20th International AIDS Conference - Melbourne, Australia

TUSY04 The Lancet Special Theme Issue on HIV and Sex Workers
  Symposia Session
Venue: Plenary 3
Time: 22.07.2014, 14:30 - 16:00
Co-Chairs: Chris Beyrer, United States
Richard Horton, United Kingdom

The women, men, and transgender persons who sell sex are among the most heavily burdened persons and communities for HIV infection, and yet face limited access to prevention, treatment and care in many settings. The Lancet has commissioned a special theme series on the global HIV epidemic among sex workers to address these issues. This symposium, based on the theme issues, will take account of the realities of the lives of sex workers through their voices; review the risk environment and its impacts; assess HIV prevention options; investigate community empowerment interventions; review the human rights, legal, and policy frameworks, including decriminalization and policing practices, which affect sex workers and can enhance or reduce their risks; and review the special issues for male and transgender sex workers. The series will include six comprehensive reviews, a call to action paper, and a series of invited commentaries.
R. Horton, United Kingdom

The global epidemiology of HIV among female sex workers: structural determinants
S. Strathdee, United States

New prevention and treatment approaches facing old challenges: fulfilling the promise for sex workers
L. Bekker, South Africa

Community empowerment-based HIV prevention among sex workers: effectiveness, challenges, and considerations for implementation and scale-up
D. Kerrigan, United States

Sex work and human rights
M. Decker, United States

Male sex workers
S. Baral, United States

Sex work among transgender women: HIV risk, prevention, and interventions
T. Poteat, United States

Call to action
A. Crago, Canada

Final remarks
C. Beyrer, United States

Powerpoints presentations
The global epidemiology of HIV among female sex workers: structural determinants - Steffanie A Strathdee

New prevention and treatment approaches facing old challenges: fulfilling the promise for sex workers - Linda-Gail Bekker

Community empowerment-based HIV prevention among sex workers: effectiveness, challenges, and considerations for implementation and scale-up - Deanna Kerrigan

Sex work and human rights - Michele Decker

Male sex workers - Stefan Baral

Sex work among transgender women: HIV risk, prevention, and interventions - Tonia Poteat

Rapporteur reports

Track D report by Purnima Mane

The session presented the main papers of the Lancet Special Theme Issue on HIV and Sex Work. Women, men and transgender sex workers often carry a disproportional burden of HIV and receive little access to needed services.  Despite this reality, there is relative lack of data on these populations. The theme issue sought to address the lack of data by ensuring a standard format of reviews of peer-reviewed and published articles, analysis of existing data, and in some instances, some case studies.  Some of the papers benefited from a large number of studies being covered but in the case of transgender sex worker s and male sex workers, the paucity of data and the small size of the sample on which the articles were based, made it a major challenge to arrive at conclusions  with any degree of confidence.  The researchers worked closely with sex workers, many of whom co-authored the articles and a community member served as a guest editor.

Stefanie Strathdee presented a review of global epidemiological studies on female sex workers who are generally 13.5% more likely to be HIV positive. She concluded that structural determinants tend to enhance risk to a greater extent including factors such as criminalization, repressive policies, law enforcement strategies and gentrification of sex worker areas and displacement, with street sex work being the most risky and most likely to encounter violence. Potential HIV infections could be averted through structural change for instance, a safer work environment, decriminalized sex work, peer outreach, and sex worker-led interventions.

Prof Bekker focused on new prevention and treatment approaches facing old challenges and concluded that the use of combination prevention (biomedical, behavioral and structural interventions) is likely to be most useful when it is tailored to the context, recognizes sex workers’ autonomy, and ensures their engagement at all levels of the intervention. This is true for established interventions as well as newer interventions including post exposure prophylaxis and PrEP with sex work friendly services at all levels with efforts to reduce discrimination and stigma.

Deanna Kerrigan’s presentation on community empowerment-based HIV prevention focused on community based empowerment as an approach rather than an activity which encouraged social cohesion, collective power, sex worker participation and access to services of a broader nature including and beyond HIV-related services. She identified it as a promising approach with meta analysis showing improvement in all outcomes including HIV and specific STIs. Nonetheless traditional approaches continue to be used when it comes to sex workers, which are more individually oriented, with few community empowerment measures. Changing the global discourse from rescue and rehabilitation to empowerment and recognition of sex work as work was critical to this process if the full promise of community empowerment was to be recognized.

