Health practitioners’ role in challenging damaging practice – more on Clitoraid

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The debate surrounding the practice of Clitoraid, the organisation that provides reparative surgery for women who are victims of female genital mutilation (FGM), has come to a head as Clitoraid published a rebuttal of their critics, accusing them of being sex-negative, likening them to defenders of slavery and Nazism, and accusing them of prejudice against the organisation’s Raelian background.  Clitoraid’s rebuttal misrepresents what their critics have been saying and fails to engage with most of the questions asked of them.  Dr Petra Boynton has posted a detailed response, explaining why the questions remain unanswered, and strongly challenging the manner in which Clitoraid have responded.  More detailed background to the Clitoraid debate to date can be found on the blogs DrPetra, Can We Save Africa?, and Sex in the Public Square.

Although I have been following the discussion closely, I have not yet posted any analysis on Clitoraid, as I am focussing on trying to find out more about their activities in Burkina Faso.  My blog contains a few links containing information I have discovered so far.  However, having seen Clitoraid’s latest response I want to contribute some thoughts, because this discussion has a lot to do with appropriate international health and development practice.

Responses by Clitoraid and its supporters to criticism have consistently tried to imply that critics condone FGM – and this despite repeated, robust statements to the contrary.  A point that has repeatedly been made by those asking questions relates to how reconstructive surgery is perceived in countries like Burkina Faso, where Clitoraid is building a hospital for the purposes of offering this surgery.  Critics have pointed out that there is already a strong indigenous movement against FGM in Burkina Faso, leading to criminalisation of the practice and to provision of reconstructive surgery in some public facilities.  But just because there is active opposition to FGM at policy level, it can’t be assumed that attitudes towards female sexuality have changed in the same way and across the whole country.

Clitoraid makes out like critics are calling for sensitivity to the community’s attachment to FGM, but they are being disingenuous.  In health practice, community sensitivity is crucial, because developing healthcare often involves introducing new technologies that are poorly understood or mistrusted.  But talking about community acceptability or community preparedness does not mean condoning traditions and practices.  It means understanding how and why cultures, traditions and practices exist, who is maintaining them, who is opposed to them, and what the barriers are to tackling them.  In the context of FGM it means identifying the overall context within which the practice takes place, because in countries where FGM is prevalent, women often suffer a range of abuses, inequalities and rights violations, not just FGM – and all of these need to be addressed.  For instance, UNICEF has identified six key elements for effectively addressing FGM and its effects.  Interventions like reconstructive surgery are incredibly important, but on their own, specific interventions are unlikely to have a major impact.

Talking about community context also means appraising the risks of trying to influence attitudes and practices, in particular the risks for those community members who wish, against majority opinion, to stand up and oppose abusive and barbaric practices.  Health and development practitioners do worry about imposing their own values (or being seen as doing so), but most of the time there are already people – albeit sometimes in the minority – who are challenging practices that are damaging.

Sex positive approaches are very important in my field, HIV prevention and treatment, but this doesn’t mean that it makes sense for westerners to barge in to every community in Africa insisting they reject widespread sexually conservative rhetoric.  I have worked a fair bit with stigmatised people in Africa, such as men who have sex with men and sex workers, and people living with HIV and AIDS.  Discussions on HIV prevention and treatment with these groups very quickly turn to their status in society and under the law, and in many countries (and not just in Africa) groups like this have become vocal in challenging the marginalisation and discrimination that they suffer.  But they do so at great risk to themselves.  People have been ostracised and some have even been killed for standing up for their rights in this way.

This is why it is important to start off by working out what changes in society’s attitudes they can realistically achieve in the shorter and longer terms, who their allies are, and who will oppose them at all costs.  The call for thoughtful community development work is about responsible and effective practice, and about working with the most marginalised; it is not about appeasement.

Where does policy end and practice start? Review of a paper on HIV programmes with sex workers.

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“Risk” groups for HIV prevention

A few years ago, colleagues in an NGO asked me to comment on their HIV prevention strategy.  The strategy had a list of priority population groups that the programme would aim to target – these groups were selected based on actual or perceived risk of HIV infection.  One of the groups on the list was “wives of unfaithful men”.

