Sex workers are among the highest risk groups for HIV. UNAIDS defines sex workers as: “Female, male and transgender adults and young people who receive money or goods in exchange for sexual services, either regularly or occasionally. Sex work varies between and within countries and communities. Sex work may vary in the degree to which it is more or less “formal” or organised, and in the degree to which it is distinct from other social and sexual relationships and types of sexual economic exchange.” 1 On average, sex workers are 10 times more likely to become infected with HIV than adults in the general population.2 However, there are significant variations between regions and countries. In low- and middle-income countries, HIV prevalence among sex workers is an estimated 12%. However, there are significant variations between regions and countries.3 In four countries, HIV prevalence is 50 times higher than in the general population.4 One study of 16 countries in sub-Saharan Africa found an average HIV prevalence of 37% among sex workers. In Nigeria and Ghana, HIV prevalence among sex workers is eight times higher than for the rest of the population.5 Although sex workers are one of the groups most affected by HIV, they are also one of the groups most likely to respond well to HIV prevention programmes. Proof of this can be seen in countries such as Cambodia, the Dominican Republic, India and Thailand, where reductions in national HIV prevalence have been helped by initiatives targeting sex workers and their clients. Why are sex workers at particular risk of HIV transmission? Sex workers often share common factors, regardless of their background, that can make them vulnerable to HIV transmission.6 Multiple partners and inconsistent condom use In general, sex workers have comparatively high numbers of sexual partners compared with the general population. However, this does not necessarily increase their likelihood of becoming infected with HIV if they use condoms consistently and correctly.7 In 2015, 32 out of 89 countries reporting on the proportion of sex workers using a condom with their last client reported greater than 90% coverage. Condom use reported by sex workers in Asia Pacific was 90% or greater in five countries, including the two largest, China and India. But elsewhere in the region, in countries with significant HIV epidemics among sex workers such as the Philippines, Indonesia and Pakistan, condom use was low. Most other regions show a similar pattern: a few countries perform reasonably well, while many others fall short. In Lesotho, for example, where HIV prevalence among female sex workers was estimated at 72% in 2015, condom use with the sex worker’s last client stood at 65%. Countries in the Middle East and North Africa generally have inadequate condom use to prevent HIV transmission to and from sex workers.8 In some cases, sex workers have no access to condoms or are not aware of their importance. In other cases, police are actively confiscating or destroying condoms found in sex workers’ possession. For example, a 2012 study by the Open Society Foundation in Kenya, Namibia, Russia, South Africa, the United States of America (USA) and Zimbabwe found evidence in all six countries of police harassing and physically and sexually abusing sex workers who carry condoms, or using the threat of arrest on the grounds of condom possession to extort and exploit them.9 We use condoms to protect ourselves from HIV/AIDS, but they don’t allow us to carry them, so how can we protect ourselves? – Sex worker, Cape Town, South Africa10 Sometimes, sex workers are simply powerless to negotiate safer sex. Clients may refuse to pay for sex if they have to use a condom, and use intimidation or violence to force unprotected sex.11 They may also offer more money for unprotected sex – a proposal that can be hard to refuse: Sex workers have told us that when they ask a client to use a condom, he offers double the price to have sex without the condom. These women are trying to provide for their children and families, so they take the offer. – Ndeye Astou Diop, Aboya (an organisation that works with HIV positive women in Senegal) 12 The clients of sex workers act as a ‘bridge population’, transmitting HIV between sex workers and the general population. High HIV prevalence among the male clients of sex workers has been detected in studies globally.13 14 15 Social and legal factors Sex workers are often stigmatised, marginalised and criminalised by the societies in which they live. In various ways, these factors contribute to their vulnerability to HIV. Even though sex work is at least partially legal in some countries, the law rarely protects sex workers. Around the world, there is a severe lack of legislation and policies protecting sex workers who may be at risk of violence from both state and non-state actors such as law enforcement, partners, family members and their clients.16 For example, a sex worker who is raped will generally have little hope of bringing charges against their attacker. This lack of protection leaves sex workers open to abuse, violence and rape, creating an environment which can facilitate HIV transmission.17 To avoid arrest that can involve violence, rape and other trauma, many sex workers try to avoid things that may identify them as sex workers – like carrying condoms or visiting health clinics for check-ups. -Kay Thi Win, Programme Manager of the Targeted Outreach Programme initiative in Myanmar, which provides peer-to-peer HIV prevention and support for sex workers 18 In addition, the stigma that sex workers face can make it hard for them to access healthcare, legal, and social services. They may either be afraid to seek out these services for fear of discrimination, or be prevented from accessing them – for instance, if a nurse refuses to treat them after finding out about their occupation. When I visited a VCT [voluntary counseling and testing] clinic, health personnel were not polite and immediately asked me if I was a sex worker. A doctor asked me outright, ‘Are you HIV‑positive?’ This discouraged me from going to the clinics. – Payal, 18, Nepal 19 Injecting drug use Sex workers who inject drugs and share needles are at a particularly high risk of HIV infection. Sex workers who use drugs can be stigmatised in workplace venues where drug use is discouraged. This forces them onto the street where control over condom and drug use is compromised and exposure to violence is heightened, all of which compounds their vulnerability to HIV. Because sex work and drug use are illegal in most countries, sex workers who use drugs are more vulnerable to frequent arrest, bribes, extortion and physical and sexual abuse. In turn, this discourages many sex workers who inject drugs from seeking HIV prevention and treatment.20 Researchers investigating HIV prevalence among sex workers have raised particular concerns about epidemics in Eastern Europe and Central Asia, where there is a significant overlap between sex work and injecting drug use.21 A 2013 review of female sex workers in Europe concluded that their HIV vulnerability was linked primarily to unsafe injecting, rather than sex work itself.22 In Central Asia, HIV prevalence is estimated to be 20 times higher among female sex workers who inject drugs than those who do not.23 For example, an estimated 62% of women in Kyrgyzstan and 84% of women in Azerbaijan who inject drugs also engage in sex work.24 Similarly, a study in Manipur, India, found that HIV prevalence among female sex workers who injected drugs was 9.4 times higher than those who did not inject.25 Migration, mobility and sex work Migration and sex work are often linked as some migrants may turn to sex work if they cannot find an alternative means of making money. Migrant sex workers often become the targets of both police and immigration officers, especially those who cross borders (both legally and illegally) and do not have immigration status. Other than facing the criminalisation of sex work, they also may also face surveillance, racial profiling, arrest, detention, deportation and other restrictions on mobility imposed by criminal, immigration and trafficking laws.26 As well as selling sex themselves, migrants may also become the clients of sex workers as a means of escaping the solitude that often accompanies migration.27 Another way in which HIV, sex work and mobility are linked is through ‘sex tourism’, whereby clients travel between countries seeking paid sex. Sex tourism is fuelling the demand for sex workers in many countries, particularly in Asia and the Caribbean. In some cases, men travel to another country in order to take advantage of lenient age of consent laws, or because they know that it will be easy to find paid sex.28 29 The relationship between human trafficking and sex work Human trafficking is defined as: “The recruitment, transportation, transfer, harbouring or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation.” 30 Large numbers of trafficked people are forced into selling sex every year. Even in countries where HIV prevalence is low, trafficked people who are forced to sell sex are highly vulnerable to HIV infection because they struggle to access condoms, cannot negotiate condom use and are often subjected to violence.31 One study conducted among trafficked people in Mumbai brothels in India found that almost a quarter of trafficked girls and women were living with HIV.32 However, many emphasise that the relationship between sex work and human trafficking should not be overplayed as it can lead to false or exaggerated anti-sex work arguments and harmful action by authorities, ultimately undermining HIV prevention for sex workers.33 In fact, evidence suggests that fewer people enter into sex wok through trafficking than enter consensually. For example, it is estimated that one in five people in the sex trade in Andrah Pradesh, India and one in 10 in Thailand have been trafficked.34 Despite this, policies that conflate sex work and trafficking have dominated approaches to sex work over the past decade. In 2003, the US President’s Emergency Plan for AIDS Relief (PEPFAR) adopted a clause that required funding recipients to explicitly oppose sex work, its legalisation and sex trafficking. As a result, many countries- including Thailand, Cambodia, and Vietnam – implemented punitive measures targeting the sex industry. Many sex workers were forced into unsafe work environments, undermining their access to health care and increasing their vulnerability to violence, abuse and, ultimately, HIV. Although the USA revoked the clause in 2013, its legacy continues, and more must be done to ensure that anti-trafficking efforts target those who commit trafficking, rather than punishing consenting adults engaged in sex work.35 Young sex workers and HIV While there is near-universal agreement between countries on the need to prevent people under the age of 18 from selling sex, there is little agreement on how to meet the needs of the significant numbers of young people who are involved in selling sex.36 Data on young people who sell sex is extremely limited, although evidence suggests that a significant proportion of sex workers begin selling sex while adolescents.37 For example, a study from Ukraine found that 20% of female sex workers were aged between 10 and 19.38 Research shows that adolescents under 18 who sell sex are highly vulnerable to HIV and other sexually transmitted infections (STIs), have higher levels of HIV and STIs than older sex workers and have limited access to services such as HIV testing, prevention and treatment.39 Young sex workers face many of the same barriers to HIV prevention as their older counterparts including the inability to negotiate condom use and legal barriers to HIV and sexual health services, which are amplified by their age.40 In many countries, organisations cannot legally provide HIV services to people under 18 years old because it is seen as encouraging ‘prostitution’ or the trafficking of minors and may bring the organisation into conflict with the law.41 Testing for HIV and STIs is impossible. In Kazakhstan, the law states that a person under 18 cannot be tested for HIV without [an] accompanying parent or guardian. As a rule, parents do not know that their daughter sells sex; therefore, girls are afraid of disclosure and do not get tested for HIV or STIs. – Sex worker, Kazakhstan42 Even where programmes for sex workers exist, the presence of ‘youth-friendly’ services to address the specific needs of young people who sell sex are normally lacking. Furthermore, young people who sell sex are often excluded from much of the research on sex work and HIV.43 This enables authorities to ignore the existence and needs of young people who sell sex.44 Preventing HIV among sex workers Sex work is diverse and occurs in various contexts around the world. Although some sex workers sell sex through brothels or other venues, others might work independently and solicit clients directly in public places or online. Effective HIV prevention packages for sex workers are those that account for the contexts in which they work and the particular risks they face.45 In order to address the high burden of HIV sex workers face, UNAIDS recommends the following: address violence against sex workers decriminalise sex work empower sex work communities scale-up and fund health and social services for sex workers46: UNAIDS also emphasises the importance of combining HIV prevention strategies for sex workers, including integrating condom distribution with other HIV services and increasing links between HIV services and other sexual and reproductive health services such as family planning services, gynaecological services and maternal health.47 Despite this, in 2015 just 3.8% of total global spending on prevention was used to fund prevention programmes for sex workers. International donors supplied 3.1% of funding, compared to 0.7% from domestic sources.48 Successful HIV prevention programmes for sex workers Studies have estimated that addressing specific key societal factors such as violence, police harassment, safer work environments and decriminalisation could reduce the number of