Stefan Baral’s paper covered male sex workers or men who sell sex on whom data were limited. To boost the limited data, reviews were conducted in lower and middle income regions and additional UN documents were analyzed.  Despite limited data a pattern developed - layered issues which stigmatized the men and criminalized their behavior (e.g.selling sex, being identified as gay, substance use, non-disclosure of HIV status) depending on their situation and the context; low self identification making reach difficult; and the need for better data on this diverse, complex and unique key population. Reaching  the men where they are (depending on the region), integrating different approaches with treatment being vital due to high rates of infection, and engaging networks supporting them, were all seen as vital.

Tonia Poteat’s paper on transgender women sex workers concluded that almost no interventions focused exclusively on these populations even though they face four times the risk of HIV and limited available evidence that indicates that in many of the countries, a large percentage practise sex work. Due to multiple vulnerabilities, they are in need of structural, interpersonal, individual and biomedical interventions which focus on social and economic aspects, health services, and legal and cultural aspects. Evidence suggests that what works best is a combination of these grounded in empowerment and led by communities themselves. Dr Poteat raised the point that little data were available on the risk imposed by surgery for reconstruction of genital organs. The high burden faced by transgender women sex workers demanded combination prevention and an understanding of the influence of legalization and stigmatization. And once again, more research was needed if we were to make any headway.

Anna Luisa Crago presented two papers- one by Michele Decker on Human Rights and a Call to action. A review of 800 studies showed a range of violations of sex workers’ rights including violence (often induced by the police) both sexual and physical, high levels of homicide, forced arrest, long detention,  and imprisonment, forced non-use of condoms, displacement and discrimination. Most common however was the issue of some form of criminalization of sex work with legalization being just as problematic due to highly restrictive practices and mandatory registration and health exams. Dismantling impunity was critical to the process of the achievement of the human rights of sex workers.

The Call to action focused on the rights to security, health and liberty for a population which suffered a disproportionate burden of HIV and the full extent of structural determinants which were never addressed, about whom little was known, and for whom much more needed to be done. The Call made it clear that sex workers needed to benefit from new biomedical technologies voluntarily and without replacement of other interventions. Access to ART and health services, valuing sex work as work, decriminalization, end of discrimination and coercive policies and end to impunity for violation of their rights were imperative  with political will, community engagement, continued research and scaling up promising that much more can be done for sex workers to end their current situation.


Track E report by Jennifer Butler

TUSY04: The Lancet Special Theme Issue: HIV and Sex Work

 Summary:The Lancet Special Theme Issue on HIV and Sex Work is the third in a series - the Theme Issue on people who inject drugs was launched in Vienna and the theme issue on men who have sex with men was launched in Washington DC, at respective AIDS conferences.

Bringing together scientists, researchers, clinicians and sex workers the series six papers cover epidemiology and structural determinants; combination prevention; community empowerment; human rights; male sex workers; and transgender sex workers.  A powerful Call to Action sets out an ambitious yet achievable agenda to halt and reverse the HIV epidemics among women, men and transgender sex workers.

All papers highlighted that criminalisation of sex work increases HIV risk and that decriminalisation of sex work and sex workers is essential to reduce HIV risk among sex workers. They all addressed violence, especially from police, and both the disproportionate burden of HIV and lack of access to treatment, prevention, care and support. The series highlights the significant lack of funding globally for HIV programming for sex workers, in particular for rights-based sex worker-led programs.

Most sex workers live and work under the threat of laws and policies that criminalize or discriminate. These structural factors continue to challenge the ability of sex workers to protect themselves from HIV and to live long and healthy lives. Importantly, sex workers were included as authors on all papers.

 Paper 1: Global epidemiology of HIV among female sex workers: influence of structural determinants.
Steffanie Strathdee's paper provided the latest available epidemiology of HIV among female sex workers.  The data shows that female sex workers are 13 times more likely to acquire HIV than all other women.  Sex workers in Sub Saharan Africa have the highest burden of HIV, with combined prevalence of HIV across the African region of 29.3%.  Further, all of the countries with prevalence rates above 50% are in Southern Africa.

·       Structural determinants play a crucial role in increasing or decreasing HIV risks for sex workers. These include laws, stigma, migration, level of community empowerment, the social, physical, policy and economic features of work environments.

       Elimination of sexual violence alone in Kenya and Canada could avert 17-20% of HIV infections over next decade among female sex workers and clients

       Decriminalization of sex work could have the largest impact on the course of HIV epidemics across generalized and concentrated epidemics, averting 33-46% of HIV infections over next decade among female sex workers and clients.

Paper 2: Combination HIV Prevention for female sex workers: what is the evidence?

Linda-Gail Bekker presented the paper with the central messages:

·       Effective prevention measures for sex workers exist but have not been taken to scale

·       Condom promotion, sexually transmitted infection prevention and treatment, HIV testing and counselling, gender-based violence prevention, access to and economic and community empowerment are existing and effective prevention programmes for sex workers.

