The US Supreme court and PEPFAR’s “pledge”

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The Supreme Court of the US is currently deliberating the constitutionality of the so-called “anti-prostitution pledge”, a requirement introduced by the US administration in 2003, according to which organisations involved in programmes to fight AIDS had to adopt a policy explicitly opposing prostitution as a condition of receiving funding from the US government’s PEPFAR programme.  The case against the pledge is that it hampers effective HIV programmes and that it constitutes a violation of first amendment free speech rights (the latter, only in relation to US-based organisations).

For more background, I can recommend the primers and analysis by Serra Sippel, Melissa Gira, Melissa Ditmore and Dan Allman, and Chi Mgbako.  The New York Times also published an editorial calling for the Supreme Court to rule that the Pledge is unconstitutional.

While I also hope that the Pledge is lifted, I think it is also important to recognise that, as important as the influence of US funding is to the global response to HIV and AIDS, the Pledge is neither the only nor the main reason that HIV programmes have failed and are continuing to fail sex workers.  Governments across the world have failed to adopt policies and implement HIV programmes with sex workers that are evidence based and respectful of human rights, irrespective of whether they are using their money, the US government’s money, or money from another source.

Nor is the Pledge the main cause of abuses of the rights of sex workers.  In the majority of countries sex workers remain criminalised or quasi-criminalised, and they face a constant threat of violence and abuse from law enforcement officials and medical authorities (one example here).  Removal of the PEPFAR pledge will, no doubt, enable programmes to work more closely with and support grassroots sex worker groups who want to challenge this situation, but they will still be largely constrained in what they can do by the national and legal context.  If governments want to arbitrarily arrest sex workers, or stop sex workers organising and claiming their rights, they will do so.

We know that it is not beyond the UN system and donor governments to be scandalised by human rights abuses – take, for instance, the justified international reaction to instances of homophobic abuse.  That the mistreatment of sex workers by governments and their agents is not a scandal is a sign of how much further there is to go.  We need more than just the removal of the PEPFAR Pledge: we need a commitment to supporting the rights of the most vulnerable, whoever they are.  At the same time we need much more humility about the impact that decisions taken in western capitals have on human rights on the ground, and much more solidarity and support for grassroots organisations.

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Counting all the things

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Since it’s all the rage to talk about measurement in aid and development projects these days I thought I’d share an indicator that I just found in a national AIDS strategy:

Outcome: fewer people have sex under conditions that could impair their judgement. % of [people] who had sex when they were drunk or when their partner was drunk reduced from 4% to 2% for women and 5% to 2% for men [over 8 year period].

Some questions:

  • How do we measure if people were drunk (or their partners were drunk) reliably? What is drunk? How far do people have to think back?
  • What tells us that we know what to do to achieve the hoped for changes (4-2% for women; 5-2% for men)?
  • What tells us that we can achieve a bigger change in men than women?

I’m not saying impaired judgement isn’t a factor. I’m not saying tackling alcohol use is a bad idea for health programmes.  This critique can be cut and pasted for a bunch more indicators in the same document.

I’m just wondering why on earth we bother making promises we don’t know how to keep and measure them in ways that lack any credibility.

 

Relative risk; absolute risk

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Howard White of 3ie discusses some of the problems we often see in how people handle data in this post, “Using the Causal Chain to Make Sense of the Numbers“.  The essay makes many excellent points which are relevant both to how programmes are designed and how they are evaluated.

However, I have to take issue with one section:

And different ways of presenting regression models can give a misleading sense of impact. A large reduction in relative risk – a ‘good odds ratio’ – can reflect quite a small change in absolute risk. Three randomised controlled trials have found circumcision reduces the risk of transmission during unprotected sex by around 50 percent. The reduction in risk was from around 3.5 percent to 1.5 percent. Just a 2 percentage point absolute reduction, so 50 men need to be circumcised to avoid one new case of HIV/AIDS.

This is a bit misleading. In assessing effects we are interested both in relative and absolute effects, yes.  But White fails to acknowledge here that the absolute risk at the outset (3.5% in the case of the pooled results of the three trials) is a characteristic of the people being researched.  And indeed the absolute risk in the populations in the three studies (Kenya, South Africa, Uganda) was different. The 3.5% and 1.5% figures come from pooling the results of the three trials.  If study subjects had come from a population where the pre-existing HIV prevalence was higher, and risk factors (including unprotected sex) were higher, then the baseline absolute risk would have been more than 3.5%.  If the risk factors had been lower, the baseline risk would have been lower. White’s estimate that 50 men need to be circumcised to avert one infection is not universally valid. In some places it will be many more; in others it will be fewer. This is one of the reasons male circumcision is primarily promoted in higher HIV prevalence settings.