female sex workers newly infected with HIV by 33%, to 46% over the next decade.49 In 2013, the WHO, UNFPA, UNAIDS, NSWP, the World Bank and UNDP released a new tool offering advice on building HIV programmes for sex workers that are led by the sex worker community.50 The tool, Implementing comprehensive HIV/STI programmes with sex workers: practical approaches from collaborative interventions, also contains examples of best practice from around the world to support efforts in planning programmes and services.51 A number of successful HIV programmes targeting sex workers are given below. Encouraging condom use The 100% Condom Use Programme, established in Thailand in the early 1990s, enforced condom use in all of Thailand’s brothels and massage parlours, distributing free condoms and making it a legal requirement for establishments to make clients use them. The programme saw condom use among sex workers rise from 14% in 1989 to more than 90% since 1992, with Thailand’s overall HIV prevalence reflecting this.52 Between 1998 and 2003, a similar programme in Cambodia reduced HIV prevalence among sex workers over the age of 20 from 44% to 8%.53 However, concerns have been raised about the absence of sex workers from participation in the design and implementation of the programme. With police, local authorities and brothel owners charged with enforcing the policy, sex workers remain vulnerable to abuse and exploitation.54 In South Africa, a 2015 study found that condom distribution and HIV communication programmes have reduced HIV incidence in female sex workers by 76% and clients by 65%.55 The Avahan programme has been working with key affected populations in six southern India states since 2003. In 2015, the programme was estimated to have increased condom use to such an extent that new HIV infections among female sex workers had reduced by between 48% and 67%.56 Similar reductions have been estimated in assessments of Project SIDA in Benin, which has promoted condoms and STI screening for female sex workers.57 HIV counselling and testing (HTC) services for sex workers The World Health Organization (WHO) recommends at least annual voluntary testing for sex workers. In a review of 52 low-income and middle-income countries in 2010 – the most recent data available – the median percentage of sex workers who had tested for HIV in the last 12 months and knew their results was 49%, with wide variation across countries.58 Several successful interventions have increased HIV counselling and testing (HTC) in sex workers. For example, in Ethiopia the Organisation for Support Services for AIDS (OSSA) implemented a peer education and outreach project with young people who sell sex (aged between 15 and 24) as part of the International HIV/AIDS Alliance’s Link Up project. Within 12 months, more than 16,000 young people who sell sex had been reached with peer education sessions, with around 5,600 referred to clinics of whom more than 1,700 took up services, the most common of which was voluntary HTC.59 In Guatemala, a sexual health clinic that offered HTC and follow-up services over a six-month period witnessed a four-fold decrease in HIV among sex workers. HIV prevalence among sex workers in Chile and El Salvador has also fallen significantly following the targeting of sex workers with similar prevention programmes.60 Access to antiretroviral treatment (ART) for sex workers UNAIDS recommended that ART coverage must reach approximately 80% of sex workers, accompanied by increased condom use, in order to significantly impact upon the global HIV epidemic. However, in many countries sex workers’ access to antiretroviral treatment (ART) continues to be lower than access for the general population, with uptake hampered by punitive legal environments, the double stigma surrounding HIV and sex work and fear that a diagnosis of HIV may be disclosed to others without consent.61 In 2015, the UNAIDS Key Population Atlas found female sex workers only had similar levels of access to treatment as other women in three out of 12 countries reporting data.62 The use of pre-exposure prophylaxis (PrEP), whereby someone who is at higher risk to HIV takes antiretrovirals before possible exposure to HIV in order to decrease their likelihood of contracting the virus, is another area of prevention that could reduce HIV transmission rates among sex workers. For example, a study from South Africa reported that combining PrEP with HTC could reduce HIV transmission between sex workers and their clients by up to 40%.63 However, PrEP availability is extremely limited, and recent UNAIDS modelling suggests that typical ART coverage will not be sufficient to slow new infections among sex workers at its current rate.64 Law enforcement practices, human rights and legal education Sex worker-led, community-based services that address legal and social barriers can have a real and lasting impact on the lives of sex workers, including by reducing their vulnerability to HIV.65 In Thailand, the Service Workers in Group (SWING) is a partnership between sex workers and the police formed in 2004, which aims to foster law enforcement practices that protect rights, and supports effective HIV programming. SWING sensitises young police cadets by giving them the opportunity to interact with sex workers in a neutral setting. Positive changes have already been noted in Bangkok constabularies, with fewer reported arrests and incidents of harassment.66 Similarly, the PT Foundation in Kuala Lumpur, Malaysia works on HIV prevention for sex workers and other key affected populations. This includes outreach strategies and workshops targeted at key community leaders, law enforcement officers and state-level religious authorities who frequently arrest or fine sex workers. The PT Foundation has also developed a leaflet to inform sex workers of their rights should they get arrested.67 This [sex worker rights leaflet] has been very helpful…when the authorities come I tell them I know my rights. As soon as we start talking about rights they just move away. – Jlofa, sex worker from Kuala Lumpur68 Addressing stigma and discrimination The Global Network of Sex Work Projects (NSWP) unites more than 160 sex-worker led groups from across 60 countries 69 in Africa, Asia and the Pacific, Europe, Latin America, North America and the Caribbean. It amplifies the voices of these organisations in order to advocate for rights-based services, freedom from abuse and discrimination, freedom from punitive laws, policies and practices, and self-determination for sex workers.70 Examples of NSWP country level organisations include:71: The Survival Advocacy Network (SAN), a transgender and female sex worker network founded by and for sex workers in Fiji, which trains healthcare providers to enable sex workers to access healthcare without fear of stigma or discrimination.72 PARCES NGO, a sex worker-led organisation in Bogotá, Colombia, which identifies the different forms of discrimination experienced by sex workers and fights oppression and violence against sex workers and others from key affected populations. The Veshya Anyay