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
DURBAN, 19 July 2016—Ten exceptional community-based organizations have won the 2016 Red Ribbon Award for their inspiring work towards ending or reducing the impact of the AIDS epidemic. They were presented with the prize in a special session at the 21st International AIDS Conference (AIDS 2016) in Durban, South Africa.
“Across regions and cultures, communities are showing the world that ending AIDS is possible. Their courage, innovation and leadership is helping us overcome barriers and better respond to the needs of those most affected by the epidemic.” said UNAIDS Executive Director Michel Sidibe.
The 2016 winning organizations are from Burundi, Mexico, Belize, Kenya, Nigeria, Iran (Islamic Republic of), Nepal, Chile, and New Zealand. Almost 1,000 nominations were received from more than 120 countries, for the Award, which is hosted by UNAIDS in partnership with AIDS 2016, the Global Network of People Living with HIV, the International Community of Women Living with HIV/AIDS, the International Council of AIDS Service Organizations and Irish Aid. A global panel of civil society representatives selected the finalists from a shortlist determined by regional panels.
Each of the winning organizations will receive a US$ 10,000 grant and have been invited to participate in AIDS 2016, where they organize the Community Dialogue Space in the Global Village.
At the Red Ribbon Award special session, the winners were congratulated by Her Royal Highness, Princess Mabel van Oranje of the Netherlands; Her Royal Highness, Princess Tessy of Luxembourg; Minister of Health and Child Welfare of Zimbabwe, David Parirenyatwa; Former President of Fiji H.E. Epeli Nailatikau, and Jan Beagle, Deputy Executive Director, UNAIDS.
“Community-based organizations are taking the lead in shaping the course of the AIDS response. The organizations here today – recipients of the 2016 Red Ribbon Award – are examples to us all of what it truly means to fast track the AIDS response, and to do so in a way which is inclusive, and that advances human rights and gender equality”, Jan Beagle, Deputy Executive Director, UNAIDS
The Red Ribbon Award was first presented in 2006 and since then has been awarded every two years at the International AIDS Conference. This year there were five award categories.
Category one: Good Health & Wellbeing (SDG 3)
Réseau National des Jeunes vivants avec le VIH/SIDA
Colectivo Seres, A.C.
Category two: Reduced Inequalities (SDG 10)
Kenya Sex Worker’s Alliance
Positive Action for Treatment Access (PATA)
Category three: Gender Equality (SDG 5)
Tehran Positive Club
Chitwan Sakriya Women’s Foundation
Category four: Just, Peaceful, & Inclusive Societies (SDG 16)
Red Nacional de Pueblos Originarios en Respuesta al SIDA
Category five: Global Partnerships (SDG 17)
About the Sponsors
The Joint United Nations Programme on HIV/AIDS (UNAIDS) leads and inspires the world to achieve its shared vision of zero new HIV infections, zero discrimination and zero AIDS-related deaths. UNAIDS unites the efforts of 11 UN organizations—UNHCR, UNICEF, WFP, UNDP, UNFPA, UNODC, UN Women, ILO, UNESCO, WHO and the World Bank—and works closely with global and national partners towards ending the AIDS epidemic by 2030 as part of the Sustainable Development Goals. Learn more at unaids.org and connect with us onFacebook, Twitter, Instagram and Youtube.
The UN partners involved in the Red Ribbon Award initiative bring together the efforts and resources of all UNAIDS Cosponsors and the UNAIDS Secretariat.
The XXI International AIDS Conference (AIDS 2016) is the premier gathering for those working in the field of HIV, as well as policy makers, persons living with HIV and other individuals committed to ending the pandemic. It is a chance for stakeholders to take stock of where the epidemic is, evaluate recent scientific developments and lessons learnt, and collectively chart a course forward. AIDS 2016 will be held in Durban, South Africa from 18 to 22 July 2016. (www.aids2016.org). The International AIDS Society is the convener and custodian of the conference.
Global Network of People Living with HIV
GNP+ is the global network for and by people living with HIV. GNP+ advocates to improve the quality of life of people living with HIV. Driven by the needs of people living with HIV worldwide, GNP+ supports people living with HIV through their organizations and networks. GNP+ works to ensure equitable access to health and social services, by focusing on social justice, rights and more meaningful involvement of people living with HIV in programme and policy development – the GIPA principle. (www.gnpplus.net)
International Community of Women Living with HIV/AIDS
ICW Global emerged to look for answers facing the desperate lack of support, information and services available for women living with HIV. The organization promotes the leadership and involvement of women living with HIV in spaces where policies and programmes are developed and implemented and where the decisions that affect the life of thousands of people who live with the virus are made. The vision is for a just world where women living with HIV are leaders in HIV programmes and policy and realize their universal rights. They dream of a world where women, young women, girls, adolescents living with HIV have full access to care and treatment and enjoy all of their rights: sexual, reproductive, legal, economic and health, regardless of culture, age, religion, sexuality, race or socio-economic status. (www.icwglobal.org)
International Council of AIDS Service Organizations
Founded in 1991, the International Council of AIDS Service Organizations’ (ICASO) mission is to mobilize and support diverse community organizations to build an effective global response to end AIDS. This is done within a vision of a world where people living with and affected by HIV can enjoy life free from stigma, discrimination, and persecution, and have access to prevention, treatment and care. The ICASO network operates globally, regionally and locally, and reaches over 100 countries internationally. (www.icaso.org)
Irish Aid is the Government of Ireland’s programme of assistance to developing countries. Its aid philosophy is rooted in Ireland’s foreign policy, in particular its objectives of peace and justice. The international development policy “One World, One Future” reflects Ireland’s longstanding commitment to human rights and fairness in international relations and is inseparable from Irish foreign policy as a whole. The Irish Aid programme has as its absolute priority the reduction of poverty, inequality and exclusion in developing countries, with a strong geographic focus on Sub-Saharan Africa. Improving access to quality essential social services such as health, education, services related to HIV and AIDS, and social protection is seen as key to the realisation of human rights, the reduction of poverty, hunger and inequality and the promotion of inclusive economic growth. (http://www.irishaid.gov.ie)
About the Red Ribbon Award
The red ribbon is a global symbol in the movement to address AIDS. The Red Ribbon Award, presented every two years at the International AIDS Conference, is designed to honor and celebrate community based organizations for their outstanding initiatives that show leadership in reducing the spread and impact of AIDS. The award is a joint effort of the UNAIDS family and as such, this year it will place particular emphasis on the organization’s newly approved global priority areas of action.
The Red Ribbon Award was first given in 2006 and has recognized 85 organizations from over 50 different countries since then as leading community-based responses to AIDS. Such organizations lie at the heart of the response to the AIDS epidemic – displaying extraordinary courage, resilience and strength in addressing one of the greatest challenges of our time. Using creative and sustainable ways to promote prevention of sexual transmission, and prevention among people who use drugs, provide treatment, care, and support to people living with HIV and demonstrating innovation in the face of stigma and discrimination through advocacy and human rights, and stopping new HIV infections in children and keeping mothers alive, and taking care of women’s health, these examples of community leadership are showing us in practical terms how to reverse a global epidemic – one community at a time.
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.
GLOBAL NETWORK OF SEX WORK PROJECTS
Good Practice and Lessons Learnt: Economic
Empowerment Programmes for Sex Workers in Africa . 1
EXECUTIVE SUMMARY. 1
Sex Worker-Led Economic Empowerment Programmes. 7
Case Study 1: Ethiopia
NIKAT . 8
Case Study 2: Kenya
Case Study 3: Kenya
HOYMAS . 17
Non-Sex Worker-Led Economic Empowerment Programmes . 22
Case Study 4: Nigeria
LIFE LINK ORGANISATION (LLO). 23
Economic Empowerment Programmes That Fail. 26
Case Study 5: Uganda
EMPOWERED AT DUSK WOMEN’S ASSOCIATION (EADWA). 27
Case Study 6: Malawi
NATIONAL FEMALE SEX WORKERS ALLIANCE IN MALAWI (NFSWAM). 30
Case Study 7: Democratic Republic Of Congo
MANAGEMENT OF YOUNG FOR RURAL DEVELOPMENT CENTRE (CEJEDER). 32
Lessons Learnt. 35
QUALITY ECONOMIC EMPOWERMENT PROGRAMMES
FOLLOWING RIGHTS-BASED APPROACHES . 35
UNSUCCESSFUL ECONOMIC EMPOWERMENT PROGRAMMES. 36
ECONOMIC EMPOWERMENT PROGRAMMES FOR SEX WORKERS: AFRICA 1
There is a lack of economic empowerment programmes for sex workers in
Africa. This situation contrasts significantly when compared to other regions.
For example, the first part of the ‘Stepping Up, Stepping Out Project’ by AIDS
Fonds documented case studies of economic empowerment programmes
in the Asia Pacific region. The output from this part of the SUSO project is
documented in the Regional Report1 ‘Sex Workers Demonstrate Economic and
Social Empowerment’ and the Regional Briefing Paper2 titled: ‘Sex Workers
Demonstrate Economic and Social Empowerment: Overcoming Practices That
Limit Sex Worker Agency in the Asia Pacific Region’.
Sex worker-led organisations are more established in the Asia Pacific region.
The work undertaken by APNSW in developing a framework for documenting
good practice in economic empowerment programmes was shared with the
African Sex Worker Alliance (ASWA) to inform them in documenting examples
of economic empowerment programmes in Africa. In addition to this, APNSW’s
good practice examples were shared with ASWA because they provide useful
models that can be adapted for the development of economic empowerment
programmes in Africa. The SUSO project’s focus in its final 2 years is twofold:
to build and strengthen the capacity of sex worker organisations working to
promote the human rights of sex workers and to document sex worker-led
responses in Africa.
The Global Network of Sex Work Projects (NSWP) received funding from the
Dutch Ministry of Foreign Affairs for the ‘Stepping Up, Stepping Out Project’ by
AIDS Fonds to support the development of advocacy tools around rights-based
economic empowerment for sex workers. This report outlines the situation
of sex work in 6 African countries where case studies were documented, and
highlights the factors that cause economic empowerment programmes for sex
workers to succeed or fail. This report also offers some recommendations for
economic empowerment programmes to succeed.
Programmes for Sex
Workers – Regional
2 GLOBAL NETWORK OF SEX WORK PROJECTS
The main finding of this report is that there is a significant absence of
economic empowerment programmes for sex workers in Africa. This situation
is worsened by certain funding Faith Based Organisations (FBOs) which see
sex work as morally reprehensible; these organisations are not willing to
fund sex work programmes unless sex workers exit sex work. As such, a lot
of programmes promote the ‘rehabilitation’ and ‘redemption’ of sex workers.
