HIV prevention, testing and treatment – opportunities and barriers for sex workers

1. HIV prevention, testing and treatment – opportunities and barriers for sex workers

2. Introduction • Access to HIV services as key component of HIV response among sex workers • Vital elements of HIV prevention and care continuum (HIV prevention, testing and treatment) • Challenges to sex workers’ access to HIV related services in Europe

3. Components of effective HIV response

4. Addressing sex workers’ vulnerability to HIV through HIV-related services • Improved service coverage for sex workers could avert a substantial proportions of HIV infections both among sex workers and in the general population! • Health services should be made available to sex workers based on the principles of avoidance of stigma, non-discrimination and the right to health! (Lancet, 2014; WHO, 2012, 2014)

5. HIV related services • HIV prevention • HIV counselling and testing • HIV treatment and care HIV prevention and care continuum

6. HIV prevention • HIV prevention refers to various practices done to prevent the spread of HIV/AIDS. • HIV prevention is of key importance because it increases one’s knowledge about HIV vulnerabilities, enables individual to protect oneself from HIV infection and creates demand for HIV testing, treatment and care.

7. HIV prevention for sex workers • Promotion of male and female condoms and water-based lubricants • Targeted information, education and communication on HIV and STIs • Screening, diagnosis and treatment of STIs • Post-exposure prophylaxis * • Harm reduction strategies for sex workers who use drugs: • needle and syringe programmes • opioid substitution therapy • evidence based substance use counselling (WHO, 2013, 2014)

8. HIV prevention - challenges • Criminalisation and stigmatisation of sex work • Limited availability of HIV prevention programmes for SWs • Discriminatory framework of service provision • Non-inclusive HIV prevention programming • ‘Criminalisation of condoms’ • Lack of access to OST

9. Limited availability of HIV prevention programming for SWs Most of the European countries report a policy or national strategy that promotes HIV prevention interventions for key populations at higher risk, including sex workers, but… • As reported by sex worker-led organisations, coverage of HIV prevention programmes targeting sex workers is very low. • There is very little funding for comprehensive HIV prevention interventions. • In most of the European countries HIV prevention services are provided on a local scale (in capital, big cities) and target only female sex workers working outdoors. e.g. In Russia only as much as 2-3% of sex workers were reached by any kind of HIV prevention and education in 2012. In 2012, only 13% of sex workers in Greece have had any access to HIV prevention.

10. Discriminatory framework of service provision • Lack of sex workers’ involvement in development of HIV programming • Biased and judgemental attitudes among service providers • Conditional access to HIV prevention e.g. In Sweden outreach workers refuse to provide sex workers with safer sex supplies, education on occupational health and safety, and training in negotiation of condom use with clients, since these are considered to facilitate, promote and legitimise involvement in sex work. Some HIV service providers encourage sex workers to exit sex work or only offer help to those SWs who directly declare willingness to cease selling sex.

11. Non-inclusive HIV prevention programming Limited number of services dedicated to: • indoor sex workers • male and transgender sex workers • sex workers who use drugs • migrant sex workers Narrowly defined and non-comprehensive services: Guided by such goals as ‘increase in coverage’ or ‘condom distribution’, many HIV prevention programmes fail to provide SWs with interventions meeting their most pressing needs, including the structural ones.

12. Counter-effective measures ‘Criminalisation of condoms’ • In some countries of the region condoms are being used as evidence against sex workers – police confiscate condoms and cite possession of condoms as justification to detain or arrest sex workers: Macedonia, France, Russia • In several countries in Europe police harass outreach workers distributing condoms to sex workers: Tajikistan, Russia Lack of access to Opioid Substitution Therapy • Currently OST is being legally prohibited in Russia, Turkmenistan and Uzbekistan

13. HIV testing The only way to know if a person is infected with HIV is for them to take an HIV test. HIV testing is critical, because it is the main route to enter into HIV care. HIV tests are used to detect the presence of the HIV in serum (blood), saliva, or urine. Such tests may detect: • Antibodies produced by the body to fight HIV (ELISA, Western blot, rapid tests) • Antigens or genetic material related to the virus (Antigen tests, Nucleic acid test/viral load test) • Rapid/express tests: finger-prick or mouth swab tests

14. HIV testing Testing services should be voluntary and follow 5 rules (5 Cs): • informed consent • confidentiality (most, preferably, anonymity) • counselling (pre- and post-testing) • correct tests results • connection to care, treatment and prevention services Members of key populations should be offered voluntary HIV testing every 6-12 months. (WHO 2012, 2014)

15. HIV testing HCT services for sex workers should be provided in variety of settings: • Health facilities, e.g.: • STI clinics • Hepatitis and TB clinics • Antenatal clinics • (Community) testing sites/outreach Controversy: in some European countries rapid home-use HIV kits enabling self-testing are also being made available: Northern Ireland, Russia, United Kingdom and France

16. HIV testing - challenges • Limited number of (community) testing sites/outreach targeting sex workers • Stigma and discrimination in testing facilities • Lack of confidentiality/ anonymity in HCT services • Mandatory HIV testing • Repressive HIV-related laws and regulations

17. Lack of confidentiality/anonymity in HCT services It has been reported that: • In several European countries of the region, admission to free HCT is conditional on the presentation of valid identification documents: Georgia, Romania, Turkey • Even if HIV testing is delivered anonymously once a person is diagnosed with HIV, their identity is revealed to public health institutions: Sweden • HIV test results are being shared with third parties, including the police, authorities, family members, sex workers’ clients, other members of the sex worker community: Kyrgyzstan, Russia, Ukraine

