HIV and Violence among Female Sex Workers in India: A Scoping Review

Abstract

Female sex workers (FSW) in India are highly stigmatised and discriminated against by the society. Additionally, this population faces public health issues, such as HIV, mental health challenges, and violence at work. Despite interventions being put in place, female sex workers continue to experience high HIV prevalence and violence. A scoping review of peer-reviewed articles was conducted by searching PubMed, PubMed Central, Embase, and CINAHL Plus using keywords. Using inclusion and exclusion criteria following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards, the identified papers were screened. Twenty-four articles were selected for this review after critical appraisal. The data extracted from these articles regarding HIV and violence among female sex workers (FSWs) in India were analysed using narrative analysis. Most of the research looked at the prevalence of sexual violence and HIV infections and the factors contributing to these conditions. At the same time, the rest focused on mood disorders (e.g., depression) among FSWs. Client and intimate partner violence were common occurrences for FSWs. HIV infection was more prevalent among women who were forced into sex slavery than among those who entered sex work voluntarily. The increased HIV infections associated with sexual violence have become a crucial issue.

1. Introduction

Sex work is one of the most longstanding professions [1]. According to a survey, there are about 10 million sex workers in India and Asia’s largest sex trade hub. India’s sex-work business value accounts for approximately 8.4 billion dollars. About 30% of sex workers are children [1]. Child sexual abuse is referred to the sexual activity that happens to an under the age of 18 reluctantly or involves pressure, manipulation, bullying, intimidation, threats, deception, or force. Nearly half a million children are dragged into the sex trade in India [1].

FSWs are a global reality regardless of whether it is localised in the community or not [2]. The high incidence of violence against female sex workers (FSWs) around the world, including sexual violence, makes them more susceptible to negative effects on their physical and mental health, particularly HIV infection [3].

The route of entry to the FSWs may have been different, with sex work as a chosen profession or as a result of sexual slavery and being a victim of sex trafficking or child sex abuse, but the consequences of all forms remain the same as FSW and all share the same type of mental and physical health risk and impact. According to a survey conducted by Rao et al. [4], two drivers that have forced Indian women into sex work were financial needs and broken families.

Gore and Patwardhan [2] argued that for Indian females the primary reasons for being a FSW are financial hardship and desperation. Broadly speaking these might include but are not limited to poverty due to widowhood or separation, family debt, lack of education, limited economic opportunities, lack of family support, lack of legal or social protection, negative social circumstances in life, vulnerabilities due to migration, sex trafficking, or even cultural tradition [2].

Although the exact number of female sex workers (FSWs) in India is not known it is estimated around 3 million out of the 1.4 billion population [5, 6]; they are a highly stigmatised group [7]. Several other laws have caused some degree of restrictions on female sex work [8].

However, most FSWs personally are not willing to admit being sex workers [9]. Estimates show that about 1% of females in urban areas engage in sex work [9]. Most of these FSWs are between 15 and 54 years [9] and their mean age is 30 years [2].

Gore and Patwardhan [2] reported that on average an individual FSW in India would meet 7 to 9 clients per day which is higher than average in the USA or Thailand with 2 and 5.4, respectively. Therefore, this level of contact poses a higher health risk in particular HIV infection to them [2]. Additionally, this population faces other public health issues such as mental health issues and violence [10, 11, 12, 13]. Notwithstanding interventions being implemented, FSWs continue to experience a surge in the prevalence of AIDS and the incidence of violence [12].

According to Ministry of Health and Family Welfare [14], more than 23 million of the Indian population are HIV patients (prevalence rate of 0.21%). Nevertheless, HIV infection among the general population has shown a decline from 1997 to 2021 [15].

However, the health challenge for the FSWs is overcoming health service access barriers such as access to HIV/AIDS treatment when needed, legal service, and protection. Therefore, these factors together make the FSWs highly vulnerable to HIV transmission [16].

According to the reports, Indian women accounted for 40% of annual new HIV infections in 2017 (see Figure 1) [17].

Figure 1.

HIV prevalence (%) among ANC client, FSW, MSM, IDU & other risk groups, India (HSS 2016–2017). Source: NACO [16].

Rao et al. [4] found that FSWs’ alcohol use has played as a negative factor in their ability to negotiate condom use during sex work and has increased their HIV vulnerability.

Research has identified that some of the sex buyers would bargain with the FSWs for paying a higher rate and having intercourse without contraception/protection [4].

FSWs in India live in an environment of risk and violence. For example, in a study of 200 sex workers, more than 95% of participants had experienced violence [12]. This shows that most FSWs have been victims of some form of violence from men in the street or from the police [12]. The first weeks into entering sex work tend to be the most dangerous. The violence comes in various forms, including cutting or stabbing with knives, acid attacks, sexual harassment, and beating [12, 18]. Some have even lost their lives to violence [19].

India is ranked third in terms of the HIV burden worldwide [20]. According to the National AIDS Control Organisation (2012), about 2.1 million people were living with HIV/AIDs in the country [20]. The epidemic is concentrated among high-risk groups such as sex workers, especially women [10]. HIV prevalence among female sex workers differs from one state to another in India. Maharashtra tends to have a high burden, with a prevalence of 7.4% [12]. While there is a decline in prevalence, it is still significantly higher among female sex workers compared to the general population.

Nonetheless, there were few reviews on FSWs, while to the best of our knowledge, there was no review on HIV and violence among FSWs in India. Therefore, this scoping review aims to explore HIV and violence among female sex workers in India.

2. Methodology

2.1 Study design

This scoping review has included quantitative, qualitative, and mixed methods of primary research studies.

2.2 Search strategy

The databases used for the initial review of literature were PubMed, PubMed Central, Embase, and CINAHL Plus. Cochrane Database of Systematic Reviews was searched for existing or ongoing systematic reviews. Different systematic reviews were found related to FSWs; however, no review was conducted on HIV and violence among female sex workers in India.

A wide range of literature searches were conducted on published literature to identify different types of publications. The literature search was limited to India only because India is placed third for the global burden of HIV [20] and a publication period from 2000 to 2021 to confine the research to recent evidence. The text words and relevant indexing were used in the search strategy to capture the concept of HIV and violence among female sex workers in India.

2.3 Search tool

See Table 1.