The rehabilitation programmes documented in the regional briefing paper
mentioned above demonstrated that these programmes do not listen to sex
workers, they do not ask sex workers what they want, they do not involve
sex workers in the design and planning of these programmes, and, perhaps
most importantly, these programmes fail to grasp the dynamics of stigma
and discrimination in the communities that programmes aim to rehabilitate
The report concludes that for economic empowerment programmes for sex
workers to succeed, sex workers must be involved at all levels to identify
the initiatives that meet the needs and demands of sex workers. The report
argues that these programmes must be run by sex workers themselves, and
programmes must adopt a rights-based approach which focuses on giving
sex workers the economic power to make informed choices about their lives,
including their sexual health and which does not necessarily focus on getting
them to exit sex work. Economic empowerment programmes for sex workers
should also aim to provide an alternative source of income to reduce the
vulnerability associated with changing jobs and the programmes should not
aim to entice them to stop sex work when they are not ready to do so.
Sex workers continue to face multiple risks including social marginalisation,
violence and poor health. These overlapping and mutually reinforcing factors
have been shown to restrict sex workers’ ability to improve their living and
working conditions and to achieve economic security. Furthermore, sex
workers – like other people working in informal economies – commonly report
a lack of access to bank accounts, saving schemes, loans and legal forms of
credit, insurance, pensions, and basic other employment benefits. Stigma and
discrimination heighten economic disempowerment by restricting sex workers’
access to financial services. This further compromises their ability to manage
and plan their finances and futures, including career development.
It is clear that some programmes that aim to empower sex workers fail to do
so: this is particularly common in the case of programmes whose primary
aim is to rehabilitate sex workers. Actions aimed at ‘rehabilitation’ through
training and steering sex workers toward alternative employment or income
generation often incorrectly assume that sex workers want to be rehabilitated
or want – or are able to – leave sex work immediately. In many countries, rather
than encouraging sex workers to build upon their own agency, programmes
instead offer income-generating activities and/or training is to rehabilitate
sex workers. This is to encourage or pressure sex workers to stop sex work
through providing them with increased employment options and reduced
risk and vulnerability. However, particpation in many of these programmes is
conditional upon leaving sex work immediately. Moreover, income generation,
training, and credit schemes are not always based on current markets and
opportunities; unsuccessful ventures risk disempowering sex workers further
because they often incur debt and experience the stigma of failure. As part of
this project, NSWP has published an accompanying briefing paper; ‘Economic
Empowerment: Does Rehabilitation Have a Role?’3.
ECONOMIC EMPOWERMENT PROGRAMMES FOR SEX WORKERS: AFRICA 3
Economic empowerment can however be an important strategy to improve sex
workers’ living and working conditions. By increasing economic options sex
workers can achieve greater financial security which makes it easier for them
to make important decisions that shape their lives. These include their choice
of work and their capacity to save and plan for the future – both for themselves
and their dependents. Improving economic options also helps sex workers to
reduce the likelihood of having to accept clients’ requests for unprotected sex
and it limits the likelihood of sex workers being put in situations that inhibit
their ability to negotiate with clients and heighten the risk of violence or abuse.
Sex worker-led organisations are emerging across Africa, primarily in
response to HIV. Some are also developing in response to the urgent needs of
their communities in relation to rights-based approaches to both economic
empowerment and the disproportionate levels of violence experienced by
female, male and transgender sex workers. Sharing similarities with the
Asia Pacific region, many projects in Africa have focused on rehabilitation
programmes that all too often have required sex workers to exit sex work,
rather than working with them to identify their own priorities and assisting
them to shape their own futures.
SEX WORK IN AFRICA
Violence, stigma, and discrimination against sex workers are commonplace
in African countries. Stigma and discrimination towards sex workers in
communities create mistrust, which leads to sex workers being dehumanised.
The dehumanisation of sex workers underlies the experience of sex workers:
complaints of victimisation, violence, and discrimination are seldom
considered by the police, judiciary, lawyers, or magistrates. Sex workers
are discriminated against in the communities in which they live, and this
results in humiliation because sex work is not regarded as legitimate work.
Stigmatisation and discrimination by state-run services also furthers rejection
by society. For sex workers in Africa, this burden is increased due to the
significantly high HIV prevalence among sex workers. According to the World
Bank report on ‘the global HIV epidemics among sex workers, 2013’, HIV
prevalence among sex workers varies globally reaches its highest at 36.9%4
in sub-Saharan Africa.
Sex workers are also vulnerable to a wide variety of human rights abuses.
These include sex workers being victims of violence perpetrated by the police,
their clients, and by members of the wider community.5 Sex workers face
many forms of violence including sexual violence (rape, harassment, emotional
abuse, humiliation, public insults, stigma and discrimination, and physical
violence such as assault and battery), as well as other violations such as refusal
of clients to adhere to the agreed transaction fee or outright refusal to pay sex
workers for services provided.
Sex work in Africa, like in other regions of the world, is not accepted as
legitimate work by society: it is considered morally reprehensible. Children of
sex workers are often insulted in schools because their mothers work as sex
workers, and this harmfully affects both mother and child. Discrimination
against sex workers in public and governmental service settings such
as governmental departments, public and private health facilities, law
enforcement, hotel and bar owners etc., are also common occurrences.
4 World Bank. The global HIV epidemics among sex workers. 2013, Washington, WA: International
Bank for Reconstruction and Development.
5 Decker, Michele R et al.; “Human rights violations against sex workers: burden and effect on HIV”; The
Lancet , Volume 385 , Issue 9963 , p. 186 –199.
4 GLOBAL NETWORK OF SEX WORK PROJECTS
Sex workers are most at risk of violence perpetrated by clients, police and other
law enforcement agencies, third parties, and partners.6 Sex workers report
various instances of violence against them including: physical abuse and/
or sexual assault from clients, police officers and/or others, refusal of clients
to pay the sex worker for their services. Hotel and bar managers who provide
premises for sex workers to work from often also perpetrate violence against
sex workers through unfair and unsafe working conditions including expecting
– and forcing – sex workers to work without condoms out of fear of arrest
(condoms can be used as evidence of sex work) and because some clients often
pay significantly more if they think they can have unprotected sex.
Moreover, some landlords introduce rules and regulations that are aimed at
barring and evicting sex workers from their premises, some male landlords
demand sex from sex workers without payment, while others extort higher
rents from sex workers simply because they can.
Adherence to Anti-Retroviral Treatment (ARV) is very low among HIV-positive
sex workers due to the nature of their jobs. Indeed, sex workers are highly
mobile and often miss taking their anti-retrovirals (ARV) if they have been
arrested and put in jail.7 In places where sex work is criminalised and highly
stigmatised, sex workers are more likely to be stopped, harassed, and arrested/
detained by police when they are working outdoors as a result. Stigma and
discrimination also affect the uptake of services at general health facilities; this
situation is more challenging for sex workers living with HIV due to a lack of
sufficient support services which continues to be dificult when implementing
prevention, treatment, care, and support programmes for sex workers living
In DRC, the Congolese legislation criminalises procuring8 in order to take
advantage of the sex work of others: the lack of information subjects sex
workers to arbitrary arrests and violence of any kind by the authorities who are
supposed to know the law. While sex work is considered to be anti-social in the
DRC, it is also perceived to be immoral by the general community.
In Ethiopia, sex work is considered an act of deviant behaviour 9 and immoral,
but it is permitted on the basis that it would be impractical to abolish it
instantly. Ethiopian law has created a free environment for sex workers to
work but it has also created unsafe working environments for sex workers, and
because sex work is not legal or illegal in Ethiopia, it is difficult for sex workers’
rights to be respected. In relation to accessing HIV-related services, sex workers
can get the service from any of the governmental clinics for free which are
located at each Woreda (Addis Ababa is divided into ten sub-cities, whereby
each sub-city contains ten or more Woredas within it). Sex workers can also
access these services from private clinics, but stigma and discrimination
towards sex workers from private service providers is a big barrier.
In Kenya, the constitution10 prohibits sex work, and earnings from undertaking
sex work are consequently considered illegal. As such, sex workers are
frequently regarded as easy targets for harassment and violence, and are
considered immoral and deserving of punishment according to traditional
cultures and the Kenyan constitution.
7 Focus Group Discussion with female sex workers in Malawi.
8 Congolese Penal Code, in Article 174b, paragraph 3.
9 Penal Code of the Empire of Ethiopia (1957) and the 2005 revised Criminal Code of the Federal
Democratic Republic of Ethiopia (FDRE).
10 The Laws of Kenya, Penal Code Chapter 63, Section 154 and 155.
ECONOMIC EMPOWERMENT PROGRAMMES FOR SEX WORKERS: AFRICA 5
In Malawi it is estimated that there are more than 20,000 sex workers, most of
whom remain hidden and marginalised because of social stigma associated
with sex work. Sex workers in Malawi face many serious challenges. The HIV
prevalence rate among female sex workers is estimated to be at 73%11 with
very low condom use and high STI cases. Yet services are not available nor
accessible to female sex workers, and many stakeholders including the police,
health workers, and sex workers themselves, are not aware of the many laws
and provisions that protect sex workers’ rights. The Prevention of Mother-to-
Child Transmission (PMTCT) of HIV programme in Malawi – considered to be
one of the best in the world – does not take into consideration the needs of sex
workers.12 The programme demands that every pregnant woman attends her
first antenatal visit with her spouse: this is a challenge for pregnant female
sex workers because they cannot bring their sexual partners. Consequently,
sex workers prefer not attend antenatal services and shun the PMTCT
In Nigeria sex work is illegal.13 The offender can be any male or female who
is ‘aiding and abetting prostitution’. The criminal code stipulates two-year
imprisonment for those wholly or partly living on proceeds from prostitution.