Targeting health programmes towards people who are most affected or most at risk makes sense.  Not only is it more economical, but it also more practical since different types of people have different circumstances and needs.  But an important aspect of targeting is to make sure that the categories being defined are “operational” from the perspective of the people providing the services.  Was the idea that programmes would specifically target women with unfaithful husbands?  How might an outreach worker identify the women in the marketplace whose husbands are unfaithful, so as to focus on them?  Were sexual health clinicians being asked to factor in the likelihood of spousal infidelity when deciding what tests or treatments to prescribe to a married woman who comes to see them with symptoms?  And if “wives of unfaithful men” really were a high-risk group, were programmes also identifying the men and reaching them with sexual health services and advice?

Redefining risk categories – a new study from Karnataka, India

I was reminded of this story when reading a recent research paper, “Devising a female sex work typology using data from Karnataka, India”*.  The authors set out to define a typology for female sex workers that more accurately predicts HIV risk than the typology currently used in India’s National AIDS Control Organisation guidelines.  A more robust typology, that can act as a “predictor” of risk for HIV, would help programmes to discriminate between sex workers at higher and lower risk and prioritise programmes reaching the former, according to the article.

The existing typology classifies female sex workers according to where they solicit sex – because this is seen as the most practical basis for delivering services or outreach.   But the authors of this new study argue that this typology masks differences in risk for HIV, specifically measured by the actual HIV prevalence in each category.  The new classification proposed by the authors is based on a combination of the place of solicitation of sex with the place where sex actually takes place.  Categories include “Brothel to brothel”, “home to home”, “street to home”, “street to rented room “street to lodge” “street to street” and “other” (in each case, the first term represents the place of solicitation and the second the place of sex). 

The authors successfully demonstrate that the newly proposed set of seven categories gives a more complex picture of how risk for HIV – measured by the current level of HIV prevalence – is distributed, when compared to the other typologies in use (which had 4 and 6 categories respectively).  The analysis shows that the category most affected by HIV is the “brothel to brothel” one (34.0%), the lowest is other (11.1%).  The authors also argue that further research might enable the development of even more sensitive categorisations can be developed based on.

How can the findings be used?

While it is true that the study shows clearly that there are bigger variations in HIV prevalence between different categories of sex worker under the new proposed typology, might the comparative statistics might be getting in the way of the bigger picture?  While the odds of HIV infection among the “street to lodge” category may well be nearly 3 times higher than it is for the “other” category, sex workers in the other category are still over 20 times more likely to be HIV positive than women in the general population.  Levels of other STIs in this group are also not negligible, as are levels of condom breakage.  Members of the “other” group were the most likely to have been raped in the past year.  Levels of unwanted pregnancy or of other health problems are not reported.

It isn’t clear that there is a strong justification for focussing on some of the new categories rather than old ones.  Are categories such as “street to home” operational when compared to “street to lodge”?  Can outreach workers or clinicians differentiate between the street-soliciting sex workers based on whether they go home or to a lodge to have sex, and should they?  And are the types of services required by members of each of these new categories demonstrably different from each other? 

On the one hand, while the commitment to understanding context and not providing a one-size-fits-all approach is commendable, it isn’t clear what to do with the findings.  Given how affected all sex workers in the study were by HIV, STIs, and violence, it hardly seems appropriate to focus only on those most at risk.  On the other hand, if the study findings demonstrate that some of the new categories are clearly “underserved” by existing programmes, the findings might help encourage programmers to ensure that this is redressed.  In India there is still a way to go in reaching sex workers with HIV and AIDS programmes: according to India’s most recent HIV report to the UN, coverage of sex workers by essential HIV programmes is only just over 50%.

When does policy stop and practice start?

Epidemiological studies on HIV risk aim to identify who the “most at risk” groups are.  They look at a number of different variables – including actual levels of HIV infection, other STIs, and behaviours that may contribute to risk.  But studies of this kind are inevitably generalisations because in any given population group, there will be subcategories, and eventually individuals, who are at higher or lower risk.  While there may be a temptation to stratify population groups further and further so as to increase the precision of risk categories, might there also be a point at which the increasing numbers of categories make it harder, not easier, to deliver programmes?  This might also be the point at which the analysis is no longer be the job of the researcher, policy maker or programme designer, but of the health care provider or outreach worker – because front line providers should be responding based on what individual clients tell them, not based on what the epidemiological categories are telling them to assume. 