Mukti Parishad (VAMP) collective, which takes a rights-based approach to sex work. Barriers to accessing HIV prevention services In many cases, laws and policies are actively stopping HIV prevention campaigns for sex workers. In 2012, the most recent data available, 60% of all countries reported such laws, policies and regulations.73 Sex work is viewed as morally corrupt or criminal in many places, and those involved are often neglected and marginalised by wider society. In 2012, 61% of countries had laws protecting key affected populations from stigma and discrimination. However, the enforcement of these laws remains an area of concern.74 In China, widespread violations of sex worker rights have been documented. A 2013 report estimates that 15,000 sex workers were detained in so-called custody and education centres that year.75 A 2009 change in the law criminalising sex work in Fiji has led to round-ups, detentions, beatings and torture. Sex work has been driven underground, isolating sex workers from each other and from government-supported HIV prevention services.76 Sex workers and human rights Some laws not only criminalise sex work but also deny sex workers fundamental civil rights. They may be unable to own property, access education, justice, healthcare, banking services or purchase utilities. The social exclusion and poverty that results leaves sex workers vulnerable to exploitation, abuse and HIV infection. 77 Under these circumstances, sex workers are not recognised by the law and cannot exercise human rights like other people can. For example, the Swaziland Girls’ and Women’s Protection Act offers no defence for girls under the age of 16 if they are forced to have sexual intercourse: “[A]t the time of the commission of the offence the girl was a prostitute.” 78 Under this law, a girl under 16 years cannot consent to sex regardless of whether she is a sex worker or not, and is therefore considered a ‘non-person’.79 Respecting, protecting and meeting the human rights needs of sex workers is vital in order to maintain their health and wellbeing.80 For more than a decade, empowering sex worker communities to address their own HIV needs has been recognised as UNAIDS Best Practice, and continues to underpin key UN policy documents regarding the HIV response.81 Community empowerment-based responses have been shown to be most effective in addressing underlying social and structural barriers to the health and human rights of sex workers.82 For example, Mynamar’s Targeted Outreach Project (TOP) began in Yangon in 2004 and has been implemented in 18 cities across the country, reaching more than 62,000 sex workers a year. TOP establishes drop-in centres where sex workers can access free health care, which is free from the stigma they often encounter from other healthcare providers. TOP provides the technical and financial support needed to open new centres, but insists that local sex workers take responsibility and control over their own centres through empowerment, advocacy, and emotional support. All ‘community educators’ that work in the centres are sex workers from the local area.83 Ashodaya Samithi (Dawn of Hope) began in 2005 as a collaboration between researchers and sex workers. Within three years it had become community-led, with more than 4,000 sex worker members. Monitoring of the programme in 2014 showed a saturation in intervention coverage and progress in HIV prevention, such as increased condom use and decreased STIs.84 Community empowerment interventions have been prominent in Asian responses to HIV over the past decade. However, a 2015 systematic reviews of sex worker interventions in Africa found fewer examples of sex worker mobilisation or empowerment being implemented there.85 Should sex work be legalised? In some countries, sex work is illegal, meaning the law prohibits it. In others, it is criminalised, meaning that the act of sex work itself is not illegal, but that associated activities such as soliciting sex or running a brothel are. In a few countries, sex work is legalised and regulated. It is argued that legalising or decriminalising sex work is beneficial to curbing the HIV epidemic, because it allows governments to monitor and regulate the sex trade. In doing so, they can ensure that sex workers are empowered to negotiate condom use, improve their access to public services, and protect them from violence and abuse. Where sex workers are criminalised, they can be difficult to reach or unwilling to cooperate for fear of being arrested. By removing legal restrictions, HIV prevention programmes could be carried out much more effectively. In 2014, The Lancet published a study which estimated that decriminalisation and the promotion of safe working environments for sex workers could avert 33–46% of new HIV infections in sex workers and clients during a decade, through its iterative effects on violence, policing, safer work environment, and HIV transmission.86 It then joined a growing number of international health and human rights organisations including UNAIDS, UNFPA and Amnesty International to call for the full decriminalisation of adult, voluntary sex work in order to address the HIV epidemic more effectively.87 This approach is in line with the International Labour Organisation’s Recommendation 200, which recognises sex work as informal labour and gives sex workers the same rights as other workers, including the right to safe working conditions that are conducive to HIV prevention efforts.88 The way forward When responding to the HIV epidemic among sex workers, empowering them and involving them in HIV prevention has had positive results. By addressing the underlying social and structural problems that make sex workers vulnerable to HIV – by giving them greater legal protection against violence, and by reducing the discrimination they face – HIV prevalence could be cut dramatically. Harassment and abuse of sex workers by the police is also a widespread issue that needs particular attention from authorities. Governments and organisations need to create an environment where sex workers are able to protect themselves against HIV, and easily access HIV prevention, testing and treatment services. Only about one third of countries report having risk reduction programmes for sex workers, but they tend to vary in quality and reach. The remaining two thirds of countries expect sex workers to obtain services through general healthcare settings, where they may not be, or may not feel, welcome. This situation is even graver for male and transgender sex workers than it is for female sex workers.89 Although spending on the global HIV response has reached unprecedented levels, funds directed at programmes for sex workers remain far below the estimated need.90 Without addressing these gaps, sex workers will continue to be left behind in the global HIV response and the world will not meet the goals it needs to end the HIV epidemic.91
Some nations, especially in Latin America, have progressive attitudes and policies regarding homosexuality and the lesbian, gay, bisexual and transgender (LGBT) community.