Population	India female sex workers
Exposure	Sex work
Outcome	HIV and violence

Table 1.

PEO.

The search terms were employed using Boolean operators (AND / OR), and the MeSH (Medical Subject Headings) browser was used for indexing articles.

The literature search in the databases used the following keywords:

• HIV/HIV infections/sexually transmitted infections

• Violence/client violence/Intimate Partner Violence (IPV)/sexual risk

• Female sex workers/sex work/sex workers/prostitution/sexual practices/sex trafficking/street-based female sex workers/FSWs, sex abuse, sex trafficking, child sexual abuse, sex slavery,

• India

The search was limited to the original research articles, English language articles and full-text articles.

In addition, reference lists of the included studies were searched to identify relevant studies, known as reference harvesting (Figure 2).

Figure 2.

Preferred reporting items for systematic reviews and meta-analyses (PRISMA) 2009 flow diagram.

2.4 Study selection

See Table 2.

Inclusion criteria	Exclusion criteria
All research studies, including female sex workers in India Articles about HIV among female sex workers Research involving violence against female sex workers Primary research articles, quantitative studies, qualitative studies, and articles published in the English language, including articles published from 2000 to 2021	Any investigations that are not involving female sex workers in India Research that is not related to HIV and violence Review articles, commentaries, letters to the editors, and case studies, other than English language articles are not included

Table 2.

Inclusion and exclusion criteria.

To avoid duplication bias, duplicate articles were removed before inclusion and exclusion criteria were implemented.

2.5 Implementation of inclusion and exclusion criteria

Initially, articles were screened for a study design that resulted after applying limitations. Further, titles and abstracts against inclusion criteria were scanned for the relevant articles, followed by the screening of complete articles identified in the initial screening as relevant potential articles. The articles with insufficient information regarding HIV and violence were excluded. Editorials, letters to the editors, review articles and commentaries were excluded. After the inclusion and exclusion criteria implementation, 21 Papers were chosen for the critical appraisal stage.

2.6 Data abstraction

Microsoft Excel was used to extract the data. The data extracted included the references of the article; research aim; the study setting, e.g., area, country; sample size; the study design, the key findings or the results related to HIV and Violence among female sex workers; the limitations of the study.

2.7 Analysis

As this scoping review includes data from both qualitative and quantitative studies, meta-analysis was not possible. The data taken from the included papers were organised and analysed using Microsoft Excel. After that, a textual narrative synthesis was performed.

2.8 Critical appraisal

The 21 studies were subjected to a critical assessment to determine their methodological strengths and shortcomings, the study’s validity, the results’ reliability, and the presence of biases. It was also done to see if the studies were designed, conducted, and published in a trustworthy manner, and if they provided a meaningful answer to the scoping review question. The studies were evaluated using a variety of appraisal methodologies, with the Critical Appraisal Skills Programme (CASP) being used to grade the qualitative research’s quality. The AXIS critical appraisal instrument was, designed expressly, used to appraise cross-sectional studies.

2.9 Ethical consideration

No ethical approval is sought for this research as this scoping review retrieves and synthesises the data from already published articles.

3. Results

3.1 The outcome of the critical appraisal

The critical appraisal resulted in 21 studies that were included in the review.

See Table 3.

Qualitative Studies: CASP tool	Section A: Are the results valid?					Section B: What are the consequences?
Reference	Was there a clear statement of the aims of the research?	Is a qualitative methodology appropriate?	Was the research design appropriate to address the aims of the research?	Was the recruitment strategy appropriate to the aims of the research?	Was the data collected in a way that addresses the research issue?	Has the relationship between the researcher and participants been adequately considered	Have ethical issues been taken into consideration?	Was the data analysis sufficiently rigorous?	Is there a clear statement of findings?	How valuable is the research?
Blanchard et al. [21]	+	+/−	+	+	+	−	+/−	+/−	+	+

Table 3.

Critical appraisal for qualitative studies using the Critical Appraisal Skills Programme (CASP) tool.

(+) = item adequately addressed, (−) = item not adequately addressed, and (+/−) = item partially addressed.

See Table 4.

	Introduction						Methods				Results					Discussion
Reference	Were the Aims/Objectives of the Study Clear?	Was the Study Design Appropriate for the Stated Aim(s)?	Was the Sample Size Justified?	Was the Target/Reference Population Clearly Defined?	Was the Sample Frame Taken from an Appropriate Population Base So That It Closely Represented the Target/Reference Population under Investigation?	Was the Selection Process Likely to Select Subjects/Participants That Were Representative of the Target/Reference Population under Investigation?	Were Measures Undertaken to Address and Categorise -non-Responders?	Were the Risk Factor and Outcome Variables Measured Appropriate to the Aims of the Study?	Were the Risk Factor and Outcome Variables Measured Correctly Using Instruments/Measurements That Had Been Trialled, Piloted or Published Previously?	Is It Clear What was Used to Determine Statistical Significance and/or Precision Estimates? (e.g., p-Values, Confidence Intervals)	Were the Methods (Including Statistical Methods) Sufficiently Described to Enable Them to Be Repeated?	Were the basic data adequately described?	Does the response rate raise concerns about non-response bias?	Were the results internally consistent?	Were the results presented for all the analyses described in the methods?	Were the authors discussions and the conclusions justified by the results?	Were the limitations of the study discussed?	Was ethical approval or consent of participants attained?
Reed et al. [22]	+	+	+/−	+	+	+/−	NA	+	−	+	+/−	+	NA	+	+	+/−	+	+
Reed et al. [23]	+	+	+/−	+	+	+/−	NA	+	−	+	+	+	−	+	+	+/−	+	+
Swain et al. [24]	+	+	+	+	+	+	+	+	−	+	+	+	−	+	+	+	+	+
Ramesh et al. [25]	+/−	+	+/−	−	−	+	−	+	−	+	−	+	−	+	+	+	+	+
Blanchard et al. [26]	+	+	+	+/−	+	+	−	+	−	+	+	+	−	+	+	+	+	+
Travasso et al. [27]	+/−	+	−	+/−	−	+/−	−	+	+	+	+/−	+	−	+	+/−	+	+	+
Saggurti et al. [28]	+	+	+/−	+	+	+/−	−	+	−	+	+	+/−	NS	+	+	+	+	+
Javalakar et al. [19]	+	+	−	+	+	+	−	+	+	+	+	+	NS	+	+	+	+	+
Patel et al. [29]	+	+	+	+	+	+/−	NS	+	+/−	+	+	+	NS	+	+	+	+	+
Sarkar et al. [30]	+/−	+	+/−	+/−	+/−	+/−	−	+	−	+	+/−	+	NS	+	+	+	+	+
Erausquin, Reed, and Blankenship [31]	+/−	+	+	+/−	+	+/−	−	+	−	+	+	+	−	+	+	+	+	+
George, Sabarwal, and Martin [32]	+/−	+	+	+	+	+	−	+	−	+	+/−	+	−	+	+	+/−	+	+
Wirth et al. [33]	+	+	+	+	+	+/−	−	+	−	+	+	+/−	−	+	+	+/−	+	−
Gupta et al. [34]	+	+	−	+	+	+/−	NS	+	+	+	+	−	NS	+	+	+/−	+	+
Heylen et al. [35]	+	+	+/−	+	+	+/−	NS	+	+	+	+	+		+	+	+	+	+
Mahapatra et al. [36]	+	+	+/−	+	+	+/−	NS	+	−	+	+/−	+	NS	+	+	+/−	+	+
Prakash et al. [37]	+	+	+	+	+	+/−	NS	+	+	+	+	+	NS	+	+	+	+	+
Reed et al. [38]	+	+	+/−	+	+	+	NS	+	−	+	+	+	NS	+	+	+	+	+
Patra et al. [39]	+	+	+	+	+	+/−	−	+	−	+	+	+	−	+	+	+	+	+
Deering et al. [40]	+	+	+	+	+	+/−	−	+	−	+	+	+	NS	+	+	+/−	+	+

