500 days and counting: Progress for girls and women means progress for all
During the 2014 International AIDS conference, The Lancet medical journal released a series of articles focused exclusively on HIV and sex work. One study by Kate Shannon et al., demonstrates that decriminalization of sex work could reduce HIV infections by 33 to 46 percent over the next decade. Shannon’s team showed that “multi-pronged structural and community-led interventions” are essential to promoting the human rights of sex workers, as well as improving their access to HIV prevention and treatment. Dr. Chris Beyrer, the researcher who coordinated this Lancet series, told AIDS conference participants that“[e]fforts to improve HIV prevention and treatment by and for people who sell sex can no longer be seen as peripheral to the achievement of universal access to HIV services and to eventual control of the pandemic,” drawing an irrefutable line between the social, legal, and economic injustices sex workers face and their subsequent vulnerability to HIV.
The Lancet series authors join many other prominent public health voices in identifying the decriminalization of sex work as vital to preventing the spread of human immunodeficiency virus (HIV) and of acquired immune deficiency syndrome (AIDS). For two decades, sex workers rights’ activists throughout the world have pushed human rights, public health, and HIV and AIDS response leaders to recognize that they, along with people who inject drugs and men who have sex with men, are “key populations” without whom an effective HIV and AIDS response is impossible. In 2012, the World Health Organization (WHO) declared that “all countries should work toward decriminalization of sex work and elimination of the unjust application of non-criminal laws and regulations against sex workers.” In South Africa (with the largest population of people living with HIV in the world), the National AIDS Council is urging its government to decriminalize sex work—a demand that advocates and health policy professionals are making in dozens of other countries as well. Amnesty International, Human Rights Watch, and the UN’s Global Commission on HIV and the Law all endorse this position. The latter points out “the impossibility of governments stigmatizing people on one hand, while simultaneously actually helping to reduce their risk of HIV transmission or exposure on the other.”
Sex work has been decriminalized in New Zealand and one province (New South Wales) in Australia leaving sex work businesses subject to standard occupational health and safety regulations. Law enforcement treats the sale of sex as it does any other business, without any intrusion or interruption unless existing laws are being violated.
Decriminalization has resulted in higher rates of condom use and enables sex workers to organize community-based health practices that demonstrably improve health and reduce HIV risk. It also makes it possible for sex workers to report and for the police to address illegal acts as they occur, such as assault, theft of services, employment of minors, or client coercion. In this decriminalized setting, sex workers can be strong allies in the fight against trafficking, intimate partner violence, and child abuse since they can report incidents to the police and social service agencies without putting themselves at risk of arrest.
So, why is the HIV-AIDS field only just beginning to recognize the connection between the decriminalization of sex work and HIV? And why is the trend toward criminalizing populations involved in the sex trades increasing in the United States—moving in the opposite direction from other countries? The following are three contributing factors.
Public debate around sex work in the United States increasingly focuses on people who have been trafficked or otherwise coerced into the sex trade. Anti-trafficking advocates conflate sex work (people choosing to sell sexual services from among employment options available to them) with trafficking (people being forced into the sex industry against their will). Laws that criminalize all people selling sex (voluntarily or involuntarily) violate the rights of the former and undermine efforts to identify and assist the latter. The Global Commission on HIV and the Law states unequivocally that, “Sex work and sex trafficking are not the same. The difference is that the former is consensual, whereas the latter is coercive.”
A commentary by Steen et al. in the recent Lancet series notes that “repressive and counterproductive police action,” including the arrest and incarceration of trafficking victims for the purposes of “rescue,” has overtaken far more effective responses in several countries. The understandable, but destructively over-simplified, mandate to “rescue and restore” sex workers is also being imposed in public health settings where providers are now charged with identifying and intervening with potential victims of trafficking in the sex trade. Certainly, health-care providers have a duty to watch for and help patients in abusive situations of all kinds. They also have a duty to understand the complexities of human experience, respond to patient-identified needs, and maintain that patients are experts of their own lives, whatever that may look like.
Providing access to health-care services targeted to consumers’ needs is a vital part of any country’s HIV response. Without it, those most in need of prevention, care, and treatment are least likely to get it.
In a 2010 survey, 53 percent of medical students said they were not adequately trained to address their patients’ sexual issues comfortably. Far fewer professional medical curricula explicitly prepare students to understand that they will encounter sex workers as patients who, like all other patients, are individuals with a wide range of experiences, backgrounds, and needs that can best be treated with patient-centered care.
