By Marlise Richter*, Cindy Gay~, Francois Venter#, Jo Veareyª & David Murdoch€
In her recent editorial, [1] Cheryl Overs rightly points out that new developments in treatment-as-HIV prevention will have far-reaching consequences for sex workers. However, we do not share her pessimism about potentially negative outcomes when policies and guidelines change to reflect scientific advances. These – we argue here – will improve our response to HIV, particularly in southern Africa. In fact, we believe that concerns over possible unintended consequences from HIV prevention and treatment strategies may result in unnecessary delays in the implementation of effective interventions.
We are involved in one of the largest prevention and treatment programmes among sex workers in Africa, and the sex work community that it works with. The provision of antiretroviral therapy has allowed our group and others to improve services for sex workers, and we trust that developments in the Treatment-as-Prevention field will have a similar effect.
What is Treatment-as-Prevention?
The first benefit of antiretroviral drugs (ARVs) is to improve the health of people living with HIV. An important second benefit is the reduction in HIV viral load, which reduces the chance of transmitting HIV to sexual partners.[2] Based on this, ‘Test&Treat’ strategies encourage people to test for HIV and immediately start ARVs regardless of their CD4 count.
What is pre-exposure prophylaxis (PrEP)?
PrEP involves HIV negative individuals taking ARVs to prevent contracting HIV, much like taking the contraceptive pill prevents pregnancy. [3]
Why would use of antiretrovirals as prevention potentially benefit sex workers?
Sex workers cannot rely solely on traditional HIV prevention methods – such as ABCs (Abstinence, Be Faithful, Condomise), sexual behaviour modification and barrier contraceptive methods – to protect themselves and their partners from acquiring HIV. Many research studies indicate that sex workers are at high risk of both contracting and transmitting HIV.[4] This is particularly true in South Africa and the southern African region.[5] Studies show that sex workers generally try to insist on condom-use when they sell sex, but clients often refuse to comply.[6] Due to unequal social and financial power relations, many sex workers have little choice but to have unprotected sex with their clients, boyfriends and husbands.[7] . New developments mean that sex workers could use ARVs to prevent themselves from contracting HIV, or from passing HIV onto others more effectively.
ARV treatment programmes emphasise that traditional, proven HIV prevention methods should not be abandoned. Therefore, it is highly unlikely that resources will shift away from the mainstays of HIV prevention as Overs fears, and we are unaware of practical examples where this has happened. In fact, providing ARVs as prevention for sex workers with HIV would allow for the delivery of a more sophisticated sexual health package at regular clinical follow-ups. PreP programmes should always include condom promotion strategies. For example, in the large study that inspired enthusiasm, PreP decreased the risk of HIV acquisition by only 44%, so other prevention methods should be at the heart of this intervention too.[8]
Health system changes and scientific developments do not address the human rights violations that sex workers experience under criminalised legal frameworks, and within prejudiced, sexually moralistic societies. Calling attention to human rights violations and the need for criminal law reform should be taken up by health care workers and patient advocates alike, and not left to sex workers and sex work advocates alone. While Prep will not change this dynamic, it will make sex work safer.
Overs rightly highlights that sex workers are all too often ignored in health and social programming, and are a much underserved and marginalised population. Many clinical trials have relied on sex workers as research participants. Given this history, we believe there is a strong ethical imperative for ensuring sex workers benefit from these new developments and have access to all prevention options.
Finally, the focus on HIV has allowed for resources to redirect the discourse surrounding sex work to that of a critical public health and human rights issue. Funds for HIV programmes have been used to support delivery of services to sex workers. Comments that focus on the ‘shifting away’ of resources from one HIV service to another ignore the fact that sex workers in our region had almost no focused health care interventions until HIV programmes were implemented. Each additional input, whether it has been HIV prevention initiatives, HIV testing or antiretroviral treatment provision implemented within a human rights based framework, has strengthened our programmatic response.
After years of gloom in the face of HIV’s unabated expansion, there is now optimism. But much work remains. We encourage sex workers and sex work advocates to embrace these scientific advances, and for all to advocate for sex workers’ full inclusion in the drafting of new policies, guidelines and programmes. If these frameworks and human rights safeguards are firmly put in place, it is vital that sex workers come forward to test for HIV in great numbers and to access – and fully benefit from – these new advances in prevention programming.
[4] UNAIDS (2011) Report on the global AIDS epidemic. Geneva: UNAIDS.
[5] Scorgie F, Chersich MF, Ntaganira I, Gerbase A, Lule F, et al. (2011) Socio-Demographic Characteristics and Behavioral Risk Factors of Female Sex Workers in Sub-Saharan Africa: A Systematic Review. AIDS Behav. (in press)
[6] Pauw I, Brener L (2003) You Are Just Whores: You Can’t Be Raped’: Barriers to Safer Sex Practices among Women Street Sex Workers in Cape Town. Culture, Health & Sexuality Nov. – Dec: 465-481.
[7] Karim QA, Karim SS, Soldan K, Zondi M (1995) Reducing the risk of HIV infection among South African sex workers: socioeconomic and gender barriers. Am J Public Health 85: 1521-1525; and Wojcicki JM, Malala J (2001) Condom use, power and HIV/AIDS risk: sex-workers bargain for survival in Hillbrow/Joubert Park/Berea, Johannesburg. Social Science & Medicine 53: 99-121.
[8] Grant R, Lama J, Glidden D, iPrEx Study Team (2011) Pre-exposure Chemprophylaxis for Prevention of HIV among Trans-women and MSM: iPREx Study. Conference on Retroviruses and Opportunistic Infections. Boston.
* International Centre for Reproductive Health, Ghent University and African Centre for Migration & Society, Wits University
~ Wits Reproductive Health and HIV Institute (WRHI) and University of North Carolina at Chapel Hill
# Wits Reproductive Health and HIV Institute (WRHI)
ª African Centre for Migration & Society, Wits University
€ Reproductive Health and HIV Institute (WRHI) and University of North Carolina at Chapel Hill