However, the majority of Africa, along with the Middle East and Russia, continues to ignore and abuse the human rights of MSM.4 Punitive laws in various countries drive this population underground, elevating their risk of HIV and preventing them from accessing healthcare including HIV services.
What factors put MSM at risk of HIV?
The fact that HIV prevalence among MSM is so high in many countries means that members of this group have an increased chance of being exposed to the virus, due to mainly having sexual relations only within this group.5 However, there are also other factors that put MSM at heightened risk of HIV.
One major reason for high vulnerability to HIV among this group is that unprotected anal sex carries a higher risk of transmission than vaginal sex. This is because the walls of the anus are thin and more easily torn, creating an entry point for HIV into the bloodstream.6
Having a sexually transmitted infection (STI) also makes a person more susceptible to HIV infection. Among MSM, HIV testing and sexual health check-up frequency is low (less than 55% across all regions), so many are living with an undiagnosed STI that may put them at higher risk of HIV.7
MSM are often not aware of the particularly high risk of having unprotected sex with a person who has recently become infected. In London, United Kingdom (UK), a study reported that 27% of infections among MSM were from a partner recently infected with HIV.8
Having multiple sexual partners is more common among this community, and many do not use condoms consistently. In fact, MSM reporting easy access to condoms in 2012 varied from 29% in upper-middle income countries, to 45% in high-income countries, meaning that access to condoms worldwide remains inadequate for this group.9
Like condom access, HIV testing access is equally low, ranging between 25% and 54% across the world. By not testing for HIV, many MSM are unaware of their HIV status which can mean they are unaware of the need to take protective measures to prevent onwards transmission to others.10
Alcohol and drugs are a common part of socialising in some communities of men who have sex with men. Whenever drink and drugs are taken, it can make it more likely that people will have unprotected sex and a higher number of sexual partners, elevating vulnerability to HIV.11
MSM living with HIV often become HIV-positive while still young (4.2% of young MSM under 25 are living with HIV). This is more common in countries where HIV prevalence among the whole MSM population is quite high. It is also harder for young men who have sex with men (YMSM) to access HIV services, due to age of consent laws or unsociable opening times. For example, HIV testing and status awareness in 2014 was lower among YMSM (36%) than among this group as a whole (43%).12
As of May 2016, a third of countries around the world (75) still criminalise same-sex conduct, affecting the rights of MSM and other members of the LGBT community. In countries such as Iran, Sudan, Saudi Arabia and Yemen homosexuality is punishable by the death penalty.13 As a result, MSM are less likely to access HIV services for fear of their sexual orientation and identity being revealed.
In many countries ‘homosexual propaganda’ is now banned too. Such laws have been introduced in countries such as Russia and Nigeria to ‘support’ homophobic laws, to prevent the promotion of homosexuality to the public and children in particular. The exact meaning of these laws is confusing, and LGBT rights groups and non-governmental organisations (NGOs) working with this community have been punished under homosexual propaganda laws for helping ‘promote’ homosexuality.14
Russian-style propaganda laws are also being proposed in Ukraine, Belarus, Bulgaria, Latvia, Kazakhstan and Kyrgyzstan. In addition, there are a further 13 states in the Middle East and North Africa where ‘morality laws’ actively target public promotion or expression of same-sex and trans realities.15
Social and cultural factors
Many men who have sex with men have experienced homophobic stigma, discrimination and violence. This drives MSM to hide their identity and sexual orientation, and many fear a negative reaction from healthcare workers. As a result, MSM are less likely to access HIV services.16
MSM are more likely to experience depression due to social isolation and disconnectedness from health systems, which can make it harder to cope with aspects of HIV such as adherence to medication.17
HIV prevention programmes for MSM
High HIV prevalence among MSM around the world is evidence of the lack of prevention strategies that are reaching this group.
Between 2009 and 2013, the percentage of MSM reached by HIV prevention programmes in 20 countries fell from 59% to 40%. However, access varies greatly between regions and within countries. For example, MSM on a higher income are more likely to be able to afford, and therefore access prevention initiatives, than those on a low income.18
When MSM are targeted by HIV prevention campaigns they can be extremely effective. It is important that a combination of prevention programmes are available.
In recognition of this, in 2015, the UNFPA, The Global Forum on MSM and HIV, UNDP, UNAIDS, WHO, United States Agency for International Development, the US President’s Emergency Plan for AIDS Relief, and the Bill & Melinda Gates Foundation released a tool for use by public health officials, HIV and STI programmes officials, NGOs (both international and community-based) and health workers.19
The tool, Implementing Comprehensive HIV and STI Programmes with Men Who Have Sex with Men, provides recommendations for HIV prevention, testing and treatment for MSM and is based on successful community-led approaches.
Condoms and lubricants
One of the most important prevention responses is to make high-quality condoms, along with water-based lubricants, available and accessible to men who have sex with men.
In some countries, gay bars and other known meeting places for men who have sex with men, such as bathhouses, provide and promote condoms and lubricants. The Blue Sky Club is a civil society group in Vietnam that provides ‘edutainment’ events in local bars and clubs, combining HIV education and condom distribution with entertainment events, which are well received by local MSM.20
Providing them in gay-friendly places is much more effective than expecting MSM to purchase them from pharmacies, or healthcare settings that they may be fearful of visiting.21
Many of the most successful HIV programmes aimed at men who have sex with men empower this group and actively involve them in a community setting.
