkplace was shaped by management practices andoccupational policies, as well as the broader legal contextof sex work. Occupational health and safety was oftenperceived as most effectively facilitated in indoor spaceswhere trust and mutual support amongst workers couldbe cultivated [41, 56]. Within such workspaces, SWs oftenshared advice on condom negotiation and use, as well asstrategies for preventing or dealing with difficult/violentclients, fostering a supportive atmosphere for HIV preven-tion in some contexts [40, 41]. As entertainment andGoldenberg et al. BMC Public Health  (2015) 15:1241 Page 9 of 15brothel-based workers in China highlighted the import-ance of SW/peer support, particularly for migrants andnewcomers to the sex industry: [49, 57]We talked about condoms, boyfriends and things likethat, such as ‘condoms can protect us’ and ‘we may beinfected by HIV if we don’t use condoms.’ Sometimesthere would be arguments among us. Some girls saidthey never used them and others said that we mustuse them.(Sex worker, Entertainment venue, China) [49]My friend [sex worker] encouraged me to use acondom when I had my first client. She told me to usecondoms to protect myself from being infected.[Furthermore,] I was too shy to buy condoms at first.My friend [sex worker] bought them for me and taughtme how to use them.(Sex worker, Indoor venue, China) [56]When I get into a conflict with clients, my colleagueswill come to mediate the conflict and persuade theclient to use a condom.(Sex worker, Indoor venue, China) [56]In India, SW/peer support was also noted to be import-ant for facilitating SWs’ ability to leverage their collectivepower to stand up against exploitative or abusive practicessuch as exploitative managerial practices, pimping, orviolence perpetrated by police or clients [38]. The narra-tives of participants in the Sonagachi project in Indiahighlighted these as positive impacts of the SHIP interven-tion, elucidating the reciprocal pathways by which peersupport can influence other features of the work environ-ment (e.g., management practices in brothels):We help each other in the brothel. The atrocitiesand the harassment inflicted on us within thelocality…the thugs who would harass us and wouldhit the young girls… sometimes the madam wouldnot give some of the girls their due share of themoney. If any such beating and harassing happens,then we stand up for each other, we support eachother and we put a stop to it.(Sex worker, Brothel, India) [38]While many studies identified peer support as criticalfor countering risks and setting norms for condom useat a venue level, stigma and criminalization often under-mined the cultivation of supportive relationship andpractices among SWs [46]. Some studies within indoorworkspaces reported on management practices thatfostered competition (rather than trusting or supportiverelationships) among SWs and undermined discussionsof condom use and safety among workers [39, 41, 53,58]. In Indonesia, limited peer support between SWs inindoor spaces was often attributed to the intersectinginfluences of economic competition (e.g., competitionfor clients or preferential treatment by management) andother macrostructural factors, such as stigma and migra-tion/mobility patterns, with newcomer/migrant SWs oftenperceived as a ‘threat’ and thus excluded from social net-works. At the same time, newcomer/migrant SWs’ experi-ences indicated that internalized stigma (i.e., self-stigmaassociated with perceptions of sex work as ‘immoral’) fur-ther deterred them from associating with peers in the work-place, exacerbating social isolation and undermining socialsolidarity and access to peer support mechanisms [58].I felt tidak pantas (inappropriate). Even though I dowhat they [other sex workers] do, I will never associatemyself with them. I will not share anything with them;I just feel it isn’t appropriate. From day one I felt thatsomeone here disliked my presence.(Sex worker, Brothel, Indonesia) [58]Moreover, SWs’ narratives in some settings (e.g.,Cambodia, Canada) suggested that peer support (e.g., peerhealth and safety mechanisms) varied widely betweenindoor venues, rendering workers in some informalspaces (e.g., guest houses, bars) more isolated andvulnerable to violence, and constraining their capacityto negotiate condom use [42]. In Canada, frequentpolice harassment and fear of arrest among street-based SWs was perceived to undermine their abilityto access peer-based safety and support mechanisms(e.g., peers acting as spotters), primarily as a result ofdisplacement away from established work environ-ments [40, 10]. Importantly, peer support was oftenperceived as less available in contexts where sex workand illicit drug use scenes overlapped to a greaterextent (e.g., on the street and in informal spaces):It’s more about the drugs and stuff down here [on thestreets], like, nobody really helps anybody down hereunless you have dope.