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Mumbai: Decriminalizing sex work will have the single greatest effect on the course of HIV epidemics across the world, and could avert at least a third of HIV infections among sex workers and their clients in the next decade through its immediate and sustained effect on violence, policing, and safer work environments, according to a seven-part series of research on HIV and sex workers published in medical journal The Lancet.

The report is based on case studies from countries including India, Canada and Kenya. It provides the most comprehensive analysis till date of HIV and sex workers, and contains contributions from sex workers, academics, and legal and public health experts.

It says people who sell sex face a disproportionate risk and burden of HIV. Across the world, they are subjected to repressive and discriminatory law, policy and practice, which fuel human rights violations against them. These factors prevent them from accessing services to effectively prevent and treat HIV infection.

In low- and middle-income countries, female sex workers have a 13.5 times greater chance of HIV infection than women in the general population. However, real access to many HIV prevention and treatment strategies, including free or subsidized access to condoms and access to antiretroviral therapy (ART) after infection, is either inadequate or absent for many sex workers, the report says.

While improving access to prevention and treatment methods is an urgent priority, the study shows that this is will not be enough. Structural determinants—the legal, social, and political environments in which people who sell sex live, and work—have an enormous effect on HIV risk, as well as general health, safety and wellbeing. Global control of the HIV pandemic will simply not be achieved if these factors continue to go unrecognized by policymakers.

For instance, the research shows that reducing sexual violence could reduce HIV infection rates in the world by around a fifth, in both high- and low-income settings, and improving access to ART could prevent around a third of HIV infections in low-income settings.

Although governments and state authorities, most notably the police, have crucial roles in helping establish an environment of safety and HIV risk reduction, they are often impediments to protection, if not sources of harm.

Sex workers in Canada, India and Kenya reported being arrested for carrying condoms, having the condoms confiscated by police, or being subjected to physical or sexual violence from state authorities.

Empowerment of the sex worker community, allowing organization, social support, and ownership of HIV prevention strategies, offers a proven and powerful way to improve HIV prevention and treatment in sex workers, the study concluded.

Pioneering projects in India and elsewhere have shown that when sex workers are able to organize and support each other, HIV prevention and treatment outcomes dramatically improve. But in many regions, the majority of sex workers simply do not have the means to achieve this kind of empowerment, hindered by criminalization and stigma.

“The efforts to improve HIV prevention and treatment by and for people who sell sex can no longer be seen as peripheral to the achievement of universal access to HIV services and to eventual control of the pandemic," says Chris Beyrer, director of Johns Hopkins Center for Public Health and Human Rights, who coordinated the Lancet series.

The diversity of sex workers also needs to be recognized, say the authors. Recognizing that the settings in which female sex workers operate can vary enormously, the series also looks at the issues facing male and transgender sex workers.

While male and transgender sex workers face many of the same vulnerabilities and risks as female sex workers—such as violence or inadequate access to healthcare—they also have unique characteristics that need to be understood by those implementing HIV prevention strategies. A lack of quality HIV research specifically addressing male and transgender sex workers means that there are substantial gaps in understanding how the HIV epidemic affects them, and they remain underserved by the global health community.

The seven-part Lancet series concludes with an action agenda for HIV and sex workers: decriminalization of sex work—with a recognition of sex workers’ human rights—and community empowerment are necessary to control the HIV pandemic.

Moreover, sex workers’ access to evidence-based treatment and prevention strategies needs to be greatly improved and research needs to be urgently undertaken into how these strategies work for female, male, and transgender sex workers.

Prevention programmes for sex workers currently occupy a tiny proportion of overall funding for HIV, despite the disproportionate burden of risk in this group. None of the “next generation" prevention strategies, such as pre-exposure prophylaxis (PrEP) have been evaluated specifically for sex workers, and for some groups—notably transgender sex workers—research specifically looking at their needs for HIV prevention and treatment is almost entirely absent. This should be an urgent international priority, say the authors, and will need to be backed up by appropriate levels of funding from international and national health programmes.

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