A meeting held on 15–17 September 2008 in Geneva brought together participants from the World Health Organization
(WHO) and its United Nations (UN) partners along with representatives from 26 countries to discuss the role that the
health sector can and should play in addressing prevention,treatment and care of HIV and other STIs among MSM,A
transgender people and their sexual partners. The following key principles were agreed on at the meeting:
• Adopting a rights-based approach guarantees the human rights of MSM and transgender people, and will
ensure that they and their male and female sexual partners have the right to information and commodities that
enable them to protect themselves against HIV and other STIs, protection from discrimination and criminalization,
as well as information on where to seek appropriate care for these infections.
• Knowing the epidemic and the response to it means knowing where infections are occurring, who is at risk or
vulnerable and who is infected. It also means understanding the local, social and structural determinants of risk.
• The HIV and STI epidemics among MSM and transgender people cannot be addressed by the health sector
alone. It requires partnerships and engagement both across sectors (particularly with the legal and education
sectors) and, crucially, with the MSM and transgender communities.
Thursday, August 30, 2012
Executive SummaryAA
Executive Summary
There is an urgent need to address the emerging and re-emerging epidemics of HIV and other sexually transmitted
infections (STIs) among men who have sex with men (MSM) and transgender people. Strengthening strategic
information systems and implementing interventions for the prevention and treatment of HIV and other STIs among
MSM and transgender people should be considered a priority for all countries and regions as part of a comprehensive
effort to ensure universal access to HIV prevention, care and treatment.
Reports from a diverse range of countries and regions have highlighted that prevalence of HIV and other STIs
among MSM and transgender people is high when compared with men in the general population. Unprotected
anal sex is common and surveys show that some MSM have female partners, many are married, some are engaged
in sex work and some use drugs. Existing second-generation HIV surveillance systems, research, and efforts of
national HIV/AIDS and STI programmes have not adequately captured biological and behavioural data on these
populations, nor implemented prevention interventions on a sufficient scale. Resources to address HIV and STIs
among MSM, transgender people and their partners do not match the burden of disease.
The risk of and vulnerability to infection are reinforced by societal attitudes, which deny human rights to MSM and
transgender people, as well as their right to health.
There is an urgent need to address the emerging and re-emerging epidemics of HIV and other sexually transmitted
infections (STIs) among men who have sex with men (MSM) and transgender people. Strengthening strategic
information systems and implementing interventions for the prevention and treatment of HIV and other STIs among
MSM and transgender people should be considered a priority for all countries and regions as part of a comprehensive
effort to ensure universal access to HIV prevention, care and treatment.
Reports from a diverse range of countries and regions have highlighted that prevalence of HIV and other STIs
among MSM and transgender people is high when compared with men in the general population. Unprotected
anal sex is common and surveys show that some MSM have female partners, many are married, some are engaged
in sex work and some use drugs. Existing second-generation HIV surveillance systems, research, and efforts of
national HIV/AIDS and STI programmes have not adequately captured biological and behavioural data on these
populations, nor implemented prevention interventions on a sufficient scale. Resources to address HIV and STIs
among MSM, transgender people and their partners do not match the burden of disease.
The risk of and vulnerability to infection are reinforced by societal attitudes, which deny human rights to MSM and
transgender people, as well as their right to health.
rights-based approach to HIV and sex wor
Member States should implement policies and programmes that support a comprehensive,
rights-based approach to HIV and sex work. Progress should be monitored by national
programmes, with support from UNAIDS.
Bilateral development organizations, international funding programmes, and the United
Nations system should support comprehensive, rights-based approaches consistent with the
Three Pillars.
Consistent with the UNAIDS recommendation that all countries should “know their
epidemic”, situational analyses and mapping exercises should be undertaken to inform the
design and subsequent monitoring and evaluating of programmes to address HIV and sex
work.
At subregional and national levels, representatives of government, sex workers, civil society,
private sector and the United Nations should be mobilized to ensure incorporation of
strategies and actions on HIV and sex work into National AIDS Plans.
Advocacy should be undertaken to increase the levels of sustainable funding for, evidenceinformed
and rights-based HIV prevention, treatment, care and support programmes that
incorporate sex workers’ involvement in their development, implementation, monitoring
and evaluation.