When sex workers receive demeaning and unprofessional treatment in health-care settings, they see health-care providers as an extension of the larger system that criminalizes them. A survey by the New York City-based Persist Health Project found that few sex workers disclosed their occupation to their health-care provider; only one study participant reported a positive experience after doing so. As one respondent explained, “I think for security reasons, I don’t usually disclose. Mainly because I don’t trust doctors … I sort of treat them like law enforcement.” Another noted that most health-care providers “have no clue who you are, no clue about your background, you can’t read them or know that they’re not going to try to lecture you or give you a stink-eye.”
St. James Infirmary, a peer-based occupational safety and health clinic for sex workers in San Francisco, corroborates these findings. Of their incoming patients, 70 percent had never previously disclosed their occupation to a medical provider for feared of bad treatment. Providing sex-worker friendly health care requires training health-care workers appropriately and supporting services designed specifically with and for the communities they serve.
People usually envision a sex worker as someone soliciting on the street, but only about 20 percent of U.S. sex workers are street-based. The vast majority see clients in other venues including massage parlors, brothels, apartments they share with other sex workers, or a client’s hotel room. Many connect with clients online.
HIV risk is high among street-based sex workers who experience high levels of violence at the hands of clients and abusive law enforcement personnel. One important way they reduce this risk is assessing a potential client before getting into his car—looking for signals that he might be violent and relaying his license number to a colleague in case the worker disappears. This assessment time is also used to negotiate price and condom use. Law enforcement crack-downs compel sex workers to complete their negotiations quickly (in order to avoid arrest), depriving them of the time needed for assessment and negotiation.
Street-based sex workers have little or no protection if a client becomes violent or refuses to use a condom. Of the street-based workers surveyed in The Lancet study by Shannon et al., 25 percent reported being pressured by clients to have sex without a condom. Those working in remote areas (such as industrial parks) to escape local policing were three times more likely to report being pressured into having sex without a condom than the study population overall. The recent Lancet series data also shows that, in some countries, up to one-third of sex workers do not carry an adequate supply of condoms due to “condoms as evidence” policies that allow police to seize a sex worker’s condom supply and use it as evidence of their intent to engaged in sex work—a widely-used policy in several U.S. cities.
Punitive laws against sex work are in place in 116 countries, including the United States, creating, according to the Open Society Foundations, “a state-sanctioned culture of stigma, discrimination, exploitation, and police and client violence against sex workers.”
Decriminalizing sex work in the United States is a long and challenging process, but there is a path to follow. The 1988 ban on federal funding for syringe exchange remained in place for 20 years and, after briefly lifting it in 2009, the Obama administration agreed to its reinstatement in 2011 at Congress’ insistence. Advocacy pressure to overturn it continues.
Thanks to the efforts of dedicated researchers and activists during the two decades between 1988-2009, public health professionals, medical institutions and virtually everyone working in the HIV-AIDS field learned why harm reduction practices are essential. Services to people who use drugs began to improve, although they are still inadequate, primarily because they are grossly under-funded. Progress has been made.
The U.S. National Institutes of Health (NIH) issued a consensus statement that addressed the need for syringe exchange but also observed that “[p]rograms targeting sex workers have been highly efficacious in other countries, but [in the U.S., programs] will encounter cultural and political barriers.” The public silence maintained on this issue for the last 17 years is emblematic of those barriers.
But sex workers’ rights organizations in most U.S. cities, though heavily marginalized, have not been silent. They are struggling to end “condoms as evidence” practices, train health-care providers, find or establish sex worker-friendly health-care services, and demand their rightful place as invaluable allies in ending human trafficking and preventing the spread of HIV. Like the harm reductionists who set up the first syringe exchange sites in the United States, they need the support of mainstream sexual and reproductive health advocates willing to learn from them and join them. Like the early harm reductionists, they need the rest of us to bring our money, skills, and political support this human rights struggle.
We can’t stop HIV in the United States without sustainable and long-term solutions to end the arrest, detention, and incarceration of sex workers in the United States, as well as end the violations against sex workers within the correctional system. A meta-analysis of more than 800 other studies and reports, published in the recent Lancet series, listed abuse experienced by sex workers as including “homicide; physical and sexual violence, from law enforcement, clients, and intimate partners; unlawful arrest and detention; discrimination in accessing health services; and forced HIV testing.” It added “protection of sex workers is essential to respect, protect, and meet their human rights, and to improve their health and well-being.”
