World Journal of AIDS, 2012, 2, 203-211 Published Online September 2012 ( 203
Mandatory Testing for HIV and Sexually Transmissible
Infections among Sex Workers in Australia: A Barrier to
HIV and STI Prevention
Elena Jeffreys, Janelle Fawkes, Zahra Stardust
Scarlet Alliance, Australian Sex Workers Association, Redfern, Australia.
Received February 21st, 2012; revised March 28th, 2012; accepted April 28th, 2012
Australia is an apt landscape upon which to measure the success of mandatory testing of HIV and sexually transmissible
infections (STIs) among sex workers. Mandatory testing is implemented in some Australian jurisdictions and not others,
allowing for a comprehensive comparison of the outcomes. It is apparent that mandatory testing of HIV and STIs
among sex workers in Australia has proven to be a barrier to otherwise successful HIV and STI peer education, preven-
tion and free an d anonymous testing and tr eatment. The outcomes of mandatory testing are coun terproductive to reduc-
ing HIV and STI rates, do not reach the intended target group, are costly and inefficient, and mandatory testing has
proven to be a very difficult policy to repeal once in place. Scarlet Alliance, the Australian Sex Workers Association , as
well as numerous academics and policy leaders in Australia recommend against mandatory testing of HIV and STIs
among sex workers.
Keywords: Sex Work; Mandatory Testing; STI and HIV Prevention; Health Promotion; Public Health Objectives;
Criminalization; Law Reform; Scarlet Alliance
1. Introduction
Sex workers in Australia are world-renowned for having
consistently low rates of sexually transmissible infection s
(STIs) and HIV. This phenomena—a result of Australia’s
partnership approach to HIV, sex worker peer education
and safer sex practices—is regularly documented in
studies on the sex industry in Australia. Research dem-
onstrates that sex workers have low rates of HIV [1,2]
(less than 1%), low rates of STIs [2,3], and high rates of
prophylactic use [4]. Sex workers maintain these stan-
dards across various states in Australia.
Studies illustrate high levels of condom use amongst
sex workers across states. In New South Wales, the Law
and Sex worker Health (LASH) report found that co ndo m
use approaches 100% in Sydney brothels in 2011 [5,6].
In 2010, Donovan et al. found in the NSW sex industry,
“condom use for vaginal and anal sex exceeds 99% and
sexually transmissible infection rates are at historic lows”
[7]. High condom use is also demonstrated in Western
Australia—the LASH Report in 2005 found close to
100% rate of condom use at work in Perth brothels [8].
In other states in Australia, epidemiology and research
consistently show that sex workers have lower rates of
STIs than the non-sex working popul at i on. The 2001-2009
annual national su rveillance rep ort demonstrates that pr e-
valence of HIV among sex workers has remained con-
sistently low—less than 1% [9]. In the Australian Cap ital
Territory (ACT), a Canberra Sexual Health Centre study
demonstrates that positive diagnosis of Chlamydia among
sex workers between 2002 and 2005 was 1.6% and
positive diagnosis of syphilis was 0.0% [10]. Such low
rates of STIs among sex workers are unique, particularly
when one reviews these statistics in the context of wider
studies on STIs rates among the general community. For
example, 2008 research from the ACT illu strates that the
prevalence of Chlamydia among tested women in general
practices was 4.3%. Among women 20 - 25 years this
rate rose to 6.5% [11]. In that same state in 2004 the
incidence of positive tests for Chlamydia was 5.1%
Similarly low rates of STIs amongst sex workers are
illustrated in research from Victoria [13]. In their 2009
study on STI screening intervals, David Wilson et al.
estimate STI incidence in Victorian sex workers based on
sexual health clinic databases as “0.1/100 person-years
for HIV, 0.1/100 person-years for syphilis, 3.3/100 per-
son-years for Chlamydia, and 0.7/100 person-years for
gonorrhea” [14]. Such studies contribute to an over-
whelming evidence base that consistently reveals that sex
Copyright © 2012 SciRes. WJA
Mandatory Testing for HIV and Sexually Transmissible Infections among Sex Workers in Australia:
A Barrier to HIV and STI Prevention
workers have lower rates of STIs than the general
community. This evidence is contrary to the public per-
ception and stereotype that forms the basis of mandatory
testing rationales.
These low rates of STIs and HIV exist despite failed
attempts to implement mandatory HIV and STI testing in
some jurisdictions. Effective prevention education, access
to free and anonymous testing and the strong uptake of
condom use by sex workers are identified as key factors
in successful engagement of sex work communities in
HIV prevention. Even though mandatory testing has not
been a feature of successful prevention strategies in
Australia, it is still entertained as a method of “controlling
HIV and STIs amongst sex workers” in Australia and
across Asia and the Pacific region, often to allay com-
munity fears around public health. This suggests the
implementation of mandatory testing is motivated by
perception, rather than evidence or the best interests of
sex worker health and safety.
