Beyond Health Promotion: Making Sex Work Safe

1. Beyond Health Promotion: Making Sex Work Safe Lecture by Chris Castle at Tulane University, Horizons/International HIV/AIDS Alliance 29 October 2001

2. Lecture Objectives • Consider design issues related to HIV/AIDS programs with sex workers • Explore policy and advocacy issues for programs with sex workers • Review actual examples of successful sex work programs

3. Overview • Rationale and motivation for sex work programs • Understanding commercial sex • Conceptual frameworks • Examples of successful programs • Policy and advocacy issues • Conclusions

4. Why do we have programs aimed at sex workers? • Public health rationale for addressing sexually transmitted infections (STIs) including HIV • Moral discourse and sex workers as a ‘threat’ to society • Feminist perspective and women’s rights • Concern about the health of clients of sex workers • Concern for the health and rights of sex workers Or a combination of some or all of the above…?

5. Understanding Sex Work The sex industry, formal and informal Who are clients? Who are sex workers? • Women, men, transgender • Young, old, married, single, poor, rich etc Partners of sex workers Commercial sex business owners, managers, others Legal status: prohibition, toleration, regulation

6. The Health Promotion Model Based on the idea that the most effective way to limit HIV transmission is to identify groups who are most likely to contract and transmit the virus to the greatest number of others and target these “core transmitters” with: • Sexual health information and counseling • STI prevention and treatment • Condom promotion Confronting AIDS: Public priorities in a global epidemic, The World Bank,1997

7. HP – Information and Counseling • Often through peer education • Emphasis on individual knowledge and behavior change • Much more than just the absence of STIs/HIV: • Different types of sex, how to negotiate with clients, how to obtain condoms and lube • Abortion, contraception, hepatitis, drug use, other transmissible diseases, and male, transgender and maternal health issues • Legal and civil rights issues, self-defense, occupational safety issues

8. HP – STI Prevention and Treatment • May be supported through registration systems or policies, e.g. Senegal • Health seeking behavior may be encouraged voluntarily or through coercive measures • Positive presumptive treatment (PPT) • May include partner notification and treatment • Can involve client education and outreach

9. HP – Condom Promotion Could be linked to social marketing and/or free distribution In the picture, a madam distributes condoms to one of her workers with a client at the brothel before sex

10. Drawbacks to the HP model? • Tends to be heavily reliant on external technical and financial expertise, with concerns about longer term sustainability • Overly focused on sexual health issues in relative isolation from broader social, legal and economic factors, e.g.: • Access to risk reduction supplies (condoms + lubricant, water, light, security) • Power relationships with clients, police and others • Social discrimination and civil/human rights

11. HP and the ‘Bigger Picture’ “health is indivisible…the domain of personal health over which the individual has direct control is very small when compared to the influence of culture, economy and environment.” Hafton Mahler, former Director General of WHO, 1995 The notion of involving communities in HP, including the need to address social inequality and broad development-related issues at the levels of the individual, community and society was already well established by the start of the AIDS epidemic

12. HP in Practice • Health Promotion has rarely lived up to the ideal • Difficult to obtain the necessary financial and political commitment needed to fully realize the radical and long term perspective and principles such as community involvement or participation • HP difficult to operationalize, and new versions of vertical programs termed ‘selective’ PHC have been developed that are top-down and disease-oriented yet still seek to enlist community support

13. The Community Development Approach Emerges from field experiences and sex workers’ own discussions and evolves around the concepts of rights and vulnerability

14. The Community Development Approach • Argues that sex workers must be supported to increase their capacity to protect their sexual health and empowered to to address broader structural, environmental and psychological factors • The appropriate role for NGOs and other external agents is to support sex workers themselves to develop and implement collective processes for improving all of their personal and occupational circumstances

15. The Community Development Approach May be challenging because it requires support for a process rather than a predetermined set of activities

16. Categories of CD Activities • Facilitating solidarity/strengthening community bonds, e.g. hosting a social or cultural event etc • Capacity building, e.g. training, securing premises etc • Operational, e.g. production of materials, costs related to collective advocacy etc

17. CD – Facilitating Solidarity The caption reads ‘Voice of Life’ about a choir of sex workers in Rio de Janeiro

18. CD – Capacity Building Sex workers often express a need or desire for training outside the area of sexual and reproductive health. Examples include: • Literacy training • How to open a bank account and to save/manage money, including planning for retirement • Computer training • Project design, fundraising, and management

