A prestigious group of HIV researchers made a loud and scientifically supported plea for the decriminalization of sex work at the 20th Annual International AIDS Conference yesterday, during a presentation of a series of seven studies published in The Lancet. The series centers around the importance of filling the gaps in sex work-focused HIV research, and providing sex workers with tools to prevent HIV infection. These steps could not only help reduce HIV infections among sex workers by up to 46 percent in countries like India and Kenya, the researchers say, but they could also help control the HIV pandemic as whole. But to do so, the editors of The Lancet say, governments must decriminalize sex work — there is "no alternative."
Stigma and criminalization
Currently, 116 countries around the world have laws against prostitution, reports Reuters. "These additional layers of stigma and criminalization that make it such that governments don’t want to engage, and that’s a loss to all of us," says Stefan Baral, a physician epidemiologist at Johns Hopkins University. The researcher was among those who presented their work last night, and called for increased support for sex workers. More specifically, however, his study discusses the lack of research on male sex workers and HIV.
"we know very little about male sex workers."
"When you think of a sex worker, the most common picture that comes to mind is a female sex worker," says Baral. This is problematic because "we end up in a dynamic where we know very little about male sex workers." His study shows that part of the problem surrounding past interventions is that researchers have often tried to target male sex workers by targeting the larger population of men who have sex with men. But male sex workers often don’t identify as either sex workers or gay men, Baral says — largely because of the combined stigma of these labels — so a lot of the interventions that target both groups never reach them.
"Often what’s happened is that people want to oversimplify and generalize the epidemic," Baral says, but the reality is that different subpopulations require different forms of interventions. "We need to accept that."
One possible solution to the problem is to concentrate intervention efforts around the venues that male sex workers frequent, such as parks, clubs, and bars, Baral says. This could go a long way toward improving outreach, and lowering HIV-transmission rates. "The reality is that if you’ve provided someone with adequate amounts of education and services and they still [engage in risky behaviors], then that’s an issue that we need to explore," he says. "But right now, these men are so underserved that any sort of blame laid upon them isn’t an evidence-based approach."
Linda-Gail Bekker, an infectious disease researcher at the The Desmond Tutu HIV Center in South Africa, also emphasizes the need for decriminalization. "We want people to be able to access services, to openly discuss their behaviors, to carry the tools and treatment they need to protect themselves, and to do so in a safe and dignified environment," she says.
Truvada can be taken without a partner's participation
In addition to discussing barriers to interventions, her study makes use of mathematical models to demonstrates which interventions are likely to lower HIV infection rates in female sex workers. Among her team’s conclusions is the idea of combining methods like pre-exposure prophylaxis — also known as the anti-HIV pill Truvada — with early HIV treatment. Such a tactic "could reduce HIV infection rates among sex workers by up to 40 percent." This finding, she explains, might be linked to the fact that Truvada is taken orally, which means it can be used without a partner’s knowledge. "Female condoms are, to a certain extent, user controlled, but you still need your partner’s agreement. And male condoms rely heavily on male involvement," she says. Truvada, on the other hand, "can be taken covertly" if need be.
Bekker isn’t suggesting that Truvada be taken as a standalone tool to prevent HIV infection, however — condoms and lubricants are still recommended. But she does think the pill represents a valuable preventative option for women who find themselves in abusive relationships, or in situations in which they have little control. Achieving this sort of female empowerment, however, "cannot be done in an environment where sex work is criminalized," she says.
Improving trans visibility
Other researchers focused on less well-studied subgroups of sex workers. In one study, scientists explain why a greater number of HIV interventions should target transgender sex workers. "In the past, researchers have included trans sex workers in studies of men who have sex with men, or studies of female sex workers — they were invisible," said Tonia Poteat, an epidemiologist also at Johns Hopkins University and a co-author of the study, in an email to The Verge. So "despite the extraordinary burden of HIV among transgender women sex workers," there’s very little data on effective HIV prevention, care, or treatment interventions that relate specifically to sex workers who identify as transgender.
Transgender sex workers experience different risk factors
Poteat’s study also highlights the particular risk factors that transgender sex workers face. These include low self-esteem, substance use, discrimination, and suicidality that stems from societal stigma. Trans sex workers also experience significant biological risks, she said, including illicit hormone and silicone injections with potentially contaminated needles. Moreover, they have a greater likelihood than other sex workers of being a receptive partner during anal sex — a sexual practice that’s more likely to result in transmission than other forms of intercourse. And because so little research has been done on this population, the HIV susceptibility of the neovagina — a vagina created surgically — among trans women who have undergone genital reconstruction remains unknown.
"We must stop conflating men who have sex with men and transgender women," Poteat said — in addition to addressing transphobia. Fortunately, scientists have a number of opportunities to turn this trend around, she wrote. "As we gather more data about effective interventions for prevention of sexual transmission, we have wide-open opportunities to ensure that trans sex workers are included in this research in meaningful ways." The best way to do so, she explained, is to ensure that data collection includes questions about sex and gender that will, in turn, allow for trans visibility.
Through the pain of MH17, a rallying call
Given the breadth of the research presented in this series, and its prominence at the AIDS 2014 Conference, the entire publication comes across as triumphant. And it might be just that, as this body of work could give researchers the ammunition they need to demand tailored interventions for sex workers, as well as safer spaces. "This is one of these times when human rights and science go totally hand in hand," Baral says.
But the specter of the recent MH17 plane crash, which claimed the lives of six conference attendees, is hard to ignore — especially since at least two of the deceased were strong advocates for increased support for sex workers. Notably, Martine de Schutter was appointed program manager for Bridging the Gaps — an international HIV program that advocates for the decriminalization of sex work, homosexuality, and drug use — in January. And famous HIV researcher Joep Lange, whom Bekker calls a "personal friend," actually spoke out against the barriers that sex work criminalization creates in an article published on July 18th, the day after his death.
Lange spoke out against criminalization in an article published after his death
"In some of their countries and some of these settings, it’s just one person driving an agenda around gay men or sex workers, just one really brave human being," he says. So, "losing them is like losing 10 years of work." HIV researchers and activists are often the only people in a region who listen to, and give voice to, people whose lives are rarely considered in the first place. That’s why the sense of loss among attendees at the AIDS 2014 Conference is indescribable. Still, the researchers who spoke to The Verge say that the crash only serves to strengthen their commitment to the cause.
"accustomed to collaborators and friends dying..."
"Unfortunately, some of us have become accustomed to collaborators and friends dying from HIV, or even from violence," says Stefan Baral, a physician epidemiologist at John Hopkins University. As a result, the predominant attitude of the HIV research community is "very much that we need to keep looking forward," he says, and keep focusing on ending HIV. Yet "this doesn’t stop the pain of these murders, especially for their family and loved ones."
Bekker noticed a similar resolve among her colleagues this weekend. "[The crash] has been a huge, huge event here, which has led to a very somber overtone to the conference," she says. But "I’m also very aware of a strong sense of determination" among the various attendees. Bekker was friends with both Lange and Jacqueline Van Tongeren, the communications director of the Amsterdam Institute for Global Health who died in the crash on Thursday, so the last few days haven’t been easy. Still, she says, "we need to honor their legacy, to get on with the job and get the science done."
And that’s exactly what these researchers are doing, starting with disseminating the message that decriminalizing sex work is an essential step in the fight against HIV.