2. Mandatory Testing: Based on Perception,
Not Evidence
Mandatory testing fails as evidence-based policy. Man-
datory testing is based on false perceptions about sex
workers, and is divorced from the ways in which sex
workers operate on a daily basis. Epidemiological evi-
dence shows that mandatory testing is unnecessary. Sex
workers already engage in safer sex practices, act as safer
sex educators of our clients, peers and communities, and
are experts at identifying, assessing and managing dif-
ferent degrees of risk.
Mandatory testing is based on a narrow view of what
constitutes sex work, wh ich assumes that all forms of sex
work involve penetrative intercourse. Sex workers pro-
vide a variety of services, and these services involve dif-
ferent degrees of risk (and some, no risk at all).
For sex workers who engage in massage, masturbation,
bondage and discipline, X-rated striptease or fantasy
scenarios that do not involve penetrative sex or exchange
of bodily fluids, mandatory testing may be unnecessary,
or at the very least, it may bear no relevance to their per-
sonal practice. Other sex workers may work infrequently,
for whom monthly STI screening intervals may be inap-
propriate and intrusive. Sex workers working in pornog-
raphy have maintain ed that a perf ormers’ use of co ndoms,
dams and safer sex supplies should be a personal one that
relates to their individual workload, practice and level of
risk. Sex workers have resisted proposals to mandate
condom use in pornographic films, and re-framed de-
bates about risk—noting that condoms can be risky for
performers where they may have a latex allergy, or
where “latex drag” can lead to rawness, bacteria and mi-
cro-abrasions that make them more vulnerable to STIs
[14]. Porn Star Madison Young argues that for perform-
ers working as part of a monogamous couple, condoms
may not be necessary, and that the use of condoms should
always be a personal decision [15]. A sex worker’s deci-
sion to seek STI and HIV testing should be based on
one’s individual practice (as is the case for non-sex
workers), rather than mandated at law.
3. Voluntary Testing Is the Optimal Model
State requirements for mandatory testing of sex workers
are in direct opposition to the Australian Government’s
national approach to STI and HIV testing. The National
STI Strategy clearly recommends voluntary, patient-ini-
tiated STI and HIV testing as the optimal approach with
demonstrated success. The HIV Strategy states that “prin-
ciples for informed consent and confidentiality underpin
high rates of voluntary testing”, and aims to increase the
number of people voluntarily seeking testings [16].
Moreover, the Strategies sp ecifically warn of the risks of
mandatory testing. The STI Strategy cautions that man-
datory testing has “potential to limit access to services
for higher ris k gr o ups” [17].
There is no evidence to suggest that voluntary testing
is inadequate or ineffective in detecting STIs and HIV.
Rather, there has been demonstrated success among sex
workers in Sydney and Perth (where testing is voluntary),
who show uniformly low STI pr evalen ce when co mpared
with sex workers in Melbourne (where testing is manda-
tory) [18]. The success of a voluntary model is further
evident in New Zealand, where, since decriminalisation
of sex work in 2005, nearly 97% of sex workers have
voluntary sexual health checks [19].
4. Criminalisation of HIV Positive Sex
Workers and Sex Workers with an STI
The same stereotypes and misconceptions that form the
foundation for rationales behind mandatory testing—that
sex workers are vectors of disease, that all sex work in-
volves penetrative sex, and that sex workers are incapa-
ble of identifying or managing risk—are further used to
justify regressive laws and policies that criminalise sex
workers living with HIV or STIs.
This means that in some states it is illegal to work as a
se x worker of you have an STI or are HIV positive, and in
some cases, you may be required to disclose your health
status to all sexual pa rtne rs. These laws act to ostracise t hose
who already bear stigmas attached to sex work and HIV,
impede health promotion, and increase discrimination from
partners, public and health providers.
The most notorious example of the damaging effects
of these laws was when an Australian sex worker living
with HIV was jailed in 2008 in the Australian Capital
Copyright © 2012 SciRes. WJA
Mandatory Testing for HIV and Sexually Transmissible Infections among Sex Workers in Australia:
A Barrier to HIV and STI Prevention 205
Territory. Despite no evidence of transmission of HIV or
unsafe sex practice, the person was prosecuted for pro-
viding a sexual service whilst knowingly HIV positive.
As a contact-chasing strategy, and against the advice of
Scarlet Alliance, the Chief Public Health Officer released
the person’s name, HIV status and unrelated personal
details to the media [20]. The person was outed, stigma-
tised and vilified in articles appearing across Australia,
New Zealand, Germany, Vietnam, Belgium and Hong
Kong [21]. Elena Jeffreys, Kane Matthews and Alina
Thomas write in their article on HIV criminalisation and
sex work that as a result of this case, “many sex workers
became fearful of testing for HIV” leading to a dramatic
drop in sex worker attendance at outreach medical ser-
vices. They report: “In the four-week period following
the court case, the numbers attending the service dropped
from an average of 40 per night to three” [21]. Ally
Daniel writes that the effect of criminalisation is then to
decrease testing, decrease detection, and therefore poten-
tially increase transmission rates overall [21].
The criminalization of sex workers working with HIV
or STIs is unnecessary and contrary to public health ob-
jectives. State criminal laws are contrary to the National
Guidelines for the Management of People with HIV Who
Place Others at Risk, which recognize the human rights
of people living with HIV, assume equal responsibility
for HIV prevention among all people, and recommend
counselling and sup port over detention or police referral.
