The decriminalization of prostitution is associated with better coverage of health promotion programs for sex workers.

OBJECTIVE: In order to assess whether the law has an impact on the delivery of health promotion services to sex workers, we compared health promotion programs in three Australian cities with different prostitution laws. The cities were Melbourne (brothels legalized if licensed, unlicensed brothels criminalized), Perth (criminalization of all forms of sex work) and Sydney (sex work largely decriminalized, without licensing). METHODS: We interviewed key informants and gave questionnaires to representative samples of female sex workers in urban brothels. RESULTS: Despite the different laws, each city had a thriving and diverse sex industry and a government-funded sex worker health promotion program with shopfront, phone, online and outreach facilities. The Sydney program was the only one run by a community-based organisation and the only program employing multi-lingual staff with evening outreach to all brothels. The Melbourne program did not service the unlicensed sector, while the Perth program accessed the minority of brothels by invitation only. More Sydney workers reported a sexual health centre as a source of safer sex training and information (Sydney 52% v Melbourne 33% and Perth 35%; p<0.001). Sex workers in Melbourne's licensed brothels were the most likely to have access to free condoms (Melbourne 88%, Sydney 39%, Perth 12%; p<0.001). CONCLUSIONS: The legal context appeared to affect the conduct of health promotion programs targeting the sex industry. Brothel licensing and police-controlled illegal brothels can result in the unlicensed sector being isolated from peer-education and support.

Improving the health of sex workers in NSW: maintaining success.

NSW has a diverse sex industry that is limited in its size by modest demand. There is no evidence that decriminalisation in 1995 increased the frequency of commercial sex in NSW. Though the largest sector, female brothels, is now mainly staffed by Asian women, condom use for vaginal and anal sex exceeds 99% and sexually transmissible infection rates are at historic lows. These gains are attributable to the long-term support of the NSW Department of Health in collaboration with the community-based Sex Workers Outreach Project and sexual health services, facilitated by the removal of criminal sanctions without the expense and access barriers of licensing systems.

Sex workers can be screened too often: a cost-effectiveness analysis in Victoria, Australia.

OBJECTIVES: Commercial sex is licensed in Victoria, Australia such that sex workers are required to have regular tests for sexually transmitted infections (STIs). However, the incidence and prevalence of STIs in sex workers are very low, especially since there is almost universal condom use at work. We aimed to conduct a cost-effectiveness analysis of the financial cost of the testing policy versus the health benefits of averting the transmission of HIV, syphilis, chlamydia and gonorrhoea to clients. METHODS: We developed a simple mathematical transmission model, informed by conservative parameter estimates from all available data, linked to a cost-effectiveness analysis. RESULTS: We estimated that under current testing rates, it costs over $A90,000 in screening costs for every chlamydia infection averted (and $A600,000 in screening costs for each quality-adjusted life year (QALY) saved) and over $A4,000,000 for every HIV infection averted ($A10,000,000 in screening costs for each QALY saved). At an assumed willingness to pay of $A50,000 per QALY gained, HIV testing should not be conducted less than approximately every 40 weeks and chlamydia testing approximately once per year; in comparison, current requirements are testing every 12 weeks for HIV and every 4 weeks for chlamydia. CONCLUSIONS: Mandatory screening of female sex workers at current testing frequencies is not cost-effective for the prevention of disease in their male clients. The current testing rate required of sex workers in Victoria is excessive. Screening intervals for sex workers should be based on local STI epidemiology and not locked by legislation.

Sex work and the law.

We reviewed publications, websites, and field observations to explore the health and welfare impacts and administrative effectiveness of different legal approaches to sex work. We identified three broad legal approaches: (1) prohibition, including the unique Swedish law criminalising sex workers' clients; (2) licensing; and (3) decriminalisation. Each of these models is employed under one or more jurisdictions in Australia. We make preliminary observations on their consequences and conclude that, on initial impression, decriminalisation may offer the best outcomes. However, more rigorous population-based research is needed to properly assess the health and welfare impacts of legal approaches to sex work.