NSWP urges more work on establishing the real cost and benefits of sex worker led HIV prevention programmes
While NSWP welcomes and supports the recommendations contained in the recent World Bank Report, we very much regret that as a member of the Technical Advisory Group we have not able to endorse this report as it stands. We continue to advocate that further work and analysis is required before the real cost benefits of sex worker-led programming are fully realised.
We strongly believe such a document is needed and could be a very strong advocacy tool for resource mobilisation, but equally strongly believe that the costings are fundamentally flawed and remain counterproductive and even potentially harmful – donors may be driven away from funding community empowerment based HIV prevention programmes for sex workers, despite the very clear epidemiological evidence presented of the need for HIV prevention in the context of sex work and the essential role that community empowerment plays. Sex worker led community empowerment based HIV prevention programmes have never cost the amounts cited in this report.
The community friendly HIV prevention project used for the costings upon which the modelling has been done does not include a budget for condoms and lubricant (distribution or marketing) or HIV & STI testing and treatment. This is such a serious omission given that condom programming is such an essential part of any HIV prevention programme and that HIV testing and treatment are important not only to maintain the health of individuals living with HIV but also for prevention purposes. For this reason alone it is not comprehensive. The other element lacking is community owned and led social mobilisation which is the key element to any community empowerment process and is the proven way that sex workers have been able to affect change in the structural drivers of the epidemic such as criminalisation, violence, stigma etc. Nor does the programme used in the costing model match the reality of most established sex worker HIV prevention programmes, whose staffing levels rarely match of the programme described, resulting in inflated costs per infection averted. The estimated cost per infection averted among female sex workers in Asia cited in the Report on Commission on AIDS in Asia was $31 based on data from Bangladesh, India and Thailand, while the World Bank report researchers modelling have estimated a cost of $66,128 per infection averted among female sex workers in Thailand.
The framing and definition of community empowerment programming continues to cause us concern as it is not clearly defined or consistent throughout the document or the various pieces of work carried out by the research team. While the concept is fundamentally in line with that of NSWP, the elements described as part of the systematic review fall well short of the essential actions required within a comprehensive HIV prevention programme as defined by NSWP members and outlined in the UNAIDS Guidance Note on HIV and Sex Work and even shorter of those advocated by NSWP. Indeed, the community empowerment programme cited in the report from Mysore, India in the World Bank report released on 1 December 2012, brings out this contradiction as the elements of this programme are very different from those described by The World Bank research team.In addition, the key components listed seem confused and miss the fundamental principle of community empowerment which is collectivisation and community mobilisation and fails to even mention legal frameworks under issues to be tackled at community and structural levels. In addition the programme costed does not include a budget for one of the three elements identified as essential for community empowerment – condom distribution. The model of community empowerment described in the report could be described as community friendly rather than community led, and do not match the recommendation for sex worker-led interventions and meaningful and sustainable community empowerment programmes.
The model used in this work is not an appropriate model particularly in the context of sex work in countries experiencing concentrated epidemics and the results from this model deviate from what is accepted as the gold standard of the modelling done for the Commission on AIDS in Asia report which better reflects the reality of concentrated epidemics. The modelling is particularly flawed because the infections averted estimate does not take into account the significant numbers of infections averted ‘upstream’ among the significant number of clients, and their sexual partners and demonstrates a lack of understanding of the dynamics and reality of commercial sex. In addition the DALY modelling would only appear to have taken into account HIV and not the impact of other STIs, which further distorts the findings in the opposite direction from that which is likely to persuade donors to provide resources to HIV prevention, treatment and care services for sex workers.
Finally the report remains silent on the impact of structural barriers created by criminalisation and other legal oppression of sex work and the negative impact legal frameworks have upon community empowerment based HIV programming.
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 Table 4:23 Technical Annex : Report on Commission on AIDS in Asia 2008. Oxford University Press