Table 4.

Critical appraisal for cross-sectional studies using the appraisal tool for cross-sectional studies (AXIS).

(+) = item adequately addressed, (−) = item not adequately addressed, (+/−) = item partially addressed, NS = not stated or “I do not know”, and NA = not applicable.

3.2 Characteristics of the included studies

Table 5 presents the results of extracted summary information from the included studies. Characteristics of the included studies will be explored then.

Reference	Research aim	Study setting/location	Sample size	Study design	Key findings	Limitations
Reed et al. [22]	The current study investigates the relationship between FSW’s reported residential instability—defined as a high frequency of reported evictions—and their experiences of violence and sexual risk factors for HIV.	Rajahmundry, within the East Godavari District of Andhra Pradesh, India.	673 female sex workers	Cross-sectional study	Residential instability remained strongly related to STIs independent of the effects of either violence or unprotected sex with clients. Violence associated with residential instability was a contributor to reported STIs. The findings highlight the connection between HIV risk, violence, and residential instability. In addition to its association with collective risky sexual activities, residential instability appears to be linked to women’s HIV risk.	The cross-sectional design did not allow for prospective FSW follow-up, a difficulty in research with hard-to-reach populations
Reed et al. [23]	This study explores violence encountered in work and personal contexts and relation to HIV risk factors in these contexts among female sex workers (FSW) in Andhra Pradesh, India.	Andhra Pradesh, India	2335 FSW	Cross-sectional survey	According to models of adjusted logistic regression, FSWs with client violence were less likely to consistently use condoms with clients, more likely to report experiencing STI symptoms, and more likely to report accepting more money for unprotected sex trades. Women who reported spousal violence were also more likely to report STI symptoms, less likely to report consistently using condoms with clients.	Stigma frequently causes sensitive topics or socially unacceptable behaviour to go unreported.
Swain et al. [24]	The purpose of this study is to comprehend the relationships between violence, risk factors for HIV infection, and reproductive health among a group of mobile FSWs in India.	22 districts from four high HIV prevalence states (Andhra Pradesh, Karnataka, Maharashtra, Tamil Nadu) in India	5498 FSWs	Cross-sectional behavioural survey	Thirty-five percent of all mobile FSWs said they had been the victim of violence at least once in the previous year; 11% said it had been physical and 19.5% said it had been sexual. The findings show that FSWs who had ever been the victim of physical or sexual abuse were much more likely to be at risk for HIV infection as well as dangers to their reproductive health. FSWs who had suffered sexual violence were more likely to report inconsistent condom usage and develop STI symptoms than those who had experienced physical violence.	First self-reports are very susceptible to underreporting and social desirability biases. Self-reported symptoms of STI may be underestimated. Second, because analyses are cross-sectional, causality cannot be inferred from relationships between violence victimisation and reproductive health measures. Finally, results cannot be applied to other FSWs in India and are particular to mobile FSWs from four states with high prevalence.
Ramesh et al. [25]	This study evaluated the individual and combined relationships between sexual risk behaviours, mobility, and violence, as well as the prevalence of HIV and STIs among female sex workers (FSWs) in India.	eight high HIV prevalence districts of Andhra Pradesh state, India	2042 FSWs	A cross-sectional survey	One fifth of FSWs (19%) reported encountering violence; 68% said they had visited elsewhere in the past year at least once and engaged in sexual activity here. Compared to their peers, mobile FSWs were more likely to report violence (23% vs. 10%, p < 0.001). One in five people had an HIV positive test result. In adjusted models, FSWs who reported both mobility and violence compared to their counterparts were more likely to report unprotected sex with occasional (adjusted OR: 2.86, 95% CI: 1.76–4.65) and regular clients (adjusted OR: 2.07, 95% CI: 1.40–3.06) and to report HIV infection.	The limitations of self-reported data are widely acknowledged, and this study’s primary independent variables were based on self-reported responses.
Blanchard et al. [26]	The authors of this research present an “integrated empowerment framework” based on theoretical and programmatic literature and then employ it to empirically analyse the relationships between empowerment and social transformation and HIV risk reduction among FSWs in south India.	Belgaum, Gulbarga, Gadag and Dharwad districts in Karnataka, and Solapur in Maharashtra.	1750 FSWs	Cross-sectional behavioural tracking surveys	More programme contact was positively correlated with both power within and power with (p < 0.01 and p < 0.001, respectively). In terms of self-efficacy for condom and health care usage, these empowerment measures were likewise linked to “personal transformation” results (p < 0.001). The “social change” factors, such as increased autonomy and decreased aggression and coercion, were most strongly associated with collective empowerment (power with others), especially in districts with longer-running programmes (p < 0.05). Power with others was linked to condom use with customers (p < 0.001), but power within was linked to more frequent use of condoms with regular partners (p < 0.01) and higher service utilisation (p < 0.05).	First, because the surveys were cross-sectional, we are unable to determine the causal chain’s direction. Second, there could be participation bias. Third, even for variables measuring communal processes of empowerment, the responses were self-reported individually. If the community participation process results in social desirability in each FSW’s responses to empowerment questions, the resultant misclassification bias may become even more severe.
Travasso et al. [27]	The purpose of this study is to investigate the relationships between FSWs’ non-paying partner status, including cohabitation, and their exposure to HIV prevention programmes, involvement in social groups and activities, and use of health care services in three Indian states.	Maharashtra, Andhra Pradesh and Tamil Nadu	8107 FSWs	Cross-sectional survey	Analysis showed that FSWs reporting a non-cohabiting non-paying partner were more likely to be exposed to HIV prevention programmes, attend meetings, and visit a sexually transmitted infections clinic at least twice in the previous 6 months as compared to those reporting no non-paying partner. However, FSWs with a non-paying partner tended to use condoms consistently and were more susceptible to contracting HIV because they lived on the streets (p < 0.001) and were in debt (p < 0.001).	First, recall and social desirability biases were present. Second, cross-sectional data cannot be used to show causal links between partner status and the use of HIV prevention programmes. Third, only three vulnerability metrics were used to produce the vulnerability score. A further limitation of any studies on women’s experiences of violence is that experiences are often measured using questions like those in the IBBA.
Saggurti et al. [28]	The association between mobility indicators, socioeconomic vulnerabilities, and HIV risk behaviours among 5498 mobile female sex workers (FSWs) residing in India’s four states with high HIV incidence is examined in this study.	Andhra Pradesh, Karnataka, Tamil Nadu and Maharashtra, India	5498 FSWs	Cross-sectional behavioural survey	Even after adjusting for a number of demographic factors and socioeconomic vulnerabilities like experiences of violence, FSWs with higher levels of mobility reported inconsistent condom use in intercourse with clients considerably more frequently than FSWs with lower levels of mobility. Additionally, it was discovered that brief visits and attendance at Jatra (religious fairs) locations were significantly associated with the users’ inconsistent use of condoms during client interactions, as well as their continued use of sex despite the presence of STI symptoms.	First, only mobile FSWs were included in the study population; no non-mobile FSWs were. Second, this study shows that each of the variables analysed, including socio-demographic traits and associated vulnerabilities, raises the risk of HIV infection among mobile FSWs. Thirdly, because the replies to the analysis’s questions were self-reported, they were prone to social desirability and memory bias.
