ABSTRACT

This study analyzed the exposure of women engaged in prostitution in downtown São Paulo to COVID-19. This cross-sectional study had a convenience sample selected in May 2021. We interviewed 219, mostly black, middle-aged, poor women with comorbidities. Among them, 61 had shown COVID-19 symptoms, 23, tested positive for the disease, seven underwent hospitalization, and four reported post-COVID-19 complications. Only 26 (30.2%) had been vaccinated. In addition to gender, race, and class inequalities, these women suffer both from a higher risk of contracting COVID-19 due to their working conditions and from the subsequent worsening of that disease due to age and lack of vaccination.

Women; Sex Workers; COVID-19, epidemiology; Risk Factors; Gender Inequality; Race Factors

INTRODUCTION

The new coronavirus, SARS-CoV-2, causes COVID-19, an infectious disease^aaBrazilian Ministry of Health, Health Surveillance Secretariat, Department of Immunization and Communicable Diseases, General Coordination of the National Immunization Program. National Plan for the Operationalization of the Vaccine against COVID-19. 4th ed. Brasília, DF; February 15, 2021. [cited 2021 Sep 12]. Available from: https://www.gov.br/saude/pt-br/media/pdf/2021/janeiro/29/PlanoVacinaoCovid_ed4_15fev21_cgpni_18h05.pdf . As of July 4, 2021, Brazil has had approximately 18.6 million cases of the disease and 518,000 deaths^bbBrazil: WHO Coronavirus Disease (COVID-19) dashboard with vaccination data. Geneva (CH): WHO; 2021 [cited 2021 Mar 12]. Available from: https://covid19.who.int/region/amro/country/br . In the state of São Paulo, vaccination began in January 2021, following priority criteria; first vaccinating healthcare providers, older adults, and persons with comorbidities^ccSão Paulo (State). #Vacina Já. São Paulo; 2021 [cited 2021 Sep 12]. Available from: https://www.vacinaja.sp.gov.br/ . In addition to these and according to social determinants of health, this vaccination plan also included highly socially vulnerable populations, but fail to include persons engaged in prostitution under the same criteria.

Despite severe socioeconomic inequalities already affecting the persons in the group of vulnerable populations, the COVID-19 pandemic caused a health, economic, political, and social crisis which further worsened these persons’ vulnerability¹1. Platt L, Elmes J, Stevenson L, Holt V, Rolles S, Stuart R. Sex workers must not be forgotten in the COVID-19 response. Lancet. 2020;396(10243):9-11. https://doi.org/10.1016/S0140-6736(20)31033-3
https://doi.org/10.1016/S0140-6736(20)31... . Thus, women engaged in prostitution’s sociodemographic characteristics, health, access to services, exposure and history of contamination should inform the attention and care allocated toward this population, so as to include them in vaccination priority groups. We conducted this study to assess the exposure of women engaged in prostitution working in downtown São Paulo to COVID-19 and evaluate what preventive measures these women adopted against the disease.

METHODS

An observational, cross-sectional study was conducted with data collected from a convenience sample between May 27 and 29, 2021, during an educational action organized by a non-governmental organization, the collective Mulheres da Luz, in partnership with the discipline of Infectious Diseases of the Santa Casa de São Paulo School of Medical Sciences. Women engaged in prostitution who attended the educational action, which took place at a square near the Luz subway station in downtown São Paulo, were included in our study. Informed consent forms were signed by all participants before research began. Interviews were conducted individually and outdoors, respecting social distancing protocols. This study was approved by the Research Ethics Committee of the Irmandade da Santa Casa de Misericórdia CAAE: 47175821.3.0000.5479.

Questions on sociodemographic data, work and behavior during the pandemic, prevention and exposure factors to SARS-CoV-2, comorbidities, medication, close contact with someone infected during the transmission period, whether they showed symptoms or tested positive for COVID-19, hospitalization, post-COVID-19 complications, and vaccination status were included in our questionnaire. At the time data were gathered, persons over 45 years of age with comorbidities or disabilities, healthcare providers over 30 years of age, puerperal and pregnant women, municipal transit workers, and homeless people over 18 years of age registered in reception centers were eligible for vaccination against COVID-19 in the municipality of São Paulo^ddSão Paulo Municipal Health Department. Instruction no. 21 for Dose Prioritization. Campaign Vaccinate Sampa against COVID-19. São Paulo; 2021 [cited 2021 Sep 18]. Available from: https://www.prefeitura.sp.gov.br/cidade/secretarias/saude/vigilancia_em_saude/doencas_e_agravos/coronavirus/index.php?p=312200 .