(Sex worker, Street, Canada) [40]“I used to be scared of getting charged”: Interactionswith PoliceAcross settings and regions, fear of arrest, harassment, orabuse by police increased structural vulnerability to HIV,Goldenberg et al. BMC Public Health  (2015) 15:1241 Page 10 of 15constituting common barriers to sexual health and safety.In addition to health-promoting establishment policiesand peer supports, an important feature of supportiveworkspaces was reduced vulnerability to negative interac-tions with law enforcement, and in some cases, improvedrelations with police. In Canada and India, SWs in sup-portive indoor venues noted how these models could pro-mote more trusting relationships with police. Participantnarratives highlighted how this often facilitated improvedhealth, safety, and access to justice, such as by fosteringSWs’ agency in reporting violent incidents, abuse, orthreats in the workplace to police [38, 40]. As a CanadianSW discussed the ways in which staff and police withinher workplace were able to assist in removing violent cli-ents, which she contrasted against the isolation and lackof agency she associated with street-based work:It’s safer. I can just yell for help, and, you know, in thealley you can’t really yell, you know? It’s hard torun away, and… you don’t know whether they’regoing to get violent or something. There’s a lot morechance of that outside than at my place…It’shappened before, and the staff have come, and theytold him to leave, or they even got the police to gethim to leave. They do that right away. It took 4cops to get this guy to leave. Then they barred him[from the place].(Sex worker, Supportive indoor environment,Canada) [40]In India, the Sonagachi project and other communityempowerment initiatives (e.g., the Ashodoya interventionin Mysore) emerged as another example of improved rela-tionships SWs were able to achieve with police; this wasaccomplished through SWs using their collective power tostand up against unjust practices and abuses by police,and to promote more cooperative relations with po-lice at an establishment level (e.g., engaging managersto stand up against police) [38, 39]. SWs’ narrativesindicated that one the key outcomes of the Sonagachiproject was the mobilization of SWs against policeharassment, abuse, and other unjust law enforcementpractices:We go door to door to these brothels when word comesin that a sex worker has been arrested and we need togherao the police station, or organize a rally to protestharassment.(Sex worker, Brothel, India) [38]Sometimes when a sex worker is picked up by thepolice, then SHIP comes to us and we [fellowbrothel residents] immediately go to the policestation to protest.(Sex worker, Brothel, India) [38]Despite the importance of these examples, interven-tions that have successfully mitigated harassment andother unjust police practices have been limited to only afew settings. In most countries - particularly those lack-ing strong SW-led community empowerment move-ments - the potential benefits of such models remainconstrained by the persistent criminalization andstigmatization of sex work. In most of the settings stud-ied, SWs’ narratives instead emphasized the significantharms of punitive policing practices such as the confis-cation and use of condoms as evidence of illegal activ-ities. In Cambodia, Kenya, Uganda, and Canada, SWsfeared carrying or accepting condoms from healthworkers as a result of policing [42, 10–45, 51, 57, 59].These practices were constrained SWs’ capacity to engagein HIV prevention in most settings, with the exception ofthe decriminalized setting of New Zealand [10, 44, 46, 60].As a SW from Kenya described her experience:[Police] look in your purse and if they find condoms,they put you in jail.(Sex worker, Street, Kenya) [44]SWs’ narratives across a range of formal and informalwork environments, such as entertainment venues inAsia and massage parlours in North America, alsoelucidated how police crackdowns and surveillance incriminalized environments limited access to condoms[42, 51]. Such actions displaced workers away fromsettings characterized by strengthened HIV preventionpractices, towards more unsafe workspaces where agencyto negotiate condoms was much more constrained. InCambodia, displacement to informal spaces such as guesthouses often resulted in enhanced HIV risks for SWscompared to the supports that had fostered condom usein brothels (e.g., access to peers, supportive venue policies)[42]. In Kenya and Canada, street-based SWs’ experiencesof displacement to more isolated spaces due to policingoften resulted in having to rush the screening of potentialclients – a critical step used by SWs to ensure safety andnegotiate the use of condoms upfront [10, 44]. In somecontexts, human rights abuses by police (e.g., extortion,sexual abuse) were so pervasive that this was de-scribed as a normalized aspect of SWs’ daily workinglife – a perception that was sometimes perceived aslegitimized by the criminalization of sex work [46].This was most commonly documented in Sub-SaharanAfrica, where human rights abuses by police, such asGoldenberg et al. BMC Public Health  (2015) 15:1241 Page 11 of 15rape and forced sex to avoid arrest/detention, directlycontributed to structural vulnerability [45, 46, 59].They mistreat us so much. Even policemen rape us,and if you try to resist, they threaten you with arrestand detention.