Moreover, these state criminal laws are largely divorced
from the ways in which people—including and especially
HIV positive sex workers—practice safer sex. Research
from the Australian Federation of AIDS Organisations
reveals that men who have sex with men already under-
take a range of non-condom based HIV risk reduction
strategies, including strategic positioning (the use of se-
rostatus to determine sexual roles during sex), serosort-
ing (the restriction of unprotected sex to partners of con-
cordant HIV status), and undetectable viral load (the use
of viral load test results to assess the risk of HIV among
non-condordant partners) [22]. These strategies indicate
that people living with HIV are aware and conscious of
negotiating, identifying and managing risks—by catering
solely to HIV positive clients, utilisin g safer sex practices,
or negotiating HIV risk reduction strategies. Janelle
Fawkes writes elsewhere:
The high number of sero-discordant relationships in
which the HIV negative partner does not acquire HIV
demonstrates that protected sex with an HIV-positive
person does not necessarily lead to transmission... The
high levels of condom use amongst Australian sex work-
ers means there is no need to exclude HIV positive peo-
ple from sex work [23] .
5. Mandatory Testing: A Policy Failure
Mandatory testing in Australia endorses a false sense of
security in the form of a “certificate”, which, due to
window periods, doesn’t actually confirm a sex worker’s
sexual health status, but instead just indicates that the sex
worker has participated with the states’ mandatory test-
ing regime. As a result, compliance with the regime has
no measurable impact on the health of sex workers who
are not experiencing STI symptoms, and has a negative
impact on those who are. The sexual health services are
overloaded by a regime that must produce certificates for
every sex worker, regardless of whether they are experi-
encing symptoms or not. As concluded by Donovan and
Harcourt, sex workers who experienced a condom brea-
kage and need to access sexual health services quickly
are particularly marginalised by mandatory testing [24].
Mandatory testing has a negative impact on the general
delivery of sexual health services to sex workers.
Mandatory testing also has had negative consequences
for sex worker confidentiality, human rights and indu str ia l
rights in Australia. In some instances, sex workers report
brothel operators requiring them to see a doctor of the
operator’s choice, following which the results are handed
directly back to the operator rather than the worker,
without regard for that worker’s privacy. Although it
may be legal to work, it may be difficult to obtain work
without a health certificate, thus mandatory testing be-
comes imbedded within industrial relations practises. In
these situations “voluntary” testing is not voluntary in
practice. In some countries, sex workers report sexual
health clinic staff arriving spontaneously at a sex work
workplace to conduct blood tests on the premises. This
was witnessed by Scarlet Alliance migration project staff
while on outreach in Thailand. Those sex workers who
declined testing were treated with suspicion.
An NGO Delegate (Asia and the Pacific) to the 2011
UN AIDS Program Coordinating Board writes that HIV
programming for sex workers is often imple mented at the
expense of sex worker human rights:
When there is HIV programming for sex workers, it is
often fraught with human rights violations. In trying to
meet donor indicators, national voluntary counselling
and testing (VCT) targets often lead to programmes that
force sex workers into unnecessary HIV and STI tests, as
evidenced in Laos, Thailand and India. Results are often
shared with brothel owners, outreach workers and NGOs.
Pre- and post-test coun selling do not inform sex workers
of their right to refuse tests. In some countries, the police
or the army are also used to enforce testin g and to Reg is-
ter sex workers [25].
In these instances mandatory testing, though not legis-
lated in developing coun tries in the way it is in Australia,
is implemented arbitrarily by police and other powerful
Copyright © 2012 SciRes. WJA
Mandatory Testing for HIV and Sexually Transmissible Infections among Sex Workers in Australia:
A Barrier to HIV and STI Prevention
institutions within resource poor developing country set-
tings, such as the 100% condo m use program.
100% condom use programmes have been imple-
mented in Thailand, Cambodia, Laos, Mongolia, the
Philippines, Vietnam, Indonesia and parts of China. Al-
though implementa tion approaches vary in each country ,
100% condom use programmes often involve reg istration
of sex workers and compulsory health checks. The Net-
work of Sex Work Projects (NSWP) reports that the real-
ity of these programmes is frequently compulsory Regis-
tration of sex workers with law enforcement authorities,
mandatory health examinations, including HIV tests,
with sex workers sometimes escorted to clinics by police,
and generally greater power over sex workers in the
hands of polic e [26].
These approaches are far less effective than funding
community-based strategies in promoting sexual health,
are an ineffective use of public resources, and remain
detrimental to sex worker human and industrial rights,
yet as they continue to be implemented in countries like
Australia are often held up as suitable for developing
countries. In their international comparative study on sex
worker human rights, the Open Society Institute found
The framing of sex work issues within health ha s been
both useful and dangerous for sex workers. Many good
organizations working with sex workers and actions for
change have been supported by health funds, especially
HIV funds [Thailand, Brazil, Australia]. However, the
most repressive forms of regulation have also been justi-
fied on public health grounds [Queensland, Australia]
Australia has a responsibility to remove mandatory
testing due to its ineffectiveness, not just to improve
outcomes for sex workers health in Australia, but also to
ensure that the same oppressive and misguided policies
are not promoted in developing country settings. All the
research shows that mandatory testing has failed in Aus-
tralia. It will fail similarly in developing country setting s .