Javalkar et al. [19].	This study looks at the characteristics of relationships between female sex workers and their intimate partners and how those factors affect IPV.	47 villages in Bagalkot district, north Karnataka.	620 FSWs	Cross-sectional baseline survey	Even though most partnerships started after a sex work encounter, 84% of IPs claimed they were unaware of their current sex work activities. In the past 6 months, 49% FSWs reported experiencing emotional, 33% physical, and 7% sexual violence, whereas 24% FSWs reported experiencing recent severe physical and/or sexual violence from IPs. In the past 6 months, their clients had used physical and/or sexual violence against them, they had engaged in sexual activity with their IP while under the influence of alcohol, and they had provided financial support to their IP.	Researchers are unable to determine if there are temporal or causal relationships between factors and intimate partner violence because the data was cross-sectional. Additionally, there were several discrepancies in the time ranges employed, which could have improved reporting accuracy. There may be underreporting of behaviours.
Blanchard et al. [21]	The goal was to investigate the experiences and understandings of intimate partner violence and HIV/AIDS among Bagalkot sex workers and their intimate partners in order to inform both theories and practice.	Bagalkot district, Karnataka state, India.	38 participants	A community-based, interpretive qualitative methodology	The findings demonstrated that several interrelated, multi-level factors contributed to the broad acceptance of violence and its continued usage in participants’ intimate relationships. This included stigma, societal gender norms, and restrictions on sex work and personal expectations that justified violence and reflected them.	Their goal was to ensure the purposive sample was as representative as possible. However, bias could have developed if people who agreed to participate shared milder examples or were less reluctant to talk about violence. Particularly with regard to the level of conflict and condom use, there was probably some social desirability bias or non-disclosure in the stories.
Patel et al. [29]	The aims of this study are to identify major depressive symptoms among FSWs in southern India and evaluate the separate and combined relationships between mobility and violence and major depressive symptoms.	Six districts (Ananthapur, Chittoor, Karimnagar, Khammam, Nalgonda and Warangal)	2400 participants	Cross-sectional survey	Major depression was detected in 29% of FSWs, more than one-fourth of the population. In contrast to those who reported neither, FSWs who were both mobile for sex work outside of their district of residence and had encountered any violence (combined association) within the previous year were six times more likely to screen positive for major depression (62% vs. 19%). According to the individual association data, FSWs were three times more likely to screen positive for serious depression if they reported being mobile outside the district and if they had been physically or sexually assaulted within the previous year.	This study’s characteristics were based on self-reported responses, and it is well known that self-reported data has certain drawbacks. The FSW populations in this study are a part of the Avahan programme, which aims to empower and engage the community, they might not be representative of all FSW populations. This study only included a small sample of FSWs who were CBO members, its conclusions cannot be applied to all FSWs in India.
Sarkar et al. [30]	To comprehend HIV infection, violence, negotiating skills, and sex trafficking among sex workers in brothels in West Bengal, eastern India.	West Bengal, Eastern India	580 sex workers	Cross-sectional study	In contrast to Bangladeshis (7%) and Indians (9%), Nepalese (43%) had a higher seroprevalence of HIV. Twenty-four percent of sex workers entered the industry through being trafficked. When this profession first began, victims of trafficking, including those sold by family members, experienced more violence (57%) than those who entered the field voluntarily (15%). With the most recent two clients, the overall condom negotiating rate was 38%. HIV was found to be substantially linked with sexual violence by multivariate analysis.	Important research limitations included convenient sampling, self-reported behaviour, the absence of minor girls in brothels as study subjects, interviewing participants in brothels where privacy and appropriate spaces were not always available, the fear of disclosing private information about the brothel owner, lost business hours, and recall bias in some instances.
Erausquin et al. [31]	In this study, researchers investigate the potential links between five police-related incidents and indicators of HIV risk and violence among a sample of female sex workers (FSWs) in Andhra Pradesh, India, and we discuss the implications for HIV prevention.	Andhra Pradesh, India	835 FSWs	Cross-sectional survey	The findings showed that sexually transmitted infection symptoms, inconsistent condom use, accepting more money for sex without a condom, and being arrested were associated with having sex with police to avoid trouble, giving gifts to police to avoid trouble, having police take away condoms, experiencing a workplace raid, and being arrested.	The data analysis was cross-sectional, which limited the capacity to determine causality. Additionally, they only examined the experiences of adult FSWs; no inferences can be made about those of younger FSWs. Furthermore, it is questionable whether FSW self-reports of either HIV risk behaviours or experiences with police in this situation are accurate and reliable.
George et al. [32]	This study looks at connections between the types of sex work done and the prevalence of recent victimisation due to physical and sexual violence among a large sample of young FSWs.	Three districts of Andhra Pradesh state	1138 FSWs	Cross-sectional survey	A significant frequency of sexual and physical violence at work; 77% of FSWs reported sexual violence and 50% of FSWs reported physical violence. Comparatively to women who participate in sex work in their home districts.	The sampling approach employed in the current investigation restricts the ability to extrapolate and might have created bias if individuals were chosen based on an unidentified factor that was pertinent to the findings of the study.
Wirth et al. [33]	Researchers looked into the possibility of both forced and early introduction into sex work as potential explanations for the link between sex trafficking and HIV. They also tested if each of these connections had been altered by sexual violence.	Four districts (Bangalore, Bellary, Belgaum, and Shimoga) in Karnataka, India	1814 adult FSWs	Cross-sectional	Overall, 372 (21%) women fulfilled either one of the two sex trafficking definitional criteria: 278 (16%) people started doing sex work before turning 18, and 107 (5%) people said they were forced into sex work. 13 people (or 0.7%) met both requirements. Regardless of age at entry into sex work, women forced into the sector had a higher likelihood of HIV than women who did so voluntarily (odds ratio = 2.30, 95% confidence interval: 1.08, 4.90). When sexual violence was present, there was a more significant correlation between forced sex work and HIV infection (odds ratio = 11.13, 95% confidence interval: 2.41, 51.40).	Data on sexual assault was only collected for the prior year. Authors will have underestimated the impact of sexual violence. Next, because information on sex work admission was gathered at the same time as HIV status evaluation, they could not confirm that participation in the sex trade preceded HIV infection. The survey did not cover women who were involved in all types of sex work, despite the use of a probability-based sampling framework.