 

* Buzdugan R, Copas A, et al “ (2010) Devising a female sex work typology using data from Karnataka, India”, International Journal of Epidemiology 39 (439-448)

UK election manifesto commitments on international development and global health

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It’s niche as far as general election issues go – but what do the election manifestos of the three main political parties say about international development and global health?  They are a bit thin, but here are a few notes, for those who need a tie-breaker that is more meaningful than the quality of leaders’ wives’ toes.

Big ideas:

·        Lib dems: Financial transaction tax; Global Fund for social protection.  “Meeting Britain’s obligations to the developing world”.

·        Labour: Debt cancellation; support to the most excluded and vulnerable; major investments in key areas of health; free access to education and healthcare.  “Our moral duty, our common interest”.

·        Tories: Transparency and accountability to the UK taxpayer; national security; wealth creation; strengthening Britain’s waning influence.  Malaria.  “Honouring our aid commitments”; “in the national interest”.  They will keep an independent DFID – which was not clear until now.

Development assistance, financing and debt:

·        All three parties commit to achieving the agreed UN target of spending 0.7% of Gross National Income by 2013, and of passing legislation to protect this level of spending.

·        All 3 parties endorse the Millennium Development Goals, to be achieved by 2015.

·        The Lib Dems and Labour both emphasise reform of global financial institutions – with the Lib Dems specifically mentioning the IMF and the World Bank and Labour additionally mentioning the UN, Commonwealth and NATO

·        The Lib Dems will introduce a financial transaction tax (something along the lines of the “Robin Hood” tax).  This is something Labour have advocated in the past but it isn’t mentioned in their manifesto, nor in the Tories’. 

·        Lib Dems say they will push for a “renewed international effort on debt”, supporting debt cancelation and measures against vulture funds buying developing country debt.  Labour also support debt cancelation and crack downs on vulture funds.  The Tories do not mention debt reduction but do mention trade deals such as a global trade deal and a Pan-African free trade area as the main poverty reduction approach.

·        The Lib Dems will support introduction of a Global Fund for social protection.

·        The Tories favour a “payment by results” approach for development organisations, and open information on all aid funded projects.  The Tories will stop supporting countries like Russia and China and will focus on Commonwealth countries.

·        Labour – development assistance targeting the poorest and most excluded.  Improvement of country tax systems, and “no enforced liberalisation of economies”.  In addition Labour commit that 5% of developing country budget support to be earmarked to strengthening the role of parliaments and civil society.

Health and other community development priorities

·        The Lib Dems talk about health and education, promotion of gender equality, reduction of maternal and infant mortality and restricting the spread of AIDS, TB and malaria.  They also single out clean water as a priority.

·        Labour provide some numbers for spending priorities – including £8.5bn on schooling over 8 years, and £6bn on health including £1bn each for the Global Fund to fight AIDS, TB and Malaria, water and sanitation and food security.  The single out the need to achieve Universal Access to HIV prevention and treatment by 2010, and the distribution of 30 million bed nets to prevent malaria over the next 3 years.  They also mention flagship initiatives on child hunger and the new UN women’s agency, as well as supporting the agenda of making health and education free at the point of delivery.

·        Tories clean water sanitation healthcare education; rights of women Tories specific commitment to spend £500m per year on malaria.  Other health themes mentioned include sanitation, healthcare, and access to services for women, children and disabled people.

And so?

·        Great news that all parties support achieving and sustaining the allocation of 0.7% of Gross National Income to development programmes by 2013, in line with UN commitments.  In theory this means that this will happen and be enshrined in national law, hopefully even if there is a hung parliament.

·        What seems to stand out is that the Lib Dems are the only party committing to finding additional funding for development assistance above and beyond 0.7% of Gross National Income by 2013, through the financial transaction tax.

 

·        Human rights and the principle of supporting poor countries to define their own development agendas don’t exactly leap out of any of the pages.

·        Labour are the party with most numbers behind their health commitments; having said this many of the figures they give are for a period beginning in 2008 so I can’t help wondering how much of their pledges include “new” money, and how much includes money that the other parties would be tied in to spending anyway.

·        Labour’s commitment to Universal Access for HIV prevention and treatment by 2010 is likely to be overtaken by events since most people in the know now accept these targets will not be met.  Does it mean however that Labour will continue to push for Universal Access, even though their tendency of late has been to pull back from HIV funding?

