Biomedical prevention of HIV and sex workers

HIV Australia | Vol. 13 No. 2 | July 2015

Cameron Cox

Cameron Cox, Joel Falcon and Gemma Keegan outline sex workers’ concerns about the potential for coercive approaches to biomedical prevention.

Scarlet Alliance, the Australian Sex Workers Association, is the peak national sex worker organisation in Australia. Formed in 1989, the organisation represents a membership of individual sex workers and sex worker organisations.

While the legal and political context of sex work differs from state to state, and between nations, sex workers as a community share concern for the direction of biomedical prevention, and the need to guarantee the future of existing prevention strategies that have proven effective for sex worker communities.

Sex worker communities haven’t been central to the conversation on the appropriateness of biomedical prevention for our community.

Sex workers continue to support increased access to HIV treatment and prevention options, including biomedical interventions, but with the understanding that these may not be suitable for use by all sex workers – especially given the success of proven prevention strategies already employed by sex workers, including community engagement, peer-led outreach, and policy advocacy addressing stigma, discrimination and enabling legal environments.

That’s not to say that biomedical interventions are of no benefit to sex workers. There may be benefits for individual sex workers living with HIV, for example, but a ‘one-size-fits- all’ approach is extremely problematic.

Sex workers in Australia have a long and complicated history of criminalisation, stigma, and discrimination by governments and communities, and have been subject to various policies under misguided public health responses that breach sex workers’ human rights and undermine sex workers’ agency.

Decriminalisation of sex work, our workplaces and our clients remains the number one priority for sex worker communities and organisations, and an integral part of maintaining the low prevalence of sexually transmissible infections (STIs) and HIV among sex workers in Australia.¹

Pre-Exposure Prophylaxis

Scarlet Alliance’s position on pre-exposure prophylaxis (PrEP) comes out of broad national and global community consultation – in particular, the Global Network of Sex Work Projects (NSWP) consultation on PrEP and early treatment: 440 participants from 40 countries participated in this consultation through 20 focus group discussions, 146 key informant interviews, and 33 online surveys, with the Australian component of the consultation conducted by Scarlet Alliance. All this work informs our stance on PrEP.²

Sex worker community-led approaches to prevention – including community engagement, peer education and outreach – have demonstrated their effectiveness over the last 30 years.

We recognise the potential positive impacts of PrEP for some communities, but are concerned about the lack of consultation with sex workers on the usefulness and effectiveness of PrEP for sex workers, the future of biomedical HIV intervention and how this will impact sex workers, and the potential for PrEP to be prioritised at the expense of other proven HIV and STI prevention strategies currently used by sex work communities.

Studies on PrEP’s effectiveness have been mostly among men who have sex with men, not trans and gender diverse, male and female sex workers.

PrEP is considered unsuitable as a primary method of safer sex for sex workers, as it only prevents HIV. The need to prevent all STIs remains an important part of health and safety for sex workers.

Focusing solely on HIV prevention detracts from proven safer sex approaches that include all STIs and overall sexual health.

Sex workers have lower rates of HIV and STI transmission than the non sex working public, due to community-based, sex worker led prevention programs and a broad culture of condom use.

Generic PrEP campaigns suggest (even by omission) that PrEP is an effective HIV prevention approach for all affected communities, and fail to acknowledge that sex workers’ strategies combine HIV and STI prevention as part of a holistic approach.

Sex workers have long been (incorrectly) assumed to be vectors of disease. This has led to criminalisation of sex work, mandatory testing and other failed health approaches that are neither human rights nor evidence based.

Promoting PrEP as the most effective HIV prevention strategy, without educating sex work business owners and governments on the reasons it may not be appropriate for sex workers, leaves sex workers vulnerable to misguided policy decisions and workplace violations.

Sex workers already have high rates of voluntary testing, and low prevalence of STIs; any health initiative or HIV prevention approach, including PrEP, must be voluntary.

Treatment as prevention

Several of the concerns sex workers have about PrEP apply equally to treatment as prevention (TasP).

While research continues to demonstrate that people with HIV who have suppressed or undetectable HIV viral loads are far less likely to transmit HIV, Scarlet Alliance and sex workers generally are concerned that the research thus far is not comprehensive enough for sex workers to rely on TasP as a new HIV prevention model.

The research on TasP has not clearly established that a person with a low viral load can be considered completely not infectious, or that a viral load test is a true indicator of infectiousness through sexual fluids.

The presence of STIs may also increase the likelihood of HIV transmission or acquisition.

Research also cannot predict if people in good health will adhere to the treatment program long term or what other behavioural prevention strategies might be abandoned long term, increasing infectiousness.

There is also a concern that the outcome of trials involving gay men and men who have sex with men are being applied to sex worker communities.

There are barriers to accessing testing, treatment and health services, especially for sex workers who are criminalised.

In states where HIV-positive sex workers are criminalised, states with mandatory testing, or in places where free, anonymous voluntary testing is inaccessible or difficult to access, sex workers may be reluctant or unable to be tested.