Descriptive statistical analyses were described by means and standard deviations, and categorical variables, by absolute and relative frequencies.

RESULTS

We evaluated a total of 219 women with a mean age of 41.3 years (SD = 12), a minimum age of 19 years, and a maximum age of 73 years. Of the total number of interviewees, 78.8% declared themselves to be cisgender, 69.3%, black or mixed, 42.7% live in rented homes, and 9.2% were homeless or in shelters. Regarding working habits, 34.2% reported working seven days a week, turning a weekly average of 18.5 tricks (SD = 14.7), with most women turning between 11 and 30 tricks per week (51.1%). Table 1 provides additional details.

In total, 166 women (77.2%) reported using masks while on the streets as a protective measure, whereas 27 failed to do so (12.6%). In our sample, 192 women (88.9%) reported wearing cloth masks, whereas 37 (17.1%) chose surgical, and seven, PFF2 ones (3.2%).

Of the 219 women interviewed, 23 (11.7%) reported having tested positive for COVID-19, of which seven had undergone hospitalization, and four, some complication due to the disease. Of the total number of participants in our study, 180 (82.6%) reported not having yet been vaccinated. Among those who already met vaccination criteria at the time of the interview, 60 (69.8%) lacked immunization.

DISCUSSION

Since the beginning of the COVID-19 pandemic, women engaged in prostitution have been unable to interrupt face-to-face services to conform to sanitary measures¹1. Platt L, Elmes J, Stevenson L, Holt V, Rolles S, Stuart R. Sex workers must not be forgotten in the COVID-19 response. Lancet. 2020;396(10243):9-11. https://doi.org/10.1016/S0140-6736(20)31033-3
https://doi.org/10.1016/S0140-6736(20)31... .

Moreover, the atypical circumstances of the pandemic induce perverse effects, imposing greater risks on the most invisible sectors of society²2. Azam A, Adriaenssens S, Hendrickx J. How Covid-19 affects prostitution markets in the Netherlands and Belgium: dynamics and vulnerabilities under a lockdown. Eur Soc. 2021;23 Suppl 1:S478-94. https://doi.org/10.1080/14616696.2020.1828978
https://doi.org/10.1080/14616696.2020.18... . In this context, due to immunization plans excluding them from priority vulnerable groups and several national government plans, from financial aid, economic crises affect even more the already socioeconomically marginalized women engaged in prostitution. Moreover, even with the end of social isolation, the economic crisis due to the pandemic will persist, possibly leading to a greater number of persons engaged in prostitution, resulting in elevated levels of vulnerability³3. Fedorkó B, Stevenson L, Macioti PG. Sex workers on the frontline: an abridged version of the original ICRSE report: “The role of sex worker rights groups in providing support during the COVID-19 crisis in Europe”. Glob Public Health. 2021;1-10. https://doi.org/10.1080/17441692.2021.1945124
https://doi.org/10.1080/17441692.2021.19... .

Our study found that comorbidities, and the lack of access to vaccination and to protective measures among these women are aggravating factors for the risk of infection by SARS-CoV-2, corroborating the data described in the recent literature⁴4. Mesenburg MA, Hallal PC, Menezes AMB, Barros AJD, Horta BL, Barros FC, et al. Doenças crônicas não transmissíveis e covid-19: resultados do estudo Epicovid-19 Brasil. Rev Saude Publica. 2021;55:38. https://doi.org/10.11606/s1518-8787.2021055003673
https://doi.org/10.11606/s1518-8787.2021... .