Further, mandatory testing consumes and misdirects
important funding. The more government expenditure on
mandatory STI screening, the less is available for cost-
effective preventative health programs with demon-
strated success (such as peer education). Contemporary
research from Victoria, Australia, indicates that current
mandatory testing rates are “excessive” [28], placing
strain on sexual health clinics that are already beyond
capacity. A study by Wilson et al. reveals that it costs
over AUS$90,000 in screening costs for every Chlamy-
dia infection averted. Their study recommend that HIV
testing be conducted every 40 weeks and Chlamydia
testing approximately once per year (this is in stark con-
trast to the monthly screening tests required for sex
workers in that state). The authors recommend that
“screening intervals for sex workers should be based on
local STI epidemiology and not locked by legislation”
[29]. This is crucial for the development of evidence-
based policy. In their study, Samaranayake et al. found
that the use of resources in screening and providing cer-
tificates to sex workers could be better spen t, particularly
as sex workers already show the lowest STI and HIV
rates out of any subpopulation [29].
As a policy, mandatory testing is far removed from
evidence-based , tailored, targeted policies that hav e been
shown to be effective for health promotion. Research
from The Lancet supports targeted investments for key
affected populations as a strategy to “change the trajec-
tory of national epidemics” [30]. Instead, Harcourt et al.
warn, “Pressure on resources can lead to poor medical
standards; including insensitiv e or inhumane treatment of
sex workers, poor-quality examinations, and breaches of
confidentiality” [3 1].
Harcourt et al. in Australia concur, “Pressure on re-
sources can lead to poor medical standards; including
insensitive or inhumane treatment of sex workers, poor-
quality examinations, and breaches of confidentiality”
In community consultation on this issue in Brisbane,
March 2005, Brisbane Sexual Health Clinic (BIALA)
staff and individual sex workers raised access problems
as a result of mandatory testing to Scarlet Alliance rep-
resentatives. A major problem raised was that over-test-
ing of a population that is underrepresented in actual in-
fection rates resulted in rushed interactions with sex
workers, who wait many hours for a short consultation
during which the nu rse will tick the boxes on the manda-
tory testing guideline sheet and then rush the sex worker
back out the door again. Mandatory testing in this in-
stance resulted in nurses no longer feeling responsible
for sex workers’ sexual health, and effectively unable to
implement a quality HIV/STI screen, because the goal of
the appointment is to pro duce a certificate, not to provide
sexual health care for the worker.
The Australian Government [32], sexual health pro-
fessionals and non-government organizations [33], in-
cluding Scarlet Alliance [34], acknowledge that volun-
tary testing is the optimum approach to sexual health
testing for sex workers in Australia.
In 2005, research by Donovan and Harcourt found
When sex workers are compelled to attend health ser-
vices in jurisdictions that attemp t to regulate prostitution,
the often cursory or inhuman treatment they receive
within these services can be co unter productive [35].
Laws requiring mandatory testing (along with registra-
tion) may actually drive sex workers away from health
Copyright © 2012 SciRes. WJA
Mandatory Testing for HIV and Sexually Transmissible Infections among Sex Workers in Australia:
A Barrier to HIV and STI Prevention 207
services. Donovan and Harcourt surmise:
While most health workers try to assist [sex workers]
in a hostile policy environment, sex workers consistently
demonstrate that capacity to protect themselves and their
clientele if the basic resources for health promotion are
available [36].
Commonwealth HIV and STI strategies in Australia
Despite the occupational risks, the incidence of STIs in
sex workers in Australia is among the lowest in the world.
This has largely been achieved through the adoption of
voluntary health policies implemented by the sex Indus-
try [36].
The long term ineffectiveness of mandatory testing,
compared with systemic sexual health education, must
also be considered. At best, mandatory testing reduces
sexual health to a mere condition of employment. At
worst, it can place the individual’s privacy at risk, and
enforce unnecessarily frequent invasive health testing.
Systemic sexual health education encourages the indi-
vidual to undertake testing of their own volition, in the
interest of their own sexual health, not simply for the
sake of meeting regulatory requirements. In addition,
information gained from sexual health education will
stay with a sex worker throughout their sexually active
life, rather than being a perfunctory action that is aban-
doned entirely once leaving the sex industry.
So with the social and clinical data already in, and
health care professionals in the field fully aware of the
failure that mandatory testing has wrought upon sex
workers health, and all the evidence pointing towards a
repeal of mandatory testing, why haven’t the laws been
6. Mandatory Testing: Who Is Responsible?
Currently a range of different laws and regulations in
some Australian states and territories require sex workers
to undergo mandatory or compulsory testing. In Queen-
sland the Prostitution Licensing Authority ensures that it
is the responsibility of brothel owners of licensed broth-
els to collect a “certificate” from sex workers
to indicate that that they have undergone a sexual
health examination. A certificate must be presented be-
fore commencing, and thereafter at least every three
months for the duration of their engagement, at the
brothel [37].
