Reaching the most vulnerable is a tenet of most international and national AIDS responses. The 2011 UN High Level Meeting on AIDS in New York this week provides an opportunity to look at the reality behind the rhetoric of reaching the most at-risk populations with HIV/AIDS information and services.
Groups that constitute most at-risk populations can vary by country and context, but usually they include men who have sex with men (MSM), injection drug users, and sex workers. UN Secretary General, Ban Ki-moon, has called on countries to enact legal and human rights protections for these very populations not only due to an ethical imperative but from a public health perspective. In his words, not protecting the legal and human rights of these groups “hurts us all.”
UNAIDS, the UN body aiming to advance universal access to HIV prevention, treatment, and care, has also recognized the importance of involving affected communities like sex workers in the design and implementation of programs, and highlights the importance of advancing the human rights of sex workers as a critical public health approach.
Despite these stated good intentions, sex workers remain disproportionately impacted by HIV infection in many countries around the world. In Ghana, Uganda, and Kenya female sex workers, their clients, and the sexual partners of clients made up one-third, 10 percent, and 14 percent respectively of all new HIV infections in 2009, according to UNAIDS. In India, government estimates [pdf] put the rate of HIV infection among sex workers at 5 percent—15 times higher than the overall HIV prevalence rate for the country.
Male sex workers, often left out of any services targeting sex workers, have been shown in some countries to be at particularly high risk of HIV infection. In Argentina, for example, again UNAIDS data shows the HIV prevalence among male sex workers to be 23 percent, compared to less than 2 percent among female sex workers.
Why this disconnect between the recognition of the importance of reaching sex workers and the appalling inability to protect this population from HIV? It cannot be that sex workers are hard to reach; making a living as a sex worker depends on accessibility. There is also ample evidence about what works to protect sex workers from HIV (see the UNAIDS guidance note). While resources for health are generally scarce, health program planners have managed to effectively reach vulnerable populations with appropriate services and reduce HIV risk.
In heated discussions about appropriate legal, policy, and program responses to sex work, morality often trumps science. Moreover, the lived reality of sex workers is often overlooked, perhaps because they are not present in the policy and program decisions intended to protect them.
Informed consent for HIV testing is recognized as a pillar of an effective HIV response. Yet, sex workers are still victims of forced HIV testing often driven by police investigations after prostitution-related arrests. For example recently in Macedonia, after 23 sex workers were arrested and detained, they were all tested for HIV, hepatitis B and hepatitis C without their consent. The sex workers who tested positive for hepatitis C were charged with intentionally spreading infectious diseases.
Similarly, in Malawi, eleven sex workers were arrested by police while at a local restaurant, taken to a local public hospital and subjected to an HIV test without their consent. The test results were announced publicly in court by the Magistrate and they were found guilty of spreading venereal disease.
Medical providers in these instances violated international human rights law as well as medical ethics by performing medical tests that were coercive rather than based on informed consent. Arguably the role of the criminal justice process confuses the matter. However, doctors first have an obligation to their patient.
There is, however, increasing evidence that sex workers face gross violations in health care facilities as a matter of routine practice even when due process procedures are not at play. Findings were recently reported from a recent study documenting ill treatment and abuse that sex workers receive as a matter of course in public health care facilities in four African countries (Kenya, South Africa, Uganda, and Zimbabwe). Individuals in the study reported that those who had told care providers of their sex work were subjected to denial of care, rude and abusive treatment, and being charged more for the same services others received for less money.
The result is that sex workers either avoid seeking care unless they can afford to attend private facilities where this abusive behavior is less common, or they do not tell their care providers of their sex work.
This is not a symptom of an underfunded, corrupt health care system. Sex workers in places as divergent as New York to Mumbai to Cape Town complain of the discrimination and abuse they receive from care providers when trying to access basic health services.
What alternatives do work then? In 2009, I had the rare opportunity to visit an International Planned Parenthood (IPPF) affiliate based in Kenya. The director had skeptically entered into a partnership with the organization Keeping Alive Societies Hope, an Open Society Foundations grantee, to train the entire IPPF clinic staff—from its drivers to the executive director—on the human rights of sex workers. Sex workers trained care providers on their specific health needs, as well as the appropriate way to address sex workers, take case histories in a nondiscriminatory way, and provide quality care no matter how one feels about sex work as a profession. Once they started to take sexual histories in a way that sex workers felt comfortable to “out” themselves, the staff was shocked to realize that a large percentage of their clientele engaged in some way in sex work, resulting in better health care all around.
Health care is political. The doctor-patient or nurse-patient relationship, however, is not a place for politics, particularly when it gets in the way of saving lives. As AIDS policy planners meet in New York this week, they will hopefully acknowledge the need to recognize, support, and promote human rights approaches as essential to ensuring care provision to sex workers.