Gupta et al. [34]	The current study’s goals were to determine the prevalence of trafficking as a means of entering the sex industry among a sample of FSWs in Andhra Pradesh, India, as well as to look at potential differences in HIV risk factors (such as the use or non-use of services targeted towards FSWs) between women who entered the sex work through trafficking and those who did not.	Coastal Andhra Pradesh, India	812 FSWs	Cross-sectional study	The UN criteria of sex trafficking were met by 1 in 5 (19.3%) FSWs. Women who were trafficked into sex work were more likely than other FSWs to report recent violent experiences, have more clients per week, and have more days of sex work per week. Regarding condom use or knowledge of HIV, there were no appreciable variations.	The cross-sectional data could not be used to evaluate the temporality of associations. The reliance on self-report may also have caused underreporting of the mode and/or age of entry; however, this may mean that the findings understate the HIV-related vulnerabilities of FSWs who enter sex work through trafficking. Lastly, the results are particularly relevant to FSWs whose demographic data are represented in the current study because they are not reflective of a valid probability sample.
Heylen et al. [35]	The current article intends to fill the gap by examining patterns of physical abuse from various partners and alcohol consumption by both the FSWs and abusive partners using data from a quantitative survey among a diverse set of FSWs who solicit and work in different venues in Chirala, Andhra Pradesh.	Andhra Pradesh, India	589 FSWs	Cross-sectional study	Eighty-four percent of FSWs admitted to drinking, and 65% said they had ever been physically abused by a partner. Most abused women experienced abuse from several partners, frequently brought on by intoxication or FSW’s defiance. The frequency of alcohol use by the FSW was linked to abuse by clients and the primary partner in multivariate logistic regressions. Still, the primary partner’s abuse was the only one for which the partner’s alcohol use was significant.	This study was cross-sectional. Hence we were unable to establish causality. Second, it’s uncertain how well the study group represented the area’s population of more concealed FSWs.
Mahapatra et al. [36]	This study aims to examine the rate of non-disclosure of violence among FSWs in India and exposure to HIV prevention programmes.	Andhra Pradesh, Karnataka, Maharashtra and Tamil Nadu.	1341 FSWs	Cross-sectional survey	With significant variations in the pattern of disclosure between states, about 54% of FSWs did not reveal their experience of violence to anybody. 36% more FSWs discussed their experience with an NGO employee or colleague. Violence committed by non-paying partners was twice as likely to be reported as non-disclosure as violence committed by paying partners or a stranger. Similarly, FSWs who were not registered with an NGO/sex worker collective were 40% more likely to report non-disclosure of violence against those noted (58% vs. 53%).	First, answers to the victimisation of violence, non-disclosure, and information about the violent offenders are based on self-reports, and there may be underreporting. Second, there were various ways to answer the question about the person who committed the act of violence. Third, the study did not collect information on the type, extent, cause, or actions in response to the experience of violence.
Prakash et al. [37]	This study intends to investigate the overall (real) impact of violence on FSWs’ self-reported STI rates and treatment-seeking behaviour in the Thane district.	Thane district, Maharashtra	2785 FSWs	Cross-sectional behavioural study	At the time of the survey, almost 18% of the sampled FSWs reported experiencing physical abuse. FSWs, who solicited clients in public locations, worked jobs other than sex work, had funds and reported having a high client volume each week had a considerably increased likelihood of experiencing such assault. The average adjusted effect of violence definitely showed a decrease in treatment-seeking (10%, p < 0.05) and an increase in the probability of any STI (11%, p < 0.05) and many STIs (8%, p < 0.10).	Physical abuse, particularly those committed by regular partners, might be unreported. Other than this, the survey did not gather data on sexual violence. There was no quantifiable data in the survey to assess how empowered FSWs were in the study area. Lastly, the results of STI are based on self-reported symptoms rather than cases that have undergone clinical testing.
Reed et al. [38]	This study investigates the relationship between the difficulties of motherhood and sexual risk factors for HIV among female sex workers (FSW).	Rajahmundry, within the East Godavari District of Andhra Pradesh, India.	850 FSWs	Cross-sectional survey	FSW who reported having three or more children in the home or currently having child health concerns were considerably less likely to report consistent condom use and more likely to accept more money for sex without a condom. Women who indicated current child health problems were also more likely to report a STI symptom in the previous 6 months. Findings imply that increased vulnerability to HIV risk among FSWs is connected to burdensome caregiving obligations for children.	The cross-sectional design does not allow for prospective FSW follow-up and does not establish the temporality of these associations. Additionally, the analyses’ items rely on respondents’ self-reported responses. Stigma can frequently lead to underreporting of delicate subjects or socially unwelcome actions, as the sexual risk factors examined in the current study. Additionally, the results of the current study may not be generalizable to other populations of sex workers.
Patra et al. [39]	This study aims to understand more about the factors that influence anal sex behaviours among female sex workers (FSWs) and to look into the relationship between anal sex and HIV-related sexual risk factors in Andhra Pradesh, India.	Andhra Pradesh, India	795 FSWs	Cross-sectional behavioural survey	Anal sex was used by one-fourth (23%) of FSWs in the previous year. The likelihood of engaging in anal sex was higher among FSWs 35 years of age or older than it was among those under 25, among those who had been married in the past as opposed to those who are still married, as well as among those who reported heavy alcohol use as opposed to those who did not and those who had experienced violence as opposed to those who had not. STI-related symptoms were more prevalent among FSWs who engaged in anal intercourse than those solely involved in vaginal sex. There was no connection between using condoms and anal intercourse.	First, cross-sectional survey data were gathered, proving a cause-and-effect relationship is challenging. As the information was self-reported and acknowledged that there is a stigma attached to sharing such sensitive experiences, the prevalence of anal sex may be under-reported. Third, no biological samples were taken throughout the survey; rather, self-reported STI symptoms served as a marker for HIV risk.
Deering et al. [40]	This study explored the association between violence and inconsistent condom usage while characterising the nature and frequency of violence against female sex workers (FSWs) committed by their clients and their primary intimate or other non-paying partner (NPP). Additionally, the risk factors for client violence were evaluated.	Karnataka state, India	1219 FSWs	Cross-sectional survey	9.6 and 3.7% of 1219 FSWs reported suffering violence at the hands of clients and the NPP, respectively. Repeat customers produced similar outcomes. The NPP found no statistically significant association between ICU and non-paying partner violence. Only being recently arrested remained substantially linked with experiencing client aggression after multivariable analysis.	This analysis relied on self-reported responses to potentially sensitive topics, and as a result, the questions are prone to social desirability bias. This study may underestimate reports of violence in particular. Although the surveys utilised a relatively broad definition of physical violence, the purpose of sexual violence was more limited and might not have included all forms of violence.