Having said that, “just” a 2% absolute reduction is actually pretty good when compared to other HIV prevention interventions. Especially when you consider that once a man is circumcised, he stays circumcised, so the risk reduction is permanent. Look at it another way: if the intervention being tested led to a 100% risk reduction, then (according to White’s post), that would be “only” a 3.5% reduction in absolute terms. Still doesn’t look very impressive, does it? Except in this case there would be no new infections whatsoever.

The reason the results of these trials (and any trials) are reported as relative risks is because if you want to estimate what the effects of the intervention might be in another population, you have to apply the relative risk reduction to the absolute risk in each and every population. Reporting it any other way is misleading.  White is of course correct that absolute risk reduction is what matters when looking at the overall effect of an intervention or policy, but absolute risk reduction is a function not just of the relative risk reduction of that intervention, but of all the other relevant factors.

PEPFAR’s Blueprint

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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:

7. Support civil society and faith-based work best able to address the epidemic in key populations through mechanisms such as country small grants.

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.

9. Prioritize engagement in health diplomacy to promote the health and human rights of women, girls, and LGBT populations, and advance gender equality.

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.

 

The devil is in the detail

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It isn’t every day that the UNAIDS website carries a feature story about African sex workers fighting for their rights.  The feature in question was published shortly after March 3rd, which is International Sex Worker Rights Day, and described initiatives supported by UNAIDS in two countries: Kenya and Namibia.  It is great that the story is featured so prominently.

I was quite involved in the Namibia work, as I’ve explained here and here.  As a result I read the UNAIDS story very closely after seeing it on Twitter.  And then I wrote to UNAIDS: 

@UNAIDS It’s great you covered Namibia in your sex work story. However there are a couple of inaccuracies in the article. Can we discuss?

I also sent an email.  It’s been a couple of days since I contacted them so I think it is fair to explain here which parts of the story I take issue with.

Firstly, this sentence:

The publications noted that sex workers are disproportionately affected by HIV due to the nature of their work—most of the time they can not negotiate the use [sic] condoms with their clients.

(Emphasis added).

I’ve read every piece of research conducted with sex workers in Namibia, dating back to 2000. The quality of the research is, on the whole, very poor, based on unspecified methods and non-representative samples.  Nonetheless none of the studies says that most sex workers cannot negotiate condom use.  The participants in the community assessment research we set up in October didn’t say this was the case either.  To be sure, condom use is not systematic.  This may have something to do with negotiation skills, but as the assessment showed it is also affected by lots of other things, such as the attitudes of clients, with the fact that police officers use posession of condoms by sex workers as evidence of criminal activity, and lack of supply. It is inaccurate and stigmatising to imply the problem is just about sex workers.

Secondly, this:

The reports include recommendations for action by national and local stakeholders to address these challenges and protect the human rights of sex workers. Such recommendations include addressing violence, abuse and stigma towards sex workers as well as reducing legal and policy barriers that block their access to HIV services.

(Emphasis added).

When sex workers involved in the work asked for changes to laws and policies, they were not doing so on the grounds that it would help them get access to HIV services.  They were doing so because the laws and policies as they stand are one of the main reasons they are so vulnerable to violence, abuse and stigma.  Yes, HIV is a big issue for sex workers in Namibia.  But it is one of many issues.  That much was clear from what sex workers said throughout this project and during their interviews with several Namibian newspapers.  Indeed the quotes from sex workers that UNAIDS uses in its feature more accurately reflect the reality.

The reason I think this is important is because the whole idea behind the work we did in Namibia was to move away from the standard survey approaches which ask sex workers the same standard questions about condom use and access to services, and to give sex workers space to talk, among other things, about the issues that HIV programmes aren’t helping them with and maybe even won’t help them with.  We achieved this to an extent, so it is frustrating to see this message get homogenised into the same old narratives that we normally hear.  I’ve written before about the need HIV policy wonks have to only discuss things that have categorically been shown to have an epidemiological association with HIV.  That’s fine up to a point, but if we’re really committed to listening to communities, we’ve got to take what they are saying at face value.