No law restricts a healthcare provider’s ability to provide medical care to
sex workers, however, due to stigma and discrimination, female sex workers
find it very difficult to disclose their job to healthcare workers. Sex workers
prefer to buy medicine anonymously from road-side drug stores rather
than from hospitals. Moreover, most of the support for healthcare services
comes from NGOs that have developed relationships with the female sex
Uganda has had an increasing HIV incidence for 30 years and is the only
country in East Africa that has recorded increasing HIV prevalence over the last
5 years. Having been closely monitored, the change in incidence coincides with
the moralisation of the HIV epidemic that saw a decline in condom promotion
and provision to communities most at risk. Sex workers are one of the most
at risk populations in Uganda where the HIV prevalence among sex workers
is 33%, approximately 5 times the national average of 7.3%.14 HIV prevalence
is also higher among females when compared to their male counterparts. The
Ministry of Health is in the process of establishing health units across Uganda
that are sex worker and MSM friendly. However, these clinics may not serve
their purpose because the new anti-homosexuality legislation drives sex
workers away from public services for fear of being arrested.15
Ugandan laws prohibit sex work and the penal code has laid down penalties for
people who engage in sex work and those living on the earnings of sex work.16
Uganda has become increasingly religious and puritan in relation to many
social issues. Indeed, the faith community has spearheaded the discrimination
against sex workers and police are constantly harassing and assaulting sex
workers as they conduct their business. The APA Walter Reed, a friendly sex
worker clinic for HIV-positive male and trans sex workers, was raided and
closed by the Ugandan government. It is clear that the security of sex workers
– female, male, and transgender – is at stake.
11 The Malawi 2010 Demographic and Health Surveillance Survey (DHS).
12 Focus Group Discussion with Female Sex Workers in Malawi.
13 The Nigerian Criminal Code Section 225A.
14 Uganda AIDS Commission Aide Memoir for the Joint Annual Aids Review (JAR) 2013.
15 Uganda AIDS Commission Aide Memoir for the Joint Annual Aids Review (JAR) 2013.
16 The HIV Prevention and Control Act 2014, the Anti Pornography Act 2013, the Anti Homosexuality
Act 2010, the Anti Counterfeit Act 2012, and the Public Order Management act 2013.
6 GLOBAL NETWORK OF SEX WORK PROJECTS
With this wave of laws that negate the freedoms and rights of human
beings as detailed in Uganda’s constitution and the international treaties
ratified by the Ugandan Government, it is likely that further marginalisation,
dehumanisation, and ostracism of female, male, and transgender sex workers,
will occur in Uganda. The passing of these bills by Parliament is tantamount to
structural violence because they deny sex workers the right to health and the
right to work, and they further marginalise an already very at-risk community.
Criminalisation is also likely to increase the risk of HIV and STIs for sex
workers in Uganda because it will fuel stigma towards sex workers in the
healthcare setting and foster police abuse and exploitation of sex workers. This
situation perpetuates the lack of sex worker involvement in the development of
health policy decisions that affect them.
NSWP would like to thank Aids Fonds for financial support in producing this
report, and Robert Carr civil society Networks Fund for contributing to the
The following people are also thanked for their contributions to the
development of the project:
Global: Gillian Galbraith, Mitch Cosgrove, Gillian Tasker, Anelda Grové,
Paul-Gilbert Colletaz; Africa Local Consultants: Democratic Republic of
the Congo: Mambo Amisi Modeste (AHUSADEC); Ethiopia: Hanna Hagos
(NIKAT Charitable Association); Kenya: Fridah Nguya (Bar Hostess); Erastus
Ndunda (HOYMAS); Malawi: Zinenani Majawa (CEDEP); Nigeria: Imaobong
Abraham Udoh (Women of Power Initiative); Uganda: Sanyu Hajjara Batte
(Lady Mermaids’s Bureau); Regional Consultant: Safari Mbewe (Malawi);
Support group: Daughtie Ogutu (ASWA); John Mathenge (ASWA, NSWP,
HOYMAS); Phelister Abdallah (KESWA); Peninah Mwangi (ASWA)
ECONOMIC EMPOWERMENT PROGRAMMES FOR SEX WORKERS: AFRICA 7
Sex Worker-Led Economic
This section considers good practice examples
of sex worker-led economic empowerment
programmes that have succeeded in having a
positive impact on the lives of sex workers.
SEX WORKER-LED ECONOMIC
8 GLOBAL NETWORK OF SEX WORK PROJECTS
This case study was conducted in Addis Ababa, Ethiopia.
Nikat Charitable Association is a grassroots community-based local NGO,
established by a group of sex workers in April 2010 and registered as an
Ethiopian Residents Charity under the Federal Democratic Republic of Ethiopia,
Ministry of Justice Charities and Societies Agency. Originally, NIKAT was
established in 2006 as a Community Based Organisation (CBO) called
‘Nikat Women’s Association’, which made NIKAT a pioneer in its field.
The association started with 108 sex workers as members; this has now
increased to 189 sex workers.
NIKAT was the winner of the ‘2010 Red Ribbon Award’ at the XVII
International AIDS Conference, organised by UNAIDS in collaboration with
Letiner Center, The Global Fund and Irish Aid, which was held in Vienna,
Austria, for their outstanding community leadership and action on HIV/
AIDS. NIKAT was also selected as one of the best six Red Ribbon Award
winners from the 25 winners and was rewarded $20, 000 (USD) as part of
ECONOMIC EMPOWERMENT PROGRAMMES FOR SEX WORKERS: AFRICA 9
NIKAT undertakes the following activities:
1 Runs a Drop-In Centre (DIC). The DIC provides a safe place to rest and
enables female sex workers to access information, peer-support, condoms,
and experience sharing. It also shares information about HIV/AIDS and
STIs and offers access to showers, cooking services, and counselling.
2 Works closely with governmental bodies including the Ministry of Justice,
Women, Children, and Youth Affairs Office, Addis Ababa Finance and
Economic Bureau, Addis Ababa Health Bureau, HABCO (HIV/AIDS Control
Office), the public, direct and indirect stakeholders including police
officers, ‘pimps’, hotel and bar owners, and traditional local drinking
houses called ‘Areke’.
3 Works closely with targeted sex workers by involving them from the start
(including the planning of a project) right up to the project’s completion.
4 Outreach activities at day and night to create formal and informal
linkages with sex workers working in town.
5 Works with partner organisations to offer referrals and resource sharing.
6 Trains former and current sex workers as Peer Educators to train other sex
workers and society. This makes the learning and practice much easier for
sex workers. Peer Educators are not paid and work as volunteers.
7 Public sensitisation by using broadcast media such as a weekly radio
programmes detailing the lives of sex workers, their rights, and the
services that NIKAT provides etc.
NIKAT’s vision is to empower sex workers in Ethiopia by ensuring their
social, political, economic, and psychological rights are improved and
respected while their mission is to improve the living and working conditions
of sex workers in Ethiopia and to fight against sexual abuse and HIV/AIDS.
Specific objectives of NIKAT include:
◗◗ Reduce the transmission of HIV and STIs by increasing condom-use
among sex workers, their clients and other Most-At-Risk Populations
◗◗ Empowering sex workers in such a way that their social, political, and
economic rights are realised.
10 GLOBAL NETWORK OF SEX WORK PROJECTS
Economic empowerment programme
for sex workers: ‘The SUSO Project’
NIKAT works in partnership with the ‘Stepping Up, Stepping Out’ programme
funded by Aids Fonds to deliver ‘The SUSO Project’ which implements
economic empowerment strategies as a means to improve the health and
wellbeing of sex workers.
The objectives and desired outcomes for the initiative are as follows:
capability of sex
workers to make
related to their
1.1 The needs of sex workers in relation
to their own, career development and
economic empowerment are identified.
1.2 Strategies are in place that effectively
responds to these needs, such
as improved access to education
1.3 Improved basic living conditions
particularly related to improved health
and wellbeing of sex workers, through
improved, safer working conditions,
improved access to health basic services,
1.4 Sex workers empowered to make healthy
choices with regard to their own health,
2 Sex workers have
which are leading
to a diversification
of income sources
or new career
2.1 Sex workers take the lead in their own
economic empowerment through peer
support systems (includes peer education,
self‑help organisation, loan/saving schemes).
2.2 Sex workers have increased access to
more diverse sources of income, including
improved access to credit schemes for
sex workers based on market value
(this includes business model, schemes for
3 Improved social
position of sex
3.1 Organisations are capable of analysing the
actual situation in relation to sex workers
and on the basis of that develop effective
lobby and advocacy activities.
3.2 Increased public attention for the situation
and position of sex workers.
3.3 Increased supportive environment towards
human rights issues of sex workers at
local, national, regional and global levels.
A total of 1,478 sex workers were intended to benefit from this project.
ECONOMIC EMPOWERMENT PROGRAMMES FOR SEX WORKERS: AFRICA 11
A more in-depth analysis of the activities of ‘The SUSO Project’ reveals that
1,716 sex workers benefited from all the activities of the project during 2013.
NIKAT conducted a needs assessment for sex workers, which included
identifying healthcare needs of sex workers in Addis Ababa through outreach
projects. NIKAT hired Momentum Professional Researchers and Consultants
and finished conducting the needs assessment. The needs assessment results
were used in the planning for the project.
8 coffee sessions with 200 participants at the drop-in centre were conducted by
inviting sex workers from the selected sub-cities to educate them about HIV/
AIDS, STIs, proper condom usage with demonstrations, contraceptives, and life
NIKAT provided educational opportunities: English lessons for 5 former
sex workers and 3 current sex workers. NIKAT signed an agreement with
Hello School of American English to provide private English lessons. NIKAT
additionally provided educational opportunities for 3 sex workers to continue
to higher education and enrolled them at 3 different colleges based on their
choices of study including a BSc Degree in Accounting and Finance at Alpha
University College, a BA Degree in Accounting at Admas University College, and
a Level III Nursing at Kea-Med University College in Addis Ababa. An allowance
for transport and other living expenses was also provided for the 3 sex workers
who enrolled at these different colleges.
NIKAT signed a MoU with Loving Shepherd International (LSI), an International
NGO which works on different activities related to sex workers as well as
providing free healthcare services for sex workers and their children. This is a
sex worker-only clinic. LSI provided free healthcare services for beneficiaries of
the project as well as for members and their children each time they required
healthcare services. A total of 118 sex workers and 47 children of the sex
workers under the age of 18 accessed free medical services and free medicine at
this sex worker-only clinic.
NIKAT provided 16 Personal Health Trainings with 400 participants at the
DIC to discuss safe sex, condom use and demonstrations, HIV/AIDS and STIs,
clinical usage, sexual reproductive health, family planning options, customer
handling, and risk avoidance during sex work. Advice on how to effectively
communicate with other stakeholders like the police, clients, hotel owners and
other parts of society were also included.