18. Mandatory HIV testing Condition of engagement in sex work In several European countries which implemented a regulatory approach to sex work, such as Austria, Greece, Hungary, Latvia and Turkey, periodic compulsory screenings for HIV and other STIs are attached to the procedure of sex worker registration. e.g. Latvia: STI and HIV screening every month/three months Austria (Vienna): weekly tests for STIs, once in 3 months for HIV Hungary: compulsory HIV and STI examination every three months

19. Mandatory HIV testing Initiated by the law-enforcement agencies In some European countries where sex work is penalised, sex workers are being forced to undergo testing for HIV and other STIs during police raids or following detention. Such practices have been documented in Kyrgyzstan, Macedonia, Romania, Russia, Tajikistan, Ukraine. e.g. Kyrgyzstan: over 30% of sex workers have been subjected to screenings for HIV and STIs in the course of arrests following police sweeps Macedonia: in 2008, 30 Macedonian sex workers were forced to undergo medical examinations for HIV and hepatitis B and C after the arrest Tajikistan: in 2014, circa 500 sex workers were tested for HIV during police raids and imprisonment

20. Repressive HIV-related laws and regulations Criminalisation of: • HIV transmission sexual act that results in HIV transmission • HIV exposure sexual act that puts sex partner at risk of HIV infection • HIV non-disclosure non-disclosure of one’s HIV status followed by a sexual act that results in HIV transmission or puts the sex partner at risk of HIV transmission or non-disclosure of one’s HIV status to the sexual partner (whether or not risk appears) In countries without HIV specific legislation, prosecutions possible under different laws criminalising: e.g. transmission of contagious diseases, STI, causing injury to health, grievous bodily harm, poisoning, manslaughter.

21. Repressive HIV-related laws and regulations HIV-related laws are also being used against migrant sex workers: • In such countries as Moldova, Russia, Kazakhstan and Turkmenistan sex workers diagnosed with HIV are being arrested and deported to their home countries. • [Some European countries have also implemented restrictions on residence and entry for people living with HIV: Cyprus, Russia and Uzbekistan.]

22. HIV treatment HIV treatment (ART) involves using antiretroviral drugs (ARVs) which reduce the reproductivity of HIV in body and allow to rebuild one’s immune system. • CD4 cells - white blood/immune cells destroyed by HIV • CD4 count – number of CD4 cells in one’s blood; the smaller the number, the weaker the immune system is (average = 500-1200 cells/mm3) • Viral load - the level of HIV in one’s blood; the higher viral load, the weaker the immune system is (undetectable = 50 copies of the HIV virus per ml of blood; high = 50,000 copies per ml). ART helps to supresses the viral load.

23. HIV treatment WHO guidance on when people should start HIV treatment (2013):

24. HIV treatment HIV treatment also includes the treatment of opportunistic infections and cancers that affect people living with HIV, e.g.: • Tuberculosis (TB) • Hepatitis B & C • STIs and cervical cancer • Cryptococcal infection Comprehensive HIV treatment and care also requires addressing nutrition and mental health needs of people living with HIV.

25. HIV treatment Universal access to HIV treatment is recognised as an indispensable element in achieving the full realisation of the right of everyone to the enjoyment of the highest attainable standards of health. It has been recognised as one of the United Nations’ Millennium Development Goal 6b: (by 2010) achieve universal access to treatment for HIV/AIDS for all those who need it. Key populations living with HIV should have the same access to antiretroviral therapy as other populations! All pregnant sex workers should have the same access for prevention of mother-to-child transmission of HIV and follow the same recommendations as other women! (WHO, 2014)

26. HIV treatment - challenges • Punitive legal frameworksgoverning sex work • Repressive laws affecting sub-populations of sex worker community • Unsupportive social environment: social and economic marginalisation, discrimination, stigma, violence • Criminalisation of HIV transmission and exposure • Detrimental and judgmental treatment in health care settings • Discrimination in access to health care settings • Institutional exclusion from health care services • Limited access to ARV medicines

27. Prejudice-based exclusion for health care settings It is reported that in numerous medical facilities providing HIV treatment and care, negative and disapproving approaches toward sex workers are expressed in judgmental and paternalistic attitudes, open hostility and reluctance, or even refusal to prescribe antiretroviral and other treatments despite no contraindications.

28. Structural exclusion for health care settings In many European countries, access to public health services, including ART and care, is linked to individual’s legal, insurance and residence status. Many sex workers who are not able to meet these requirements are effectively excluded from public health system: • Sex workers without identity documents • Sex workers without health/ medical insurance (bond to employment status) • International migrant sex workers (without official residence or work permit, non-EU citizens) • Internal migrants sex workers

29. Availability and accessibility of medicines Limited access to effective ARV treatments: • poor medicine registration, supply and distribution system • shortage of supplies • low investments in the health care sector • high costs of safe and effective medicines Stock-outs of ART: Reported in Albania, Belarus, Georgia, Macedonia, Russia, and Ukraine Serious concern in Armenia, Bulgaria, Estonia, Romania, and Tajikistan (ECDC, 2013)

30. Retention in care - challenges Adherence – taking HIV medicines every day according to prescription. • Prevents virus from multiplying • Improves health outcomes • Reduces the risk of drug resistance Main causes of treatment interruptions among sex workers: • police raids, arrests, detention, imprisonment • violence by state and non-state actors • stigma related to HIV-status • discrimination in health care settings • high mobility • stock-outs of medications

31. ARV related prevention (Early) treatment as prevention HIV prevention methods that use antiretroviral treatment to decrease the chance of HIV transmission Post-exposure prophylaxis PEP is an intervention that uses ARVs to reduce the likelihood of HIV infection after possible exposure (recommended to sex workers! [WHO, 2012]) Pre-exposure prophylaxis PrEP is a method of HIV prevention, which involves people who are HIV-negative taking ARVs (Truvada) on daily basis to reduce their risk of becoming infected