·       Modelling suggests that condom promotion may have already reduced incidence in sex workers and their clients by 70% in South Africa.

·       Earlier initiation to antiretroviral therapy, with requisite services, is likely to be beneficial to the health of sex workers and reduce HIV incidence in their clients and other sexual partners.

New biomedical technologies, such as PrEP and TasP, must be additive to more established prevention approaches.  More work is needed on the efficacy, feasibility and acceptability of PrEP for sex workers. 

Paper 3: A Community Empowerment Approach to the HIV Response among Sex Workers: effectiveness, challenges, and considerations for implementation and scale-up. 

Deanna Kerrigan presented a clear and compelling for the central role of community empowerment in the HIV response among sex workers. Community empowerment, it was explained, is a process and not an activity - it is about collectivisation for the common good and public health, and the promotion and protection of the human rights of the community: it is always sex worker-led and sex worker owned.  Power shifts from others to the community. 

Through a systematic review and meta analysis and four case studies as a part of practice -based literature (implementation science led by sex workers themselves) - the evidence showed clearly that community empowerment results in a 32% decrease in the odds of HIV infection; between 25% and 50% reduction in the odds of sexually transmitted infections and a three times increase in the odds of consistent condom use.

These results show clearly that investing in community empowerment of sex workers makes sense from a public health point of view; it is human-rights based; and provides the essential platform for structural, biomedical and behavioural responses to HIV. The paper calls for sex work to be recognised as work and that sex work is not to be conflated with trafficking in persons.  

Paper 4: Male sex workers: practices, contexts, and vulnerabilities for HIV acquisition and transmission.

Stef Baral addressed the lack of specific data on male sex workers and men who sell sex, reporting that self-identification as sex workers is low. Only 27 of 192 countries have reported male sex workers’ prevalence. In 7 countries, male sex workers had an HIV prevalence rate equal or greater to 20%. Male sex workers are heterogeneous and range from gay to straight.

Most clients of male sex workers are other men.  Criminalisation of sex work, same-sex practices and HIV non-disclosure all represent barriers to male sex workers and safe commercial sex. Male sex workers are a unique key population.  There is a need for better surveillance to track everyone within their sexual networks. 

 Improved access to condoms and lubricants is important, as is a combination prevention approach, including antiretoviral prevention and treatment approaches, as well as an understanding of the social contexts in which male sex workers engage in selling sex.

Paper 5: HIV risk and preventative interventions in transgender women sex workers

If data on male sex workers is limited and conflated within data for men who have sex with men, the data for transgender sex workers is scarcely existent.  Nevertheless, Tonia Poteat, presented a clear account of the significant vulnerabilities faced by transgender sex workers.  Key among the data presented was: 54%-80% of transgender women in Asia Pacific are sex workers; trans women sex workers have four times the HIV risk of all female sex workers.

 Transgender sex workers have a unique combination of risk factors, including biological (silicone and illicit hormone injection), individual (need for gender affirmation), interpersonal (high risk male partners) and structural (systemic discrimination and violence based on perceived sexuality, gender expression and occupation)

Poteat concluded, consistent with the other papers, that condom use and combination prevention are essential and have to be sustained.  Again, the issue of violence towards sex workers was clear. 

Paper 6: Human Rights violations against sex workers: burden and effect on HIV

 Anna-Louise Crago presented the paper on human rights firmly and clearly calling for decriminalisation of sex work; an end to discriminatory, coercive or repressive policies and practices and an end to the gender-based violence sex workers experience and the impunity for violence by state and non-state actors. 

She set out a clear articulation of the different legislative frameworks leading the audience to the understanding that decriminalisation of sex work is the only legislative approach that is human rights based and will result in improved HIV and health outcomes for sex workers.

 Confiscation of condoms or condoms being used in evidence against sex workers increases HIV risk and vulnerability.  So too does the widespread, rampant, sexual violence by police.  Criminalisation of sex workers and/or clients of sex workers means sex workers sell sex in more dangerous settings, such as on the streets with no condoms.  Addressing human rights violations is critical.

Policy reform, sex worker mobilisation, and organisation, are essential and mutually reinforcing strategies that have achieved success in health and human rights promotion for sex workers.

 Call for Action

The Call for Action bold and clearly sets out the forward agenda based on evidence and human rights.  Including:

·       structural measures, including decriminalisation of sex work, addressing migration and stigma, and work environmental features, including the elimination of violence, police harassment, are crucial to stem HIV epidemics in sex workers and clients.

·       the provision of antiretroviral- based PrEP and earlier antiretorviral treatment as prevention are crucial voluntary additives to established prevention measures. 

·       Access to ART is a human right.

