NSWP Response to PEPFAR Guidance 2012

Source (institute/publication)

World AIDS Day was marked by an air of optimism amongst many donors, international funders and governments last year. Due to a history of exclusion from the President’s Emergency Plan for AIDS Relief (PEPFAR), we as the Global Network of Sex Work Projects (NSWP) were particularly interested to see the US Government’s revised blueprint for ‘Creating an AIDS-free Generation’.

Following ambitious targets to reverse the AIDS epidemic made by Secretary of State Hillary Clinton at the International AIDS Conference 2012, the new guidelines for investment through PEPFAR lays out the US Government’s priorities for funding. These include a commitment to scaling up combination prevention and treatment services, and a renewed focus on evidence-based interventions and a shift to focusing on “Populations at Greatest Risk”. Included within these key affected populations, the guidelines specify people who inject drugs (PWID), men who have sex with men (MSM), and importantly for us, sex workers (SW).

NSWP welcomes the discussion put forward in the guidelines around barriers to accessing healthcare services for key affected populations, and we confirm the detrimental impact of the barriers listed in this document of stigma, discrimination, fear of violence and legal sanctions. However, the limited discussion of these barriers in the guidelines falls short of any meaningful analysis, including a lack of data on prevalence, access to treatment, nor any informed discussion on how these barriers impact upon key affected populations in terms of HIV. The one global review that is mentioned in the guidelines highlights the severity of the situation for sex workers worldwide, specifying that sex workers are 13.5 times more likely to be living with HIV when compared to other females of reproductive age in the general population. This figure supports our own evidence that sex workers experience unacceptable levels of discrimination in terms of HIV prevention tools, ill-informed and abusive testing practices and unequal access to treatment services.

The guidelines state a commitment to the creation of an enabling environment that would reduce legal and policy structural barriers, reduce stigma and discrimination, and ensure that key populations are involved in the planning and implementation of programs that affect their lives (See p31). However, this commitment is proved to be rhetorical since it is undermined at other points throughout the document where sex workers are excluded from discussions completely. For example, in the analysis of human rights, people who use drugs are also omitted. Whilst stigma and discrimination are noted as barriers to health services, the guidelines provide no recognition of these issues as drivers of the HIV epidemic within key affected populations. The criminalised, stigmatised and marginalised context within which sex workers must carry out their work creates an environment that encourages violence and discrimination, leading many sex workers to disengage from health and other services. Discriminatory laws and practices (such as police seizure of condoms as evidence of prostitution), alongside the inadequacies and problems associated with non rights-based based health services, do not enable sex workers to fully protect their health in terms of prevention practices, nor do they continue care for HIV positive sex workers. This situation will increase rates of both contracting and transmitting HIV, and therefore these barriers must be recognised and tackled within any funding guidelines. Furthermore, this lack of recognition of these barriers as driving the concentrated epidemics sits alongside a worrying focus within the blueprint on behavioural change as a tool for prevention. At the expense of meaningfully recognising structural and legal conditions that act as drivers of stigma, an individualised analysis of behaviour underpins much of the discussions on key affected populations. While the guidelines clearly state that PEPFAR seeks to promote an “enabling environment of supportive laws, regulations, policies and social norms”, there is no commitment made by the US Government to change this environment or to support key affected communities to advocate for change.

Where there are links to PEPFAR guidance on people who inject drugs and men who have sex with men, there is no guidance currently available from PEPFAR on sex work. However, noting the appraisal of the 100% Condom Use Program in Cambodia, a program that in practice led to many human rights violations of sex workers in relation to informed consent for HIV testing and STI treatment, we would be sceptical of PEPFAR guidance specifically on working with sex workers. The focus on scaling up and supporting faith-based organisations is of particular concern to NSWP. Faith-based organisations have often been at the forefront of campaigns and programs that aim to rescue and rehabilitate sex workers. These programs are driven by a moral agenda on sex work that is incompatible with a rights based approach and the lived experience of sex workers. The practices associated with these programs have led to severe violations of the human rights of sex workers worldwide and have further disadvantaged the global HIV response by denying sex workers access to adequate and appropriate health and other services.

At the heart of our scepticism of the US Government’s blueprint for creating an AIDS free society is a fundamental paradox in theory and practice. Whilst sex workers are explicitly recognised as a key affected population both in these guidelines and other international guidelines on addressing HIV there is no recognition of the work that sex worker-led organisations have done in addressing the epidemic. Sex worker communities and particularly sex worker-led organisations, often supported financially by other international donor organisations, have played a pivotal role in delivering rights-based HIV prevention, testing and treatment services across the world. They have improved the uptake of services and engaged sex workers in the move to eliminate transmission of HIV. This work at the community level has been vital across all key affected populations alongside the wider community of people living with HIV and yet PEPFAR systematically ignores and devalues this work by continuing to stipulate that sub-grantees adopt an explicit position opposing sex work as work, a requirement that explicitly rules out any engagement of sex worker led-services. This fundamental dismissal of sex workers and sex worker-led services creates a situation whereby health service funding is premised upon alignment with a moral position on sex work. Those who must engage due to the need for funding are brought in line with US policy position on sex work; this position is incompatible with the empowerment of sex workers, who must challenge the many human rights violations that are faced globally, such as unequal access to healthcare.

While the new blueprint on PEPFAR may pride itself on the work it has already done in the global fight against HIV and AIDS, we fail to see how rhetorical commitments will change PEPFARs engagement with sex workers. We will not stay silent about the anti-prostitution pledge or its impact upon sex workers globally and we will continue to challenge USAID and organisations that sign the pledge, until it is revoked.

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