·        The fact that the Tories single out one disease – malaria – for a financial commitment is intriguing, especially as global health thinking moves toward a more integrated approach to healthcare development.

·        To the extent that there is any clear water between the two main parties, it is perhaps the Tories’ greater use of language on the “national interest”, and their insistence on increasing UK citizens’ ownership of aid programmes.  Labour’s pointed reference to “no enforced liberalisation of economies” may be an intended contrast to the Tories’ focus on trade agreements, but there’s not much to go on.  The devil is in the detail…

Where do the “Stats on Prostitution” come from?

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In the past few weeks a new Infographic called The Stats on Prostitution has been circulating online.  It was produced by the website http://www.onlineschools.org/ which carries similar “Infographics” on a diverse range of topics including infidelity, breasts, money and robots.

The Stats on Prostitution gives global figures for numbers of prostitutes, percentage of men buying sex, average prices, and a host of other related topics.  If you scroll to the end of you will see the references, many of which are news sources rather than original studies. 


Is it possible to accurately represent prostitution and related issues using such a short summary? 

Take the first figure given in the graphic: “At this given moment there are 40 million prostitutes at work”.  Getting a global figure for something like the number of prostitutes or sex workers is beset with difficulties.  You obviously have to start by getting figures for each country.  There are probably three main techniques of calculating such numbers at a national level: censuses (where all sex workers are counted in a given country); multiplier techniques (where figures are extrapolated based on specific studies or data from a limited number of locations); or expert opinion.  Using any of these techniques rests on a number of assumptions.  A good introduction to them can be found here.  It is often the case that initiatives to estimate numbers of sex workers will use a combination of these techniques.

Whichever of these techniques is being applied, there are quite a few major problems.  The first one is to do with definitions.  Most of the terms and concepts being dealt with are fairly hard to define.  What is a sex worker?  What is sex, for that matter?  What constitutes selling or receiving a reward for sex?  Do your data sources cover male, female and transgender sex workers?  How you define the basic concepts has a major impact on any estimates.

If you can sort these problems out – so that you are fairly sure that all of the data sources you are using in your country are using more or less the same definition – you have another set of problems.  Although sex work tends to be thought of as a more or less “permanent” or full time occupation, this is not always the case.  Many sex workers have other sources of income, or do sex work for short periods of time or on an irregular basis.  Mobility and migration are very common in sex work, and potentially have a major impact on population size estimates.  In many countries, the volume of sex work has a seasonal character, with numbers working expanding and decreasing over the course of a month or a year.   How do you know how representative your data are of different types of sex work?  Is there a risk that they over- or under- represent people doing sex work in different ways? 

Because of the often highly stigmatised nature of sex work, it is fair to assume that enumeration exercises don’t always capture the most “hidden” or discreet groups.  Censuses may over estimate brothel-based sex work.  If data from a small number of locations are being used as a basis for “multiplier” calculations, how do we know how representative these locations are – the character of the sex industry tends to vary a lot from location to location, as it is influenced by a range of factors including local economies, demand, law enforcement practices, and culture.

All of these definitional problems increase the risk of systematic errors in population size estimates.  Sampling error can also be a problem, especially if estimates are based on surveys with small samples.  Although confidence intervals can help in assessing the possible scale of sampling error, they are no help at all in resolving the errors that stem from bias rather than random effects – so the fact that there are confidence intervals shouldn’t in itself be taken to mean the figures are accurate.  What is more, it is hard to know which direction the biases are taking the estimates – so it isn’t even that easy to be confident about whether an estimate is a minimum or a maximum.   

Once you have satisfactory national estimates then you need to compile them, again confronting definitional issues – do all the data from all of the countries meet the same definitional requirements?  And do they meet the same quality requirements – some estimates may be based on fair lower levels of rigour than others.  Different researchers are happy with different levels of rigour.  In a recent report to the UN on its AIDS programming efforts, the UK did not report any data on sex workers.  This isn’t because there are no data, nor because nothing has been achieved in this area – it is simply because the only data available that strictly met the definitions of this indicator were from one study, of one sample, in one town.  The people filling in the report didn’t think it was appropriate to claim that these data are representative of all of the UK.  If you look at other reports on the same page you will see that many other countries do give figures on sex work – and often the figures are based on just one study, of one sample, in one town.  On the other hand, the most commonly quoted figure for the sex worker population in the UK – 80,000 sex workers – was based on a highly approximated multiplier calculation and the researcher who made the estimate has repeatedly expressed surprise that it is used as a basis for policy, saying “…I was never myself at all confident about it.  I felt it could be higher, but it also could have been lower”.  The reality is that many countries don’t really have the sort of data required to allow for a remotely accurate global estimate, as this exhaustive review of global data shows. 

