AIDS Universal Access and the Lancet’s equivocation

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Universal access and excluded groups

2010 is the deadline set by the international community at the UN General Assembly for providing universal access to HIV prevention, treatment and care.  As the WHO’s recent report reveals, while progress is being made, we’re still quite far from reaching this target.

One of the most consistent gaps across the world is in the provision of services to stigmatised and excluded groups: drug users, men who have sex with men, and sex workers.  Indeed, even the figures we have for these groups don’t give us much to go on since very small numbers of countries report  anything at all.  Fewer than 60 provide any information on services provided to drug users; 21 on the extent to which prevention programmes reach men who have sex with men; and 38 on the extent to which programmes reach sex workers.  And those countries that do report reveal very low levels of coverage of these groups.

The way forward according to the Lancet Infectious Diseases

A leader in the Lancet Infectious Diseases discusses the findings of the Universal Access report.  Here is the analysis of the failure to properly reach these groups:

“Although overlooked in the past, there is increasing recognition of the role of most at-risk groups in the epidemic, including injecting-drug users, men who have sex with men, and sex workers. The criminalisation of homosexuality and the exclusion of illegal drug users and sex workers from health services have made more difficult the tailoring of interventions to these populations. Men who have sex with men and drug users still lack access to HIV prevention services since stigma attached to homosexuality and drug use impose a barrier to increased access to HIV/AIDS prevention. The lack of gender equity and the oppression of girls and women also increase the risk of transmission of HIV. Prevention measures have been slow to contemplate these risks. In many developing countries, women are socially and economically dependent on men, and as a result they have a limited access to health and economic information.”

The leader is right to point out that there is increasing recognition of the role of these groups in the epidemic; it might have added that they are disproportionately affected by HIV in most countries in the world.  But what is more worrying is that while the leader identifies criminalisation of homosexuality as a barrier to progress, when it comes to sex workers and drug users, it merely talks about their exclusion.  To me, what this is saying is: we can’t achieve universal access for men who have sex with men without achieving decriminalisation of homosexuality; but in the case of drug use and sex work, we’re relaxed about criminalisation but just need to find a work-around so that we can still provide these law-breakers with services.  As Cheryl Overs at the Paulo Longo Research Initiative points out, it’s a bit like saying “it is Ok for sex work to be illegal so long as we can HIV test sex workers and tell them they are responsible for making their clients use condoms”.

But if it is possible to achieve Universal Access for sex workers and drug users even in contexts of criminalisation, then surely it is also possible to do so for men who have sex with men in the context of criminalisation?  From a public health and service provision point of view, I don’t understand the logic behind the different positions in each case. As programme managers, service providers and outreach workers all know, any sort of criminalisation severely compromises the ability to deliver programmes – it’s not worse for some groups than for others. Although what is particularly noticeable in contexts where sex work is criminalised, is that programmes end up being implemented through or under the control of law enforcement officials – the same people that are at the origin of a lot of the abuse received by sex workers.  But maybe this is the sort of work-around that the Lancet’s leader writer has in mind.

AIDS and the law

UNAIDS, the UN’s Joint Programme on AIDS, is somewhat clearer in its analysis of the impact of criminalisation on doing effective AIDS work with men who have sex with men, drug users and sex workers.  It aims to “encourage and support countries to remove punitive laws, polices, practices, stigma and discrimination that block effective responses to HIV by driving people away from HIV services and thus reducing an individual’s ability to avoid HIV”.  It hasn’t yet made a clear statement on what sort of legal framework would be most appropriate in each case.  A UN commission on law and HIV will hopefully provide some guidance in the near future.

It is encouraging that the global AIDS movement continues to raise issues around legislation and human rights: AIDS has always brought human rights violations and injustice to the fore because it has so often affected victims of injustice.  Fairly recently AIDS-related activism played no small part in the release of a couple jailed in Malawi for homosexuality.  

The problem though, is that in my view AIDS alone can not be the prime motivator for changing laws.  AIDS helps to uncover injustices, but it is not the cause of these injustices, and they need to be resolved whether AIDS is a problem or not.  Otherwise the call for action on decriminalisation can be easily rejected on the grounds that some sort of “work-around” has been found that makes it possible to provide men who have sex with men (and drug users, and sex workers) with HIV treatment and condoms even while repressing them.  

 

Absolutist abolitionists

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The sorts of things that are said about sex work

Westminster skeptics recently hosted a discussion on sex work and the law, featuring Dr Belinda Brooks-Gordon and Dr Brooke Magnanti.  It is well worth a listen : Dr Brooks-Gordon provides an overview of the legal context for sex work in the UK, recent legal changes, and most importantly, the effects that laws have that are often quite different from their stated intention.  Dr. Magnanti discusses the principles that it is important to adopt when researching or discussing sex work: starting with listening to how sex workers themselves describe their experience rather than making assumptions, such as the assumption that all foreign sex workers in the UK are trafficked, or that sex work is inherently exploitative or coercive.  In a follow up blog post the convenor, David Allen Green, talks about how important it is to have open conversations about sex work. 

The themes that are raised in the discussion are reminiscent, in many ways, of the themes that come up when sex work is raised in my line of work, HIV/AIDS programming in low-income countries.  One of the most common threads is a refusal to listen to sex workers, a refusal to accept that they have a right to assess and lead their own lives.  Because of the differences in how opposition to sex work is expressed, there are differences in how the refusal to listen to sex workers is rationalised.   Opposition to sex work in the UK tends to come from a feminist perspective, informed by concepts like “exploitation” and “coercion”; and the voices of sex workers who question this perspective are dismissed as being those of a tiny minority, as “Happy Hooker” fantasists.  Or worse still as suffering from false consciousness, some form of Stockholm syndrome… the subtext being that someone who is downtrodden is incapable of commenting on their situation.  But in the contexts where I work, dismissing what sex workers say is a lot more straightforward: “They are programmed to lie”, said a woman who runs an operation to rescue workers in India recently; alternatively, as this article from Nigeria shows, sex workers are asked to “repent”. The perspective here is more of a moral or a religious one.  There’s no particular implication of coercion.  The sex workers in these cases aren’t denied their agency: at the most basic level, they’re just judged and stigmatised for what they do. (Having said this, the trafficking/exploitation paradigms are increasingly gaining traction in poorer countries).

Both of these approaches are based on a highly generalised perspective that makes assumptions about the realities of sex workers – whether they are seen as powerless or as immoral.  As such, and despite the different rationalisations given in each case, to me they are both coming from an ideological starting point… and that’s always suspect.   

A glimmer?

The global AIDS movement has been relatively rigorous about promoting the importance of actively involving the people most affected and most vulnerable in developing policies and programmes.  Although there is still a long way to go in ensuring the principle is adhered to, the existence of events such as the recent regional consultation on HIV/AIDS and Sex Work in Asia, which brought together government officials, sex workers, and UN officials, is an encouraging example of HIV and AIDS providing an entry-point for broader discussions on human rights.  But the question remains, whether principles of participation that are established in this fairly niche area, can be a springboard to a more respectful way of communicating with sex workers in other areas of policy, legislative and ethical debate.