This sexual health examinatio n prior to the production
of the certificate must have been carried out in a pre-
scribed manner, which is scripted for nurses and doctors
easy compliance [38] and the certificate must be filled
out using a specific form [39].
What is different about these guidelines and forms
compared to others in the “Priority Groups” section of
Queensland Health’s clinical management guidelines, is
that sex workers’ testing is regulated by criminal law,
while other such health testing is governed by health
policy. The Prostitution Licensing Authority explains
that Queensland brothel owners in licensed brothel
premises will be assumed to have known that they have
permitted a worker to work with an
infective STI unless they can prove that they be-
lieved on reasonable grounds that the sex worker had
been medically examined or tested at three monthly in-
tervals (as per s.9 of the Prostitution Regulation) and
was not infective [40].
As such, brothel owners and/or licensees of brothels
will be held criminally liable if a sex worker is found to
be working with an STI and/or HIV on their premises
unless the proper procedures were followed by Queen-
sland Health nurses in the implementation of mandatory
testing and regardless of whether or not an STI or HIV
was actually transmitted by that sex worker.
Similarly in Victoria sex industry business owners
and/or licensees must prove they have taken all reason-
able measures to ensure employees of their business do
not have an ST I or HIV:
It is an offence to permit a sex worker to work if you
know they are infected with a STI. It is also illegal for sex
workers to work if they know they are infected. If one of
your sex workers is found working with a STI, you are
presumed to have known they were infected unless you
believed, on reasonable grounds, that the sex worker had
been undergoing regular blood or swab tests; or was not
infected [41].
Private sex workers are also required to maintain such
certificates [42].
The certificate itself is not accompanied by any results.
It only sho ws that the sex work er attended the clinic, not
that they are uninfected. As such, the purpose of the cer-
tificate is clear—it is intended to protect the business
owner from being charged for knowingly allowing a sex
worker to work with an STI (including HIV). The cer-
tificate admonishes the owner by assuming that if a sex
worker goes to testing regularly they must be relatively
uninfected with STIs (including HIV). What is unclear
however, is why the testing regime is described as the
responsibility of the sex worker by Melbourne Sexual
Health on their website [43 ].
It is simultaneously suggested in the health messaging
in Victoria that both brothel and the sex worker are re-
sponsible for the implementation of mandatory testing,
yet nowhere does it suggest that mandatory health care
provision is the responsibility of the health care provider
(in this case, Melbourne Sexual Health). And this is
where the first of many ethical and practical problems
with the implementation of mandatory testing become
Copyright © 2012 SciRes. WJA
Mandatory Testing for HIV and Sexually Transmissible Infections among Sex Workers in Australia:
A Barrier to HIV and STI Prevention
clear. Once a health issue falls into the domain of being
able to be criminally prosecuted, no-one wants to take
full responsibility for its implementation—least of all the
health care services.
Similarly, in the implementation of mandatory testing
in Queensland, it is acknowledged that sex workers
“prefer that only their professional name be recorded
when these Certificates are issued” [44]. Requiring sex
workers to give full legal names and identifying details
would be a barrier to sex workers attending clinics for
screening and health tests, and as such, a legal name is
not required. However because the clinic has a legal ob-
ligation to terminate the validity of the certificate should
any of the sex workers in question’s STI or HIV tests
return positive, Queensland Health must maintain records
enough to contact the sex worker. This adds a more in-
tensive burden of record storage upon the clinic than
otherwise would be necessary. This is due to legal re-
quirements, yet the Guidelines state that “Queensland
Health must balance the sex worker’s right to privacy
with the duty of care both to the client and the public”
[45]. In this case, as in Victoria, the health agency re-
sponsible for implementing mandatory testing is care-
fully avoiding using language that would show that it is
their responsibility, preferring instead to describe it as a
responsibility to the “client” and the “public” rather than
what it actually is—a requirement by law, determined by
In a recent public forum in Victoria when questioned
about their participation in mandatory testing regimes,
staff from a range of services repeatedly and emotionally
argued that mandatory testing was neither their response-
bility nor their concern [45].
This raises further policy questions: if health bureau-
crats are reluctant and reticent to take legal, administra-
tive, moral and practical responsibility for mandatory
testing implementation, who is taking responsibility for
its failure?
7. Mandatory Testing: How to Repeal?
As with all nasty infections, prevention is better than a
cure. There is mounting evidence that decriminalization
provides a best practice model of sex industry regulation
for public health and human rights outcomes and that
mandatory testing is unnecessary. The Australian Sixth
National HIV St rat egy e xpl ains:
In relation to sex workers, some data suggest that un-
der a decriminalized and deregulated legislative frame-
work sex workers would have increased control over
their work and be able to achieve similar or better health
outcomes without the expense and invasiveness of man-
datory screening [46,47].
