Control of HIV pandemic will not be achieved without radical improvement in support for sex workers

People who sell sex face a disproportionate risk and burden of HIV; in low- and middle-income countries, female sex workers have a 13.5 times greater chance of HIV infection than women in the general population. However, although many HIV prevention and treatment strategies -- including free or subsidised access to condoms, and access to anti-retroviral therapy (ART) after infection -- are proven to work in people who sell sex, access is inadequate or entirely absent for many sex workers [Paper 2].

While improving access to interventions such as ART, condoms and lubricant for sex workers needs to be an urgent priority for health policymakers across the world, the Series shows that a focus on providing greater coverage of biomedical interventions will not be enough. Structural determinants -- the legal, social, and political environments in which people who sell sex live, and work -- have an enormous effect on HIV risk, as well as general health, safety, and wellbeing. Global control of the HIV pandemic will simply not be achieved if these legal, social, and political factors continue to go largely unrecognized by global and national policymakers.

New research conducted for the Series [Paper 1] shows that changes in structural determinants could have a profound effect on HIV infection rates. The research shows that reducing sexual violence could reduce HIV infection rates by around a fifth, in both high- and low-income settings, and improving access to ART could prevent around a third of HIV infections in low-income settings. However, the study shows that decriminalization of sex work would have the single greatest effect on the course of HIV epidemics across all settings studied, and could avert at least a third of HIV infections among sex workers and their clients in the next decade, through its immediate and sustained effect on violence, policing, and safer work environments.

Although governments and state authorities, most notably the police, have crucial roles in helping to uphold human rights and establish environments that support public health goals of safety and HIV risk reduction, they are often impediments to protection, if not sources of harm. The Series contains testimony from sex workers in Canada, India, and Kenya who report being arrested for carrying condoms, having their condoms confiscated by police, or being subjected to physical or sexual violence from state authorities [see case study quotes from Series papers].

The central importance of decriminalizing sex work is reinforced by the Series' examination of sex workers' human rights [Paper 4], which suggests that global commitments to achieving an AIDS-free generation will not be possible unless the human rights of sex workers receive global recognition. The authors review over 800 recent studies addressing human rights violations against sex workers, HIV, law and policy, concluding that criminalization of sex work fuels and fosters human rights violations and increases sex workers' susceptibility to HIV, including by reducing sex workers' access to HIV prevention, treatment and care. Furthermore, the study finds that partial criminalization, and other criminalization of clients and third parties (often referred to as the 'Swedish approach') reproduces many of the same harms as full criminalization.

Empowerment of the sex worker community, allowing organization, social support, and ownership of HIV prevention strategies, offers a proven and powerful way to improve HIV prevention and treatment in sex workers [Paper 3]. Pioneering projects in India and elsewhere have shown that when sex workers are able to organize and support each other, HIV prevention and treatment outcomes -- not to mention broader outcomes such as safety and wellbeing -- dramatically improve. But in many regions, the majority of sex workers simply do not have the means to achieve this kind of empowerment, hindered by criminalization, stigma, and inadequate recognition of their human rights.

The diversity of sex workers also need to be recognized, say the authors, and as well as recognizing that the settings in which female sex workers operate can vary enormously, the Series also looks specifically at the issues facing male and transgender sex workers [Paper 5 and Paper 6]. While male and transgender sex workers face many of the same vulnerabilities and risks as female sex workers -- such as violence or inadequate access to healthcare -- they also have unique characteristics, which need to be understood by those implementing HIV prevention strategies. The risks they face are complex, but a lack of quality HIV research specifically addressing male and transgender sex workers means that there are substantial gaps in understanding of how the HIV epidemic affects them, and they remain underserved by the global health community.

The Series concludes with an action agenda for HIV and sex workers [Paper 7]. Decriminalization of sex work -- with accompanying recognition of sex workers' human rights -- and community empowerment will be necessary if the HIV pandemic is to be controlled, say the authors. Moreover, sex workers' access to evidence-based treatment and prevention strategies needs to be greatly improved -- and research needs to be urgently undertaken into how these strategies work for female, male, and transgender sex workers.

Prevention programs for sex workers currently occupy a tiny proportion of overall funding for HIV, despite the disproportionate burden of risk in this group. None of the 'next generation' prevention strategies, such as pre-exposure prophylaxis (PrEP) have been evaluated specifically for sex workers, and for some groups -- notably transgender sex workers -- research specifically looking at their needs for HIV prevention and treatment is almost entirely absent. This should be an urgent international priority, say the authors, and will need to be backed up by appropriate levels of funding from international and national health programs.

According to Professor Chris Beyrer, Director of Johns Hopkins Center for Public Health & Human Rights, USA, who coordinated the Series, "Efforts 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. We must do better, and we can."

The Series, which provides the most comprehensive analysis to date of HIV and sex workers, contains contributions from sex workers, academics, and legal and public health experts, and will be presented at AIDS 2014, the 20th international AIDS conference of the IAS, taking place in Melbourne, Australia, from 20-25 July, 2014. It is accompanied by Comments introducing the Series, dispelling myths about sex workers and HIV, and addressing trafficking, children and adolescents who sell sex, and sex workers who use substances.

The Series can be found online at: http://www.thelancet.com/series/HIV-and-sex-workers