Sex workers
Overview
- Currently, there is no evidence that sex workers in Australia have higher rates of sexually transmitted infections (STIs) than the general population. Sustaining low STI rates remains a priority.
- High priority groups include street-based sex workers, sex workers who inject drugs, culturally and linguistically diverse sex workers, Aboriginal and Torres Strait Islander sex workers and men who have sex with men and transgender sex workers.
- There has been widespread adoption of safer sex practice in the Australian sex industry through sex worker advocacy, peer-based education and support and outreach services.
- Regular testing for STIs and blood borne viruses is recommended.
- Frequency of testing should be determined in consultation with the sex worker and guided by risk assessment. Sex workers may request more frequent testing to comply with jurisdictional-based legal frameworks and workplace requirements.
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Infection |
Consideration |
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Consider self-collection of samples for testing. |
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Consider self-collection of samples for testing. If NAAT test result is positive, take swab at relevant site(s) for culture, before treatment. |
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Repeat test if patient exposed within previous 45 days (window period). Consider PEP if a patient was exposed in the last 72 hours, and consider PrEP if the patient has ongoing risk of human HIV exposure. |
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Repeat test if patient exposed within previous 12 weeks (window period). If clinical suspicion of syphilis, refer to the syphilis guideline. |
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Confirm hepatitis A virus (HAV) immune status (history of prior vaccination or serology) and offer vaccination if not immune and susceptible (e.g. Men who have sex with men). Further testing unnecessary after completing vaccination. For more information The Australian Immunisation Handbook. |
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Confirm hepatitis B virus (HBV) immune status (history of prior vaccination or serology) and vaccinate if not immune. Vaccination is free in most states and territories for sex workers. Serological testing (hepatitis B surface antibody only) is recommended 4-8 weeks after completing the primary course of vaccination for people at risk of hepatitis B. For more information The Australian Immunisation Handbook |
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If antibody positive, test for hepatitis C RNA to determine if patient has active hepatitis C. |
PEP - Post-exposure prophylaxis
PrEP - Pre-exposure prophylaxis
RNA – Ribonucleic acid
Specimen collection guidance
- Recommendations about the frequency of testing may be guided by jurisdictional-based legislation and guidelines.
- Offer testing more often if condom and dental dam use is < 100% (including history of condom breakages or slippages) or at the request of the person.
- If condom breakage or slippage (regardless of whether there has been ejaculation): discuss with the sex worker how long it has been since the breakage, the last time they had a sexual health test, and their sexual practices to determine when the initial testing should be.
- If the sex worker has been testing regularly and uses condoms in their personal and professional lives, recommend STI testing 7 days after breakage or earlier if symptoms present.
- If the sex worker has not had a recent test, offer baseline testing immediately and then follow-up testing 7 days after breakage or earlier if symptoms present.
- If baseline testing performed: Inform the sex worker of incubation periods and that STIs detected on baseline testing are not a result of the breakage.
- Consider emergency contraception and HIV post-exposure prophylaxis (PEP)and hepatitis B PEP, as appropriate. Offer repeat swabs in 2 weeks and repeat serology in 3 months (i.e. after appropriate window periods).
- It is not recommended to test for herpes or genital warts with serology. Herpes is a clinical diagnosis supported by a swab of a lesion tested for HSV PCR.
- Reflex testing is an HCV PCR test done if an HCV antibody test is positive. The opportunity to diagnose HCV status is done without having to recall the client. Two Potassium ethylenediaminetetraacetic acid (EDTA) samples need to be collected with the initial serum sample. Request HCV PCR if HCV antibody (anti-HCV) confirmed positive (ensure with the local pathology service if this test is possible, as sample preparation will differ in metropolitan, regional and rural areas)
Special considerations
Privacy
Ask about the best way to contact with results and reminders. Sexual health clinical services, where a Medicare card is not required, are available in major cities.
Certificate of sexual health check attendance
A certificate of attendance or sexual health check certificate may be requested by the patient (NB. working name only can be used, at the patient’s request). This document is to certify that the patient attended a clinic for tests for STIs only. It should not include examination, findings or results and does not provide evidence that there is no infection. A certificate of attendance may reiterate that some infections may not be detectable for weeks or months after infection, if they become detectable at all (e.g. herpes and human papilloma virus (HPV)).
Laws
Laws regarding sex work vary between states and territories.
Queensland legislation requires sex workers in licensed brothels to provide a Sexual Health Check Certificate of Attendance every 3 months. Prostitution Act 1999 QLD (s89, s90)
The law in Victoria is changing. Sex work is being decriminalised in two stages. Stage 1 began on 10 May 2022 and included several key legislative changes related to sexual health:
- End to mandatory 3-monthly testing for sex workers
- Repeal of offences for working with an STI or BBV or permitting a sex worker to work with an STI or BBV
- Repeal of offence for engaging in vaginal, oral, or anal services without the use of a condom or other appropriate barrier
Men who have sex with men sex workers
For men who have sex with men sex workers, test for hepatitis A and offer vaccination if non-immune.
If test results are positive, refer to STI management section for advice:
Provide advice about avoiding oral, vaginal and anal sex until no longer infectious (exclusion period). In some jurisdictions, it is an offence for a sex worker to knowingly work during any period when they are known to be infectious with an STI. Advice may be sought from specialist sexual health clinicians.
Contact Tracing
It may be difficult or not possible for sex workers with STIs to disclose the identity of clients. It should be borne in mind that protected sex is practised almost universally within the sex industry. Provider referral whereby the health practitioner or specialist contact tracer gains consent of your client to inform the contacts (notification is anonymous and maintains client confidentiality) may be the preferred method of contact tracing. Advice on provider referral can be sought from the local sexual health clinic, public health unit or sex worker organisations.
Even if all test results are negative, use the opportunity to:
- Provide information about safer sex practices and risk minimisation strategies. This information may include:
- Condom and dental dam use
- PEP, PrEP and U=U (undetectable equals untransmittable) to prevent HIV, for those sex workers who may be at risk (e.g. men who have sex with men, or trans and gender diverse sex workers).
- Contraception choices
- For more information about safer sex tools and risk minimisation strategies for sex workers refer to the Scarlet Alliance RED BOOK — STI & BBV RESOURCES FOR SEX WORKERS BY SEX WORKERS
- Provide contact details for sex worker organisations , e.g. the Scarlet Alliance
- Vaccinate for hepatitis A and hepatitis B, if susceptible
- Consider human papillomavirus (HPV) vaccination if under 30 years old
- Discuss and activate reminders for regular testing. State-based requirements and/or risk assessment will guide the frequency of testing.
100% documentation of hepatitis B immunity or vaccination status in current sex workers.