Table 5.

Data extraction table.

4. Characteristics of the included studies

Based on the inclusion criteria, overall, 21 articles were considered for this study. All the research was carried out between 2000 and 2021. The most often used scales for identifying sexual violence HIV infections were the Integrated Behavioural and Biological Assessments (IBBAs) and Polling Booth Surveys (PBS). Most research looked at the prevalence of sexual violence and HIV infections and the factors contributing to these conditions. At the same time, the rest focused on depression and mood disorders among sex workers. Around 11 papers emphasised both sexual violence and sexually transmitted infections, approximately seven papers depicted HIV infections solely among FSWs, and few papers prioritised depressive mood and emotional instability of the female sex workers. The characteristics of the included studies are presented in Table 5.

4.1 Design of Studies

The selected 21 papers comprised cross-sectional studies, descriptive studies, and some qualitative studies. The studies were undertaken by questionnaire, online survey, convenience sampling and in-person interviews to get consistent data.

4.2 Female sex workers and HIV infections

Client and intimate partner violence (CIPV) was an everyday occurrence for female sex workers. In the setting of alcohol use, harassment and forced group sex created intense obstacles to condom use negotiation. Furthermore, women’s inability to negotiate condom use with intimate relationships was dictated by established gender conventions. However, there was evidence of women’s positive views of their contributions to family well-being through sex work and the adoption of successful survival mechanisms in the face of risk. Sexual assault, physical violence, accepting more money for unprotected sex, and a recent sexually transmitted infections (STIs), including HIV infection symptoms were all more common among FSWs who reported household instability.

Domestic violence (DV) and unprotected sex with customers contributed to reported HIV infections, however, domestic instability remained strongly related to STIs (e.g., AIDS) even when both violence and unprotected sex with clients were considered. The studies show a link between homelessness, victimisation, and the chance of contracting HIV. In addition to its connection to individual risky sexual practices, residential volatility appears to be linked to women’s HIV risk. Almost one out of every four sex workers (24%) had been trafficked into the industry.

Almost half of those surveyed (50.2%) were forced or pressured into sex labour before they became 18 (41.7%). FSWs who initially were victims of child sexual abuse had more unprotected transactional intercourse compared to adults (Adjusted Odds Ratio (AOR) = 2.06); however, being forced or coerced into sex work was associated with a lower risk of HIV transmission (AOR = 0.45). Participants were on average, 32 years old, 22% were married. They experienced physical (22%) and sexual (21%) assaults from their customers and spouses. Adjusted logistic regression analysis models suggested FSWs who had experienced client violence were more common among those accepting extra money for unprotected sex (AOR = 1.7; 95% CI;1.4 to 2.2), less likely to be consistent in condom use (AOR = 0.6; 95% CI;0.5 to 0.7), and more likely to report STI symptoms (AOR = 3.5; 95% CI; 2.6 to 4.6) [41].