Efforts should be made to document and disseminate specific programme models, interventions
and good practices relating to HIV and sex work.
Partnerships should be established and strengthened between governments, sex workers
and community organizations working with sex workers, and the UN at global, regional,
national and local levels.
In-reach training of UNAIDS programme staff will be developed and undertaken to
increase understanding of evidence-informed and rights-based programming on HIV and
key populations at higher risk, including sex workers.
Programmes to reduce and eliminate stigma and discrimination and gender-based violence
towards key populations at higher risk, including sex workers, should be developed and
implemented for health care providers, uniformed services, and the judiciary.
Carefully tailored initiatives should be implemented to promote sound, evidence-informed
programmes and policies that address the needs of migrants, transgendered people, men
and ethnic minorities. Work also needs to be undertaken with specific groups such as
clients, displaced persons, the police and the military.
Efforts should be made to expand opportunities for sex workers who desire to leave sex
work. Meaningful employment alternatives should be promoted through ready access to
education, training, microcredit, and health services.
Comprehensive responses should address structural issues that contribute to HIV vulnerability
in the context of sex work. Structural interventions should aim to reduce poverty,
address gender inequality by empowering women and girls, redefine gender norms, create
and expand employment opportunities, and ensure education for all.
UNAIDS and nongeovernmental organization partners should advocate for increased
involvement of sex worker organizations and networks on Country Coordinating
Mechanisms of the Global Fund to Fight AIDS, Tuberculosis and Malaria and on National
AIDS Committees, and provide capacity building support to facilitate their involvement.
rights-based approach to HIV and sex work. Progress should be monitored by national
programmes, with support from UNAIDS.
Bilateral development organizations, international funding programmes, and the United
Nations system should support comprehensive, rights-based approaches consistent with the
Three Pillars.
Consistent with the UNAIDS recommendation that all countries should “know their
epidemic”, situational analyses and mapping exercises should be undertaken to inform the
design and subsequent monitoring and evaluating of programmes to address HIV and sex
work.
At subregional and national levels, representatives of government, sex workers, civil society,
private sector and the United Nations should be mobilized to ensure incorporation of
strategies and actions on HIV and sex work into National AIDS Plans.
Advocacy should be undertaken to increase the levels of sustainable funding for, evidenceinformed
and rights-based HIV prevention, treatment, care and support programmes that
incorporate sex workers’ involvement in their development, implementation, monitoring
and evaluation.
Efforts should be made to document and disseminate specific programme models, interventions
and good practices relating to HIV and sex work.
Partnerships should be established and strengthened between governments, sex workers
and community organizations working with sex workers, and the UN at global, regional,
national and local levels.
In-reach training of UNAIDS programme staff will be developed and undertaken to
increase understanding of evidence-informed and rights-based programming on HIV and
key populations at higher risk, including sex workers.
Programmes to reduce and eliminate stigma and discrimination and gender-based violence
towards key populations at higher risk, including sex workers, should be developed and
implemented for health care providers, uniformed services, and the judiciary.
Carefully tailored initiatives should be implemented to promote sound, evidence-informed
programmes and policies that address the needs of migrants, transgendered people, men
and ethnic minorities. Work also needs to be undertaken with specific groups such as
clients, displaced persons, the police and the military.
Efforts should be made to expand opportunities for sex workers who desire to leave sex
work. Meaningful employment alternatives should be promoted through ready access to
education, training, microcredit, and health services.
Comprehensive responses should address structural issues that contribute to HIV vulnerability
in the context of sex work. Structural interventions should aim to reduce poverty,
address gender inequality by empowering women and girls, redefine gender norms, create
and expand employment opportunities, and ensure education for all.
UNAIDS and nongeovernmental organization partners should advocate for increased
involvement of sex worker organizations and networks on Country Coordinating
Mechanisms of the Global Fund to Fight AIDS, Tuberculosis and Malaria and on National
AIDS Committees, and provide capacity building support to facilitate their involvement.
