What do I exchange sex for? Food, housing, everything.
—Donald, 40-year-old African-American man, New Orleans, March 2013
More than 1.1 million people in the United States are living with HIV and an estimated 56,000 people become newly infected each year. Some of the highest HIV-infection and death rates in the US are found in southern states such as Louisiana, where deep poverty combines with harmful laws and policies that increase the risk of acquiring, transmitting and dying of HIV. In the city of New Orleans, many people struggle for survival by exchanging sex for money, drugs, or life necessities while trying to protect themselves from HIV. This report presents the voices of sex workers, drug users, transgender women and others neglected, punished, and stigmatized by state laws and policies that endanger their safety, health and lives.
Eight years after Hurricane Katrina struck in 2005, many in New Orleans continue to feel its devastation. More than half of New Orleans’ 350,000 residents live in or near poverty and the city has the second-highest rate of homelessness in the nation. One quarter of the city’s housing stock is blighted or vacant. Yet the Louisiana state government does little to invest in housing, health care or support services for people unable to meet their basic needs. At the same time, state criminal laws block rather than facilitate a public health approach to sex work and injection drug use, which contributes to a death rate from AIDS in Louisiana that is more than double the national average.
Louisiana Governor Bobby Jindal steadfastly opposes expanding the Medicaid program, an option now being offered to states under federal healthcare reform. Instead of seizing an opportunity that would extend insurance benefits to an estimated 400,000 Louisiana residents, the state is moving in the opposite direction by planning to remove thousands of disabled persons from Medicaid eligibility in the coming year. State officials point to the quality of their public hospital system that serves more than 500,000 patients a year, most of whom are uninsured. But even a strong safety net is not a substitute for comprehensive prevention and primary care services, particularly when at least 90 percent of the cost will be borne by the federal government.
For many, safety nets remain out of reach. Louisiana has utterly failed to implement harm reduction methods proven to reduce HIV infections among people who inject drugs. Emphasizing public health and human rights, harm reduction programs provide essential health information and services while respecting individual dignity and autonomy. For drug users, access to clean syringes and equipment have been shown to lower HIV risk and hepatitis transmission, prevent overdose and provide a gateway for drug treatment programs and other important health information. Endorsed by public health authorities worldwide and an important part of the US National HIV/AIDS Strategy, syringe access programs and other effective harm reduction measures have made injection drug use the only mode of HIV transmission that has been in consistent decline since the epidemic began in the US.
Yet Louisiana prohibits sale and distribution of syringes not intended for medical use, categorizes syringes as illegal drug paraphernalia, and criminalizes even trace amounts of illegal drugs that may be found in a syringe. These laws combine to drive most syringe distribution programs underground, keeping clean needles out of the hands of those who need them the most. In New Orleans, the work of the public health authorities is done by activists like Nancy, a 28-year-old woman who delivers clean syringes and health information to drug users on her bicycle. Not surprisingly, neither Louisiana nor New Orleans has been able to reduce its rate of HIV infection among injection drug users in the last five years.
In Louisiana, drug users are also among those most likely to develop AIDS after testing positive for HIV and least likely to be receiving medical care. But the response of state and city officials to the urgent health needs of people who use drugs has been a failure, both in effort and result. Law reform is imperative to ease restrictions on syringe access, but there are many steps the state can take to increase drug users’ access to essential care and services. Health and harm reduction education is not illegal in Louisiana, even for people who inject drugs.
Louisiana also needs to reform its laws related to prostitution. Its “crimes against nature” statutes are insidious vehicles for state-sponsored discrimination against the lesbian, gay, bisexual and transgender (LGBT) communities and women of color and should be repealed without delay. The New Orleans municipal code also criminalizes “loitering for prostitution,” an offense so vague and broadly drawn that it permits police to consider a wide range of behavior to be grounds for arrest, including where people are, what they are wearing, and what they may have done in the past. Loitering statutes interfere with the right to be free from arbitrary arrest and invite discriminatory application, particularly on the basis of gender, race and ethnicity. In New Orleans, Human Rights Watch found that enforcement of these laws targeted transgender individuals, who described a community under siege from the police, subject to constant harassment, verbal abuse, stops for suspicion of prostitution, and demands for sex in exchange for leniency.
Sex workers and people suspected by police of engaging in sex work also reported that police use condoms as evidence of prostitution. In stops and searches related to possible prostitution, officers frequently commented on, confiscated, or threatened arrest on the basis of how many condoms someone was carrying. There is no indication that condoms have been used in prosecutions for prostitution; nonetheless, this practice has an alarming consequence for public health. Sex workers, transgender women and others at high risk of HIV infection told us that they were afraid to carry condoms and that they sometimes had to engage in sex without protection out of fear of police harassment. The New Orleans Police Department should immediately end this practice.
Louisiana has chosen punishment over public health for sex workers and people who use drugs. The United States has the highest incarceration rate in the world, and Louisiana’s incarceration rate is double the national average, giving it the unfortunate distinction of the world’s incarceration capital. In New Orleans, the NO/AIDS Task Force visits every prisoner who tests positive for HIV at the Orleans Parish Prison and arranges a medical appointment upon release. However, their clients are often arrested again before they can make it in to see the doctor; one transgender woman was arrested for prostitution 10 times in three years, and has yet to keep her appointment with the clinic. Jail inevitably interrupts the ability to take one’s HIV medications on a regular basis. Reports from the Orleans Parish Prison indicated delays ranging from two weeks to three months in commencing or resuming HIV treatment.
People who exchange sex for money, drugs, and life necessities have difficult and often dangerous lives. The challenge to public agencies of reaching a population whose primary concern is daily survival is not an easy one, and in New Orleans there is an active network of community organizations, medical providers and officials in the health department who are working to ensure access to care and services. In recent years, state and local health officials have significantly increased the number of people with HIV who are in treatment. Unfortunately, their work is undermined by state and local laws and policies, as well as police practices, that not only fail to reduce the risk of harm but exacerbate a high-risk environment where it is difficult for people to avoid HIV infection and to access life-saving treatment and support.
To effectively address the HIV epidemic and protect the human rights of people who exchange sex for money, drugs, or life necessities, the Louisiana state legislature should reform laws and policies on possession of syringes. Consensual, adult sex work should be decriminalized, and the city of New Orleans should expand community-based HIV prevention and treatment programs and engage individuals from high-risk communities in an effective response to their needs. The New Orleans Police Department is currently under federal oversight for constitutional violations and it should remain so until it has met its obligation to respect the human rights of the LGBT community. Until Louisiana substitutes a public health approach for punitive and discriminatory policies and invests in housing, health care and other basic human needs, HIV will continue to endanger the lives of the state’s most vulnerable residents.