·       Effective prevention measures need to be brought to scale.

·       occupational health approaches that recognise sex work as work are key

·       investment in community empowerment and promotion and funding of sex worker-led approaches and organisations are core to the response

·       promotion and protection of the human rights of sex workers is fundamental

·       special and particular attention needs to be paid towards male sex workers and transgender sex workers including the decriminalisation of "cross dressing" and the provision of gender-affirming health care.

·       meaningful engagement of sex workers in the design and implementation of all programmes is essential

·       increased support of sex worker-led, community empowerment efforts that integrate structural, behavioral and biomedical intervention elements  

·       improved data on HIV prevalence among sex workers informing evidence-based and human rights-affirming services dedicated specifically to male sex workers

·       Finally, investment in sex workers is cost effective. 

·       Estimates of cost-effectiveness depend on the intervention, but they also depend on local epidemiology and economics and study methods.

·       Despite this variation, all of these interventions are cost-saving or highly cost effective by WHO standards—the cost per DALY is less than the per-capita GDP for the country.

The papers conclude that effective combination prevention and treatment approaches for sex workers are feasible, can be cost-saving, tailored for context and cultural competency and can help address the unmet needs of sex workers and their communities in ways that uphold their human rights and work with them as equal partners.





Community report by Smarajit Jana

The Lancet Special Theme Issue on HIV and Sex Workers

Chris Beyrer, United States
Richard Horton, United Kingdom

Richard Horton, on behalf of the Lancet, shared the Lancet Special Theme Issue on HIV and Sex Workers. This issue not only included sex workers as authors but also as co-editors. The clear need for more concerted attention and advocacy for sex worker’s rights, a strikingly clear conclusion noted in the issue, was only magnified by news that as some of the papers were being presented at conferences they received reports that two transgender sex workers from India and 30 female sex workers in Iraq has been massacred. This only served to epitomize the sort of violence and repressive stigma attached to sex work and sex workers.

All five speakers conducted an extensive search, review and analysis of all peer reviewed articles addressing sex work published since 2007 and resoundingly concluded that structural barriers are the most severe of all impediments to the success of HIV intervention programs. Their analysis showed that reductions of violence inflicted on sex workers alone can reduce the incidence of HIV by as much as 18%. They also concluded that the full decriminalization of sex workers – which also includes clients of sex workers – can bring down HIV incidence as much as 33% to 46%. They recommended a combination intervention approach that by necessity would have to include behavioural, biomedical and structural intervention focusing on the complete decriminalization of sex workers, their clients and sex work environments.

Steffanie A Strathdee gave the first presentation, which focussed on the impact of structural determinants on intervention programs aimed at sex workers operating on global, national local levels. She strongly protested the common conflation of sex work with human trafficking issues and demanded that sex work be handled like any other type of work.

Deanna Kerrigan then spoke about community empowerment policies and strategies. She expressed serious concerns with the practice of ’rescue and rehabilitate approaches,’ widely used around the world, contending that they undermine the agency of sex workers and consequently make them more vulnerable to HIV. She concluded by positing that the implementation of community empowerment approaches can lead to as much as a three-fold increase in rates of condom use and as much as a 32% reduction in HIV transmission.

Stefan Boral then spoke about male sex workers and suggested that they are biologically more vulnerable to HIV acquisition because of the increased risk of HIV transmission through condomless anal sex. He also shared that there is paucity of data on male sex work and a dire need for more research to be conducted.

Tonia Poteat presented a paper on transgender communities. She shared data that revealed that as many as 75% of transgender women in US are involved in sex work. In Malaysia evidence ranged from 24% to 80. She also spoke about the introduction of newer tools like oral PrEP (in addition to other intervention tools) and the urgent need to initiate legal changes to acknowledge sex work as an occupation.

Anna Luisa Crago then presented on New Zealand’s prostitution reform act and suggested that other regions should take similar approaches to fully decriminalize sex work. She also asserted that structural and community- led interventions were going to be the key to successfully addressing HIV/AIDS among sex workers globally.

Based on the evidence collected in their research a number of key recommendations were made for next steps:

  • Rapid scale up of sex worker interventions across the globe through the mobilization of resources
  • Introduction of newer prevention options like oral and vaginal microbicides to compliment other tools
  • Scaling up of effective prevention measures
  • Meaningful engagement of sex workers in design and implementation of programs
  • Evaluation of novel HIV prevention tools including PrEP, microbicides, and treatment as prevention, specifically for sex workers
  • Access to ART for sex workers living with HIV. Access to ART is a human right.
  • Ensuring that new biomedical technologies are voluntary and that they add to, rather than replace, more traditional options.


    The organizers reserve the right to amend the programme.