Once in legislation though, mandatory testing laws
have proven to be difficult to shift, and strong evidence
has not been enough to result in the necessary policy
Laws and policies which promote or enforce manda-
tory or compulsory testing are in o pposition to best prac-
tice models of voluntary testing and self regulation of
sexual health amongst sex workers [48]. Yet even in
Australia, where mandatory testing regimes are not sup-
ported by current epidemiology [49], the political will to
change the laws is thin on the ground.
In Victoria, health professionals, policy experts, sex
workers and researchers have recommended that man-
datory testing laws be repealed. Changes to the Sex
Work Act in 1994 did not repeal mandatory testing but
instead inserted the ability for the state’s Health Min ister
to change the frequency of testing from the current
monthly requirement. As yet the Health Minister has
refused to reduce frequency of testing [50].
8. Conclusions
Mandatory testing fails to acknowledge that Australian
sex workers already practice safe sex as a fundamental
occupational health and safety practice. There is no evi-
dence that mandatory testing produces better results than
well resourced, targeted community based health promo-
tion strategies involving sex worker communities in a
comprehensive response, including provision of peer
education and pro phy l act i c s.
Testing is invasive for many sex workers. This is ex-
aggerated when the frequency of testing is both unneces-
sary and without any benefit to the individual.
Mandatory testing is expensive, especially when medi-
cal, pathology, infrastructure and administration costs are
considered. Furthermore, frequent testing places an un-
necessary burden on existing, already stretched, health
resources. Mandatory testing programs exacerbate exist-
ing social injustices by labeling sex workers as “dis-
eased” and unable, or unwillin g, to take responsibility fo r
their own and their clients’ sexual health.
Mandatory testing places an undue burden on sex
workers: a burden which is not based on a high risk of
transmission. It is also worth noting that clients of sex
workers clients are not subject to mandatory testing re-
gimes, although HIV is at least three times as efficient in
male-to-female transmission, as it is in female-to-male
transmission [51].
Mandatory testing creates a false sense of security for
clients (that all sex workers are free of infection) thereby
undermining the fundamental message of safer sex and
decreasing the ability of individual sex workers to im-
plement protected sex. Mandatory testing programs un-
dermine individual sex workers’ autonomy and empow-
erment. Mandatory testing fails to acknowledge that
Copyright © 2012 SciRes. WJA
Mandatory Testing for HIV and Sexually Transmissible Infections among Sex Workers in Australia:
A Barrier to HIV and STI Prevention 209
Australian sex workers are far better informed on safe
sex practices than the broader Australian community.
There are wider consequences of mandatory testing.
As Scarlet Alliance write in the Principles for Model Sex
Work Legislation:
Mandatory testing for sex workers perpetuates preju-
dices and unfounded fears of sex workers as diseased. It
fuels stereotypes that have flow on effects in the way sex
workers are treated by the public, media, health organi-
zations and the wider community. These stereotypes are
reflected in the higher health insuran ce and superannua-
tion premiums sex workers pay [52].
These prejudices have wide ramifications. The Austra-
lian Red Cross, for example, bans sex workers from do-
nating blood because sex workers are perceived to be
“high risk” [53]. As this paper demonstrates, this “risk”
has no evidentiary b asis, but its myth serves as a founda-
tion for ongoing discrimination, and the maintenance of
prejudicial and damaging laws such as criminalization of
sex workers with HIV and mandatory testing.
[1] Australian Government Department of Health and Ageing,
“Sixth National HIV Strategy 2010-2013,” Commonwealth
of Australia, Canberra, 2010, p. 16.
[2] Australian Government Department of Health and Ageing,
“Second National STI Strategy 2010-2013,” Common-
wealth of Australia, Canberra, 2010, p. 16.
[3] NSW Department of Healt h, “STI Strategy Env iron ment al
Scan,” Sydney, 2006, p. 20.
[4] R. Perkins and F. Lovejoy, “Call Girls,” University of
Western Australia Press, Sydney, 2007.
[5] B. Donovan, C. Harcourt, S. Egger, L. W. Smith, K.
Schneider, J. M. Kaldor, M. Y. Chen, C. K. Fairley and S.
Tabrizi, “The Sex Industry in New South Wales: A Re-
port to the NSW Government,” Kirby Institute, Univer-
sity of New South Wales, Sydney, 2011, p. 7.
[6] B. Donovan, “Preliminary Findings,” Proceedings of the
Sex Workers Outreach Project Policy Meeting, Australian
Society for HIV Medicine, 9 September 2011.
[7] B. Donovan, C. Harcourt, S. Egger and C. K. Fairley,
“Improving the Health of Sex Workers in NSW: Main-
taining Success,” Public Health Bulletin, Vol. 21, No. 3-4,
2006, p. 74.
[8] B. Donovan, C. Harcourt, S. Egger, K. Schneider, J.
O’Connor, L. Marshall, M. Y. Chen and C. K. Fairley,
“The Sex Industry in Western Australia: A Report to the
Western Australian Government,” National Centre in
HIV Epidemiology and Clinical Research, University of
New South Wales, Sydney, 2010, p. 7.
