The British medical journal The Lancet published a special issue on HIV and sex workers for this year's 20th International AIDS Conference (AIDS 2014), held in Melbourne, Australia in July.
Researchers estimated that decriminalization of sex work would have the greatest effect on prevention, avoiding 33-46% of new infections over the next decade through "combined effects on violence, police harassment, safer work environments, and HIV transmission pathways."
"This Series calls on governments to decriminalize sex work. There is no alternative if we wish to reduce the environment of risk faced by women, men, and transgender people worldwide," write editors Pamela Das and Richard Horton.
Overall, sex workers are 13.5 times more likely to be infected with HIV. In this issue, "sex worker" is defined as anyone who exchanges sex for money.(Others have different definitions, which include such work as stripping and phone sex for pay.)
The issue first looked at structural determinants, those factors that either protect against HIV or which increase risk of infection. Where sex work iscriminalized, workers often struggle to access testing, treatment, and other services, which include condom distribution.
"Efforts to roll out antiretroviral therapy (ART) or distribute condoms to FSWs [female sex workers] in settings where criminalization and stigma deteraccess to condoms or health services continue to hamper HIV prevention, treatment, and care efforts," write Kate Shannon and colleagues.
It is now known that being on successful HIV treatment is highly protective against transmitting the virus to sex partners, but sex workers have reportedbeing mistreated in clinics or social service agencies, and, as a result, leaving before accessing care or not returning for it. In dozens of examples, theissue shows how sex workers are stopped from accessing HIV prevention services or treatment owing to stigma and discrimination, and the violence, includingverbal and non-verbal, that it breeds. The situation is such that, while pregnant, they have been denied medicine to prevent mother-to-child HIVtransmission.
A great deal of violence, the various articles show, comes from the state (government) itself -- primarily the police. Police officers have even brutalizedsexually exploited teenagers, and government efforts to place the young people in institutions expose them to rape and other violence by officers, fosterparents, and others.
Also, as reported in last year's conference coverage, police around the world confiscate condoms to use as evidence of prostitution, intimidating sexworkers from being able to protect themselves against HIV for fear of arrest (See "Risky Business for Sex Workers" at. (See also "Risky Business: Sex workers are threatened by laws and policies that add to their risk of infection.")
This situation can be changed, however. One article reports that when an organization in India conducted training in response to police violence, officerslater joined sex workers in solidarity at a protest against a law detrimental to those workers.
Sex Workers, Unite!
The issue calls over and over for participation of sex workers in any programs or services for them. It emphasized the need for sex worker organizations tohelp create needed changes and programming.
"A community empowerment-based response to HIV is a process by which sex workers take collective ownership of programs to achieve the most effective HIVoutcomes and address social and structural barriers to their overall health and human rights," note Deanna Kerrigan and colleagues in the article oncommunity empowerment, which was found to decrease risk of HIV. This approach differs from typical HIV programming in that "community empowermentapproaches do not merely consult sex workers, but rather are community-led, such that they are designed, implemented, and assessed by sex workers."
The same goes for teens: "Policy makers, programmers, researchers, and youth organizations should work together to ensure that adolescents are involved atall levels of program and policy design, implementation, and evaluation, so that the response is shaped by their realities, needs, and aspirations," saycommenters in the letters section.
Of special concern is the equating of sex work with trafficking. Oftentimes anti-trafficking efforts harm sex workers by promoting police actions. Victimsof trafficking themselves are arrested and put in handcuffs.
"Trafficking occurs in sex work as it does in other types of labor," write Richard Steen and colleagues in the comments section. "However, the issue oftrafficking in sex work has been singled out, its scale and potential for harm frequently misstated or exaggerated to bolster antiprostitution arguments,inflame public opinion, and justify repressive and counterproductive police action. Conflation of sex work with trafficking leads not only to difficultieswith definition and harm to sex workers on the ground, but also to conflicts that undermine HIV prevention. ... For most adult sex workers who choose theirprofession without coercion ... it is the official response to trafficking, particularly police actions, which is most likely to increase vulnerability toviolence or HIV acquisition."