NIKAT published necessary Information, Education and Communication (IEC)
materials and Behaviour Change Communication (BCC) materials for the office,
as well as introducing the project to different partners (governmental and nongovernmental)
through letter-heads, business cards, invitation cards, banners,
large umbrellas, flags with logos of NIKAT, DKT and SOA AIDS, which all
promoted relevant sex work-related messages. NIKAT also purchased training
materials required for the hair dressing training centre, and they also selected
the targeted beneficiaries and appointed a trainer for the Hair Training Salon.
After finishing setting up the Hair Training Centre, NIKAT started to provide
training for 30 selected beneficiaries.
NIKAT also enrolled 17 sex workers at two Food and Catering Schools called
Lion Ethiopia Catering and Food Preparation School which is owned by the
government, as well as Benvenido Catering and Food Preparation School which
is privately owned. 8 selected sex workers who had completed high school have
been enrolled at Lion Ethiopia Food and Catering School for a Diploma including
a 7 month-long training for a Level I qualification, and 9 selected sex workers
who did not complete high school have been enrolled at Benvenido Food and
Catering School for a Certificate including a 10 month-long training.
12 GLOBAL NETWORK OF SEX WORK PROJECTS
NIKAT gave five SSG Trainings for selected beneficiaries of the project with
125 participants. NIKAT managed to establish three SSG’s each containing 25
members. They also provided match funding for all SSG members who have
been participating in the saving scheme, to help motivate them to continue and
strengthen their savings.
NIKAT signed an agreement with Addis Credit and Saving S.C. and selected
sex workers that managed to save the 1000.00 birr in 2013 (this amount was
required to borrow the money from the financial institution). Training was
facilitated by Addis Credit and Saving S.C, and undertaken in offices located in
each sub-city and Woreda in Ethiopia. One group managed to establish itself as
a CBO by obtaining their work permits with license. The group opened a small
food processing and a restaurant service for daily labourers and other workers
of Kolfe/Keraniyo sub-city in Addis Ababa. The other 3 groups are still trying
to get their license to form a CBO from the government: a license is required to
receive a loan and open a business in Ethiopia.
NIKAT managed to sign an agreement with a financial institution called Addis
Credit and Saving, one of the top financial institutions in Ethiopia – to manage
the interest free loan, additional saving and loan training required and monitor,
and most importantly manage, the revolving fund for the project. The financial
institution has provided the first loan and it has also organised training for
groups taking the loan.
NIKAT conducted seven sensitisation workshops for the stakeholders with 156
participants including police officers, hotel owners, ‘pimps’, and government
officers. Prior to conducting the training, NIKAT conducted an outreach activity
at day and night to communicate formally and informally with targeted
stakeholders. NIKAT also invited stakeholders to undertake the training.
ECONOMIC EMPOWERMENT PROGRAMMES FOR SEX WORKERS: AFRICA 13
NIKAT believes that each programme’s activity must be based on the needs
and demands of sex workers. Sex workers should be part of the planning and
implementation of the project at all levels. NIKAT’s experience of delivering
these activities as part of the SUSO project gives unique insight into how good
practice sex worker-led initiatives should be the benchmark for designing
economic empowerment programmes. The success of this empowerment
programme attracts sex workers but capacity to deliver similar projects is
limited. In order for sex workers to become more economically empowered,
NIKAT concludes that funding for economic empowerment activities for sex
workers in Ethiopia should be scaled up to match the high demand.
Factors contributing to the initiative’s success
1 Sex worker-led initiative.
2 Sex workers were not required to exit sex work while they were developing
new skills and learning new trades.
3 Initiative is based on the needs and demands of sex workers themselves.
4 Sex workers are part of the planning and implementation of the project.
5 Continuous monthly review meetings with sex workers on vocational
trainings and other economic empowerment activities like micro-scales,
savings, and others.
6 Tight follow-up, monitoring, evaluation, and learning by the programme
7 Successful sensitisation programmes which created close relationship with
the government and other relevant stakeholders including police officers,
hotel and bar owners, traditional ‘Areke’ houses, ‘pimps’, and others.
8 Continuous outreach programme activities created a close relationship
between the sex workers and programme staff directly and indirectly.
9 Sustained funding of the programme enabled sex workers to benefit for a
significant amount of time, which improved the chances of success of the
10 The project’s success required strong relationships between different
SEX WORKER-LED ECONOMIC
14 GLOBAL NETWORK OF SEX WORK PROJECTS
Survivors is a community-based organisation that works in Busia county in the
larger part of Western Province in Kenya. It was initially founded as ‘Muungano’
– a network of sex workers – and then later changed its name to Survivors to
connote ‘member’s resilience’. The organisation was formed in the year 2000
by a group from the University of Nairobi and Manitoba because of the high
prevalence rates of HIV/AIDS along the Kenya-Uganda border. Later, female sex
workers took over the organisation’s operations working on HIV and human
rights issues affecting sex workers in the county and the wider country. To date
the organisation has reached out to over 3,000 male and female sex workers.
Survivors is an organisation led by – and working for – sex workers and is
known in Busia County for its involvement with sex workers. The community
commends the organisations’ work in the HIV/AIDS field through condom
distribution and demonstration campaigns, and their HIV/AIDS testing
and counselling services.
ECONOMIC EMPOWERMENT PROGRAMMES FOR SEX WORKERS: AFRICA 15
The organisation’s vision is to have a world where all sex workers can enjoy
their health and human rights, and confidently undertake their work in a safe
environment; the organisation’s mission is to support and empower female
sex workers to make informed choices regarding their sexuality. In order
to achieve this, it carries out capacity-building training, advocacy, legal aid
clinics, networking and dialogue with different stakeholders, and economic
empowerment initiatives to promote self-sufficiency for sex workers. Survivors
also actively participates in sexual and reproductive health and policy forums,
to discuss and advocate for issues that affect its members. The organisation
exists to serve vulnerable women who are sex workers and sex workers living
with HIV. Survivors works in partnership with the National AIDS Control
Council and currently is being funded by the Open Society Institute, The Aphia
Plus, and the Liverpool VCT for health and human rights programmes. The
organisation is a founding member of the Kenya Sex Workers Alliance (KESWA)
– a sex worker-led movement in Kenya.
Economic empowerment initiative for sex workers:
Survivors employs various strategies to economically empower sex workers.
It particularly promotes self-sufficiency as an alternative source of livelihood,
and the organisation’s activities include peer education training, condom
demonstration and distribution campaigns, advocating for the human rights
of sex workers, outreach activities for HIV Voluntary Counseling and Testing
(VCT) services (mobile, daytime and night), facilitating support groups for
people living with HIV including sex workers, and emergency support schemes
for sex workers.
Dubbed as the ‘Economic and Livelihoods programme’, Survivors seeks to raise
the standard of living and improve the quality of life for sex workers in Busia
through income-generating activities. These activities also add sustainability
for the organisation, meaning that they don’t have to be too reliant on
donations to fund the organisation. The main objective of this programme is to
mobilise members to contribute funds to support their peers especially during
specific emergency needs, maintain HIV/AIDS and STI prevention, treatment,
care and support activities, as well as to develop mechanisms to ensure
sustainability of both the organisation and sex workers.
The organisation currently has 128 registered sex worker members, all of them
being part of this scheme. Under this programme, the organisation currently
runs a Savings and Credit Cooperative (SACCO) whereby all sex workers
contribute a certain amount of money monthly and receive their shares
annually, and they also operate an emergency support scheme (ESS). The ESS is
an intervention that responds to the need for a health insurance policy tailored
to the needs and financial capabilities of the members. It covers health issues
and provides benevolence funds for bereaved members. To raise funds for this
initiative, the organisation runs a catering business that provides catering
services during functions and events such as weddings, funerals, and parties,
among others, around the Busia area. The money earned from catering is then
put back into the organisation fund.
16 GLOBAL NETWORK OF SEX WORK PROJECTS
These initiatives have not only benefited sex workers in the county of
Busia: other sex workers in Kenya have also learnt from the best practice
demonstrated by Survivors, and they have been motivated to run
empowerment projects in their own organisations. Indeed, the initiatives have
triggered a positive impact among sex workers and this has played a major
role, especially in harm reduction. Due to the sex worker involvement in these
initiatives, the need to earn money quickly from sex work has been reduced.
It is also evident that sex workers have become empowered because very few
tested positive with STIs: this demonstrates that condom negotiation skills
have improved. In addition, with Survivors being located in a rural area where
MSMs are considered more immoral than female sex workers, the initiatives
have attracted and motivated male sex workers who were previously in hiding
and afraid to access services for fear of stigma and discrimination from the
The involvement of sex workers in designing and planning this initiative has
contributed immensely to its success. Sex workers proposed ideas that they
felt they would most benefit from and that they felt suited their circumstances
best. Sex workers also felt more inclined to take part in this programme and
to tell other sex workers about it because – having been part of the design and
planning of the programme – they had a personal stake in it. This in itself is
an empowering element and it contributes to the overall goal of economic
empowerment programmes. It is consequently clear that input of sex workers
is fundamental if economic programmes for sex workers are to succeed.
Factors contributing to the initiative’s success
1 Sex workers were meaningfully involved in all aspects of the initiative.
2 The initiative’s planners understood the challenges and needs of sex
workers and involved them in all the planning stages.
SEX WORKER-LED ECONOMIC
ECONOMIC EMPOWERMENT PROGRAMMES FOR SEX WORKERS: AFRICA 17
This case study on economic empowerment for sex workers was conducted
in Nairobi, Kenya. It was conducted and run by a Nairobi-based male sex
workers’ collective, HOYMAS.
HOYMAS was formed in May 2009 by male sex workers and people living
with HIV and is registered as a Community Based Organisation (CBO) by the
Ministry of Social Services and Gender. HOYMAS serves male sex workers,
young men, and other men who have sex with men (MSM) with practical
knowledge on safe sex, preventive materials distribution, general information,
and economic empowerment.
HOYMAS has partnered with the National AIDS and STI Control Programme
to roll out programmes targeting male sex workers. HOYMAS has been a
stakeholder in the KNASP III policy17 as well as the National MARPS and Sex
Workers Policy. It is one of the steering committee members of the Kenya Sex
Workers Alliance (KESWA). It is also in the Technical Working Group (TWG)
of the National AIDS Coordinating Committee (NACC) and the National Sex
Workers Guidelines Committee.