Fundamental to reducing HIV risk and vulnerability is enhancing access for all,
Fundamental to reducing HIV risk and vulnerability is enhancing access for all,
including those engaged in sex work, to HIV prevention, treatment, care and support.
Comprehensive rights-based programmes on HIV and sex work are critical to the success
of the HIV response. Working in partnership with sex workers to identify their needs and
to advocate for policies and programmes that improve their health, safety and engagement
in the AIDS response is a proved strategy and an essential feature of UNAIDS approach.
Alongside the global epidemic of HIV is an epidemic of violence against women, girls and
other vulnerable groups, including men who have sex with men. Far too often, stigma and
discrimination, gender-based violence and other critical human rights violations, such as
denial of education and employment on the basis of gender, constitute the norm in many
parts of the world. Women’s rights are human rights. Progress for women is progress for all.
Efforts to address the construction of dominant norms of masculinity and to redress gender
imbalances are essential to the success of rights-based approaches to HIV and sex work, for
all people selling sex—female, male and transgender.
HIV and sex work is a complex issue and needs to be understood as such. The delivery
of effective services to sex workers and their clients often encounters barriers and resistance
that reflect complex and longstanding cultural, religious, and social dynamics. While
these barriers will not be overcome overnight or with ease, delaying action to address these
factors will merely continue to undermine the global response to HIV. Through honest
dialogue and evidence-informed action, sustained progress towards universal access to HIV
prevention, treatment, care and support for sex workers can be achieved.
The Three Pillars outlined in this Guidance Note together provide a framework for
developing effective strategies to reduce the immediate HIV risk to sex workers and their
clients, and to the spouses and regular partners of clients; provide care for sex workers
living with HIV; and reform official policies, practices and legislation to protect the human
rights of sex workers. These strategies should be accompanied by programmes to build
supportive environments to facilitate full and equal participation of sex workers, provide
meaningful alternative livelihoods and life choices, ensure full and universal enjoyment
of human rights, combat stigma and discrimination, and strengthen partnerships between
government, civil society, and community actors.
including those engaged in sex work, to HIV prevention, treatment, care and support.
Comprehensive rights-based programmes on HIV and sex work are critical to the success
of the HIV response. Working in partnership with sex workers to identify their needs and
to advocate for policies and programmes that improve their health, safety and engagement
in the AIDS response is a proved strategy and an essential feature of UNAIDS approach.
Alongside the global epidemic of HIV is an epidemic of violence against women, girls and
other vulnerable groups, including men who have sex with men. Far too often, stigma and
discrimination, gender-based violence and other critical human rights violations, such as
denial of education and employment on the basis of gender, constitute the norm in many
parts of the world. Women’s rights are human rights. Progress for women is progress for all.
Efforts to address the construction of dominant norms of masculinity and to redress gender
imbalances are essential to the success of rights-based approaches to HIV and sex work, for
all people selling sex—female, male and transgender.
HIV and sex work is a complex issue and needs to be understood as such. The delivery
of effective services to sex workers and their clients often encounters barriers and resistance
that reflect complex and longstanding cultural, religious, and social dynamics. While
these barriers will not be overcome overnight or with ease, delaying action to address these
factors will merely continue to undermine the global response to HIV. Through honest
dialogue and evidence-informed action, sustained progress towards universal access to HIV
prevention, treatment, care and support for sex workers can be achieved.
The Three Pillars outlined in this Guidance Note together provide a framework for
developing effective strategies to reduce the immediate HIV risk to sex workers and their
clients, and to the spouses and regular partners of clients; provide care for sex workers
living with HIV; and reform official policies, practices and legislation to protect the human
rights of sex workers. These strategies should be accompanied by programmes to build
supportive environments to facilitate full and equal participation of sex workers, provide
meaningful alternative livelihoods and life choices, ensure full and universal enjoyment
of human rights, combat stigma and discrimination, and strengthen partnerships between
government, civil society, and community actors.
Education is critical to HIV prevention
Promote Education for All
Education is critical to HIV prevention, treatment, care and support, and to mitigate the
effects of HIV on individuals, families and communities99. Education expands choices,
reduces risky behaviours, diminishes stigma and discrimination, and promotes individual
and community resilience. Education contributes to poverty reduction and the elimination
of gender inequalities, and fosters economic independence, delayed marriage, and improved
of sexuality. Education also creates economic and life opportunities apart from sex work100.