19. CD - Operational May include activities such as: • Police liaison and advocacy • Arbitration with neighborhood groups, hotel operators, other municipal authorities • Public and client education about sex work and sexual health

20. Challenges to CD approach • May take longer than a more straightforward and narrowly focused health promotion model • Breaking the habit of top-down management and the development of leadership can be difficult • Demonstrating the tangible link between CD activities and improvements in health outcomes is not easy to do in a convincing way • Measuring and evaluating the benefits of the CD approach is particularly challenging

21. Challenges to Reaching Sex Workers • Sex workers may not be readily visible or accessible due to the illegality of sex work, high mobility, and/or the stigma that surrounds it • Involving sex workers may be difficult because of distrust of the public health system, or because of a lack of time or skills to participate in activities

22. Sonagachi • Started in 1992 in Calcutta, the essential feature of this well-known project is that sex workers themselves, including their family and friends, have taken the lead and carry out the work of the intervention • The original aim was to reduce levels of STDs, increase condom use, and to develop an effective strategy that could be replicated elsewhere. In terms of sexual health and HIV, it has been successful with diminished syphilis infections and clinically detected genital ulcers. HIV rates among the sex workers remains relatively low at 6% as of 1998

23. Sonagachi • Sex workers formed their own organization in 1995 that has become the major force of the program. • Components include: • Behavioral - including peer education • Clinical - treating STIs for sex workers and their families and clients • Financial - credit cooperative, condom sales etc • Political - protests against counterproductive policies • Legal – training for over 300 sex workers

24. Sonagachi • The project is widely credited for addressing both the short term needs to control the HIV epidemic, as well as the longer term requirements to reduce vulnerability of women in the sex industry • A key lesson observed from others attempting to replicate the Sonagachi success is that the effort should not be to copy the model or the specific ‘outcomes’ as determined by the women of Sonagachi, but to replicate the process of supporting the sex workers to determine their own needs and priorities

25. Programa Integrado de Marginalidade • PIM is an NGO working with sex workers in Rio de Janeiro state for over a decade • Health promotion including paid ‘health agents’ and training in self-help and empowerment • Challenge of maintaining momentum with sexual health focus and workshops on STI prevention and treatment • Collaboration with Horizons to study the effect of adding CD approaches prospectively

26. PIM • Research data providing impetus to identify and address issues such as violence, lack of access to hygiene, need for solidarity and communal action • Formation of the ‘Fio da Alma’ choir • Establishment of a drop in space for meetings, training, advocacy base etc • Anti-violence kits • ‘Ugly mugs’ and police liaison • Advocacy for better lighting and security

27. 100% Condom Programs • Pioneered in the early 1990s in Thailand and later replicated elsewhere • Recognized that sex workers refusing clients who did not wish to have sex with a condom might lose the client to another sex worker who would • Involves government policy mandating condom use in commercial sex, otherwise risk sanctions against brothel owners • Evaluations have suggested that the policy contributed to large scale reductions in HIV transmission

28. 100% Condom Programs • Concerns have emerged about effect of the policy on non-brothel based commercial sex, or ‘indirect’ sex work • Newer programs are attempting to combine policies and risks of sanctions, with solidarity-building measures and empowerment efforts among sex workers • Experience appears to confirm the importance of CD approaches and the inclusion of broader structural and environmental factors

29. Income Generation and ‘Rehabilitation’ • Many examples exist of projects that have attempted to help sex workers leave the industry, however few if any proven to be successful • Training for sex workers to obtain new skills can be a welcome part of programs: • Helps them to top up income • May broaden their options for retirement • Can be an option for sex workers who become ill and choose to no longer sell sex • New skills can support sex worker CD efforts

30. Conclusions • Interventions for sex workers should be established in a way that empowers and supports sex workers themselves to design, implement and evaluate the programs • The most innovative and successful programs appear to be those that seek to address the broader range of needs and priorities of sex workers, going beyond just sexual and reproductive health • Target commercial sex, not just sex workers, so include clients, influencers, private partners, etc

31. Conclusions • Community development approaches may take more time and resources, but should pay off in terms of better sustainability and more effective programs • Be critical when assessing programs that claim to include community involvement since this has become a popular buzz word in development, and it is not always achieved in practice • Support the process of community involvement and have faith that this will pay off in the longer term