In sub-Saharan Africa, studies have shown how HIV services that are targeted at, and run by MSM, have seen the greatest response and uptake.22 This avoids the necessity of attending general healthcare settings, where MSM risk identity and sexual orientation exposure that could be met with stigma and discrimination.23
Educating peers who are part of the MSM population to educate others, provide prevention commodities and link people to MSM-friendly HIV services has shown to effectively reach and engage this population. This prevention strategy works on the basis that there is an elevated sense of trust between members of the MSM population, whereby fear of stigma is eradicated.24 Organisations staffed by MSM are also more credible and accessible to recipients.25
In the Philippines, one initiative attempted to help civil society engage with local government in the HIV response. 18 community-based groups were set up and 200 MSM and transgender people were trained in sexual health and rights. After three years, community leadership led to dialogue with local government officials on HIV, gender and human rights issues. One outcome of this process was an anti-discrimination ordinance in the city of Cebu in 2012 which prohibits discrimination on the basis of sexual orientation, gender identity and health status (including HIV).26
HIV testing initiatives
Two of the most effective ways to encourage HIV testing among MSM are to permit home-based testing, and provide community-based testing.
Home-based testing has the benefit of the user being able to avoid identification by healthcare workers.27 The privacy of conducting an HIV test alone at home is very favourable among MSM for this reason. One study in Brazil found that 90% of MSM participants would use self-testing kits, although concerns included receiving the result alone and being able to read the result properly.28 MSM should be educated about the use of self-testing kits, to heighten their confidence in using one if they are unwilling to test at regular healthcare settings.
Community-based testing at local pop-up clinics or mobile vans is also favoured among MSM. It means that they can access testing in a setting they are comfortable in, without having to travel to clinics where they may be seen or experience discrimination.29
PrEP and PEP
Recent research has shown that pre-exposure prophylaxis (PrEP) can reduce HIV transmission among MSM by 92%. The World Health Organisation (WHO) states that if its use is scaled up, an estimated 20% to 25% of new HIV infections among this population could be prevented.30
PrEP is a single pill taken every day by people who are at risk of HIV exposure, such as MSM. However, it is stressed that in order for the preventative effects to be realised, it must be taken correctly and consistently, alongside using condoms.31 MSM should be counselled and informed about the correct use of PrEP before it is offered.
By contrast, post-exposure prophylaxis (PEP) is taken after potential exposure to HIV. WHO recommends offering PEP to MSM as part of a package of prevention options. It must also be coupled with counselling about the importance of finishing the treatment course. One study found that only 67% of MSM on average completed the 28 day course, limiting the effectiveness of PEP.32
Due to the preference for anonymity when it comes to accessing healthcare, some studies have shown that technology, messaging, and social media have helped to provide HIV prevention information to MSM.
One study in South Africa found that sending text messages to MSM over a period of time encouraged men to test for HIV.33 The Adam’s Love organisation in Bangkok,Thailand, used a dedicated website, social media and web message boards for online counselling, recruitment and appointment making. Between September 2011 and January 2015, over 11,000 MSM received online counselling while over 8,000 were referred to HIV testing services.34
These types of programmes should be further explored as an avenue to engage MSM in the HIV response and their own healthcare.35
Access to antiretroviral treatment for MSM
Currently, data on HIV treatment access among MSM is very limited. Worldwide, only 40% of MSM living with HIV are thought to be accessing treatment. Reasons cited for such low access include homophobia, stigma and discrimination, as they can cause MSM to delay, interrupt or avoid treatment altogether. Experiencing these reactions from healthcare workers is also given as a predominant reason.36
Likewise, information on treatment retention rates is also very low. However, one study that recruited 6,095 MSM from 145 countries reported a drop-off at every point along the treatment cascade. Drop-off was particularly dramatic among YMSM and MSM in lower-income countries due to a lack of investment and youth-friendly services. By contrast, comfort with provider, more community engagement and better accessibility of ART were associated with higher retention rates in care.37
Barriers to HIV prevention programmes for MSM
High-risk sexual behaviour
Due to widespread stigma, many MSM want to keep their sexual orientation secret, and may also continue to have heterosexual relationships and even get married. In Asia and the Pacific between 2003 and 2007, 21% to 42% of MSM were married.38
Many MSM have a low risk perception of HIV as a result of not being included in sex education classes in school, and not being reached with HIV prevention initiatives. Having multiple partners is also more common among this community, with alcohol and drug abuse fuelling high-risk sexual behaviour such as not using a condom.39
One internet survey found that 32% of men reported having unprotected anal sex with someone of the opposite HIV-status to themselves, therefore risking HIV transmission or being exposed to HIV.40
Where there are laws that criminalise same-sex sexual relations, governments are unlikely to promote any sort of HIV interventions aimed at men who have sex with men. As a result, MSM living in these countries are unaware of their risk of HIV, can be turned away from HIV services, are fearful of accessing HIV testing, and find it difficult to get hold of condoms and lubricants.41
They are also unlikely to participate in research or prevention initiatives:
“…certain states would rather publicise their diplomatic distaste for atypical bodies, genders and sexualities instead of endorsing the protection of human rights and wellbeing of everyone.” – Gloria Carega & Azusa Yamashita 42
Stigma, discrimination and violence
A huge proportion of MSM worldwide have reported experiencing violence due to their sexual orientation. This is especially evident in machismo cultures, and patriarchal societies such as those in Latin America.43
In some areas, it is public officials or even healthcare workers that are committing these offences. The fear of being identified as homosexual deters many men from accessing these services, avoiding healthcare check-ups and treatment in order to keep their orientation secret.44
Lack of research
Although some statistics give an indication of the impact that HIV is having on men who have sex with men, data is still extremely scarce in many countries. This is largely due to the fact that MSM often have no separate social identity, and are simply counted as part of the general population.
