Health Exchange

Sex work, human rights and HIV epidemics

The Paulo Longo Research Initiative (PLRI) is a new partnership between sex workers, academics and policy analysts to conduct and synthesise ethical and useful research on sex work in developing countries to improve policy and practice. Cheryl Overs and Kate Hawkins report on how sex workers’ human rights are abused and the programmes operating to help address the problems they face.

Sex workers in Cambodia demonstrating against anti-trafficking legislation

In countries where there have been sustained prevention efforts, HIV prevalence among sex workers usually remains low. In countries where prevention programmes were late to develop – such as Rwanda and Angola – HIV prevalence among sex workers is reportedly high at above 30 per cent. Where governance is poor and the rule of law is weak, female, male and transgender sex workers are typically exposed to severe and pervasive human rights abuses. Abuses may consist of: denial of health services; compulsory health checks; violence, arbitrary arrest and detention; unlawful confiscation of property; limits on freedom of movement; and discriminatory and corrupt treatment in both public and private domains.

In developing countries in particular, sex workers remain disproportionately affected by illnesses and conditions caused by social exclusion, poverty and gender-based violence. Migrants, drug users, adolescents and other specific sex worker sub-populations are disproportionately vulnerable to HIV and sexually transmitted infections (STI).
Sex workers universally claim that their human rights are abused. Research by Carol Jenkins in Cambodia found that of the female and transgender sex workers surveyed, approximately half reported being beaten by police; about a third were gang-raped by police; slightly more than one-third were gang-raped by gangsters; and about three-quarters were gang-raped by clients (who are often also gangsters and out-of-uniform police) during the past year . More recent research from South Africa, Namibia and Botswana found that sex workers reported routine police abuse, extortion, confiscation of condoms, unlawful arrest and detention – migrant, male and transgendered sex workers were often targeted with more severe violence and discrimination . Chronic abuse of this kind will impact negatively on any person’s physical and mental health and wellbeing – quite apart from increasing their vulnerability to HIV infection. Responding to these matters has been a key focus of sex worker activism globally.

Building strong and effective health services
Programmes and policies to support sex workers to stay safe and access health services have shown considerable success. To be effective, services must be adequately resourced, sex worker-friendly, physically and financially accessible, and technically competent. Sex workers living with HIV must have access to HIV treatment, care and support services on a non-discriminatory basis.  Correct use of condoms for penetrative sex is a cornerstone of effective HIV prevention. It is crucial to ensure the availability of affordable quality condoms with easily understood information about safer sex. Participatory methods of developing and spreading messages have been particularly successful.

Clients, as well as sex workers, should be targeted. Clients have been reached not only in sex work settings but in other occupational and recreational environments. Programmes have focused on truck drivers; heavy transport workers; tourists and business travellers; men who are separated from their families for long periods; migrants; uniformed services, including police; construction, mining and infrastructure projects, or seafarers.

Structural interventions, community mobilisation and empowerment are also now proven to be important components of the response to HIV. Risk is lowest where sex workers are able to assert control over their working environments, and highest where sex workers are most powerless and unable to demand safe practices. Because the conditions in which commercial sex takes place strongly influence levels of HIV risk and vulnerability, policies and structural interventions that affect the sex work environment, reduce vulnerability and empower sex workers economically and socially play a key role in the response to sex work and HIV .

You can find out more about PLRI, and a range of resources on sex work and HIV, on our website www.plri.org.

CASE STUDIES

Ethiopia NIKAT: A collective of 12 women, NIKAT, had been operating for two years from a very basic building donated by a local authority near a slum in central Addis Ababa. They had been trained as peer educators but their main activity was cooking injarra, the main local dish, for delivery to businesses and to serve directly to the public at lunchtime. This was providing some supplementary income but not enough to enable them to stop sex work (three women over 40 years of age had stopped). In 2006 a condom social marketing company, DKT, established a peer education and condom distribution programme for sex workers. DKT contracted NIKAT and asked them to provide training and other support to their national HIV prevention project for sex workers, Wise Up. NIKAT was contracted to open a drop-in centre providing sexual and reproductive health services and emergency shelter for sex workers. This additional source of income made the group more viable and for the first the members began to earn the same or more than they earned as sex workers.

“Our Clinic”, Russia: On Tuesdays and Thursdays, outreach workers from “Our Clinic” drive through Tomsk in the clinic’s van, distributing small plastic bags filled with HIV prevention brochures and condoms to sex workers. The messages seem to be getting through. Maria says condoms are always used and other sex workers echo her experience. “We usually explain the rules – that we don’t work without condoms” says Alena (23), who is receiving counselling in the van. Every three months outreach workers also collect blood from sex workers for HIV testing. They receive the results at the Tomsk AIDS Center which provides another opportunity for giving information and counselling.

National AIDS Foundation, Mongolia: The first community-based sex workers organisation was formed in Darkhan, a city of 85,000, on the train route in which a busy railway station and several bars and hotels form part of a growing commercial sector. Local government authorities have provided space for a support centre for sex workers near the railway station, offering condoms, health services and shelter. Training by peer educators along with other activities, has clearly increased solidarity, self-esteem and human rights awareness among sex workers who are working in the railway station area and in bars around the city. Training sessions have been conducted amongst municipal authorities, the police, railway workers and local bar staff. These have prompted clear attitudinal changes with a reduction of the conditions favourable for HIV transmission – increased access to services and information, a decrease in discrimination, a rise in the incidence of protected sex, less violence towards the women participating in the project, and a decrease in STI rates. Diagnosis of STI is occurring earlier than previously noted and self-medication has been replaced by effective treatment.

Cheryl Overs – Department of Epidemiology and Preventative Medicine, Monash University Medical School, Australia
Kate Hawkins – Communication and Research Officer, Institute of Development Studies, UK

Paulo Longo Research Initiative
www.plri.org