Invariably then, any figures like those presented in this graphic will be built on assumptions which are built on assumptions, which are in turn built on other assumptions.  This is true for all of the “Stats on Prostitution”.  Many of the findings that are presented as global can be sourced to one study in one town in one country.  The US dollar figures set against the size of the sex industry or of sex trafficking can similarly be shown to be based on very imprecise estimates.  Nearly all trafficking figures are (I talked about trafficking estimates for the South Africa World Cup in a recent post) – and while this doesn’t mean trafficking does not exist, it means that there is a real risk that policy becomes based on assumptions. If you are interested in the issues involved in evaluating the economics of sex work, take a look at this annotated bibliography on the subject.

What other problems might there be behind the “Stats on prostitution”?  Well, the graphic provides data on 11 different statistics, with some country level illustrations for contrast and impact.  Clearly the authors have made choices about which information to display and which not.  There are no figures presented on family life, or on the impacts of stigma against sex workers.  Although the stats on murder for sex workers in the US are compared with those for other occupations, we don’t get information on sex workers’ access to justice or protection when they are victims of violence.  It states that sex work is “completely legal & regulated within 22 countries”, but does not discuss whether and how regulation or criminalisation regimes affect numbers of sex workers, and their vulnerability to violence and HIV – it simply talks about the cost to the justice system of people breaking laws on prostitution.  The thing is, it is quite hard to generalise about these things because in many countries the impacts of laws often have less to do with rates of arrest and prosecution and more to do with the effects laws have on the behaviours of individuals who are trying to avoid falling foul of them – as I talk about briefly here and as this fascinating study on the effects of brothel closures in Bangladesh on levels of violence and risk experienced by sex workers shows.  Given these nuances it is almost impossible to make meaningful generalisations about these issues.

The language used in the “Stats” also represents a choice.  Many sex workers would reject the notion that clients “purchase a prostitute” – which is loaded with connotations of coercion or slavery – rather talking about “buying sex” or “buying a sexual service”.  Similarly the graphic ironically talks about the “perks” of sex work in terms of risks of violence and HIV infection.  Sex workers do often face higher risks, but they don’t always see these risks as being inherent to their work.  Sex workers also often talk about the benefits of working flexibly and for incomes that are considerably higher than they could earn otherwise.

 

Why is it important?

Clearly, any presentation of figures such as those shown in the “Stats” should be surrounded with caveats.  But what difference does it make?  Very often, we find that inaccurate numbers as well as a reductionist understanding of the issues are used as a basis for legislative changes, as the UK’s recent change in legislation on prostitution and trafficking shows. 

In my own field, HIV prevention in developing countries*, having reliable data – and avoiding misleading or biased data – is essential for the development and delivery of effective programming with sex workers.  Here also, the needs are quite nuanced.  For a local NGO or health facility, having a national estimate of the number of sex workers in the country is actually not that useful.  Because such national figures are necessarily based on generalisations, they are unlikely to help frontline service providers in understanding the specific needs of the people they are trying to reach.  Indeed, because national figures require an a priori definition of what sex work is, using these figures as a basis for local service provision can be misleading, since the service providers may know of groups or individuals who should be targeted even if they don’t fit the national definitions.  Moreover, counting people as being sex workers often implies that they recognise or define themselves as sex workers – but as local service providers and outreach workers around the world know, it is not always useful or helpful to impose or assume that beneficiaries accept that identity.  So, frontline service providers do need numbers – but numbers that are relevant to their own contexts and situations.  Not only that but they also need to know what else is relevant to the people they are working with – the extent to which violence, poverty, and discrimination are factors putting them at higher risk of HIV, for instance, so that services can address these issues too.