Among the 219 interviewees, 86 reported comorbidities, the most common of which were hypertension (AH) (40.7%), severe chronic pneumopathy (24.4%), immunosuppression (22.1%), and diabetes mellitus (19.8%). According to the 2020 Brazilian Guideline on Arterial Hypertension, 21.4% of the Brazilian population reports suffering from AH, a prevalence that increases to 65% in persons over 60 years of age⁵5. Barroso WKS, Rodrigues CIS, Bortolotto LA, Mota-Gomes MA, Brandão AA, Feitosa ADM, et al. Diretrizes Brasileiras de Hipertensão Arterial - 2020. Arq Bras Cardiol. 2021;116(3):516-658. https://doi.org/10.36660/abc.20201238
https://doi.org/10.36660/abc.20201238... . In this study, however, interviewees’ mean age was 41.3 years, and only 7.3% of them were over 60 years of age. This age disparity allows us to infer that such women show an increased incidence of AH at earlier ages, possibly due to the exacerbation of other risk factors.

According to the National Immunization Plan (PNI) in Brazil, individuals with comorbidities belong to one of the vaccination priority groups against COVID-19. However, in this study, only 26 of the 86 women who reported having comorbidities had received immunization (30.2%). Thus, even if government agencies prioritize the ill, it seems that this information fails to reach the most vulnerable populations. Vaccination of women engaged in prostitution depends on their access to social and health centers¹1. Platt L, Elmes J, Stevenson L, Holt V, Rolles S, Stuart R. Sex workers must not be forgotten in the COVID-19 response. Lancet. 2020;396(10243):9-11. https://doi.org/10.1016/S0140-6736(20)31033-3
https://doi.org/10.1016/S0140-6736(20)31... . The stigma hanging over them may be one of the factors distancing them from public social and health services, including immunization campaigns. Historically, society has viewed these women, and still does, as “disease reservoirs” transmitting STIs, disregarding the risk of illness they run.

Regarding masks, we found that most women used them (59.4%), but this proportion falls short of satisfactory due to the sanitary situation of COVID-19 and the mode of transmission of the virus. One explanation for this is that the number of their usual clients decreased due to the pandemic, which led these women to accept new clients in whom they had no trust or whose care against COVID-19 they could not know⁶6. Singer R, Crooks N, Johnson AK, Lutnick A, Matthews A. COVID-19 prevention and protecting sex workers: a call to action. Arch Sex Behav. 2020;49(8):2739-41. https://doi.org/10.1007/s10508-020-01849-x
https://doi.org/10.1007/s10508-020-01849... . Moreover, these clients may demand the removal of their masks during sessions⁶6. Singer R, Crooks N, Johnson AK, Lutnick A, Matthews A. COVID-19 prevention and protecting sex workers: a call to action. Arch Sex Behav. 2020;49(8):2739-41. https://doi.org/10.1007/s10508-020-01849-x
https://doi.org/10.1007/s10508-020-01849... . Thus, as with the fight against HIV, the fight against COVID-19 is extremely complex⁶6. Singer R, Crooks N, Johnson AK, Lutnick A, Matthews A. COVID-19 prevention and protecting sex workers: a call to action. Arch Sex Behav. 2020;49(8):2739-41. https://doi.org/10.1007/s10508-020-01849-x
https://doi.org/10.1007/s10508-020-01849... and, despite educational measures and donations of masks to these women, many continue to turn tricks without using them due to their financial needs. Thus, the difficulty in wearing a mask during sessions makes explicit the need for specific care for this population, such as vaccination priority.

CONCLUSION

This study shows that the women engaged in prostitution interviewed were mostly black, middle-aged, poor, and unvaccinated against COVID-19. Thus, in addition to gender, race, and class inequalities, these women suffer both from a higher risk of contracting COVID-19 due to their working conditions and the subsequent worsening of that disease due to age and lack of vaccination. Other aspects, such as the prevalence of comorbidities, absence of the use of masks during sessions, and the impossibility of social distancing contribute to these factors, making the scenario even more delicate.

Finally, we must not underestimate the impact of the lack of access to information and to already available health services due to the notable precariousness of care for this population.

The multiple vulnerabilities shown, therefore, point to the pressing need for specific public policies for this population located in a vulnerable area such as downtown São Paulo. Currently, these women are invisible to society and to the Unified Health System (SUS) due to the lack of respect for its principles of universality, integrality, and equity of access to health. Thus, the visibility of women engaged in prostitution in all contexts, especially during the pandemic, is crucial for Brazilian public health to realize its principles.

Acknowledgements

To the collective Mulheres da Luz for all the help during the research; to professor Taiana Cunha Ribeiro for the conception of the extension project in which our data was collected.

REFERENCES

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