Combination HIV prevention for female sex workers: what is the evidence?

Sex work occurs in many forms and sex workers of all genders have been affected by HIV epidemics worldwide. The determinants of HIV risk associated with sex work occur at several levels, including individual biological and behavioural, dyadic and network, and community and social environmental levels. Evidence indicates that effective HIV prevention packages for sex workers should include combinations of biomedical, behavioural, and structural interventions tailored to local contexts, and be led and implemented by sex worker communities. A model simulation based on the South African heterosexual epidemic suggests that condom promotion and distribution programmes in South Africa have already reduced HIV incidence in sex workers and their clients by more than 70%. Under optimistic model assumptions, oral pre-exposure prophylaxis together with test and treat programmes could further reduce HIV incidence in South African sex workers and their clients by up to 40% over a 10-year period. Combining these biomedical approaches with a prevention package, including behavioural and structural components as part of a community-driven approach, will help to reduce HIV infection in sex workers in different settings worldwide.

Can rights stop the wrongs? Exploring the connections between framings of sex workers' rights and sexual and reproductive health.

BACKGROUND: There is growing interest in the ways in which legal and human rights issues related to sex work affect sex workers' vulnerability to HIV and abuses including human trafficking and sexual exploitation. International agencies, such as UNAIDS, have called for decriminalisation of sex work because the delivery of sexual and reproductive health services is affected by criminalisation and social exclusion as experienced by sex workers. The paper reflects on the connections in various actors' framings between sex workers sexual and reproductive health and rights (SRHR) and the ways that international law is interpreted in policing and regulatory practices. METHODS: The literature review that informs this paper was carried out by the authors in the course of their work within the Paulo Longo Research Initiative. The review covered academic and grey literature such as resources generated by sex worker rights activists, UN policy positions and print and online media. The argument in this paper has been developed reflectively through long term involvement with key actors in the field of sex workers' rights. RESULTS: International legislation characterises sex work in various ways which do not always accord with moves toward decriminalisation. Law, policy and regulation at national level and law enforcement vary between settings. The demands of sex worker rights activists do relate to sexual and reproductive health but they place greater emphasis on efforts to remove the structural barriers that limit sex workers' ability to participate in society on an equal footing with other citizens. DISCUSSION AND CONCLUSION: There is a tension between those who wish to uphold the rights of sex workers in order to reduce vulnerability to ill-health and those who insist that sex work is itself a violation of rights. This is reflected in contemporary narratives about sex workers' rights and the ways in which different actors interpret human rights law. The creation of regulatory frameworks around sex work that support health, safety and freedom from abuse requires a better understanding of the broad scope of laws, policies and enforcement practices in different cultural contexts and economic settings, alongside reviews of UN policies and human rights conventions.

The tide cannot be turned without us: sex workers and the global response to HIV.

Improved knowledge, better programmes and policies, effective treatment and other scientific developments have reduced levels of new HIV infections globally. Evidence shows that programmes that prevent HIV among sex workers and their clients are most successful when all aspects of vulnerability are addressed and when they are underpinned by policy that advances human rights. This is particularly important in the context of the introduction of antiretroviral-based HIV prevention, which could have harmful consequences if not well planned. In this context, law and policy on sex work should not be limited to aiming to deliver medicine and services to sex workers in dangerous working conditions. A high-priority aim should be to ensure that the law enables commercial sex to take place in the safest possible conditions. To achieve this, the meaningful involvement of sex workers at all levels of the response is crucial. However, although that has been recognized in theory, it has not been achieved in practice.

Toward a legal framework that promotes and protects sex workers' health and human rights.

Complex combinations of law, policy, and enforcement practices determine sex workers vulnerability to HIV and rights abuses. We identify "lack of recognition as a person before the law" as an important but undocumented barrier to accessing services and conclude that multi-faceted, setting-specific reform is needed-rather than a singular focus on decriminalization-if the health and human rights of sex workers are to be realized.

Community development and HIV/STI-related vulnerability among female sex workers in Rio de Janeiro, Brazil.

The Sonagachi Project of Kolkata, India has been recognized as a model community development and human immunodeficiency virus/sexually transmitted infection (HIV/STI) prevention intervention among female sex workers. Limited research has been conducted regarding its applicability outside the South Asian context. This study sought to document the process and effectiveness of integrating community development activities based on the Sonagachi model into an ongoing HIV/STI peer education program with female sex workers in Rio de Janeiro, Brazil. Structured cross-sectional surveys examining HIV/STI-related behaviors and community development measures were conducted among approximately 500 sex workers at pre- and post-intervention. We found that several community development components including social cohesion and mutual aid were significantly associated with consistent condom use among sex workers and their paying clients at pre-intervention. However, only a minority of women actively engaged in community-building activities over the 18-month study period. In turn, limited changes in community development components and no significant increases in the HIV/STI-related protective behaviors assessed were documented. Findings indicate that internalized stigma and socioeconomic pressures may have constrained the scope and pace of community mobilization in this setting during the study observation period.