While there has been steady progress towards the global goal of Education for All, significant
gaps remain, as some 70 million children—more than half of whom are girls—are still
not enrolled in primary school. It is essential that educational opportunities be expanded to
meet the needs of children, young people and adults.
A comprehensive approach to HIV and sex work: A Call for Action, Maputo 2007102
Ensure the development of strategic plans of action on HIV and sex work as an
integral part of the national HIV response, including the collection and analysis
of data relating to HIV and sex work.
Advocacy for the promotion and protection of the human rights of sex workers
and the establishment of local, national and regional networks of sex workers.
Ensure sex workers have access to HIV prevention, treatment, care and support
and to comprehensive, integrated and user-friendly health services.
Elimination of violence towards sex workers, including from clients and law
enforcement, uniformed services, and managers of sex work establishments.
Advocate for the Southern African Development Community to recognize and
support the availability of cross-border services for vulnerable groups, including
sex workers.
Eliminate stigma and discrimination by health service providers and law enforcement
officers and authorities against sex workers.
Undertake country-level mapping of sex work settings, including mobility and
migration trends, service access, and legal frameworks and their impact on the
vulnerability of sex workers and clients.
Strengthen partnerships in support of programming for HIV prevention, care,
treatment and support, and sex work, including the engagement of labour
organizations, trade unions, the private sector, local communities and national
governments.
Protect the children of sex workers from discrimination and harm, paying particular
attention to their ability to attend school and prioritizing measures to
reduce their vulnerability to entry into sex work.
In consultation with sex workers, create employment and educational opportunities
responding to the identified needs of sex workers, such as microfinance
opportunities, and support the provision of vocational skills training, including
for sex workers living with HIV.
Support comprehensive programmes for clients, including respect for the human
rights of sex workers and client responsibility.
Promote sexuality education, gender equity and equality, partner communication
and prevention of HIV, within marriage and cohabiting relationships to
reduce demand for sex work.
Education is critical to HIV prevention, treatment, care and support, and to mitigate the
effects of HIV on individuals, families and communities99. Education expands choices,
reduces risky behaviours, diminishes stigma and discrimination, and promotes individual
and community resilience. Education contributes to poverty reduction and the elimination
of gender inequalities, and fosters economic independence, delayed marriage, and improved
of sexuality. Education also creates economic and life opportunities apart from sex work100.
While there has been steady progress towards the global goal of Education for All, significant
gaps remain, as some 70 million children—more than half of whom are girls—are still
not enrolled in primary school. It is essential that educational opportunities be expanded to
meet the needs of children, young people and adults.
A comprehensive approach to HIV and sex work: A Call for Action, Maputo 2007102
Ensure the development of strategic plans of action on HIV and sex work as an
integral part of the national HIV response, including the collection and analysis
of data relating to HIV and sex work.
Advocacy for the promotion and protection of the human rights of sex workers
and the establishment of local, national and regional networks of sex workers.
Ensure sex workers have access to HIV prevention, treatment, care and support
and to comprehensive, integrated and user-friendly health services.
Elimination of violence towards sex workers, including from clients and law
enforcement, uniformed services, and managers of sex work establishments.
Advocate for the Southern African Development Community to recognize and
support the availability of cross-border services for vulnerable groups, including
sex workers.
Eliminate stigma and discrimination by health service providers and law enforcement
officers and authorities against sex workers.
Undertake country-level mapping of sex work settings, including mobility and
migration trends, service access, and legal frameworks and their impact on the
vulnerability of sex workers and clients.
Strengthen partnerships in support of programming for HIV prevention, care,
treatment and support, and sex work, including the engagement of labour
organizations, trade unions, the private sector, local communities and national
governments.
Protect the children of sex workers from discrimination and harm, paying particular
attention to their ability to attend school and prioritizing measures to
reduce their vulnerability to entry into sex work.
In consultation with sex workers, create employment and educational opportunities
responding to the identified needs of sex workers, such as microfinance
opportunities, and support the provision of vocational skills training, including
for sex workers living with HIV.
