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Senegal’s legalization and regulation of sex work has been applauded for controlling the nation’s HIV rate.

At 0.4%, HIV prevalence in the country is significantly lower than many of its West and Central African neighbors; the average for the region is 1.5%, per UNAIDS. That figure is even higher in East and Southern Africa, where HIV prevalence is 7.1%.

It’s also the only nation on the continent where sex work is legal and regulated by health policy, according to the Global Network of Sex Work Projects (NSWP), which advocates for decriminalization of the profession.

Some public health experts suggest that Senegal’s registration system opened dialogue about sexual behavior and laid the groundwork for future HIV prevention programs targeting vulnerable populations.

But questions remain about the policy’s efficacy in controlling the HIV/AIDS epidemic. Sex work is still criminalized in Senegal for those who are unregistered, which effectively creates a two-tiered system in which “clandestine” prostitutes fall through the cracks.

And signing up for the legal scheme is not such a simple choice in Senegal, a 96% Muslim-majority nation where sex workers face enormous social stigma and discrimination. NSWP says that leaves sex workers open to exploitation by police. Plus, the system only applies to women over 21, leaving male sex workers without support (homosexuality is illegal under Senegalese law).

These factors combined are cited by researchers to explain the low level of registration — only 20% of sex workers across Senegal and 43% in Dakar have signed up to get the card.

“Right now, the system doesn’t work,” says Khady Gueye, program coordinator for the HIV division of Senegal’s Ministry of Health, who provides support to both registered and unregistered women through outreach programs.

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