Expert voices in support of community-led, sex worker-centered health care in the fight against HIV are becoming more and more numerous. When will the mainstream HIV and AIDS organizations and women’s health advocacy communities join loudly in this demand?
by Anna Forbes and Sarah Elspeth Patterson
13 August 2014
The first time Alfred went to a HIV voluntary testing centre, the healthcare provider did not treat him well. As a gay man, his story is not so rare.
“He [healthcare worker] asked me are you a man or a woman? I answered I am a man. Then he asked me about my parents,” said Alfred, who lives on the Caribbean island of Saint Lucia.
“He just looked at me and treated me as if I was a disgrace to my parents. I decided not to go to the health centre after that. Because I do not want to go to a place where I am judged based on my sexual orientation. I am gay and I have sex. So what? ”
Challenges for youth to accessing sexual and reproductive health
Key populations in the HIV epidemic, such as men who have sex with men, sex workers and transgender people, have the same sexual and reproductive health rights as anyone else— the right to have sexual relations free from coercion, to have children and to protect themselves from infection.
Last week’s International AIDS Conference in Melbourne, Australia was an opportunity for young people, especially youth from key populations, including young people living with HIV, to discuss the barriers and challenges they face in accessing sexual and reproductive health services.
During a session moderated by the Athena Network and the International HIV/AIDS Alliance, one young panelist Violet Lindiwe, 23, from Malawi, said: “In my community, when you attend HIV testing and family planning, healthcare professionals are likely to judge you because they think you misbehaved and that’s why you are there.”
Myo Minn Htet, a young man from Indonesia, added: “Culture and religious beliefs make it very difficult to talk about sex and to go to sexual and reproductive health services. Moreover discrimination against young key populations make their access to these services more difficult.”
The legal age to attend health centres is also one of the barriers identified by young people. Annie Zamina from Malawi said: “In my country though the legal age to have sex is 16, you cannot go a clinic and ask for contraceptive pills without your parents’ approval. It seems that while the law says you’re old enough to have sex, you are still too young to use contraception or to protect yourself from HIV.”
Young people vulnerable to HIV infection and unwanted pregnancies
According to the UN, globally young people account for 40% of all new HIV infections. Each day, more than 2,400 young people become infected with HIV, and some 5 million young people aged 15–24 live with HIV.
Apart from HIV infection, poor access to sexual and reproductive health and sex education opens the door to many other consequences, such as unintended pregnancies and dropping out of school.
Violet said: “When you listen to me, you may think I have a PhD but in fact, I stopped school when I became pregnant. I have to care for me and my son now. And this is what happens to young women in my community when they get pregnant when still students.”
According to the World Health Organization, linking sexual and reproductive health with HIV services is an approach that has the potential to increase universal access to prevention, treatment, and care services.
This is what Link Up— a programme to improve the sexual and reproductive health and rights of young people—is trying to achieve. The project works with young people living with and affected by HIV in Bangladesh, Burundi, Ethiopia, Myanmar, and Uganda and is implemented by a consortium of organisations, including the International HIV/Aids Alliance, Global Youth Coalition against Aids, and the Athena Network.
Sexual and reproductive health rights
Reproductive rights only become tangible when reproductive health services that offer a high quality of care are made widely available. Availability includes both affordability and easy access, which also implies a range of services under one roof.
Like Alfred, Rebeccah, a young woman living with HIV from Zimbabwe, was also treated badly the first time she went to a clinic to receive counselling about contraception. She said: “The nurse said she was surprised I was still having sex considering my ‘condition’. And she told me I should abstain from sex since I am HIV positive. I cried a lot in her office and decided not to go to that clinic anymore.”
But Rebeccah, like many other young people, is now getting to grips with her rights. “As a young woman living with HIV, I am sexually active and I have the right to go a clinic for family planning services,” she said. “My status should not be an argument to be denied this service. And I really hope people should not use our status, our sexual orientation or sex work as argument to deny access to healthcare because we need, no, we demand access to comprehensive sexual and reproductive health services.”
