1. The Global Epidemiology of HIV among Female Sex Workers: The Influence of Structural Determinants Shannon K, Strathdee SA, Goldenberg S, Duff P, Mwangi P, Reza- Paul S, Rusakova M, Lau J, Deering K, Pickles M, Boily MC

2. HIV Burden among Female Sex Workers (FSWs) FSWs bear a disproportionate burden of HIV worldwide 13.5 times more likely to be HIV positive than general population* Despite decades of research and program activity, the epidemiology of HIV and structural determinants in sex work remain poorly understood Behavioural and biomedical interventions alone have had only modest impact, leading to calls for combination HIV prevention, including structural and community-led efforts *Baral et al, Lancet 2013

3. Overview of Methods Systematic review of available epidemiological data on HIV and female sex work Review role of structural determinants in HIV epidemics among FSWs and gaps in data Deterministic transmission dynamic models to determine the prevention potential of structural interventions to avert HIV infections in 3 settings (Kenya, India, Canada) with different epidemic settings and history of interventions Key structural factors modeled based on context-specific epidemiological, qualitative and grey literature

4. Systematic Review: State of HIV Epidemiology in Female Sex Work All published studies 2008-2013 including HIV (HIV/STI) or condom use outcomes Majority of studies from LMIC (93%), data disproportionately drawn from Asia Large gaps in science from high HIV burden regions (e.g. Sub-Saharan Africa, Russia, E. Europe) <50% of published studies explicitly examined structural determinants Yet broader literature underscores the centrality of structural determinants for this component of the global HIV epidemic

5. Macro-Structural Determinants that promote HIV risk among FSWs  HIV Criminalized and punitive laws & policies Law enforcement strategies & local policing Demolition/gentrification of red light districts “You know, you get these asshole cops and security kicking us off and moving us to darker and darker areas. This has to stop” -Sex Workers, Vancouver (Shannon et al, 2008)

6. Macro-Structural Determinants that promote HIV risk among FSWs  HIV risk Suboptimal access to safe, appropriate sexual health care, condoms, HIV/ STI testing, ART “When I fell sick and went to a health centre and they realised that I was a sex worker, they did not treat me like a human being […] I was told that he had no time for me. So I left without getting treatment.” -Sex Worker, Mombasa, Kenya (Scorgie et al., 2013)

7. Sex Work Environments that Reduce HIV Risk among FSWs  HIV Supportive work environments Community empowerment “I hear and see mistreatment of sex workers by clients but I throw them out. I call the police patrol too, the mobile jeep, and get the client out” -Transgender Woman Sex Worker/ Lodge Owner, Karnataka, India (Argento, Reza-Paul, et al., 2011)

8. Dynamic Pathways for Structural Factors & HIV Acquisition/ Transmission in Female Sex Work PWID : Person who injects drugs IRR: relative incidence ratio of experiencing violence RRc >1 Relative risk of inconsistent condom use (ICU) following this experience of violence Structural factors = Work environment Vancouver: Injection drug use (  risk) Kenya : Binge drinking(  risk) India: Sex work collective (  risk) Structural factors = Work environment Vancouver: Injection drug use (  risk) Kenya : Binge drinking(  risk) India: Sex work collective (  risk)

9. Dynamic Pathways for Structural Factors & HIV Acquisition/ Transmission in Female Sex Work PWID : Person who inject drug IRR: relative incidence ratio of experiencing violence RRc >1 Relative risk of inconsistent condom use (ICU) following this experience of violence Included in model (based on available data) Vancouver: Recent and non recent history of police harassment and client sexual or physical violence Kenya : Recent workplace sexual violence India: Recent workplace physical/sexual violence and fear of condom confiscation Included in model (based on available data) Vancouver: Recent and non recent history of police harassment and client sexual or physical violence Kenya : Recent workplace sexual violence India: Recent workplace physical/sexual violence and fear of condom confiscation

10. Fraction of new HIV infections averted among FSWs and clients over ten years Vancouver, Canada: Potential HIV Infections Averted through Structural Change ICU: Inconsistent condom use Modest impact due to sustained negative effects of past exposure to client sexual violence

11. Fraction of new HIV infections averted among FSWs and clients over ten years Vancouver, Canada: Potential HIV Infections Averted through Structural Change ICU: Inconsistent condom use Modest impact due to combined, frequent and iterative effects of client physical violence and police harassment

12. Fraction of new HIV infections averted among FSWs and clients over ten years Vancouver, Canada: Potential HIV Infections Averted through Structural Change ICU: Inconsistent condom use

13. Fraction of new HIV infections averted among FSWs and clients over ten years Vancouver, Canada: Potential HIV Infections Averted through Structural Change ICU: Inconsistent condom use

14. Mombasa, Kenya: Potential HIV Infections Averted through Structural Change Fraction of new HIV infections averted among FSWs and clients over ten years

15. Mombasa, Kenya: Potential HIV Infections Averted through Structural Change Fraction of new HIV infections averted among FSWs and clients over ten years

16. Mombasa, Kenya: Potential HIV Infections Averted through Structural Change Fraction of new HIV infections averted among FSWs and clients over ten years

17. Mombasa, Kenya: Potential HIV Infections Averted through Structural Change Fraction of new HIV infections averted among FSWs and clients over ten years

18. Bellary, India: Potential HIV Infections Averted through Structural Change Fraction of new HIV infections averted among FSWs and clients over ten years

19. Policy & Program Implications Critical need for structural change to have major impact on HIV response in sex work = decriminalization of sex work; elimination of violence, police harassment; safer work environments Major gaps in coverage and equitable access to HIV prevention and treatment for FSWs (and dearth of data) – scale-up must occur in tandem with structural change and SW-led efforts Need research to better disentangle complex, dynamic and context-specific pathways of structural determinants

20. Key Messages Elimination of sexual violence alone due to immediate and sustained impact could avert 17-20% of HIV infections over next decade In heavy HIV burden settings (Mombasa Kenya): Scale-up of ART to meet WHO guidelines for both FSWs and clients could avert 34% of HIV infections over next decade Even modest scale up of SW-led outreach could avert 20% of HIV Decriminalization of sex work could have the largest impact on the course of HIV epidemics across all 3 settings averting 33-46% of incident HIV infections over next decade among FSWs and clients Findings confirm calls for multi-pronged structural and community-led interventions, alongside biomedical, to reduce HIV burden and promote human rights for SWs globally

21. Acknowledgements International Co-Author Team – affiliations: Gender & Sexual Health Initiative, BC Centre for Excellence in HIV/AIDS; University of British Columbia, Canada University of California San Diego School of Medicine, United States Bar Hostesses Empowerment and Support Program, African Sex Workers Alliance, Kenya Stellit NGO, Russia Ashodaya Samathi Collective, India Chinese University of Hong Kong, China Imperial College London, United Kingdom Funding: This work was directly supported through partial funds from UNFPA, Bill and Melinda Gates Foundation & NIH NIDA (R01DA028648; PI: Shannon) for assistance with modeling, analysis and planning meetings in London and Vancouver. S. Strathdee is supported by a NIDA MERIT award (R37 DA019829).