The US government has published its Blueprint for Creating an AIDS-free Generation: despite funding stalling, this World AIDS Day is characterised by the optimism of all the big agencies, the narrative is that the end is in sight.
I’ll get round to reading the whole thing some day, but for now I’ve turned straight to page 26, which is all about what PEPFAR is going to do with Populations at Greatest Risk of HIV. Here are a few notes.
The first thing to note is that “Populations at Greatest Risk” are subdivided into several categories: people with tuberculosis; Key Populations; people living with HIV; women and girls; orphans and vulnerable children; and young people. Some might say the definition of “greatest risk” is rather broad, particularly given that strategies aimed at supporting women will also, of necessity, target men. While the blueprint does put welcome dollars against some specific initiatives, it does not go as far as stating how it will allocate PEPFAR’s substantial funds to these different groups.
However, the use of the term “key populations” to describe men who have sex with men, sex workers, transgender people, and people who inject drugs, will be seen by many as progress, given that up until recently the preferred term was the more stigmatising “most at risk populations”.
Advocates for key populations are likely to pay particular attention to the language on sex workers, given PEPFAR’s history of very restrictive and highly conditional support to programmes with this group. First thing to note: PEPFAR is now firmly using the term “sex worker” rather than “prostitute”: another welcome shift in language. There is no word on whether PEPFAR intends to develop guidance for programming with sex workers (guidance on programming with men who have sex with men and people who inject drugs is already available). There is good language on the importance of properly involving key populations in developing and delivering programmes; however, PEPFAR still requires subgrantees to adopt a policy explicitly opposing sex work as work, a regulation which effectively rules out the involvement of sex worker led organisations.
Among the key actions PEPFAR plans to take, there are points that led me to raise my eyebrows:
Without wishing to deny the undoubtable contribution faith-based organisations have made to the response to AIDS, particularly in the area of care and support, I know of few if any examples of effective programming by faith-based organisations with key populations. And every faith-based project with sex workers I have ever seen has involved ineffective, misguided and sometimes damaging “rehabililtation” programmes.
The omission of sex workers, and people who use drugs, from this section on human rights, is glaring. The blueprint does acknowledge the existence of laws and stigma against key populations, but while it emphasises that these laws and stigma affect peoples’ access to services, it stops short of recognising that these laws and stigma are at the very heart of what makes key populations vulnerable to HIV, and all manner of human rights abuses, in the first place. It’s also worth thinking carefully about PEPFAR’s stated support for science-based approaches and human rights, given that the section on “principles” cites Cambodia’s 100% condom use programme for sex workers as an exemplary strategy. The approach raises significant concerns, in particular in relation to informed consent for HIV testing and STI treatment, and the role that law enforcement officers are given in implementing the policy.
Summary: despite some encouraging improvements (not least the very existence of the Blueprint in the first place), we may still have a long way to go before key populations in general and sex workers in particular receive the support they need from the global response to AIDS.