title: Work environments and HIV prevention: a qualitative review and meta-synthesis of sex worker narratives.
abstract: BACKGROUND
  Sex workers (SWs) experience a disproportionately high burden of HIV, with evidence indicating that complex and dynamic factors within work environments play a critical role in mitigating or producing HIV risks in sex work. In light of sweeping policy efforts to further criminalize sex work globally, coupled with emerging calls for structural responses situated in labour and human-rights frameworks, this meta-synthesis of the qualitative and ethnographic literature sought to examine SWs' narratives to elucidate the ways in which physical, social and policy features 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 to elucidate SWs' narratives and lived experiences of the complex and nuanced ways in which physical, social, and policy 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' narratives revealed the nuanced ways that physical, social, and policy features of work environments shaped HIV risk and interacted with macrostructural constraints (e.g., criminalization, stigma) and community determinants (e.g., sex worker empowerment initiatives) to shape SWs' agency in negotiating condom use. SWs' narratives revealed the ways in which the existence of occupational health and safety standards in indoor establishments, as well as protective practices of third parties (e.g., condom promotion) and other SWs/peers were critical ways of enhancing safety and sexual risk negotiation within indoor work environments. Additionally, working in settings where negative interactions with law enforcement were minimized (e.g., working in decriminalized contexts or environments in which peers/managers successfully deterred unjust policing practices) was critical for supporting SWs' agency to negotiate HIV prevention.
  
  
  CONCLUSIONS
  Policy reforms to remove punitive approaches to sex work, ensure supportive workplace standards and policies, and foster SWs' ability to work collectively are recommended to foster the realization of SWs' health and human rights across diverse settings. Future qualitative and mixed-methods research is recommended to ensure that HIV policies and programmes are grounded in SWs' voices and realities, particularly in more under-represented regions such as Eastern Europe and Sub-Saharan Africa.
authors.affiliation: Gender and Sexual Health Initiative, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada. gshi@cfenet.ubc.ca.|Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada. gshi@cfenet.ubc.ca.
authors.forename: Shira M
authors.initials: SM
authors.lastname: Goldenberg
authors.affiliation: Gender and Sexual Health Initiative, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.|Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
authors.forename: Putu
authors.initials: P
authors.lastname: Duff
authors.affiliation: Gender and Sexual Health Initiative, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.|Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
authors.forename: Andrea
authors.initials: A
authors.lastname: Krusi
mesh_terms: D017280:Condoms / Q000706:statistics & numerical data; D015658:HIV Infections / Q000517:prevention & control* / Q000523:psychology / Q000635:transmission; D006801:Humans; D033262:Narration; D009784:Occupational Diseases / Q000517:prevention & control* / Q000523:psychology / Q000821:virology; D016272:Occupational Health / Q000592:standards; D011209:Power, Psychological; D012111:Residence Characteristics; D021841:Safe Sex; D011477:Sex Work / Q000523:psychology*; D060386:Sex Workers / Q000523:psychology*; D012725:Sexual Behavior; D057545:Social Stigma; D017132:Workplace / Q000523:psychology*