It is also due to the reluctance of many governments to acknowledge men who have sex with men, and monitor this group. As a result, data about HIV among MSM is sparse, especially in regions like Eastern Europe and Central Asia. This is due mainly to the punitive laws that criminalise same-sex behaviour in the region, and an unwillingness of governments to accept that there is a disproportionate epidemic emerging among this population.45 73 countries failed to report on HIV prevalence among MSM in 2013.
It has been suggested that in settings where MSM are a particularly stigmatised group, collaborations between the government and NGOs are the most effective way to reach this population.46
“The frightening truth is that, in many parts of the world, we simply do not know how bad the epidemics among MSM groups may be… transmission among MSM is still not tracked in most countries, resulting in a significant research gap. More research is urgently needed to inform more effective HIV prevention efforts.” – Dr. Chris Beyrer, Director of the Johns Hopkins Fogarty AIDS International Training and Research Program 47
Lack of funding
Apart from a handful of countries such as Brazil and Cuba, the majority of funding for HIV services targeted at MSM comes from international sources rather than domestic funding. In 2013, only 11% was domestically sourced worldwide.48
Between 2005 and 2013, 38 countries did not report on their budget for MSM programming at all, suggesting no money was allocated for this key population. In sub-Saharan Africa, 30 of the 45 countries reporting in 2013 reported no spending on MSM programming.49
Even in countries where the rights of men who have sex with men are legally respected, there is generally a greater need for more funding from donors and governments, as the amount of money put towards campaigns is often disproportionate to the scale of the problem.50
The way forward
The evidence shows that providing HIV and AIDS services to those who are most at risk can be hugely beneficial to a whole country’s approach to HIV and AIDS. Governments and international donors must therefore cease to neglect the HIV epidemic among men who have sex men, and acknowledge the situation.51
Not only is funding needed to provide HIV prevention, testing and treatment for MSM, but it’s also needed to generate research and data to inform effective programming. Without allocated funding for research and programme delivery, high HIV prevalence among MSM will remain.
Stigma and cultural opposition to same-sex relations are often largely to blame for rising epidemics. Until these issues are addressed, it will be difficult to reduce HIV infection levels among men who have sex with men.52 National and community level leadership is required worldwide to end stigma and discrimination of homosexuality.53
Progress on rights for LGBT people in Commonwealth countries remains painfully slow. Will the new Secretary-General use her tenure to do her bit for human rights and the HIV response and push for the decriminalisation of homosexuality?
On 1 April, Baroness Patricia Scotland took office as the sixth Commonwealth Secretary-General. She was elected at the Commonwealth Heads of Government Meeting (CHOGM) in November 2015 in Malta and succeeds Secretary-General Kamalesh Sharma.
Progress in Malta
The CHOGM in Malta was an historic moment for the Commonwealth LGBT community as for the first time LGBT issues were discussed at the People’s Forum. Secretary-General Sharma said that ‘discrimination and criminalisation in any form on grounds of sexual orientation is incompatible with our Commonwealth values’ and the host Prime Minister Muscat called for LGBT equality. Equally, Secretary-General Scotland has committed to tackling the criminalisation of LGBT people during her tenure.
This represents great strides forward for the LGBT community. Unfortunately, the reality remains that 40 out of 53 Commonwealth countries still criminalise LGBT people. In an intergovernmental organisation that promotes the core values of equality and non-discrimination, this is unacceptable.
To coincide with CHOGM, we launched the Paradise or Persecution campaign to raise awareness of the number of top holiday destinations in the Commonwealth that still criminalise same-sex activity and since then we have seen some progress. The Seychelles has recently announced plans to scrap the law that criminalises homosexuality, hopefully by the end of 2016. Tourism accounts for nearly 20% of the Seychelles’ GDP – and the industry employs 15 percent of the country’s workforce. However, it has largely remained a ‘no-go’ area for LGBT tourism due to anti-homosexuality law. Although convictions under the law are very rare, this colonial hang-over perpetuates an environment of discrimination and violence.
Criminalisation and HIV
Despite this progress, it is really concerning that the Seychelles represents the exception rather than the rule in a region that is conversely seeing a rise in anti-gay sentiment. We are concerned about the criminalisation of homosexuality across the Commonwealth because of the crushing impact it has on the HIV response. Criminalisation only serves to drive and deepen the persecution many LGBT Commonwealth citizens face, to undermine the HIV response amongst LGBT people and deny their human rights. It will be impossible to end AIDS until all people – regardless of their identity or sexuality – can get access to health services and treatment.
More to be done
Anti-gay laws in the Commonwealth are a legacy of the British colonial era and the Paradise or Persecution petitioncalled on the Commonwealth Secretary-General to do more to get rid of these laws. Support from the Secretary-General to repeal Section 377 in India would, for example, add a powerful voice to the campaign and give a boost to the advocates in the country.
The next Commonwealth Heads of Government Meeting will take place in the UK in 2018. This offers Secretary-General Scotland an opportunity to work with a strong LGBT community and a progressive host to ensure LGBT issues are a substantive item on the official CHOGM agenda.
We welcome Secretary-General Scotland into her new role and wish her every success as she takes on this important position.
