HIV/AIDS and Sex Workers: Implications for Policy Carol Jenkins Alternate Visions Bangkok September 15, 2005

HIV/AIDS and Sex Workers: Implications for Policy “..communities, like individuals, cannot respond to the challenges of HIV unless they can express the basic right to be involved in decisions that affect them.” -- Jonathan Mann

What Is Sex Work? The term “sex work” was coined by Carol Leigh (aka Scarlot Harlot) in 1979 “Provision of sexual services or performances by one person (prostitute or sex worker) for which a second person (client or observer) provides money or other markers of economic value” Priscilla Alexander, Sex Work and Health: A Question of Safety in the Workplace in JAMWA vol 53, no. 2.

Commercial Sex Trade Commercial sex is central to many of the the HIV epidemics of the region Big business, organized, protected But sex workers usually the easiest group to work with, respond quickly to respect

Females Biologically more susceptible than male partners Stigma, external and internalized At high risk of violence and sexual coercion Little social power, education

Males Large numbers sexually active with both males and females Highly stigmatized Greater likelihood of risk-taking as part of masculinity

And Transgenders Transgenders occupy an important role in sexual transmission in many countries Nearly always have higher HIV levels than any other group of sex workers Gender-benders, cultural challenge

Summary of Key Issues  Where epidemic driven by sex trade, large impact possible.  Few countries cover more than 20% of SWs.  Few programs reach all types of sex workers.  Personal partners, clients, part-timers, suburban and rural SWs often missed.  Condom use can rise very high if clients also addressed.  Sustainable if group norms change but vigilance is required.  Violence, rape, police harassment undermine effectiveness  Improving social capital, social inclusion has impact on condom use.  Best set of components Peer outreach Build social group Quality STI treatment Condom (M/F/Lub) sales

Components of Effective HIV Prevention

Peer Outreach  Requires training, supervision  Requires payment  Training : technical knowledge, communication skills, safer sex, gender & society, working safety, legal rights, counseling skills, fitness, health, & beauty, M&E  HIV support group

Exposed vs non-exposed: % MSW using condoms by type of exposure to intervention All effects p=.000

Exposed vs non-exposed: % MSW showing condoms and seeking STD treatment last time by type of exposure to intervention

Exposed vs non-exposed: Sex with personal partners: % MSW having all last anal sex with condoms and any last oral sex with condoms p=.000

Dhaka Street Sex Workers-syphilis, condom use and STD treatment

Violence against Sex Workers-Bangladesh -2004

Prevalence of gang rape among sex workers in Phnom Penh, Cambodia (n=1003)-2004

Conditions at last gang rape among sex workers in Phnom Penh, Cambodia

Drug Use at last gang rape among sex workers in Phnom Penh, Cambodia

HIV Prevalence among injecting drug users and sex workers - Kathmandu

Who Makes Policy? Governments, politicians? Protectors, NGOs? Self-help groups of marginalized people?