HOYMAS has partnered with NACC in delivering HIV/AIDS programmes
aimed at both MSM and male sex workers. HOYMAS has also partnered with
organisations such as Mama Lucy Referral Hospital, Casino Special Treatment
Centre, Sex Workers Outreach Program (SWOP) clinics, and Liverpool Health,
in both service provision and referrals of MSMs and male sex workers.
HOYMAS has many international partners including American Foundation for
Aids Research (AMFAR), Stop Aids Netherlands (SANL), University of Manitoba
(UOM), VU University in Netherlands, Red Umbrella Fund, Global Network
of Sex Work Projects (NSWP), Africa Sex Workers Alliance, and UNAIDS
17 Kenya National AIDS Strategic Plan 2009/10 – 2012/2013
18 GLOBAL NETWORK OF SEX WORK PROJECTS
HOYMAS has been instrumental to various sex workers’ events including the
International Day to End Violence Against Sex Workers on Dec 17th, and the
International Sex Workers Rights Day on March 3rd.
HOYMAS activities include:
◗◗ Referrals of MSMs and male sex workers to service providers such as the
Kenyatta National Hospital, LVCT, SWOP.
◗◗ Outreach to MSM/MSW communities in various hotspots in Kenya. This
helps with documentation and mapping for data.
◗◗ Training of peer educators and healthcare workers in collaboration with
MSM Training groups/organisations, e.g. LVCT.
◗◗ Counselling and Testing (CT) services to male sex workers, MSMs and clients
during CT drives.
◗◗ Offering condoms and lubricants as well as prevention commodities to
MSMs and male sex workers and their clients.
◗◗ Sensitisation by healthcare providers as well as other stakeholders including
government, the media, and police officers.
◗◗ Production of safer sex brochures and IEC materials for distribution and
creating awareness to MSM/MSW and communities.
◗◗ Providing monthly nutrition programmes with support from government
◗◗ Conducting economic empowerment training and support for vocational
training, micro-finance training, and financial literacy sessions.
◗◗ Documenting and addressing cases of violence with support of HOYMAS’
paralegal team and police.
HOYMAS has also managed to intensify the campaign against harassment
and violations of sex workers by training more paralegals to offer help to sex
workers when they are arrested. The paralegals also educate sex workers on
their human rights, and on steps to take incase their rights are violated. As
part of the campaign, HOYMAS has been vocal by participating in various
protests and organising stakeholder meetings and events purposely planned
for sensitisation purposes; for example, the Champions Day saw numerous
partners of the organisation participate. The sensitisation efforts have
positively impacted the many sex workers who endure victimisation because
they can now stand up for themselves and have the unrelenting support of the
organisation’s partners, including the government. As James says, “Interacting
with law enforcers has opened up my mind and I have realised that the police are just
human beings like me and I can go to them with my problems and assist me when
my rights are violated as a sex worker.” This shows a direct benefit that MSW gain
from interacting with law enforcement partners.
ECONOMIC EMPOWERMENT PROGRAMMES FOR SEX WORKERS: AFRICA 19
Economic empowerment programme for
male sex workers: ‘HOYMAS Savings and
Credit Cooperative’ (SACCO)’
HOYMAS is committed to supporting male sex workers to acquire life skills,
education, and vocational skills without telling – or forcing – them to abandon
sex work. This approach enables MSWs to make informed choices about their
lives. HOYMAS believes that by obtaining income from other activities, sex
workers will be able to reduce their number of sexual partners and negotiate
safer sex practices, which will also reduce their HIV/AIDS and other STI risk
and vulnerability. HOYMAS runs an economic empowerment project called
‘HOYMAS Savings and Credit Cooperative’ (SACCO).
Small micro-enterprise initiatives is one economic empowerment strategy
in Kenya and most of these programmes in Kenya specifically target women,
youths who are out of school, people living with HIV etc. The programmes
have not targeted sex workers because of the stigma and discrimination they
face in society and even from providers of such programmes. When sex work
is not recognised as legitimate work and not associated with generating a
consistent income like other jobs, most financial institutions are reluctant
to offer financial services – particularly loans – to sex worker groups and
individual sex workers because they are perceived to be high risks.
Due to legal issues it is a huge challenge to register sex worker groups so that
they are able to acquire financial support or access loans services; most sex
worker groups are not registered as sex worker groups, and consequently, they
have to hide their identity in order to access such services. In addition, the
majority of male sex workers do not have identification documents such as the
National Identification Card, which is required to open a bank account.
HOYMAS has been providing business and micro-finance skills training to
male sex workers in conjunction with the Small Micro-Enterprise Programme
(SMEP), a micro-finance institution that works with grassroots organisations
to address poverty and livelihood support systems alongside the Co-operative
Bank of Kenya. In addition HOYMAS has empowered a number of male sex
worker peer leaders who are trained as facilitators – or Training of Trainers
(ToTs) – in the area of financial literacy.
The training has been focusing on:
◗◗ Financial literacy and management
◗◗ Business development skills
◗◗ Savings and loans acquisition processes
As a direct result of this training, HOYMAS members have since started a
group savings and credit scheme (SACCO) whereby some members of the
organisation contribute money every month and can access loans and other
financial assistance at any time, with agreed-upon conditions. This has
shaped a positive change in the living conditions of the sex workers who,
before the financial and savings training, had no permanent living structures
and could not meet essential basic needs such as food and clothing due to
difficulties in managing their earnings from sex work.
20 GLOBAL NETWORK OF SEX WORK PROJECTS
In addition, HOYMAS also offers support to male sex workers by advising
them on the importance of obtaining a National Identification Card and the
importance of a bank account because most male sex workers (MSWs) lose
their money through theft by clients or fellow sex workers. Policemen and
other law enforcers also take advantage over MSWs by asking for bribes –
especially if they are caught on the streets or at their hotspots without their
HOYMAS realises that male sex workers – especially those living with HIV –
face serious health challenges that can make them want to move elsewhere
when they feel they are becoming a burden to their families, or to live in
isolation, especially when their health condition deteriorates. For many
MSWs, this is because they are yet to accept their HIV status; the majority
suffers from mental illnesses which makes it hard for them to engage or
participate in any economic activities. Due to a growing need for immediate
first aid and medical assistance and psycho-social services, a home-based
care (HBC) centre for male sex workers living with HIV/AIDS facility was set
up. HOYMAS established a home-based care programme that was meant
to support and protect members from self-defeating behaviour as a result
of poor health. This is linked with income-generating activity because once
patients recover, they need to start providing for themselves once again and
living a normal and productive life.
Results and conclusion
Results of the training and support from HOYMAS demonstrate that 53 male
sex workers have been able to obtain their National IDs and open personal
bank accounts. Most of them are now fully housed, and by offering financial
loans with fair interest rates when any HOYMAS members needs it, the
savings and credit scheme ensures that this situation remains.
Due to the growing need for a safe space for MSW in need of immediate
medical and first-aid assistance, a home-based care service (HBC) for sex
workers living with HIV/AIDS has been set up by HOYMAS. To date, the
centre has had a total of over 160 patients: patients who have been in the
centre and discharged testified to the fact that the HBC centre changed
their lives and enabled them to be able to resume sex work – which is their
livelihood – sooner than they would have if their needs had not been met by
the centre. “[…] the HBC changed my life, when I went, I was very sick, I had TB,
and I wasn’t taking my ARVs […] but with the help of the nurse and other staff
members, they took me in like family, fed me and ensured I took my medication
well and went to seek medical help regularly at Liverpool clinic”, says Fabian, an
HIV-positive MSW. Individuals underwent a basic course of HBC under the
guidance of National AIDS and STIs Control programme NASCOP, and the
District AIDS Coordinator (DASCO), Nairobi County.
ECONOMIC EMPOWERMENT PROGRAMMES FOR SEX WORKERS: AFRICA 21
The economic wellbeing of sex workers is almost an unreachable goal because
they are a criminalised group. Through the project, HOYMAS managed to
expand on the possibility of securing financial futures for their members and
other sex workers by setting up training on basic income-generating activities:
for instance 25 sex workers have been trained on making knitting mats and
bead work. They then sell the handicraft that they make to supplement their
sex work income. In addition, they have offered micro-finance and savings
training to their members with the help of the SMEP (Small Micro Enterprise
Programme). As a direct result of the training, HOYMAS members have since
started a savings scheme where some members of the organisation contribute
to, and can access, loans and other financial assistance at any time with agreed
upon conditions. This has seen a positive change in the living conditions of
sex workers who, before this financial and savings training, had no permanent
living arrangement. Most of them are now fully housed, and SACCO ensures
that this lasts by offering financial aid when any of the members need it.
Commenting upon this, one male sex worker says:
“I used to live in a brothel but since the training I have been able to plan the little
money I earn for rent, food and other needs, I also save and they can finance me
if I have a business idea, so it has really empowered me.”
The project has also directly impacted the lives of sex workers by providing
capacity-building as well as helping them to establish economic foundations.
It has also resulted in financial independence for most of the male sex workers,
and sex workers have experienced the project’s benefits and view it as a great
success. One male sex worker said “I am empowered, as I gained skills in planning
and budgeting my money, I am happy now that I can save part of my income at our
group saving account, and I can make a living out of the skills and I have become a
good role model among my peers.”
Addressing the economic needs of male sex workers is key to addressing their
health needs. HOYMAS seeks to strengthen its economic activities for male
sex workers because they are important factors in HIV response. HOYMAS is,
however, strongly persuaded that by supporting income-generating activities
for male sex workers, they will continue to live – and sustain – healthy
lifestyles. Moreover, by doing so, HOYMAS and its members gain respect from
the society and greater credibility to engage in even wider outreach.
Factors contributing to the initiative’s success
1 The initiative was spearheaded and run by sex workers. Consequently,
fellow sex workers were more open to the ideals and objectives of the
project because they received these from their peers, which made them
2 Unlike most research projects, the benefits of this project are direct and can
be clearly seen by sex workers who were part of the project. This in turn
encouraged more sex workers to be part of the programme.
3 Successful sensitisation and the reduction of victimisation saw the
programme receive more attention from other sex workers.
4 Community members were involved at all levels of the programme – i.e.
design, implementation, monitoring, and evaluation – which made the
project more responsive to the community’s needs.
22 GLOBAL NETWORK OF SEX WORK PROJECTS
Non-Sex Worker-Led Economic
This section documents a good practice example
of a non-sex worker-led economic empowerment
programme that had a positive impact on the lives
of sex workers.
