Despite the shadow cast over the 20th International AIDS Conference by the Malaysia Airlines tragedy that claimed the lives of six delegates among its 298 victims, people gathering this week in Melbourne have reason to be optimistic about the struggle against the disease. The latest World Health Organization (WHO) report indicates the epidemic shows signs of abating: new infections are falling, deaths from AIDS have been reduced by 25 percent since 2009, and the goal of providing antiretroviral treatment to 15 million people (almost half of those living with HIV) by 2015 is well within reach.
But there are also some sobering statistics: HIV remains stubbornly high among men who have sex with men, sex workers, and transgender persons – groups that are criminalized, stigmatized, and marginalized around the world. Criminalization undermines access to health services, and the reverse is also true. A new study in the medical journal Lancet estimates that if sex work were decriminalized, 33 to 46 percent of HIV infections among sex workers and their clients could be averted in the next decade.
Another strategy for reducing HIV infections in at-risk individuals is pre-exposure prophylaxis, or PreP. By taking antiretroviral drugs before infection, the risk of acquiring the virus can be significantly reduced. It has tested well enough, with minimal side effects, for WHO to recommend it for men who have sex with men as part of a comprehensive HIV prevention package. Globally, sex workers are 13 times more likely to be living with HIV than their female counterparts who are not working in the sex industry.
Sex workers have had a cautious response to the idea of PreP. The Global Network of Sex Work Projects (NSWP) surveyed 440 members from 40 countries on whether health authorities should prioritize PreP for sex workers to reduce new HIV infections. Most expressed concern that the potential harm of a PreP initiative would outweigh the benefits. According to sex worker delegates to the AIDS conference, most sex workers live in a punitive or heavily regulated environment. “Things that are voluntary for most people tend to become compulsory for sex workers,” explained Janelle Fawkes of the Scarlet Alliance, a leading sex worker advocacy organization in Australia.
Members of NSWP also expressed concern that as police in many countries currently use condom possession as evidence of prostitution, police might also use Truvada – a drug used to treat HIV – to support criminal charges. The NSWP concluded that WHO, UNAIDS, the Global Fund, and other health authorities should continue to consult and include sex workers in all discussions about PreP initiatives. “Nothing about us without us,” becomes an increasingly urgent demand as biomedical breakthroughs in HIV prevention and treatment outpace human rights reforms. Sex worker advocates see the need for both, but, not surprisingly, prioritize decriminalization of sex work as the most effective protection against not only HIV, but violence and other human rights abuses as well.