What’s the point in national numbers then?  In many countries, for quite some time, HIV and AIDS programmes have all but ignored some of the groups that are most at risk for HIV infection, including sex workers.  Ironically, this neglect may in part be due to a fear of stigmatising sex workers by targeting them, a hangover from the early response to HIV and AIDS and indeed from sexual health programming pre-dating AIDS, that treated sex workers as “vectors” of disease.  The neglect is almost certainly also a consequence of stigma against sex workers and denial of the relevance of sex work on the part of decision makers.  Having some sort of aggregated national estimate can be extremely useful for epidemiologists and advocates who are advising national AIDS programmes on how they should allocate resources, and in identifying the potential need for policy and legislative changes that can effectively help to reduce the HIV risk (and other dangers) faced by sex workers. 

Organisations like UNAIDS are developing tools to help national AIDS programmes model the relevance of sex work and other “risk” factors to the dynamics of HIV in their countries.  But using these models requires denominators – estimates of the size and extent of risk of each population group.  Many countries have so little good information about sex work that they end up using figures from neighbouring countries to populate their epidemiological models.  Even if there is agreement on the overall numbers and relevance of sex workers to epidemic dynamics, it is also important to have data that shows what exactly determines risk and vulnerability, so that decision makers understand that it is not enough to assume sex workers will be reached by general population based programmes, and so that they allocate sufficient resources to address problems such as violence, lack of access to social welfare, and the impact of legislation against sex work on vulnerability and risk.  So we have a conundrum: at national level, it is important to have summary, reductionist numbers, but it is also important to have detailed, qualitative data to ensure that policy and practice respond to real needs. 

The “Stats on prostitution” is a global summary, and in HIV and AIDS programming, some sort of global picture can also be useful as it helps to pinpoint the major gaps in the global response – although as this graphic from UNAIDS shows, very few countries seem to report data at all.  Indeed, UNAIDS has recently started to reemphasise not only the epidemiological reasons but also the human rights rationales for paying more attention to sex work in HIV and AIDS programmes.  But it is essential that any “big pictures” be presented with all the relevant nuances, and with as much objectivity as possible.  It is also essential that at local level practitioners have the skills and resources needed to understand in much more detail who they are working with.

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*I recognise that there are reasons other than HIV to talk about sex work, but I’m focussing on what I know best for illustrative purposes.  Also, the reality in many low-income countries is that HIV and AIDS is one of the only issues that brings sex work onto the agenda of decision-makers.

 

 

World health day redux – Sex workers develop materials to support health and human rights projects

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I just wrote a blog post on World Health Day that talked broadly about the current funding crisis for health programmes, the false arguments being provoked between AIDS programmes and other health programmes… and the basic underlying fact that, in the developing world, nearly all health problems are grossly underfunded… just that some are less underfunded than others.  Anyway, my computer crashed and it all disappeared and I can’t redo it.  Hey ho.

It also talked a little bit about “practice”, and the general lack of attention to good, evidence based practice in HIV prevention programmes.  One of the most important principles is to support people to develop their own solutions rather than dictating to them what they should do.

So sticking to the theme, I’ve dug up this poster, which describes a workshop a few years ago during which sex worker associations, in Madagascar, developed some materials to support their HIV, health and human rights work.  To my mind this is still one of the most useful activities I’ve had the privilege of being involved with.  In AIDS programmes, big bucks are spent on developing “perfect” messages to inform people about the risks of HIV and how to prevent it.  Often, these messages overlook the tricky issues about sex and vulnerability and focus instead on anodyne, detached messages.  In many countries you see crowds of people wearing red-ribbon t-shirts, without much of an idea of what might make them vulnerable to HIV and what to do about it.

But, as this meeting showed, if you get the people most concerned to decide what sorts of messages and materials they need – and what they don’t need – the results are quite different.  The group did produce some health promotion materials, but also produced a number of materials aimed at changing the attitudes of the police and of health care providers who, they argued, had quite a big influence on their ability to protect themselves and to get treatment for STIs and HIV.  They also argued, compellingly, that the materials aimed at sex workers should talk not just about health, but also about stigma, human rights, and how to avoid and address violence.

The poster gives a quick summary and a few nice pics… I’m happy to provide more information to anyone who needs it!

Please note also the acknowledgements – this work was carried out jointly by International HIV/AIDS Alliance and by FIMIZORE, the malagasy network of sex worker associations.

 

You can also find tips on how to facilitate a process like this one here.