As heterosexual HIV accelerates in many regions of China, preventing sexual HIV transmission among female commercial sex workers is increasingly important.1 Approximately 49% of the 70 000 estimated new HIV infections since 2005 were from sexual transmission, and estimates for those living with HIV reveal a similarly large number of sexually transmitted HIV infections.2 Studies of sex workers in China show inconsistent condom use,3 high prevalence of syphilis4 and concomitant intravenous drug use among a subgroup.5 6 Although domestic groups and international organisations have made HIV control a national public health priority in China, commercial sex workers are still routinely coercively detained in an administrative system called re-education through labor (RTL).7 Since RTL was created to provide political “re-education”, 3.5 million individuals have been detained and today there are at least 340 centres with the capacity to detain 300 000 people.8 China’s “top down” mobilised police system has a number of options to punish commercial sex workers ranging from community-based shaming to several years of RTL detention.7 Instead of referring these women to medical and social services, detention centres may increase stigma and complicate traditional HIV prevention programmes. Until very recently, there were no epidemiological data showing that detained commercial sex workers have greater HIV risk and no legal basis for addressing the structural inequalities implicit in this draconian system.

Incarcerated sex workers in China likely have a higher risk of sexually transmitted infections (STI) and HIV. A systematic review of 174 syphilis seroprevalence studies in China showed that incarcerated sex workers had a median syphilis prevalence of 12%—over tenfold higher prevalence compared to sex workers at entertainment establishments.4 This difference in syphilis seroprevalence between women at entertainment establishments and re-education centres is likely related to a higher prevalence of syphilis before women are incarcerated because there are few opportunities for sex during incarceration. Sex workers who are detained may not present to healthcare services as early as women in the community who have greater access to routine STI prevention and treatment.

Detained commercial sex workers face the stigma of being incarcerated as well as selling sex, with substantial implications for healthcare seeking behaviours.9 Police efforts to crack down on sex workers and confiscate condoms to secure criminal conviction of prostitution further distance women from the prevention resources that they need most.10 Many incarcerated sex workers are younger, more poor and have less social capital compared to those women who are not arrested.11 12 Ethics guidelines and Institutional Review Board approval for research and action on behalf of these women have made it more challenging to understand and challenge treatment of sex workers detained in RTL in China. Incarcerated sex workers in China are unique in terms of systematic exclusion from both domestic and international HIV programmes. Although incarcerated and former sex workers likely represent a small percentage of the total number of sex workers in China, their social position and vulnerability to HIV infection demand greater attention.

Administrative policy and law developments in China suggest that the RTL system will soon be changed, creating a window of opportunity to improve the lives of incarcerated sex workers. During the last session of the China’s National People’s Congress in March 2007, several plans to reorganise RTL were debated.13 A legal basis for STI/HIV testing and treatment among incarcerated groups was issued in 2006 as part of the “Regulations on AIDS Prevention and Treatment”, providing a mandate for reforming these institutions.14 More RTL centres are testing women for STIs and HIV, but cohesive treatment programmes are still scarce and implementation of laws varies widely.15 Since these administrative detention centres have and will continue to be separate from local public health, medical and social services, bolstering community-based and non-governmental organisation groups for formerly incarcerated sex workers will be important. The period of re-entry following incarceration may pose unique risks—supported by a study of formerly incarcerated sex workers in the USA showing 12-fold higher mortality in the two weeks after release.16 Structuring community-based programmes following the release of incarcerated sex workers in China could work to decrease their HIV risk and deal with common co-existing problems like substance abuse, domestic violence, poverty and unemployment.

Programmes within China and other parts of Asia show how correctional and public health initiatives can serve marginalised groups in correctional settings. The overhaul of Vietnam’s Ministry of Evils suggests that police infrastructures can be used to help intravenous drug users. In China, community-based harm reduction advances, including methadone programmes and needle exchange, provides a template for the reorganisation of health services to highly stigmatised groups. Post-incarceration programmes for sex workers could link women to essential HIV prevention resources and decrease stigma. The current legal and political climate suggests that China’s re-education through the RTL system will be radically overhauled in the near future, gaining traction for reform that could explicitly protect the sexual and human rights of incarcerated sex workers.