Participatory research and generalisability

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Yesterday I shared some media coverage of international sex worker rights day events in Namibia, as well as reports of some work I was involved in last year that were launched on the same day.

I want to draw attention to one of the reports in particular.  Because there has been very little research on sex work in Namibia, and because most of the programmes designed to support sex workers are framed around a very narrow HIV focus (information, condoms, cajoling or even coercing people to get tested and have STI check ups; and no attention to issues like violence, discrimination and insecurity), UNFPA and UNAIDS wanted to do a bit of qualitative research to look in more detail at what was going on.  

Although I’m a big fan of epidemiological research (quantitative and qualitative), and I use the results of research all the time, it seemed in this context that it wasn’t particularly feasible (given the resources available) or appropriate to see this as a classic research project, with publication in a peer-reviewed journal or changing national policies as the ultimate goal.  What seemed more important, given that a major new HIV programme aimed at sex workers was about to be launched, was to document some of the specific situations in the towns that the programme was going to target, to help influence the sorts of things that get addressed, and to identify and point out any gaps in the programme.  Moreover, there are quite a few sex workers in Namibia who are very involved in community work, whether in relation to HIV or more broadly, and we wanted to help them get even more involved.  

So we decided to provide some introductory training on one qualitative method – focus group discussions – and got them to think through what sorts of issues their colleagues might want to discuss.  We used those suggestions to develop a guide, and sent them out to conduct their own research.

The report describes the results in detail.  It also describes the limitations, of which there are many.  Although I remain adamant that the purpose of this activity was never to extract data that will tell the whole story and represent the realities of sex workers throughout Namibia, some common themes come out of each of the five towns.  But there are also differences.  It’s the differences that interest me.  I wanted to give people an opportunity to discuss and think about what was going on in their own towns, and what, practically, immediately, might be done to fix some of the problems in each town.  And to an extent, I think that’s what we got.  It’s not generalisable; in fact the results from each town are probably very biased.  We know, for instance, that in most of the towns, we failed to talk to any male or transgender sex workers.  But if we recognise the biases and their relevance to each town, but use the information to get positive change in each town, then that’s OK.

We’ve also got a team with a new set of skills, who can do the same thing again, or can replicate it in other towns, or – why not – help other marginalised groups like men who have sex with men, migrants, or people living in slums do the same thing.

Maybe “research” is the wrong term to describe using research techniques in creative ways.  This participatory approach isn’t new to community development work: far from it.  It isn’t new to public health researchers either.  Practitioners have been advocating it for decades.  But it remains a marginal rather than a maintream practice.  So that’s why I’m making it a big deal.

Update: The Namibian Sun carried a feature describing the assessments on 7th March 2012. The article is a good reflection of the findings, although some of the stock sex worker library pictures they’ve used as illustrations are a little unfortunate.

Sex worker rights and HIV: Namibia

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The 3rd of March was International Sex Worker Rights day, marked by sex worker rights activists and defenders across the world.  Although sex workers have been campaigning for rights in Namibia for years, the movement is still very much “emerging” since, until the last 3 years or so, they have received very little support.  

In Namibia, as in many other countries, sex workers have limited opportunities to be heard when they want to talk about human rights, and as a result, the discussions are often constrained by the need to relate them to issues like HIV (as I discussed here) or trafficking.

In this context it is heartening to see not only that news outlets in Namibia gave significant coverage to the events organised by local sex worker organisations (front page of The Namibian; articles in New Era and Republiklein), but that the coverage didn’t focus just on the HIV angle, and acknowledged the broader issues.  Since the event took place, some of those involved have told me that the feedback from different decision-makers has been very positive, and they are optimistic that we are now seeing a step-change in how some of the media and decision-makers are approaching sex worker rights.

I’m particularly proud to have played a role in supporting some of the work that went into these events, with the support of UNFPA and UNAIDS: this review of the literature on sex work and HIV in Namibia:

This report of a series of local assessments done by sex workers to investigate human rights, health and HIV in five towns:

And this report of a national policy meeting, which aimed to get programmes and policy makers to pay more attention to the issues of human rights of sex workers:

The job isn’t done of course: it has barely started.  But many of the partners in Namibia have committed to following up on this work, so things are looking positive.

For more of a discussion on the aims of the local assessments, click here.