Track D report by Purnima Mane
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.
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
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
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.
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.
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.
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
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.
epidemiology of HIV among female sex workers: influence of structural
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.
2: Combination HIV Prevention for female sex workers: what is the evidence?
Linda-Gail Bekker presented the paper with the central
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
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.
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.
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
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
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
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
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
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
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.
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.
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.
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
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
of newer prevention options like oral and vaginal microbicides to compliment
- Scaling up of
effective prevention measures
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