Earlier this year I went to a meeting on sex work in the global AIDS epidemic. The purpose was to look at the current information on HIV in populations and among sex workers and assess the relationship, and to look at how effective different types of intervention and programme in reducing the risk of HIV among sex workers. Most of the best quality evidence comes from a fairly narrow set of interventions, that have been shown (or not, as the case may be) to have a direct impact on HIV transmission or acquisition. Things like vaginal microbicides, presumptive STI testing and treatment, HIV testing, peer education, and condom distribution and counselling. Things that, to all intents and purposes, “look” like HIV interventions.
Of course, for an intervention to be discussed as part of the evidence base, there has to be decent evidence – whether it is evidence of positive effects or of negative ones. So some things didn’t come up in the discussion, despite being widely implemented in the context of HIV programmes, because there is no evidence of their impact. Things like microfinance and income generating projects aimed at reducing numbers of sex workers, which I began to review a few years ago and never properly finished… but take my word for it, there isn’t much in the way of quality research or good theory for this approach. Although the approach does not feature prominently in the current UNAIDS guidance on sex work and HIV, it remains a central pillar of the US government’s strategy on HIV and sex work.
Untested approaches are at best a waste of money and at worst actually harmful. It is certainly the case that economic programmes such as these only reach a fraction of the numbers reached by “classic” HIV programmes, for the same amount of money.
But what is more alarming is the things that don’t come up in the discussion of the programme evidence base, despite there being a pretty strong association between them and HIV. On Saturday December 17th, it is the International Day to End Violence Against Sex Workers, and I am talking about violence. Time and again, sex workers tell us that the criminalised nature of sex work, and in particular the role played by law enforcement agents and health care workers in committing violence and in failing to address it properly, mean that violence is one of the biggest risks they face, and is a far more immediate threat than HIV. The epidemiological association between violence and HIV has also been documented in a number of observational studies: in Bangladesh, in Cambodia, in India and in Kenya, for instance. Other reviews can be found here (disclosure: I wrote that one), and here.
But as with income generation strategies, because hardly any well designed intervention studies have looked at how best to tackle violence, fighting violence against sex workers as a means of tackling HIV doesn’t come up in many systematic reviews on HIV prevention with sex workers. To be sure, many HIV programmes acknowledge that it is an issue but they generally don’t do much to tackle it – and of course there is hardly any commitment to tackling the laws and attitudes that make it so easy for the perpetrators of violence to get away with it. When tackling violence does appear in programme plans, it is often something along the lines of “training police officers to refrain from violence”. Or, as Cheryl Overs would put it, sending them to workshops with a nice buffet lunch and a perdiem for the purpose of telling them something they already know, rather than handing them a ticket to a jail cell. “Sure, there is a role for the carrot, but justice demands some stick too sometimes”.
Funding proposals that do attempt to tackle violence are required to demonstrate and justify how their efforts will directly impact HIV transmission. When it comes to sex workers, violence is not seen as something worth tackling in its own right.
Sure enough, during the meeting I talked about at the top, someone pointed out that tackling violence against sex workers was unlikely to appear in any evidence-based guidelines on how to design HIV programmes for sex workers because the evidence base is so weak. But the thing is, when the discussion is about young women, or men who have sex with men, or children, building efforts that tackle violence into HIV programmes irrespective of the evidence for a link between violence and HIV is a no-brainer; and rightly so.
Which explains the angrily scrawled note which I passed to the person sat next to me and which you saw at the start of this post.