ECONOMIC EMPOWERMENT PROGRAMMES FOR SEX WORKERS: AFRICA 23
NON-SEX WORKER-LED ECONOMIC
Life Link Organisation (LLO)
This case study on economic empowerment for sex workers was conducted
in Lagos and Cross River State in Nigeria as part of the regional efforts at
developing advocacy tools around rights-based economic empowerment for
A sample framework was developed, consisting of sex worker-focused
organisations in Lagos and Cross River States that had implemented
economic empowerment programmes for the female sex worker community.
An email was sent to the organisations introducing the case study project
and its objectives, while requesting approval to engage the organisations
in the study. The email was followed up with telephone communications.
Approval was obtained from 2 organisations, enabling documentation of a
project that has been successful. Data was collected from the organisations
through one-on-one interviews with key officials of the organisations and
also through desk reviews of project reports on female sex workers’ economic
empowerment programmes; the data was collected using the given guiding
questions. A number of sex workers who benefited from the projects also
documented their experiences, which details the impact of the programmes
on their lives as sex workers.
LLO is a non-sex worker-led, non-governmental, and non-profit making
organisation founded in May 1994. Registered with corporate affairs
commission of Nigeria, its sole aim is to provide health services in the
community, focusing on most-at-risk populations, the prison community,
and uniformed personnel. It is an indigenous Nigerian NGO that works in
various states of the federation including Akwa-Ibom, Lagos, Kano, Abuja,
Ogun, Oyo, Kaduna, Enugu, Plateau and Delta states. LLO operates a welldefined
organisational structure with a Board of Directors – consisting of five
directors – to oversee the organisation’s policy and management.
24 GLOBAL NETWORK OF SEX WORK PROJECTS
The organisation’s goal is to provide services to members of society in health
and education-related areas, and to meet socio-economic and psycho-social
needs. Their mission is to provide health and psycho-social services through
dissemination of information, education, and counselling to members of the
community, particularly female sex workers and the prison community, using
well-trained personnel. Their vision statement is dedicated to enhancing the
following in the community: health, education, psycho-social, and economic
wellbeing. LLO is institutionalised with funding support from domestic
resources – Lagos State AIDS Control Agency, Civil Society for HIV and AIDS in
Nigeria, AIDS Prevention Initiative in Nigeria and Society for Family Health. LLO
also has international donors – Family Health International Nigeria/AHNI, The
Futures Group International, International Family Health/Femope Foundation.
LLO is a member of the following sex work networks in Nigeria and Africa:
Civil Society for Health and Rights of Vulnerable Women and Men in Nigeria
(CISHRWIN) and African Sex Workers Alliance (ASWA).
Economic empowerment intervention for sex workers:
The Sex Workers Project
This project was supported by Family Health International. The goal of the
project was to reduce the prevalence of HIV and STI infections among mostat‑risk
women, and the objectives of the project were as follows:
◗◗ To build the capacity of female sex workers to enable them to implement
quality condom use and other prevention activities in Lagos state.
◗◗ To build the capacity of female sex workers to enable them to access HIV
and STI treatment, care, and support services.
◗◗ To strengthen the capacity of female sex workers who desired to leave sex
work through skills action training for 20 sex workers in 5 LGAs Lagos State.
The activities that were carried out were as follows:
◗◗ Monthly meetings of the project management team – the Project Advisory
Committee (PAC) that includes the female sex workers, project officers, and
◗◗ Training/capacity-building on HIV/AIDS, condom use and negotiation skills
for safe sex, including the training of female sex workers as peer educators
reaching out to their peers in various brothels.
◗◗ Dialogue for action activities, condom education, and risk reduction
◗◗ Skills acquisition/vocational training for female sex workers on tie and dye,
cake making, hairdressing, hat making, manicuring and pedicuring. The
duration of this skill-building training was between 2 weeks and 6 months.
Sex workers were given seed grants to help fund their small business as part
of the project.
Organised programmes on financial management that linked sex workers with
existing banks enabled them to open a savings account, rather than keep their
money with the local thrift and credit facility.
ECONOMIC EMPOWERMENT PROGRAMMES FOR SEX WORKERS: AFRICA 25
Results and conclusion
The project planned to reach 20 female sex workers but this target was
exceeded: 25 female sex workers received various vocational skills-building
training. Some of the female sex workers started their own businesses – some
went into fashion design, cake making, and hairdressing – and they were able
leave brothels and rent their own apartments.
Following the economic empowerment programme, one of the female sex
workers joined the police and today she is a Nigerian Police Officer. The project
was also able to support young female sex workers who were interested in
going back to school: through this initiative LLO was able to support a female
sex worker to enrol and sit the SSCE Examinations, and she secured admission
into a higher education institution to complete the National Diploma degree.
Economic empowerment programmes can be very effective in socially
empowering female sex workers. Programmes that take into account the needs
of sex workers as articulated by sex workers themselves, and which develop
their skills, appear to be more successful. Social empowerment also encourages
sex workers to negotiate safer sex. Such initiatives will not necessarily force
them to exit sex work, but rather, it gives sex workers the economic knowledge
and power to make rights-based choices for their lives.
Factors contributing to the initiative’s success
The project adopted a rights-based approach to the economic empowerment
programme as it did not focus on the sex workers exiting the sex work. Instead
it focused on building sex workers’ skills to be able to make the right choices for
themselves. The female sex workers were empowered to negotiate for safe sex
practices with their clients.
Another key factor that facilitated the success of the programme was the
integrated approach that addressed sex workers’ sexual and reproductive
health needs and economic empowerment support. The full empowerment
programme – which included seed grants for them to start up their businesses
– played a large role in helping them put their newly acquired knowledge and
skills into practice. Technical support – in the form of a financial management
programme and follow-up for a period of 6 months – facilitated a culture
of savings whereby sex workers were able to open bank accounts with the
micro-finance banks. Through saving they were also able to rent their own
apartments and make informed choices for their lives.
26 GLOBAL NETWORK OF SEX WORK PROJECTS
This section looks at examples of economic
empowerment programmes that failed and
negatively impacted on the lives of sex workers.
Programmes That Fail
ECONOMIC EMPOWERMENT PROGRAMMES FOR SEX WORKERS: AFRICA 27
PROGRAMMES THAT FAIL
Empowered at Dusk Women’s
The economic empowerment case study was conducted in Uganda from July
to August 2014 and the key informant interviews were held with Empowered
at Dusk Women’s Association (EADWA), a sex worker-led organisation.
Guiding questions were used in the economic empowerment case studies’
organisational interview and a desktop literature review was conducted.
This review considered the following issues: the background of HIV, sex
workers’ violations, and economic empowerment in Uganda. Organisational
visits were also performed, aiming to gather evidence-based information to
ensure credibility and effectiveness of the economic empowerment results.
EADWA is a female sex worker-led organisation established in 2011 to
advocate for health rights and human rights of sex workers. Located in in
Kampala suburbs, Kawempe Division, EADWA is registered as a Community-
Based Organisation in Uganda. EADWA is a member of Uganda Harmonised
Rights Alliance at national level and a member of the African Sex Workers
Alliance (ASWA) and the Global Network of Sex Work projects (NSWP).
It has grown into a membership of 55 female sex workers and it provides
information and education to its members to empower them through
knowledge on human rights, legal procedures and HIV/AIDS.
EADWAs mission statement is to promote awareness of human rights,
economic issues, health, and the social development of sex workers. Their
vision is to ensure that the rights of all persons – including marginalised
groups and especially female sex workers – are central to social, health, and
28 GLOBAL NETWORK OF SEX WORK PROJECTS
EADWA values non-discrimination, equal opportunity, justice, and fairness.
They also value practical methodology and teamwork: their slogan is ‘together
we can’. The organisation has the following objectives:
◗◗ Promote interest in human rights through presentations and sharing
experiences among sex workers.
◗◗ Promote a non-violent culture in the community through networking,
dialogue with policy-makers, and working with the media. EADWA also
undertakes sensitisation workshops on violence, HIV/AIDS, alcoholism, and
drug and substance abuse awareness and prevention.
◗◗ Offer psychosocial support to stigmatised and other marginalised groups,
HIV/AIDS clients through counselling and referrals.
◗◗ Promote self-esteem, self-respect, and the value of human life.
◗◗ Promote empowerment schemes among sex workers to improve their
standards of living.
◗◗ Offer basic education to females, young people, and orphans, especially
those who are affected by HIV/AIDS.
Economic empowerment intervention for sex workers:
‘Provision of entrepreneurship skills in hairdressing,
salon management and art/crafts’
EADWA embarked on an intervention called ‘Provision of entrepreneurship
skills in hairdressing, salon management and art/crafts’. The goal of this
project was to empower EADWA members with entrepreneurial skills.
The following activities were undertaken:
◗◗ Training in hairdressing.
◗◗ Entrepreneurial skills training.
◗◗ Salon management training.
◗◗ Arts and crafts training.
◗◗ Regular breaks were used to discuss other issues affecting EADWA members.
27 members were intended to benefit from this project which aimed to
help sex workers look after their health and to avoid violence, including
clients demanding unprotected sex, rape, and police arrest. This economic
empowerment project also suggested that EADWA members could be good role
models by being heads of their families with available and adequate money to
support their families.
Results and conclusion
A lack of attention on important elements such as saving skills, marketing,
and branding was found. This was due to different issues affecting members
individually. When it came to sex workers’ products, marketing was very
competitive because members had no marketing skills and there was frequent
stigma and discrimination. There was no demand for sex workers’ products
because of social discrimination, and culturally, the community believed that
sex workers’ products were bad omens. Moreover, members were not used
to these somewhat outdated types of jobs and they were inexperienced. Sex
workers had to work long hours and they were subjected to sexual exploitation
by the buyers: one member stated that “once they knew that we were sex workers
they wanted free sex in order to buy our goods”.
ECONOMIC EMPOWERMENT PROGRAMMES FOR SEX WORKERS: AFRICA 29
Due to the surrounding communities’ negative attitudes towards sex workers,
members who worked in the salon earned very little money. Even with the
stigma of sex work – and the higher risks that sex workers face as a result
of such stigma and discrimination – sex workers felt they were better off
continuing to work in brothels and/or outdoors.