When sex work is criminalized, sex workers experience decreased control over the conditions of their work and they are subject to increased violence and discrimination. Survivors commitment to the decriminalization of sex work is informed by our work with sex workers from the Busia Town, across Western and around the world. Decriminalization is a necessary step to protecting the safety and rights of sex workers by ensuring that they have full access to health, safety and human rights. In addition to law reform, Survivors is also committed to challenging oppressive social conditions that constrain women’s and M,S,M economic options. These social conditions include poverty, homelessness, addiction and colonization. All sex workers deserve to have their choices respected and be able to work safely, without fear of violence, discriminationand social stigma.
Busia First Lady meets Sex Workers Women’s Day demands
Busia First Lady Judy Ojaamong today met the Sex Workers’ International Women’s Day Demands of availing them with condoms.
The workers through their umbrella body the Survivors Self Help Group had appealed through the event host and sponsor Florence Mutua, the Busia Women MP, for assistance in terms of condoms and lubricants.
” We have our cousins who include women sex workers , MSM ( Men having sex with men) and trans gender men and women, but they lack condoms and lubricants. We are Kenyans and your children who care.
Our membership currently stands at 2,500 with members spread to various urban centres including Nambale, Bumala, Funyula, Matayos, Busia Town and Port Victoria,” thus the need for concern she said.
Handing over a carton of condoms to the Group on Thursday, Judy said the donation which was courtesy of the National Aids Control Council will help the workers as per their demand.
Owing to the large number of the members, Judy said she would approach NASCOP for more condoms and lubricants to meet the group’s demand.
The First Lady said being a cross border town which has a high spread of HIV and Aids and sexually transmitted diseases, it was paramount to take precautions and avoid unprotected sex.
Judy said she was happy that the survivor organization through its Director Caroline Kemunto had come out openly to talk about sexual workers in the county.
She promised to bring more condoms through National Aids Control Council and other organizations to help sex workers in the county protect other people from contracting HIV and Aids.
Judy urged sex workers not to shy away from talking about their status in the society because whatever they do brings them daily income.
She told the sex workers who openly talked to her to help in buying them condoms to educate other people on the importance of protecting themselves while having sexual intercourse especially with people who are not their partners.
Kemunto said the condoms will be distributed to Bars and other places which attract sex workers in Nambale, Matayos, Bumala, and Budalangi.
She thanked the First Lady for being mindful of their members welfare saying the quick response was a true testimony that Judy cares about our welfare.
Client violence against sex workers should be considered in the context of the high levels of violence against women in the society. A sturdy conducted a few weeks ago showed that, a quite number of sex workers have been violated and mistreated by clients, police, health workers in the hospitals and even family members.
In our investigations, some of the sex workers shared their experience of which some cases revealed to us that some of them were even raped. In the health sector, some were not given proper care when they went for services at the health facility. Their was a case where by a male sex worker was given drugs that are not subjected to P.E.P after the health attendant realized that he is a sex worker. This negative attitude has left sex workers fear to go for services at the health facility with the fear of getting exposed. This leads to improper care and support with the MARPs of which the reduction of health issues as been a barrier at the Key Population. This are the state actors who should be on the front line in implementation of health but some of them still have negative attitude of which it has to be eliminated at all cost.
Other state actors who still need to be equipped with knowledge are the police. Still some of the have been using their powers to manipulate and harass sew workers on their hotspots. Some have even ended up demanding for sex through threat, creating a bigger barrier when it comes to law enforcement. Secondly some of them have been involved in cases where by they end up being suspended or get transferred due to their irresistible attitudes and behaviors.
With all this issues, we as Survivors have tried with all efforts to ensure that meeting and forums have been organized with the aim of passing information to the Police, Health Implementer s and Key people in the society including religious leaders.
Stop violence against sex workers
Busia have been terrorized by a two man gang in full police gear stealing from patrons in bars and shops, bringing fear to residents of busia county.
On Wednesday 26th of November 2014, it was just a normal day as any other , business was usual until 8.30pm when the power went off the whole town and it was raining heavily , the patrons at Sultana pub were enjoying their drinks and slow music when all of a sudden two men in police uniforms entered the pub, the patrons thought it was a normal routine patrol of the officer on duty, only to be told down! Down! And remove anything in you pockets. The patrons were robbed of any available thing they had including their phones and money ,the smart phones were smashed and left on the tables, the other old fashioned phones were taken away, they took almost one and half hours in the pub.
After Sultana , they marched to the nearest pub “cheers” they entered through the back door the cheers security guard saw them and ran , took a motor bike to the police station , but the police on duty, told him to go and look for the police officers on duty(on patrol) , the thugs ordered the patrons to lie down , one of the patrons tried to hold the leg of the man who had a panga , but the one with the gun told him to try , he will see a long day, they had to cooperate , and like in Sultana they robbed them of all valuable , they took two hours , leaving Cheers , they entered the neighboring shops and took all the money the man had sold during the day ,air time, the M-Pesa money and the M-Pesa phone.
At around 2.30am ,they went to another club called Changes , it was a ladies night so the club was parked , it was hard for them to enter the club , when they were still standing outside , one of the lady who parks at changes went greeted them asked if they are new in town because she didn’t know them and yet she knows all the police at the police station , they didn’t answer her , she went on with her business , the manager of changes came out and saw them and he went to them , he asked the same question the lady had asked , they sensed that they have been noticed , they ordered every body to lie down, the manager thought it was a joke and refused to lie down , the gun man shot him on the thigh ,they walked off pushing a motor bike which they left a few meters away and went on foot using the yuonear guest house route.
Something hurting is that all this was going on and the police had been alerted but they didn’t act, now the big question is WHO WILL PROTECT US IF THE POLICE CAN’T?!!!!!!!!!!!!!!!!!!.