[9] National Centre in HIV Epidemiology and Clinical Re-
search, “HIV/AIDS, Viral Hepatitis and Sexually Trans-
missible Infections in Australia, Annual Surveillance
Report 2010,” National Centre in HIV Epidemiology and
Clinical Research, The University of New South Wales,
Sydney, 2010.
[10] C. J. Sturrock, M. J. Currie, H. Vallay, E. J. O’Keefe, R.
Primrose, P. Habel, K. Shamburg and F. Bowden, “Com-
munity-Based Sexual Health Care Works: A Re- view of
the ACT Outreach Program,” Sexual Health, Vol. 4, 2007,
pp. 201-204. doi:10.1071/SH07003
[11] F. J. Bowden, M. J. Currie, H. Toyne, C. McGuiness, L.
L. Lim, J. R. Butler and N. J. Glasgow, “Screening for
Chlamydia Trachomatis at the Time of Routine Pap
Smear in General Practice: A Cluster Randomised Con-
trolled Trial,” MJA, Vol. 188, No. 2, 2008, pp. 76-80.
[12] M. J. Currie and F. J. Bowden, “An Epidemic of Infection,
Not Just Testing: Chlamydia Prevalence Estimates in the
Australian Capital Territory 1998-2004,” Australian and
New Zealand Journal of Public Health, Vol. 30, No. 3,
2006, p. 286. doi:10.1111/j.1467-842X.2006.tb00873.x
[13] D. Wilson, K. Heymer, J. Anderson, J. O’Connor, C.
Harcourt and D. Donovan, “Sex Workers can be Screened
too Often: A Cost-Effective Analysis in Victoria, Aus-
tralia,” Sexually Transmitted Infections, October 2009.
[14] T. Clark-Florey, “Porn’s Last Taboo: Protected Sex,”, 2009.
[15] M. Young, “Free Choice on Condoms,” Opposing Views:
Issues, Experts, Answers, 2010.
[16] Australian Government, Department of Health and Ag-
ing, “Sixth National HIV Strategy 2010-2013,” Com-
monwealth of Australia, 2010, p. 28.
[17] A. Samaranayake, M. Chen, J. Hocking, C. Bradshaw,
R. Cumming and C. Fairley, “Second National Sexually
Transmissible Infections Strategy 2010-2013,” Common-
wealth of Australia, 2010, p. 26.
[18] D. Wilson, K. Heymer, J. Anderson, J. O’Connor, C.
Harcourt and D. Donovan, “Sex Workers Can Be Scr-
eened Too Often: A Cost-Effective Analysis in Victoria,
Australia,” Sexually Transmitted Infections, 2009.
[19] C. Healy, “Decriminalization in New Zealand, New Zea-
land Prostitutes’ Collective,” Proceedings of the Austral-
asian Society for HIV Medicine Conference, Sydney,
2010. doi:10.1016/S0968-8080(10)35496-6
[20] E. Jeffreys, K. Matthews and A. Thomas, “HIV Crimina-
lisation and Sex Work in Australia,” Reproductive Health
Matters, Vol. 18, No. 35, 2010, pp. 129-136.
[21] A. Daniel, “The Sexual Health of Sex Workers: No Bad
Whores, Just Bad Laws,” Social Research Briefs, NSW
Health, No. 19, 2010, p. 1.
Copyright © 2012 SciRes. WJA
Mandatory Testing for HIV and Sexually Transmissible Infections among Sex Workers in Australia:
A Barrier to HIV and STI Prevention
[22] M. Holt and J. Ellard, “HIV Risk Reduction Strategies
among Gay Men,” Discussion Paper, Australian Feder-
ation of AIDS Organizations, Sydney, 2011, p. 1.
[23] J. Fawkes, “Pos Worker Won’t Get Fair Trial,” In: E.
Jeffreys, K. Matthews and A. Thomas, Eds., Scarlet Alli-
ance Media Release, 2008.
[24] B. Donovan and C. Harcourt, “Sex Workers,” In: C. K.
Fairley, D. Russell and D. Bradford, Eds., Sexual Health
Medicine, IP Communications, Melbourne, 2005.
[25] NGO Delegate (Asia and the Pacific), “Sex Workers
Fight Back,” Proceedings of the 2011 UN AIDS Program
Coordinating Board, 18 April 2011.
[26] Canadian HIV/AIDS Legal Network, “A Human Rights-
Based Commentary on UNAIDS Guidance Note: HIV
and Sex Work,” 2007, pp. 13-14.
[27] P. Saunders, “Eight Working Papers/Case Studies, Ex-
amining the Intersections of Sex Work Law, Policy,
Rights and Health,” Open Society Institute, 2006, p. 2.
[28] D. Wilson, K. Heymer, J. Anderson, J. O’Connor, C.
Harcourt and B. Donovan, “Sex Workers Can Be Screened
Too Often: A Cost-Effective Analysis in Victoria, Aus-
tralia,” Sexually Transmitted Infections, 2009, p. 117.
[29] A. Samaranayake, M. Chen, J. Hocking, C. Bradshaw, R.
