Invisibility, Violence and HIV: Ugly Truths about Sex Trafficking and Public Health Jay G. Silverman, Ph.D. Associate Professor of Society, Human Development and Health Director, Violence Against Women Prevention Research Harvard School of Public Health

Sex Trafficking Forced or coerced migration within or across national borders for sexual exploitation Recognized as a health and human rights violation UN (2000): “the recruitment, transportation, transfer, harbouring or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception ….for the purpose of exploitation” ALSO, based on CRC, all under age 18 in prostitution

Overview Trafficking context and mechanisms Health consequences of trafficking  South Asia, Southeast Asia State of HIV prevention re: Trafficking and adolescent female sex workers  Sources of conflict and marginalization Necessary steps to move the field forward

Sex Trafficking and HIV in South and Southeast Asia Major NGOs, NGO networks, and academic partners across India, Nepal, Bangladesh, Cambodia, Indonesia and Thailand Review and coding of case and medical records Analyses of pilot surveillance databases (U.S. State Dept., NIAID (CFAR), UNDP-AP)

India and Nepal

Trafficking of South Asian Women and Girls: Process India and Nepal (N=495) 51% under age 18 15% under age 15 56% recruited via economic lures 17% kidnapped via drugs 9% abducted via force 46% trafficked by strangers 29-40% by acquaintances 9-16% by family members 49% family disruption as proximal context (38% family violence) (Silverman et al., 2007: IJGO; JAMA)

Trafficking of South Asian Women and Girls: HIV Nepal (N=287): 38.0% HIV+ overall Greatest risk for under 15 – 60.6% 2% increased risk for HIV for each month in brothels Highest prevalence - survivors trafficked to Mumbai (49.6%); other Indian cities (13.6%) Serving in multiple brothels (53.9%) vs. single (36.6%) (Silverman et al., 2007: JAMA)

Violence During Initiation …when she refused [sex work], she was tied on the bed and beaten very badly At first she refused [sex work] and for this she was beaten with sticks and pipes until she relented. Every time she was made to work she rebelled, and each time she rebelled she was beaten. For one month she endured the beating and when she could not bear, she submitted and started to work. (Gupta and Silverman, 2009)

The NGO Joint Statistics Project on CSE Trafficking collected information from 25 NGOs representing 63 shelters, referral agencies and legal aid NGOs in 17 Provinces – ECPAT Cambodia Trafficked based on age at entry, forced or coerced entry Cambodia (N=136 women and girls receiving support services)

STI Infection by Duration: Cambodia

STI & Sexual Violence: Cambodia (McCauley & Silverman, in press IJGO)

IOM Jakarta mission for shelter and care of trafficking victims case-level data Indonesia ( N=509 )

HIV Infection by Duration: Indonesia (Silverman et al., 2009)

Thailand Cross-sectional survey conducted with a stratified, national sample of FSWs in Thailand in 2007 (n=815) Trafficking defined as being a) under the age of 18 at the start of sex work, or b) entering via force, fraud, or coercion (UN, 2000)  10.4% reported having been trafficked Trafficking victims were compared with non-trafficked FSWs

Violence & Working Conditions: Thailand AOR=2.40 (1.11, 5.18) AOR=1.97 (1.32, 2.93) AOR=3.31 (2.22, 4.95) *adjusted for current age, type of establishment and recruitment province (Decker & Silverman, 2010 STI)

Sexual Risk and Trafficking: Thailand *adjusted for current age, type of establishment and recruitment province (Decker & Silverman, 2010 STI) AOR=1.91 (1.21, 3.26) AOR=3.67 (1.57, 8.60) AOR=1.39 (0.56, 3.48)

Recent Risk/Violence: FSWs entering as Adolescents-Mumbai Unprotected sex in the past 90 days 36% vs. 22% (among entering at 18yrs or older) Anal sex in past 7 days 8% vs. 3% Sex after client condom refusal in past 7 days 10% vs. 5% Violence in past 7 days 52% vs. 34% (Silverman & Raj, unpublished)

Preliminary Conclusions Sex Trafficking as Forced Migration and GBV Victims of sex trafficking across South and Southeast Asia demonstrate extensive HIV risk  Violence – both at initiation and ongoing  Coercion leading to elevated risk Efforts needed to  Develop integrated or complementary programs to both provide FSWs HIV prevention and identify and assist victims of trafficking  Prevent trafficking as a form of GBV and HIV prevention

Why hasn’t it happened? Collective/Peer empowerment and harm reduction approaches  Works for adults in previous studies  NO evidence works for either reducing the numbers of adolescents in CSW or reducing HIV among adolescent FSWs Likely to work if could somehow include adolescents?

Why doesn’t it work? CSW is hierarchical Most powerful members of collectives (brothel owners/managers and senior FSWs) are those bringing adolescents in, profiting from them, and holding them in either physical and or debt bondage Participatory models fail when the most vulnerable are systematically eliminated for the process  Need to collect and disseminate data where this is being tried

Challenging Complexities Need to think beyond peer-based models for this population ***Major barrier is combative/intolerant relationship between many FSW rights groups and HIV prevention professionals and anti-trafficking and children’s rights advocates  Reasonable fears that intervention to detect and assist adolescents in CSW will drive operation underground, putting FSWs at greater risk  Exacerbated by abuses by police during raids to remove adolescent FSWs

But……Challenges cannot Justify Inaction We must find a way to hold both realities!  FSWs are highly vulnerable to HIV as well as GBV and many other abuses, and their rights to health and safety must be protected  Adolescents are present in CSW, and are at even higher risk, at least in part due to the actions of those controlling CSW The rights of adolescent FSWs must also be protected Currently, we are failing to protect them from either GBV or HIV Tremendous legal, ethical and logistical issues….

Moving Forward…. Voices of the affected and those working directly with those affected must be at the table – it is not possible to develop a solution without them.

Next Steps: Research Trafficking, CSW and HIV in SW China  Including migrant Vietnamese FSWs in modeling the emerging HIV epidemic Southeastern Europe South Africa and Tanzania Evaluation of existing FSW programs Primary and secondary prevention efforts

Next Steps: Research and Policy Agendas Trafficking as element of HIV prevention Trafficking as key facet of GBV Role in provision of care OGAC/PEPFAR UNAIDS, WHO DHHS

OTHER WORK! Roles of GBV:  HIV infection and transmission  Reproductive health  Neonatal, infant and child health  Social and legal policy