Women who reported IPV were more likely to accept more money for unprotected sex trades (AOR = 2.1; 95% CI;1.2 to 3.7), less likely to use condoms consistently with clients (AOR = 0.5; 95% CI;0.3 to 0.8), and more likely to report STI symptoms (AOR = 2.6; 95% CI;1.6 to 4.1). The findings show a significant frequency of work-related physical and sexual violence, with 50% of FSWs reporting physical violence [34] and 77% reporting sexual violence.

When compared to women involved in sex work in their home districts, FSWs undertaking contract labour were at a higher risk of physical and sexual violence during work. Individual association findings suggest that FSWs who reported travelling outside of their area of residence and FSWs who had been beaten or raped in the previous year were three times more likely to screen positive for severe depression. There were no significant variations in HIV awareness or condom usage consistency.

4.3 Female sex workers and sexual violence

Around 54% of FSWs did not inform anybody about their violent experiences, with state-by-state variances. A further 36% of FSWs told an NGO worker or a peer about their experience. Non-paying partners were twice as likely to report non-disclosure as paid partners/strangers (53% vs. 68%, AOR = 1.8, 95%CI; 1.3–2.4).

Physical violence was reported by 18% of the FSWs polled at the time of the study. FSWs who recruited clients in public locations, engaged in other economic activities than sex work, possessed funds and reported a high client volume per week had a much-increased risk of encountering such assault. While engaging in sex with frequent partners and customers, FSWs suffering violence were likewise inconsistent condom users. The most recent two clients’ overall condom negotiating rate was 38%. HIV was shown to be substantially linked with sexual violence in multivariate analysis (odds ratio = 2.3; 95% confidence range 1.2–4.5) [27]. The study found that trafficked victims [24] were subjected to more violence, including sexual assault, and that sexual violence was linked to HIV infection.

The average adjusted impact of violence showed an increased probability of any STI (including AIDS). FSWs with three or more children in their home or current child health issues were considerably less likely to report safe sex practices (AORs ranged from 0.5 to 0.6) and more likely to pay more money for sex without a condom (AORs: 2.5). Women with current child health issues were more likely to have experienced a STI symptom in the last 6 months (AOR = 1.6; 95%CI:1.1–2.3).

Overall, 372 women (21%) satisfied one or all of the criteria used to define sex trafficking: 278 (16%) started sex work before the age of 18, and 107 (5%) were forced into sex work. Thirteen people (0.7%) satisfied both requirements [31]. Women who were forced into sex work were more likely to be HIV-positive than women who entered freely (odds ratio = 2.30, 95%CI: 1.08, 4.90).

Anal sex was more common among FSWs aged ≥35 years than those aged less than 25 years (AOR: 2.05, P = 0.05), in those who were previously married compared to those who are currently married (AOR: 1.88, P = 0.01), in those who had an income solely from sex work compared with those who had other sources of income (AOR: 1.54, P 0.05), in those who reported heavy alcohol consumption compared to those who had not (AOR: 2.80, P < 0.01).

About 34.9% of FSWs reported that they had been the victim of recent physical or sexual violence. Domestic (27.1%), workplace (11.1%), and community (4.2%) perpetrators were all involved in recent violence, with 6.2% of participants reporting both domestic and non-domestic (workplace/community) perpetrators. According to an adjusted study, workplace/community perpetrators’ experience of violence is more relevant than household violence in raising HIV/STI risk during sex work (lack of safe sex practices with clients; client or FSW under the influence of alcohol during last intercourse). When compared to FSWs who only reported violence by domestic or workplace/community perpetrators, women who reported recent violence by domestic and workplace/community perpetrators had the highest odds of high titre syphilis infection, current STI symptoms, and condom breakage at last sex, as well as the lowest odds of condom use at last sex with regular clients.

5. Discussion

The issue of sex work is multifaceted. On one hand, there is a challenge with some communities’ moral values and appear to be insupportable, on the other hand, it appears to be an unavoidable reality of life [2].

In India, female sex workers struggle in a violent atmosphere. FSWs who recruited clients in public locations, engaged in other economic activities than sex work, possessed funds and reported a high weekly client volume had a more significant chance of encountering such assault. While engaging in sex with frequent partners and customers, FSWs suffer violence and inconsistent condom users. Almost half (41.7%) of the female sex workers were forced or pressured into sex labour under a malicious ground called sexual slavery before turning 18 years old [42]. FSWs entering as a child had more unprotected transactional intercourse in the previous 90 days than those entering as an adult; nevertheless, being forced or coerced into sex work was associated with a higher risk of HIV transmission. Women were abused by several partners, typically because of intoxication or disobedience on the side of the FSW. This community’s other public health challenges include a high HIV prevalence, mental health difficulties, and violence [10, 11, 12]. Cutting or stabbing with knives, acid assaults, sexual harassment, and beatings are all examples of violence [12, 18]. Some have even died because of the violence [19].

According to a WHO report, violence against FSWs is common and admitted by many [3].

Law on sex work and its law enforcement regularly have failed to safeguard FSWs and therefore the risk of violence has increased. WHO report on India’s sex work indicated that sex workers were beaten by police (70%) and arrested (80%) without acceptable evidence [43].

The violence was fuelled by physical torture, rape, and insistent and forced unsafe sex, which harms the cognitive behaviour of female sex workers. In addition to its link to individual hazardous sexual practices, residential instability appears to be linked to women’s HIV risk. Compared to their peers, mobile FSWs were more likely to report violence (23% vs. 10%).

FSWs who were a non-paying spouses were more likely to be exposed to HIV prevention tools [41] and use them than those who did not. According to the findings, FSWs who were not supported financially by their partners and non-cohabiting partners were more likely to use the HIV prevention programmes.

Even after adjusting for many demographic variables and socio-economic vulnerabilities, including experiences of violence, FSWs with more mobility reported inconsistent condom usage in intercourse with clients considerably more frequently than FSWs with reduced mobility. Partner violence is always vulgar and crucial from the perspective of more propensity of spreading HIV infections among female sex workers.

Another important thing is the consumption of alcohol and other recreational drugs by FSWs to alleviate depressive moods. Domestic, workplace, and community perpetrators were the sources of violence, with 6.2% of participants reporting recent abuse from domestic and non-domestic (workplace/community) perpetrators. The widespread acceptability and continuance of violence, as well as the absence of safe sex practices in participants’ relationships, were caused by several interconnected, multi-level causes.