The stigma and discrimination routinely faced by sex workers may also result in poor or disrupted access to treatment, affecting capacity to adhere to the required treatment schedule and potentially affecting the effectiveness of TasP.

The stigma and discrimination that sex workers face impact the ability to access testing and treatment, and thus to adhere to treatment long-term.

Scarlet Alliance is also concerned that the promotion of TasP as suited to all communities could lead to compulsory or coercive testing and treatment policies used against or aimed at sex workers.

This is not an unlikely eventuality in light of the mandatory testing of sex workers in some Australian states and internationally.

Sex workers living with HIV, particularly where the person is also using drugs or has mental health issues, have been managed by public health committees where there wasn’t a need for them to be.

There are human rights implications if non-voluntary use of PrEP or TasP were to be seen as an appropriate public health measure by governments or committees who manage people who put others at risk.

As with PrEP, sex workers are concerned that a push for TasP could eclipse current STI prevention strategies, which have been effective in preventing HIV and STI transmission in sex worker communities for 30 years.

TasP could also negatively impact the ability of sex workers to negotiate safer sex with clients.

Rapid testing

Rapid testing has the potential to lower barriers to testing for some communities and groups of marginalised people; however, it also has the potential to be abused and used against those same communities.

As a low prevalence population with high levels of voluntary testing, sex workers should not be targeted for rapid testing as the likelihood of false positives is high.³ Health care providers should not be incentivised to target sex workers.

Furthermore, Scarlet Alliance does not support the use of rapid testing where sex workers could be unfairly targeted, criminalised, stigmatised, discriminated against or forced to undergo testing that breaches their privacy or violates their human rights.

In jurisdictions where sex workers working with HIV or an STI are criminalised, rapid testing can be rapid criminalisation, making workers liable for prosecution and compromising sex workers’ careers, incomes and lives.⁴

This is particularly concerning where testing is combined with contact tracing. Sex workers must be able to access testing in a way that does not breach their privacy or allow them to be publically vilified.

Apart from the fact that the risk of false positives should preclude targeting sex workers for rapid testing, rapid testing in sex workers’ workplaces would compromise the privacy and livelihood of sex workers.

Employers may coerce workers into being tested in the workplace under threat of their jobs being terminated if they refuse.

Testing must always be voluntary; no sex worker should be coerced or compelled to undergo rapid testing. Voluntary, confidential, anonymous and patient-initiated testing remains the best-practice approach to STI and HIV testing, in keeping with the National Strategies.

Conclusion

It is clear, from years of research and the first-hand experience of sex workers, that the most effective means of improving the health and safety of sex workers is decriminalisation of sex work.

From The Lancet series on sex work, ‘across both generalised and concentrated HIV epidemics’ it was determined that decriminalisation would ‘have the largest effect on the course of the HIV epidemic’ in preventing HIV transmission for sex worker communities.^{5 6}

New HIV prevention techniques cannot be considered a substitute for community engagement, provision of safer sex supplies combined with peer education strategies on how to negotiate their use, or community-led health promotion.

They are not an alternative to evidence and human rights based health approaches and should not redirect funding from proven, effective approaches implemented by sex worker organisations.

As the conversation surrounding biomedical intervention and sex work continues, it is imperative that sex workers are consulted about the potential repercussions of biomedical interventions for sex workers in Australia and internationally.

References

1 Donovan, B., Harcourt, C., Egger, S., Watchirs Smith, L., Shneider, K., Kaldor, J., et al. (2012). The Sex Industry in New South Wales: A Report to the NSW Ministry of Health. The Kirby Institute, University of New South Wales, Sydney.

2 Scarlet Alliance. (2014). Pre-Exposure Prophylaxis (PrEP) and Early Treatment. Scarlet Alliance, Sydney. Retrieved from: www.scarletalliance.org.au/library/prep_2014

3 Scarlet Alliance. (2014, June). Rapid Testing Position Paper.Scarlet Alliance, Sydney, 7. Retrieved from: www.scarletalliance.org.au/library/rapidtesting_2015

4 Stardust, Z. (2014, February). Rapid Testing = Rapid Criminalisation of Sex Workers. Paper delivered at the 13th Social research conference on HIV, viral hepatitis and related diseases, UNSW Australia, Sydney. Retrieved from: www.youtube.com/watch?v=AFrdHjohSB4

5 Shannon, K., Strathdee, S., Goldenberg, S., Duff, P. , Mwangi, P., Rusakova, M., et al. (2015). Global epidemiology of HIV among female sex workers: influence of structural determinants. The Lancet, 385(9962), 55–71. doi: dx.doi.org/10.1016/S0140-6736(14)60931-4

6 Beyrer, C., Crago, A., Bekker, L., Butler, J., Shannon, K., Kerrigan, D., et al. (2014). An action agenda for HIV and sex workers. The Lancet, 385(9964), 287–301. doi: dx.doi.org/10.1016/S0140-6736(14)60933-8

Cameron Cox is the Male Sex Worker Representative at Scarlet Alliance. Joel Falcon is the Male Sex Worker Representative Double at Scarlet Alliance. Gemma Keegan is the Policy Officer at Scarlet Alliance.