Cumming and C. Fairley, “Legislation Requiring Monthly
Testing of Sex Workers with Low Rates of Sexually
Transmitted Infections Restricts Access to Services for
Higher Risk Individual,” Sexually Transmitted Infections,
Vol. 85, No. 7, 2009, pp. 540-542.
[30] Investment Framework Study Group, “Towards an Im-
proved Investment Approach for an Effective Response to
HIV/AIDS,” The Lancet, Vol. 377, No. 9782, 2011, pp.
2031-2041. doi:10.1016/S0140-6736(11)60702-2
[31] C. Harcourt, S. Egger and B. Donovan, “Sex Work and
the Law,” Sexual Heath, Vol. 2, No. 3, 2005, pp. 121-
128. doi:10.1071/SH04042
[32] Commonwealth Department of Health and Ageing, “Na-
tional HIV/AIDS Strategy—Revitalising Australia’s re-
sponse 2005-2008,” Australian Commonwealth Govern-
ment, Canberra, 2005.
[33] B. Donovan and C. Harcourt, “Sex Workers,” In: C. K.
Fairley, D. Russell and D. Bradford, Ed., Sexual Health
Medicine, IP Communications, Melbourne, 2005.
[34] S. Metzenrath and L. Banach, “Public Health and Man-
datory Testing,” In: S. Metzenrath and L. Banach, Eds.,
Model Principles for Sex Industry Law Reform, Scarlet
Alliance and AFAO, 2000.
[35] B. Donovan and C. Harcourt, “Sex Workers,” In: C. K.
Fairley, D. Russell and D. Bradford, Eds., Sexual Health
Medicine, IP Communications, Melbourne, 2005.
[36] Commonwealth Department of Health and Ageing, “Na-
tional Sexually Transmissible Infections Strategy 2005-
2008,” Commonwealth of Australia, 2005, p. 28.
[37] Prostitution Licensing Authority, “Key Responsibilities
for Brothel Licensees and Approved Managers,” Prostitu-
tion Licensing Authority, 2012, p. 12.
[38] Queensland Health, “Section 2: Screening Priority Groups,”
Queensland Sexual Health Clinical Management Guide-
lines, Queensland Government, 2010, p. 10.
[39] Queensland Health, “Sexual Health Check Certificate of
Attendance,” Queensland Government, 2012.
[40] Prostitution Licensing Authority, “Key Responsibilities
for Brothel Licensees and Approved Managers,” Prostitu-
tion Licensing Authority, 2012, p. 11.
[41] Consumer Affairs Victoria, “Sexual Health of Sex Work-
ers,” Victorian Government, 2012.
[42] Business Licensing Authority Victoria, “Small Owner-
Operators (Exempt),” 2012.
[43] Melbourne Sexual Health, “Sex Workers,” Alfred Health,
2012, p. 1.
[44] Communicable Diseases Branch, “Queensland Health
Sexual Health Clinical Services and Privacy Policy,”
Communicable Diseases Branch, Population Heal th, Qu e e n-
sland Health, Queensland, 2008, p. 11. / docs/pol/qh-pol-3
[45] Un-Named Participants Speaking from the Floor, Pro-
ceedings of the Inner South Community Health Service
Shining a RhED Light Public Forum, Melbourne, May
[46] G. Abel, L. Fitzgerald and J. Brunton, “The Impact of
Decriminalization on the Number of Sex Workers in New
Zealand,” Journal of Social Policy, Vol. 38, No. 2, 2009,
pp. 515-531. doi:10.1017/S0047279409003080
Copyright © 2012 SciRes. WJA
Mandatory Testing for HIV and Sexually Transmissible Infections among Sex Workers in Australia:
A Barrier to HIV and STI Prevention
Copyright © 2012 SciRes. WJA
[47] B. Donovan, et al., “The Law and Sexworker Health
(LASH) Project,” Proceedings of the Australasian Society
for HIV Medicine Conference, Commonwealth of Austra-
lia, 2010, pp. 39-40.
[48] Commonwealth Department of Health and Ageing, “Na-
tional HIV/AIDS Strategy—Revitalising Australia’s Re-
sponse 2005-2008,” Australian Commonwealth Govern-
ment, Canberra, 2005.
[49] National Centre in HIV Epidemiology and Clinical Re-
search, “HIV/AIDS, Viral Hepatitis and Sexually Trans-
missible Infections in Australia, Annual Surveillance
Report 2006,” National Centre in HIV Epidemiology and
Clinical Research, The University of New South Wales,
Sydney, Australian Institute of Health and Welfare, Can-
berra, 2006.
[50] J. Medew, “Monthly Sex Worker Tests are Ridiculous,
Health Experts Say,” The Age, Melbourne, 2011.
[51] J. Mann, D. J. M. Tarantola and T. W. Netter, Eds.,
“AIDS in the World,” Harvard University Press, Cam-
bridge, 1992.
[52] Scarlet Alliance, Australian Sex Workers Association,
“Principles for Model Sex Work Legislation,” Redfern,
Sydney, 2012, in Press.
[53] Australian Red Cross, “Eligibility Policy,” 2012.