(Sex worker, Street, Uganda) [59]DiscussionThis synthesis elucidated the nuanced and complex im-pacts of physical, social, and policy features of work en-vironments on SWs’ agency to negotiate HIV preventionacross a range of settings and regions, as well as their in-tersections with broader macrostructural constraints(e.g., criminalization, stigma) and community determi-nants (e.g., SW/peer empowerment initiatives). Drawingon a structural determinants conceptual framework aswell as theoretical concepts of structural violence, thissynthesis identified four main broad themes elucidatingthe influence of workplace social, physical, and policyfeatures on HIV prevention and vulnerability. Acrossworkspaces and settings, participant narratives highlightedhow structural vulnerability and agency to engage in HIVprevention is shaped by working conditions such as (1)occupational health and safety standards, (2) access tothird party protections, (3) opportunities to work collect-ively with peers, and (4) initiatives to address/remove pu-nitive legal environments surrounding sex work. Thefindings support calls for multi-level interventions, includ-ing scaling-up models of occupational health and safetywhere SWs’ human and labour rights are promoted, as acornerstone of effective HIV prevention [5, 61]. Supportfor community empowerment and peer outreach, inter-ventions that engage third parties as partners in HIV pre-vention, and strategies to shift away from punitive legalapproaches (e.g., decriminalization, police education pro-grammes to align law enforcement and HIV preventionpriorities) represent promising strategies warranting fu-ture investigation [5, 61, 62].This review highlights the critical need for additionalqualitative research and mixed-methods research amongdiverse contexts to ensure that local, national, and inter-national HIV policies and programmes in sex work aregrounded in SWs’ voices and realities. Additionally,given that many of the studies identified emphasized pri-marily risky, rather than supportive, features of work en-vironment, mixed-methods studies examining specificfeatures that confer resilience across a more diverserange of settings remains needed. The design and testingof safer workplace interventions is an especially import-ant avenue for future research in Eastern Europe andSub-Saharan Africa, where we identified a particulardearth of information.While a number of prominent work environmentthemes emerged from our analysis, their manifestationsvaried regionally, often reflecting their interplay withbroader macro-structural determinants and communityempowerment initiatives [37, 40, 53]. Indoor settingswhere occupational standards, health-promoting prac-tices of third parties, and peer supports were availableoften supported SWs’ safety, rights, and agency to nego-tiate condoms; however, the extent to which indoorvenues were health-promoting hinged strongly on locallegal and human rights conditions. For instance, withinthe decriminalized context of New Zealand, managersoften encouraged HIV prevention and occupationalsafety [37], whereas within criminalized settings, such asmassage parlours in Canada, managers often faced legalconstraints to supporting HIV prevention (e.g., policeraids) [52]. Despite evidence that managers can (andoften do) play a critical role in HIV prevention, they arein many settings criminalized through legislation tocombat trafficking for sexual labour, which inadvertentlyincreased structural vulnerability and undermined SWs’health and safety. For example, in Canada, third partieshave been historically criminalized, and continue to bethrough new legislation that prohibits the purchase ofsex and criminalizes third parties who economicallyprofit from sex work (i.e., the Protection of Communitiesand Exploited Persons Act) [63]. Clear evidence indicatesthat legislation criminalizing aspects of the exchange ofsex between consenting adults severely constrains SWs’vulnerability to violence and poor sexual health [64].Supporting opportunities to consensually work withpeers and third parties (e.g., security, managers) andlegal approaches that avoid conflation of sex work andtrafficking remain critical for more effectively supportingSWs’ health and human rights [65].In this meta-synthesis, participant narratives stronglyemphasized the positive implications of peer supportfor enabling HIV prevention. These findings largely re-flect investments in community empowerment initia-tives in Asia, which foster supportive managerialpractices, peer supports, reductions in stigma, and insome cases, improved relations with police [38, 49, 57].In regions lacking strong community empowermentinitiatives (e.g., Sub-Saharan Africa), SWs’ narratives in-dicated that criminalization, stigma, and exploitativethird party practices limited peer support and agency tonegotiate sexual risk [46, 58]. For example, SWs inKenya, South Africa, Uganda and Zimbabwe, describedhow violence and human rights abuses (e.g., unlawfularrests and detention, sexual violence, extortion by po-lice) undermined health and safety; although SWs inthese settings recognized the benefits of unified actionto counter risks in their work environment, criminal-ized and stigma often limited such collectivization [46].Goldenberg et al. BMC Public Health  (2015) 15:1241 Page 12 of 15Community empowerment interventions have beenassociated with reductions in HIV/STIs and sexual risksin India, the Dominican Republic, and elsewhere [62],often through their effects on access to