Kerrigan and colleagues write, "Policies that hinder the community empowerment process include the global raid-and-rescue discourse, in which non-sexworkers characterize sex workers as passive victims needing rescue. These programs often deny sex workers' support in choosing their livelihoods andundermine the legitimacy of sex work as work. Additionally, this discourse often conflates consensual adult sex work with human trafficking."
They mention the consensus statement of the Global Network of Sex Work Projects (NSWP), with 160 sex worker groups from 60 countries, which promotes thehuman rights of sex workers, including reducing their risk of HIV.
Of Human Rights
The article on human rights by Michele R. Decker and colleagues reports that, "Published research documents widespread human rights violations against sexworkers, perpetrated by both state and non-state actors. These violations increase HIV risk, and undermine effective HIV prevention and intervention.Violations include homicide; physical and sexual violence from law enforcement, clients, and intimate partners; unlawful arrest and detention;discrimination in accessing health services; and forced HIV testing." (Forced testing exposes people to discrimination and extortion, and to added legalpenalties if HIV-positive, and is not done in order to provide treatment.)
They go on to note that, "Without addressing human rights violations among sex workers, merely providing HIV prevention and treatment services will remainan insufficient and misguided response. HIV responses for sex workers should ensure their human rights through active promotion of equality, andnon-discrimination in accessing prevention and interventions across the full continuum of care."
In an action agenda, Chris Beyrer, MD, and colleagues note that the findings "underscore the need for social and political change related to therecognition of sex work as work." As such, sex workers would benefit from the same safety and other protective regulations as other workers.
"Laws against consensual adult sex work impede HIV prevention, allow for police harassment and violence, and weaken sex workers' ability to negotiate safesex. These laws deter sex workers from accessing services for HIV and other health issues and raise HIV vulnerability," they state.
In an article on transgender sex workers, Tonia Poteat and colleagues reported that these workers have a disproportionate risk for HIV, but that there'slittle research published on this group. It also noted that, "Transgender sex workers have a unique combination of risk factors, including biological(e.g., illicit hormone and silicone injection), individual (e.g., need for gender affirmation), interpersonal (e.g., high-risk male partners, andstructural (e.g., systemic discrimination and violence based on gender expression, perceived sexuality, and occupation)."
Regarding male sex workers, the issue states that most clients are other men, but both the sex workers and the clients may not identify as gay or bisexual,and many have female partners. The risks for HIV "exist at many levels for male sex workers," including "large and complex sexual networks, and compoundedintersectional stigmas."
Data suggests that transgender and male sex workers, in particular, need biomedical interventions, such as PrEP and rectal microbicides, to preventbecoming infected with HIV, the editors noted.
All in all, solutions to the harms can be found in noting that sex work is work-in the category of labor and labor law.
"Why should we condemn and criminalize the exchange of money for sex, especially if the severely adverse conditions we create for such exchange hurt womenand men and often fatally so?" write editors Das and Horton. "The persistence and ubiquity of sex work suggests only that sex, and the human desire forsex, is a normal part of human societies. Sex work is part of the human story. Accepting and embracing sex work-supporting those engaged in sex work toprotect their health and bodily integrity and autonomy-should be our human, as well as our pragmatic, approach to the reality of our human lives. And toour common efforts to defeat AIDS."
See the issue abstracts at www.thelancet.com/series/HIV-and-sex-workers. The authors talk in a five-minute video at www.websedge.com/videos/aids_2014_tv/#/lancet_series_hiv_and_sex_workers.
Official Conference News
See abstracts, videos, and Powerpoint presentations at AIDS2014.org. Official reports for AIDS 2014 were produced by the community-based National AIDS Map(NAM) in London and write-ups by doctors from Clinical Care Options in the U.S. Visit aidsmap.com and clinicalcareoptions.com.