Meaningful engagement and consultation with sex workers during the
planning stages of economic empowerment programmes are critical. EADWA’s
programme staff trained sex workers in hairdressing, entrepreneurial skills,
hair salon management, and arts and crafts, without consulting sex workers
about their preferred area of work. Furthermore, the programme staff did not
conduct an analysis of the services that there is demand for in the community;
if this analysis had been undertaken, it would have helped programme staff
match the sex workers to the vocational trainings they preferred, while also
training sex workers to undertake vocations and skills that were needed within
Other factors also need to be considered – especially those specific to particular
communities – to determine how they impacted on sex workers in that
community. For example, in EADWA’s programme, the management did not
consider the stigmatising views held by the wider community with regard to
goods and services provided by sex workers. This placed the sex workers who
participated in the programme in a very vulnerable position: the sex workers
were outed as sex workers and subjected to stigma and discrimination. As
a result, the sex workers’ ability to earn an additional income was severely
limited. Therefore, programme staff must ensure that the initiatives they put
forward and that encourage sex worker participation are informed by the
experiences of the sex workers themselves. Sex workers are best-placed to
discuss their needs and expectations of economic empowerment programmes.
This case study shows that sex work is highly stigmatised and sex workers
are discriminated against in their communities. Sex workers often feel that
they have little choice but to continue generating their income by working in
brothels or outdoors at the expense of having the respect of their community.
It is consequently reasonable to expect that economic empowerment
programmes that do not demonstrate awareness of, and implement strategies
for, the issue of stigma and discrimination within communities, are destined
to fail. Worse still, this approach fundamentally fails the sex workers and
increases their vulnerability in the communities.
Factors contributing to the initiative’s failure
1 “We realised that there was a gap in economic empowerment policy-making
because there was no consultation between the project officers and the members
(sex workers) on what exactly the sex workers had wanted to carry out”. It can
therefore be concluded that the lack of consultation with sex workers was
one of the main factors that made the initiative unsuccessful.
2 Lack of training for sex workers in the trades that they were encouraged to
take up as part of this economic empowerment programme.
3 Stigmatising attitudes of the programme’s organisers, especially in relation
to the objectives of the programme that called for sex workers to become
‘good role models’ in their communities (wording which implies that sex
workers are bad people).
4 Lack of sentisation training with the community, which would assist in
reducing sex workers being targets of stigma and discrimination.
30 GLOBAL NETWORK OF SEX WORK PROJECTS
PROGRAMMES THAT FAIL
National Female Sex Workers
Alliance of Malawi (NFSWAM)
This case study on economic empowerment for sex workers was conducted in
Lilongwe District, Malawi, as part of the regional efforts at developing advocacy
tools around rights-based economic empowerment for sex workers.
The National Female Sex Workers Alliance of Malawi (NFSWAM) was formed on
7 November 2012 with the aim of advocating sex workers’ rights, encouraging
health awareness through practices such as HIV testing and counselling among
sex workers, and protecting underage children from entering sex work. The
Alliance’s leadership comprises 10 sex workers from different parts of the
country. It has just applied for membership to the African Sex Workers Alliance
(ASWA) and the Global Network of Sex Work Projects (NSWP).
The Alliance implements different activities as follows:
1 Stakeholder meetings with the police to address human rights abuses
committed against sex workers.
2 Stakeholder meetings with health workers to promote accessible and
friendly services for female sex workers.
3 Condom distribution in hotspots and among female sex workers.
4 Peer education training for sex workers.
5 Peer discussion sessions on HIV prevention and STI management.
6 Working with chiefs and bar owners to protect underage children from
7 Dealing with violence that is perpetrated by clients of sex workers.
8 Economic empowerment programmes through village savings and loans.
9 Psychosocial support among sex workers.
ECONOMIC EMPOWERMENT PROGRAMMES FOR SEX WORKERS: AFRICA 31
However, the National Female Sex Workers Alliance of Malawi is currently
underdeveloped. It has no clearly defined membership and no office to
operate from. It also has a lack of systems and procedures and does not have
its own bank accounts. As a result, the Alliance does not decide on its own
programmes; instead, it waits for partner organisations to involve them in
undertaking their programmes.
Intervention on economic empowerment for sex workers
The Family Planning Association of Malawi (FPAM) embarked on the Economic
Empowerment Project for sex workers. The aim of the programme was to
rehabilitate sex workers through training 40 sex workers in tailoring, salon
management, mushroom production, and restaurant management, to give
them an alternative to sex work. 10 sex workers were trained in tailoring, 10 in
salon management, 10 in mushroom production and 10 in running a restaurant.
FPAM managed the whole programme without meaningful engagement with
the NFSWAM. After the training, a group of 10 was given MK45,000, equivalent
to $100 (USD), to start a group business.
Results and conclusion
All the groups started the group business programme but within 3 months
everything had collapsed. All the sex workers continued undertaking sex work
because no one actually benefited from the economic empowerment initiative.
The three main factors that contributed to this economic empowerment
initiative being unsuccessful was the failure of the FPAM management: they did
not meaningfully engage sex workers. Rather, they coerced them to take part
in the initiative and strongly focused on ‘rehabilitation’. During the planning
process FPAM did not listen to, or consult with, sex workers to establish
which training opportunities they were interested in. Another factor that
contributed to the initiative’s failure was the unsustainability of the economic
empowerment initiative. The grants given were insufficient to sustain small
businesses for long enough to turn over a profit, and this was combined with
the challenge of stigma and discrimination dynamics within communities.
Factors contributing to the initiative’s failure
1 Failure to meaningfully engage sex workers and NFSWAM in designing the
economic empowerment initiative.
2 The managers of the programme (FPAM) wanted to rehabilitate the sex
workers in order to stop them undertaking sex work . However, the sex
workers themselves did not share this view.
3 The sex workers were coerced into participating in the programme: it was
not what each of the sex workers wanted to do or what they had a passion
for. Sex workers often accept to be coerced into the programmes fearing
that, if they refuse, they may be left behind in future programmes that
might be beneficial to them.
4 The funds that the project provided (MK45,000) were not enough to start any
tangible type of business.
32 GLOBAL NETWORK OF SEX WORK PROJECTS
PROGRAMMES THAT FAIL
REPUBLIC OF CONGO
Management of Young for Rural
Development Centre (CEJEDER)
This case study on economic empowerment for sex workers was conducted
in Kivu Region-DRC. The case study documented an economic empowerment
project in DRC that aimed to rehabilitate sex workers and have them exit
Management of Young for Rural Development Centre (CEJEDER) is a non‑sex
worker-led organisation in Democratic Republic of Congo (DRC), in Uvira, South
Kivu. It is a non-governmental organisation with a Board of Trustees and it
runs health, protection, education, human rights, and agro‑breeding activities.
The vision of the organisation is to promote a society that respects and
promotes the right to health, human rights, and the right to self-determination
for women in general and for female sex workers in particular.
The organisation’s specific objectives are to ensure the rights of access to
equipment, goods, and services, without discrimination, in particular for sex
workers and key populations of vulnerable or marginalised groups; to fight
against HIV/AIDS and STIs as well as rape and sexual violence against women;
to support the creation and development of micro and small enterprise for
women with low income; to ensure access to minimum food sufficiency and
agro pastoral production to combat hunger and ensure food security for the
The organisation’s resources are funded by grants by external partners,
membership fees, and specific contributions of non-partisan individuals and
legal entities. It is affiliated to the Africa French-speaking network of sex
ECONOMIC EMPOWERMENT PROGRAMMES FOR SEX WORKERS: AFRICA 33
Economic empowerment intervention for sex workers
The programme’s idea was the sale of second-hand clothing, whereby the sales
generated would alleviate the poverty of 200 female sex workers in the town of
Bukavu, South Kivu. The programme was also funded by the Scottish Catholic
Aid Fund (SCIAF). The main goal of the SCIAF was to rehabilitate 200 female
sex workers in the community through the sale of the second-hand clothing.
The objectives were that 70% of female sex workers would be able to support
their families through the sale of second-hand clothing, and that 90% of female
sex workers would be reintegrated into the society. Another aim was that the
initiative would benefit 200 female sex workers directly and reach 350 female
sex workers indirectly. SCIAF, as the funder of this initiative, strictly imposed
conditions for the empowerment programme: the requirements ultimately
aimed for sex workers to exit sex work.
CEJEDER decided to implement this initiative despite the fact that the
conditions of the initiative contradicted with their own mission and beliefs.
Their partnership with SCIAF was due to funding pressure combined with
a lack of funding because, due to negative attitudes towards sex work
even among funding organisations, there were not – and are not – many
organisations willing to fund programmes that deal with sex workers.
The following activities were implemented as part of the initiative:
◗◗ Identifying female sex workers to take part in the programme.
◗◗ Identifying suitable locations where second-hand clothing could be sold.
◗◗ Organising the female sex workers into small groups to enable them
to support each other.
◗◗ Purchasing and distributing second-hand clothing to 200 female
◗◗ CEJEDAR staff and SCIAF staff conducted follow-up visits with sex workers.
Rather than being an opportunity to provide meaningful support to the sex
workers, these visits tended to evaluate the sex workers’ performance when
selling the second-hand clothes.
Results and conclusion
The work undertaken through this initiative did not achieve the expected
outcome. For instance, the majority of the female sex workers had no
savings and could not make profit because they were unable to determine
the right selling prices. This was not considered during the implementation
of the project.
Almost all the female sex workers ended up using some of the second-hand
clothes themselves instead of selling them. Due to this, they ended up having
very little income and, as a result, the economic status of the sex workers in the
initiative was very low. The sex workers used what little money they received
from sales of the second-hand clothing to satisfy basic family needs. Many of
the sex workers had no savings at all for the duration of the initiative as they
were not allowed to undertake sex work.
Less than 1% of the female sex workers involved in the project were able to
support their families. Almost all of the sex workers continued with sex work
during the programme and none stopped sex work as a result of this initiative.
This contrasts with the project’s aim: to rehabilitate the sex workers and have
them exit sex work entirely.
34 GLOBAL NETWORK OF SEX WORK PROJECTS
This initiative failed because it implemented a rehabilitation approach in which
the ultimate goal was for the sex workers to stop sex work and be reintegrated
into the community. Furthermore, during the duration of the initiative, sex
workers’ ability to undertake sex work was restricted. This led to a loss of
income to the extent that the sex workers did not see value in continuing with
The failure of programmes such as this demonstrates the need to involve sex
workers in the whole process, from problem identification, conception, and
implementation. Sex workers must also be involved in the monitoring of the
initiative in order for it to be successful. Above all, there is a need to take a
rights-based approach where economic empowerment initiatives support sex
work rather than substitute it.
Factors contributing to the initiative’s failure
1 The initiative was based on discrimination and stigmatisation of sex
2 It aimed to rehabilitate sex workers without considering whether sex
workers were able to sustain themselves while undergoing training and
3 The initiative was not needed by sex workers themselves, but was instead
imposed by the project’s staff.