Nina Benedicte Kouassi is a member of the Key Correspondents network, which focuses on marginalised groups affected by HIV to report the health and human rights stories that matter to them. The network is supported by the International HIV/AIDS Alliance.
Feature image credit: Sheikh Rajibul Islam/International HIV/AIDS Alliance
In-post image credit: Julie Mellin/GYCA
By Nina B. Kouassi
30 July 2014
The latest version of the zero draft report from the Open Working Group developing the Sustainable Development Goals (SDGs) hit the internet late Monday evening. This is the final draft that member states will have a chance to respond to before the final report is produced and shared with the Secretary General prior to the United Nations General Assembly in September. It is fairly similar to the last draft in that it still has the same 17 goals, with small semantic differences. Overall, there are fewer targets, but both the targets and the process are becoming increasingly convoluted.
This draft misses the integration, aspiration, transformation and sustainability that were meant to drive the post-2015 agenda. We see important targets missing in this lengthy draft, but we have yet to really see the difficult trade-offs that a final set of implementable goals would require.
Sexual and reproductive health has disappeared from the Health Goal. While a target on sexual and reproductive health was previously included under both the Health and Gender goals, it now only appears under the Gender goal as “ensure universal access to sexual and reproductive health and reproductive rights in accordance with the Programme of Action of the ICPD and the Beijing Platform for Action.” This is problematic for two reasons:
1. Without SRH under the health goal, family planning is in jeopardy of not being recognized in this new development framework. SRHR is a major component of overall health not only for women and girls, but also for men and boys. It is therefore critical to be included within a discussion of health.
2. The qualifier of ICPD and Beijing is unnecessary and weakens the human rights frame of the target. Nowhere else in the Open Working Group’s draft document is such a caveat introduced. As such, it undermines the principle of arriving at a forward-looking set of SDGs. There is no need to qualify universal access to sexual and reproductive health or reproductive rights. With a reference to ICPD and Beijing already in the introduction, we hope to see this qualifier removed.
In New York for the Open Working Group session last week, you could see will, desire, and investment on the faces of delegates, civil society, co-chairs. But you could also see the fatigue. This has been a long and intensive exercise that has lasted nearly two years already. Now is the time point to put words down on paper and respond to drafts in order to rescue the jumbled mess that the draft goals have become.
The final round of informal discussions by the Open Working Group takes place July 14 to 18. The co-chairs (from Kenya and Hungary) will incorporate this final feedback from member states into a final report submitted to the Secretary General in August. A report will simultaneously be submitted by the Intergovernmental Committee of Experts on Sustainable Development Financing. The Secretary General will then take these inputs, among others, and produce his own report, and full negotiations are expected to start in January 2015. The co-chairs of the post-2015 summit (September 21 to 23) are Denmark and Papua New Guinea.
By A. Tianna Scozzaro, Population and Climate Associate -
3 July 2014
With a little over a year to go to ensure the eight MDG targets are met, the UN this week issued a progress report, which showed that goals on poverty reduction, improving drinking water sources, improving the lives of slum dwellers and achieving gender parity in primary schools had already been met.
Progress was also being made on MDGs covering hunger, debt relief and malaria, tuberculosis and HIV treatment.
‘However, some MDG targets related to largely preventable problems with available solutions, such as reducing child and maternal mortality and increasing access to sanitation, are slipping away from achievement by 2015, despite major progress,’ the UN said.
‘The report calls on all stakeholders to focus and intensify efforts on the areas where advances have been too slow or not reached all.’
More reliable statistics were needed for monitoring development, the report said. It noted that the number of member states submitting progress reports on HIV/Aids increased from 102 in 2004 to 186 in 2012, helping galavanise global efforts. Funding for HIV programmes more than tripled in this period and 9.5 million people living with HIV were accessing antiretroviral treatment in 2012.
UN member states are currently considering a new set of development goals that can replace the MDGs in 2015. These are likely to be agreed in September next year.
UN secretary general Ban-Ki Moon said: ‘Our efforts to achieve the MDGs are critical to building a solid foundation for development beyond 2015. At the same time, we must aim for a strong successor framework to attend to unfinished business and address areas not covered by the eight MDGs.
‘Tackling growing inequality, in rich and poor countries alike, has become the defining challenges of our times. Our post-2015 objectives must be to leave no one behind.’
By Vivienne Russell
9 July 2014