Individual expectations that justified violence and mirrored society’s gender norms were among them, and they were exacerbated by stigma and economic constraints associated with sex work. In India, there have been significantly high-rate incidents that reported to be work-related physical and sexual assault. FSW alcohol usage was linked to abuse by both the client and primary partner; however, abuse was seen with alcohol usage by only primary partner, not client. Inconsistent condom users were also violent while having sex with regular partners and customers. The average adjusted impact of the violence showed an increase in the probability of any STI including HIV infection. Violence compromises Sexual and Reproductive Health (SRH), with mounting chances of incidents like unplanned pregnancies, STI and in particular AIDS [43].

FSW in India hesitated to indicate if they had Unprotected Receptive Anal Intercourse (URAI) with a client in the previous 30 days as in Face-to-Face Interviews (FTFIs) compared with the anonymous Polling Booth Survey (PBS) that was 18.8% vs. 36.2% [44, 45]. FSWs who had anal intercourse were more likely than those who solely used vaginal sex to have HIV infection sexually transmitted infection (STI) symptoms. Baggaley et al. [46] has reported that the HIV transmission risk from Unprotected Receptive Anal Intercourse (URAI) is up to 18 times higher than from receptive vaginal intercourse (URVI). This is mainly explained by the fact that rectal mucosa lacks the protective immune barrier compared with cervico-vaginal secretions and also is more susceptible to traumatic abrasions that enable transmission [44, 45]. There was no link found between anal intercourse and the usage of safe sex practices.

While engaging in sex with frequent partners and customers, FSWs suffering violence were likewise inconsistent in adhering to safe sex practices The average adjusted effect of violence [47] showed a considerable increase in the probability of any STI (11%) and multiple STIs (8%), as well as a decrease in seeking treatment (10%). The extremity of partner violence and the helpless attitudes of women seemed to extend their harassment at work. There are different prospective studies in South India depicting a bit of diminution in HIV incidence in the last 5 years which could be possible by intensifying condoms among men. Moreover, client violence in sex work and constant harassment by an intimate partner have accelerated the suffering of female workers.

A “harm reduction approach” to complex problems like sex work would not deny that reality, but in contrast, aims to ensure safer and more equitable circumstances for sex workers. FSWs experience very complex, but potential risks including infection with HIV, violence, stigma, personal debt, criminalisation, trafficking, etc. Nevertheless, considering comprehensive governmental agencies strategies such as education, empowerment, prevention, care, occupational health and safety, and decriminalisation, have been proven to be highly effective and supportive for FSWs [2, 48]. But despite these initiatives, problems still exist, such as inequalities in access to treatment and support services and gaps in the healthcare system, especially for marginalised communities.

Generally speaking, as a population health preventive measure if the HIV infection epidemic in India needs to be managed, as one of the main sources of transmission, FSWs should be included in planning for the HIV prevention interventions/programmes [49].

5.1 Recognition of legal

On 19 May 2022, the Supreme Court of India announced sex work as a profession, like any other professionals, and sex workers are subject to dignity and constitutional rights, protective arrangements [50].

The recognition of sex work as a profession by the Supreme Court of India may have a potential positive impact as a kind of protection against the FSWs vulnerability, e.g., physical violence and some kind of social support. FSW must be regulated given that it has been recognised as a profession, and the safety of sex workers should be the primary consideration. This will lead to less harm being done to sex workers and a stronger system for protecting them from abuse and exploitation. Therefore, sex workers including FSWs are less exposed to sexually transmitted diseases like HIV and AIDS, and more likely to be protected from police violence, low pay, and harassment [1].

Nonetheless, the stigmatisation practised by the Indian diverse community for faith and cultural norms remains as barrier to the new legal arrangement being implemented fully. Additionally, to some extent, HIV and other infectious disease risk reduction remain heavily dependent on the behavioural patterns of both FSWs and their clients that would need more compliance to the health protection informed by health education and promotion under this category. Legislative actions and regulations have been attempted to address these challenges in recent years. For instance, discrimination in the workplace and hospital settings is prohibited under legislation in India that safeguards the rights of individuals living with HIV/AIDS. These regulations seek to advance equality and guarantee AIDS/HIV patients’ access to necessary care. National policy makers should realise that reduction in violence was proven to be another effective factor in HIV transmission and needs to be part of the joint policies for both public health interventions and social protection initiatives.

Legalisation of sex work in India offers a path to decriminalising the sex work and status as a profession that may ensure a better quality of life and socio-economic living status for the sex workers [50]. Following professional recognition, there is clearly an indication for authorities to establish a mandated health screening programme (especially AIDS) for the FSWs as part of the strict industry regulations [1].

6. Strengths and limitations

To the best of authors knowledge, this study is the first scoping review on HIV and violence among female sex workers in India. To reduce bias, the critical appraisal was conducted twice, with a one-week gap between the first and second appraisals, and the two assessments for each study were then compared. Only peer-reviewed articles were included in the study, both a strength and a weakness. Only papers published in English are included in the review, which adds bias due to location and language. Furthermore, omitting articles that are not available in full text may result in the omission of current articles.

7. Conclusion

In India, female sex workers are a severely stigmatised community. The increased HIV infections associated with sexual harassment has become a crucial issue. Findings suggest that women’s entry into sex work are primarily due to financial hardship. Even though female sex workers are acquainted with the violent and risky behaviour of their partner, they cannot negotiate with free consent due to their vulnerability (e.g., physical and financial). The prevalence of violence and its link to reproductive health and HIV risk demonstrates that abuse, in general, is a key driver of reproductive health hazards, and sexual harassment is strongly linked to HIV risk among people who have been victims of violence. FSWs unsafe sex practices, negligence about using condoms, job insecurity, and economic crisis all play crucial roles in enhancing sexual violence and HIV infections among female sex workers. Domestic violence is associated with physical injuries, homicide, suicide, emotional distress as well as spreading of sexually transmitted diseases among female sex workers. The violence rate should be highlighted along with the HIV intervention program. The importance of addressing violence as a significant part of the HIV reduction programme should be clarified to the policy makers. Appropriate measures can reduce the vulnerability of female sex workers, ensure their fundamental rights, and provide a violence-free healthy work environment.