supportiveworkspaces (e.g., opportunities for collective action,improved police relations, reduced stigma). The prom-ise of such models for promoting safer work environ-ments and reductions in HIV/STIs across a broadervariety of settings (e.g., Sub-Saharan Africa, EasternEurope) warrants future research and scale-up.Lastly, this review highlighted the heterogeneity ofsex work environments, as well as the complex path-ways through which work environment features shapethe experiences of SWs negotiating HIV preventionwithin these spaces. The findings highlight the needfor mixed-methods research (particularly to evaluatesafer work environment models), given that suchcomplexities may not be well captured by epidemio-logical methods alone. Comparative research acrossgeographic, epidemic, and policy settings, includingsettings in which sex work is decriminalized, isneeded to identify the most effective approaches andpathways by which different work environmentmodels influence HIV prevention, particularly inheavy-HIV burden settings of Sub-Saharan Africa andEastern Europe.This synthesis built on a recent comprehensive reviewof the epidemiological evidence on structural determi-nants of HIV in sex work [5], to gain a better under-standing of the nuanced and intersecting impacts ofwork environment features on SW’s agency in negotiat-ing HIV prevention with their clients. To our know-ledge, this is the first attempt to systematically reviewand synthesize this body of work. Not all of the studiesreviewed clearly delineated the pathways by which workenvironment characteristics influenced SWs’ capacity tomitigate HIV risk, despite our best efforts to identifythese studies. Additionally, studies were excluded whichwere not peer-reviewed or published prior to 2008, orwhich did not have an explicit work environment focus(e.g., studies of economic determinants, individual riskfactors, or community empowerment determinants whichlacked a work environment focus).ConclusionFindings of this meta-synthesis highlight the imperativeto promote ‘enabling environments’ that support SWs'agency to negotiate HIV prevention with their clientswithin the workplace – including access to formal/in-call indoor workspaces with occupational standards,supportive third party practices that promote HIVprevention and safety, access to peer/sex worker sup-port, and protection from criminalization. While thesecommon themes were identified across settings, theirmanifestations often varied regionally, reflecting theirinterplay with broader macro-structural determinants(e.g., the criminalization of sex work) and communityempowerment initiatives. To foster the realization ofSWs’ health, human and labour rights, policy reformsand community initiatives to remove punitive ap-proaches to sex work, ensure supportive workplacestandards and policies, and foster SWs’ ability to workcollectively are recommended across diverse settings.Future qualitative and mixed-methods research is rec-ommended to ensure that HIV policies and pro-grammes in sex work are grounded in SWs’ voices andrealities, particularly in more under-represented regionssuch as Eastern Europe and Sub-Saharan Africa.Additional fileAdditional file 1: Table S1. Description of Qualitative Studies Includedin Meta-Synthesis, 2008-2014 (n = 24 studies). (DOCX 50 kb)Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsSMG conceptualized the review, designed the methodology and oversaw allstages; SG and PD carried out the review and extracted and analyzed thedata; SMG, PD, AK interpreted the results and contributed to writing thearticle. All authors read and approved the final manuscript.AcknowledgementsThis Review was partly supported by the U.S. National Institutes of Health(R01DA028648 and R01DA033147), the Bill & Melinda Gates Foundation,and the United Nations Population Fund. For assistance with the review,we thank Kate Shannon, Nancy Stimson, Ursula Ellis, Katherine Miller, Julie Souand Kathleen Deering.Author details1Gender and Sexual Health Initiative, British Columbia Centre for Excellencein HIV/AIDS, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z1Y6, Canada. 2Faculty of Health Sciences, Simon Fraser University, 8888University Drive, Burnaby, BC V5A 1S6, Canada. 3Department of Medicine,University of British Columbia, Vancouver, BC, Canada.Received: 13 July 2015 Accepted: 16 November 2015References1. Baral S, Beyrer C, Muessig K, Poteat T, Wirtz AL, Decker MR, et al. Burden of HIVamong female sex workers in low-income and middle-income countries: asystematic review and meta-analysis. Lancet Infect Dis. 2012;12(7):538–49.2. 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Lancet Global Health. 2015;3(3):e118–9.doi:10.1016/s2214-109x(15)70082-3. •  We accept pre-submission inquiries •  Our selector tool helps you to find the most relevant journal•  We provide round the clock customer support •  Convenient online submission•  Thorough peer review•  Inclusion in PubMed and all major indexing services •  Maximum visibility for your researchSubmit your manuscript atwww.biomedcentral.com/submitSubmit your next manuscript to BioMed Central and we will help you at every step:Goldenberg et al. BMC Public Health  (2015) 15:1241 Page 15 of 15

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