4 No component in the programme focused on improving the selling skills
of the sex workers.
5 No pre-market study was conducted to identify the practicality of
ECONOMIC EMPOWERMENT PROGRAMMES FOR SEX WORKERS: AFRICA 35
This section looks at the lessons
that have been learnt by looking
at the factors that led to economic
empowerment programmes for sex
workers to succeed or fail. It is hoped
that these lessons will be fully utilised
in order to ensure that future economic
empowerment programmes for sex
workers have a positive impact on
A number of factors that positively
shape economic empowerment
programmes for sex workers have
been identified. Programmes that
are informed by a thorough needs
assessment for sex workers are
best‑placed to identify the appropriate
strategies for implementing economic
empowerment programmes. Indeed,
it is often the case that programmes
run by sex workers have higher success
rates than programmes that do not
meaningfully engage sex workers.
Programmes in which sex workers
report a strong sense of belonging and
ownership of their own destiny have
also been shown to be more successful.
The economic empowerment
programme that NIKAT runs is an
excellent example of how sex workerled
programmes achieve success.
ELEMENTS OF SUCCESSFUL
PROGRAMMES FOR SEX
IN CASE STUDIES
Specific training for
sex workers to build on
and improve their skills
for sex worker
Dissemination of IEC/
HIV/AIDS training and
workshops for sex workers
Access to improved
healthcare for sex workers
for sex workers
Conduct focus group
with project participants
(i.e. sex workers)
Conduct coffee mornings
at drop-in centres
Needs assessment with
sex workers conducted
36 GLOBAL NETWORK OF SEX WORK PROJECTS
One-to-one contact with peers, and employing sensitive and understanding
project staff, is also reported to have had a positive impact on sex workers
who participate in an initiative. Meaningful interaction with peers in similar
situations can also be beneficial: it reduces the sense of isolation that many sex
workers have. Moreover, sex workers are more likely to continue to participate
in a project if there is a sense of consistency and continuity.
Projects that adopt a rights-based approach to economic empowerment
programmes like the HOYMAS and NIKAT projects enhance and build sex
workers’ skills. This enables and empowers sex workers to make the right
choices for themselves. Alongside implementing a more integrated approach
that addresses sex workers’ sexual and reproductive health needs, these
elements clearly contribute to a project’s success.
Improved healthcare access as part of economic empowerment programmes
has many obvious benefits. Benefits are also derived from improved HIV
prevention, treatment, care, and support services for sex workers. Sex workers
who are better informed are more empowered to effectively negotiate condom
use with clients.
The opportunity for further education also contributes to the likelihood of
projects being successful, especially when these opportunities are sufficiently
funded. Funding for education eases the overall financial burden that studying
can place on sex workers because they have less free time to earn an income.
Further education opportunities can also provide specific training for sex
workers to strengthen their existing skills.
Unsuccessful economic empowerment programmes
Economic empowerment programmes that are aimed at sex workers but that
do not meaningfully engage sex workers in establishing the programme’s goals
and objectives often fail. The case studies in this briefing paper highlight 4
examples of unsuccessful economic empowerment programmes: the impact of
these programmes failing can be very negative and does not help to improve
the social and economic empowerment of sex workers. One of the main
failures of the economic programmes highlighted in this paper is that these
programmes did not have built-in mechanisms to sustain alternative incomegenerating
activities for sex workers. For example, not enough seed money
was available for sex workers to set up the small businesses that they trained
to start. There is also very little training that can be provided indefinitely as
costs become prohibitive. Another factor is that in communities into which
sex workers are ‘re-integrated’, sex workers are often discriminated against
because of societal stigma: in one case study, participants ended up being
more marginalised in their communities because the programme did not
properly take into account how stigma and discrimination would affect other
income-generating activities that sex workers undertook. The case study of the
Empowerment at Dusk Women’s Association highlights that stigma against sex
workers in the communities in which they work negatively impacts upon the
chances of the programme being successful.
ECONOMIC EMPOWERMENT PROGRAMMES FOR SEX WORKERS: AFRICA 37
Other negative factors that impact sex workers include:
1 Initiatives based on discrimination and stigmatisation of sex workers and
aimed at rehabilitating sex workers to stop sex work.
2 Initiatives that are not based on the needs of sex workers but are imposed
3 Initiatives that do not have a capacity-building component to enhance the
skills of sex workers.
4 Failure to conduct market research to identify suitable business areas where
there is a demand for a particular good or service to be provided.
5 Sex workers are not appropriately engaged in programmes: their
participation is a requirement and is often regarded as something they must
do ‘for their own good’. This is stigmatising and undermines the agency and
autonomy of sex workers.
6 Lack of experience of management to implement successful programmes
based on the needs identified through meaningful engagement with sex
7 Poorly funded programmes that are not able to sustain activities for longer
than the initial pilot period.
8 Programmes can be compulsory and often do not take into account the jobs
or skills that the sex workers themselves are interested in undertaking.
9 Rather than ensuring that the intervention and training provided is of
sufficient quality, programmes are often more interested in the number of
sex workers reached and ‘rehabilitated’ .
10 Lack of good monitoring and evaluating frameworks to enable learning and
improvement for future programmes.
11 Lack of consultation and inclusion of sex workers in design and
implementation of programmes.
38 GLOBAL NETWORK OF SEX WORK PROJECTS
There is, in general, a lack of economic empowerment programmes for sex
workers in Africa. This situation contrasts significantly when compared to
other regions. For example, the first part of this SUSO project documented
case studies of economic empowerment programmes in the Asia Pacific
region. The output from this part of the SUSO project is documented in
the Regional Report18 ‘Sex Workers Demonstrate Economic and Social
Empowerment’ and the Regional Briefing Paper19 titled: ‘Sex Workers
Demonstrate Economic and Social Empowerment: Overcoming Practices
That Limit sex Worker Agency in the Asia Pacific Region’.
The Africa Regional Report and Briefing Paper draws similar conclusions
with regards to the role of sex workers in the planning and design stages
of these programmes. Sex workers should be at the front of the process: to
inform programme staff of their expectations of economic empowerment
programmes and of their past experiences with other programmes. This
learning can be a way of limiting harmful outcomes that impact upon
sex workers, such as increased levels of stigma, and the various forms of
abuse and harassment from the communities in which they live and work.
The failed Family Health International project in conjunction of EADWA
in Uganda is a case in point. Without targeted programmes that improve
sex workers’ access to quality economic empowerment programmes, sex
workers will continue to face marginalisation.
If run correctly using the principles from the lessons learnt in this
report, these types of programmes are excellent vehicles for sex worker
empowerment. For economic empowerment programmes for sex workers
to succeed, the needs and the programmes should be determined by sex
workers themselves, and each programme’s activities must be based on
the needs and demands of the sex workers. Sex workers should also be
part of planning and implementing the projects. Stakeholders should
strengthen the capacity of the sex worker-led organisations for them to
be effective and efficient, but sex workers themselves should run the
ECONOMIC EMPOWERMENT PROGRAMMES FOR SEX WORKERS: AFRICA 39
Many sex workers enter sex work because of poverty. Economic
empowerment programmes for sex workers need to be enhanced if the
initiatives are to succeed: there is a need to involve sex workers themselves
in identifying economic empowerment programmes. For economic
empowerment programmes for sex workers to be successful, business ideas
must be driven by the sex workers to ensure that they are able to choose the
initiatives they have a passion for.
In almost all the communities in Africa, sex work is heavily stigmatised and
people have negative perceptions about sex work. It is therefore reasonable
to expect that economic empowerment programmes which do not consider
the dynamics of stigma and discrimination within communities are
destined to fail. Worse still, the programmes fail sex workers by increasing
their vulnerability in their own communities.
Economic empowerment initiatives for sex workers must adopt a rightsbased
approach that focuses on giving sex workers the economic power
to make informed choices about their lives, including their sexual health.
These initiatives should not necessarily focus on making sex workers exit
sex work. Economic empowerment programmes for sex workers should aim
to provide an alternative source of income to reduce their vulnerability, but
the programmes should not aim to entice sex workers to stop sex work when
they are not ready to do so.
40 GLOBAL NETWORK OF SEX WORK PROJECTS
1 Build and strengthen the capacity of sex worker-led organisations to
faciliate economic empowerment programmes for sex workers. Funding
for these organisations should be sustained for a sensible period of time to
maximise the benefits for participants of projects and the capacity of sex
worker-led organisations in general.
2 Organisations that work with sex workers should adopt rights-based
approaches to sex worker programming which centre upon the needs of
sex workers (as articulated by sex workers themselves).
3 Appropriate strategies for meaningful engagement of sex workers
should be identified at the earliest opportunity. Such strategies will help
programme planners establish the needs of sex workers in terms of their
objectives for participating, and to manage their expectations once they
are involved in the programme. Meaningful engagement can contribute to
effective capacity-building with sex workers and contribute to the overall
success rate of these programmes.
4 Programmes should include continued training support for participants for
as long as possible, coinciding with regular follow-up visits to participants.
These visits should take the format of a friendly neighbourhood visit where
support is provided and sex workers’ progress is recorded. Programmes
can also facilitate post-training group support networks enabling
participants to share their experiences with others participating in the
5 On a national level, communication and collaboration with financial
institutions should be explored in order to promote the development of
initiatives to improve financial literacy of participants. While this approach
contributes to the economic empowerment of sex workers, it also helps to
increase sex workers’ access to financial services. Furthermore, financial
institutions should ensure that they do not discriminate against sex
workers who want to access financial services.
ECONOMIC EMPOWERMENT PROGRAMMES FOR SEX WORKERS: AFRICA 41
6 Economic empowerment programmes should build in sensitisation
training elements into their programmes in order to facilitate the wider
community’s acceptance of sex workers – both as current and former sex
7 Programmes should have an appropriate monitoring and evaluation
(M&E) framework to measure the impact of the economic empowerment
intervention. A well-designed M&E framework will help organisations
to learn from the design and implementation phases of programmes, to
improve and build upon successful strategies, and to avoid less successful
approaches in the future.
8 Agencies or organisations that fund economic empowerment programmes
should support sex worker-led organisations and work with them to
establish vocational skills centres. To ensure a holistic approach to
addressing the needs of sex workers, vocational skills programmes should
also be integrated into reproductive health education and services as part
of economic empowerment programmes.
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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