Researchers call for improvement in support for sex workers to control HIV pandemic

Many factors prevent sex workers from accessing the services they need to effectively prevent and treat HIV infection, according to a new series on HIV and sex workers presented during AIDS 2014 and also published in The Lancet.

“Efforts to improve HIV prevention and treatment by and for people who sell sex can no longer be seen as peripheral to the achievement of universal access to HIV services and to eventual control of the pandemic. We must do better, and we can,” series coordinator Chris Beyrer, MD, director of Johns Hopkins Center for Public Health and Human Rights, said in a press release.

Chris Beyrer

People who sell sex face a disproportionate risk and burden of HIV; in low- and middle-income countries, female sex workers have a more than 13-fold greater risk for HIV infection than women in the general population. However, although many HIV prevention and treatment strategies — including free or subsidized access to condoms and access to antiretroviral therapy after infection — are proven to work in people who sell sex, access is inadequate or entirely absent for many sex workers, according to a study by Linda-Gail Bekker, PhD, of the Desmond Tutu HIV Centre in Cape Town, South Africa, and colleagues.

Improving access to interventions such as ART, condoms and lubricant for sex workers needs to be an urgent priority for health policymakers across the world; however, the series of papers highlights that a focus on providing greater coverage of biomedical interventions will not be enough. Structural determinants — the legal, social and political environments in which people who sell sex live, and work — have an enormous effect on HIV risk, as well as general health, safety and well-being. Global control of the HIV pandemic will not be achieved if these legal, social and political factors continue to go largely unrecognized by global and national policymakers, according to a press release from The Lancet.

New research by Kate Shannon, PhD, Gender and Sexual Health Initiative, BC Centre for Excellence in HIV/AIDS, University of British Columbia, and colleagues conducted for the series showed that changes in structural determinants could have a profound effect on HIV infection rates. The research indicated that reducing sexual violence could reduce HIV infection rates by approximately one-fifth, in both high- and low-income settings, and improving access to ART could prevent about one-third of HIV infections in low-income settings.

However, the researchers also found that decriminalization of sex work would have the single greatest effect on the course of HIV epidemics across all settings studied and could potentially avert at least one-third of HIV infections among sex workers and their clients during the next decade, through its immediate and sustained effect on violence, policing and safer work environments.

The series of papers contains testimony from sex workers in Canada, India and Kenya who reported being arrested for carrying condoms, having their condoms confiscated by police or being subjected to physical or sexual violence from state authorities.

Michele R. Decker, ScD, of the department of population, family and reproductive health at the Center for Public Health and Human Rights, and colleagues emphasized the importance of decriminalizing sex by sex workers’ human rights. Results of the study suggest that global commitments to achieving an AIDS-free generation will not be possible unless the human rights of sex workers receive global recognition. The authors reviewed more than 800 recent studies that addressed human rights violations against sex workers, HIV, law and policy.

“Sex workers’ human rights are rarely addressed within human rights conventions or declarations. All people are entitled to the fundamental rights and protections articulated by the Universal Declaration of Human Rights (1948), the International Covenant on Economic, Social and Cultural Rights (ICESCR; 1966), and the International Covenant on Civil and Political Rights (ICCPR; 1967),” the investigators wrote. “These rights are not abrogated by status as a sex worker.”

Empowerment of the sex worker community, allowing organization, social support and ownership of HIV prevention strategies, offers a proven and powerful way to improve HIV prevention and treatment in sex workers, according to another paper in the series by Deanna Kerrigan, PhD, Johns Hopkins Bloomberg School of Public Health, and colleagues.

Pioneering projects in India and elsewhere have shown that when sex workers are able to organize and support each other, HIV prevention and treatment outcomes — along with broader outcomes such as safety and well-being — dramatically improve. But in many regions of the world, most sex workers do not have the means to achieve this kind of empowerment.

The diversity of sex workers and settings in which female sex workers operate can vary enormously and also need to be recognized, Kerrigan and colleagues wrote.

Stefan David Baral

Two papers in the series took on issues faced by male and transgender sex workers. Along with their colleagues, Stefan David Baral, MD, and Tonia Poteat, PhD, both from Johns Hopkins, concluded that efforts to improve health outcomes services are needed to decrease HIV acquisition and transmission among male sex workers, and HIV risk and preventive interventions in transgender women are needed as well. Male and transgender sex workers face many of the same vulnerabilities and risks as female sex workers — such as violence or inadequate access to health care — but they also have unique characteristics, which need to be understood by those implementing HIV prevention strategies, according to the press release.

The series concluded with an action agenda for HIV and sex workers, written by Beyrer and colleagues, and called for community-based interventions.

“Effective combination prevention and treatment approaches are feasible, can be tailored for cultural competence, can be cost-saving, and can help to address the unmet needs of sex workers and their communities in ways that uphold their human rights,” Beyrer and colleagues wrote.

Beyrer also said prevention programs for sex workers currently receive a small proportion of overall funding for HIV, despite the disproportionate burden of risk in this group. None of the “next generation” prevention strategies, such as pre-exposure prophylaxis (PrEP) have been evaluated specifically for sex workers, and for some groups, including transgender sex workers, there is a lack of research that focuses specifically on their needs for HIV prevention and treatment. The study authors said this should be an urgent international priority and needs appropriate levels of funding from international and national health programs.

Editors’ note: The Lancet noted that decriminalization of sex work is not the same as legalization of sex work. Decriminalization of sex work applies to laws that criminalize adult consensual sex and related activities, including laws criminalizing sex work; buying, soliciting or procuring; brothel-keeping and management of sex work; and vagrancy, loitering and public nuisance that are also used to target sex workers or clients. The objective of legalization is containment, control and taxation of sex work, whereas the objective of decriminalization is to uphold human rights and the occupational health and safety of sex workers. Decriminalization does not repeal laws against trafficking, child sexual exploitation or other forms of violence.

For more information:
Baral S. #TUSY0406.
Bekker L. #TUSY0403
Beyrer C. #TUSY0409.
Crago A. #TUSY0408.
Decker M. #TUSY0405.
Kerrigan D. #TUSY0404.
Poteat T. #TUSY0407.
Strathdee S. #TUSY0402.
All presented at: International AIDS Conference; July 20-25, 2014; Melbourne, Australia.