Support comprehensive programmes for clients, including respect for the human
rights of sex workers and client responsibility.
Promote sexuality education, gender equity and equality, partner communication
and prevention of HIV, within marriage and cohabiting relationships to
reduce demand for sex work.
HIV responses should challenge the power
Demand for sex work
The Commission on AIDS in Asia reports that the HIV epidemic in Asia is
mainly driven by men who purchase sex. It is estimated that some 75 million men
in Asia purchase sex from 10 million women. From an epidemiological standpoint,
men who buy sex from women in Asia far outnumber injecting drug users and men
who have sex with men, underscoring the likely role of paid sex in the epidemic’s
future trajectory in the region. The proportion of people living with HIV in Asia
who are women increased from 19% in 2000 to 24% in 2007, with most of these
women infected through sex with husbands or boyfriends who were themselves
infected during paid sex or through injecting drugs HIV responses should challenge the power relations and division of labour between
women/girls and men/boys and promote gender equality at home, at work, in the legal,
economic and political arenas, and throughout society at large. Interventions should engage
men and boys—both to reduce women and girls’ vulnerability to HIV and to minimize
the harmful effects that societal norms about masculinity and gender often have on men
and boys themselves.88 Structural measures such as national and regional policy reform
should address the norms and factors that increase demand for paid sex, including labour
migration, mobility, and the separation of families for extended periods of time. Workplace
HIV education programmes have an important role to play in redefining gender norms
and reducing the demand for sex work. Evidence indicates that such programmes can be
successful. In Thailand, for instance, broad-based efforts to alter social norms and male
behaviours led to a significant reduction in the sexual initiation of young men through
paid sex, helping bring about a sharp decline in the rate of new HIV infections89.
Address poverty and limited economic options
Although no person should be obliged to enter into sex work as a result of insecurity,
poverty, or coercion90, the majority of people who engage in sex work have few other
economic options91. Strategies that expand educational, economic and social opportunities,
especially for women and girls, represent an urgent necessity. Economic inequality is associated
with HIV risk92, and laws and policies that empower women to own property and
access schooling reduce that risk. Programmes are needed to address harmful employment
practices and to extend access to skills, credit and jobs. The United Nations has endorsed
the concept of ‘decent work’ as a vital path out of poverty93. Decent work sums up the
aspirations of people in their working lives—for opportunity and income; rights, voice and
recognition; family stability and personal development; and fairness and gender equality.94
Governments should prioritize strategies to create local employment opportunities for
women and girls. Focused programmes should be immediately developed in areas where
recruitment into sex work is active. In devising and implementing such strategies, policymakers
and programme planners should heed evidence of the effectiveness of initiatives
that provide livelihood skills, vocational training, local job creation and microfinance
to girls and young women95. Providing women and girls with opportunities for greater
ownership and control over economic assets empowers them to make their own choices
The Commission on AIDS in Asia reports that the HIV epidemic in Asia is
mainly driven by men who purchase sex. It is estimated that some 75 million men
in Asia purchase sex from 10 million women. From an epidemiological standpoint,
men who buy sex from women in Asia far outnumber injecting drug users and men
who have sex with men, underscoring the likely role of paid sex in the epidemic’s
future trajectory in the region. The proportion of people living with HIV in Asia
who are women increased from 19% in 2000 to 24% in 2007, with most of these
women infected through sex with husbands or boyfriends who were themselves
infected during paid sex or through injecting drugs HIV responses should challenge the power relations and division of labour between
women/girls and men/boys and promote gender equality at home, at work, in the legal,
economic and political arenas, and throughout society at large. Interventions should engage
men and boys—both to reduce women and girls’ vulnerability to HIV and to minimize
the harmful effects that societal norms about masculinity and gender often have on men
and boys themselves.88 Structural measures such as national and regional policy reform
should address the norms and factors that increase demand for paid sex, including labour
migration, mobility, and the separation of families for extended periods of time. Workplace
HIV education programmes have an important role to play in redefining gender norms
and reducing the demand for sex work. Evidence indicates that such programmes can be
successful. In Thailand, for instance, broad-based efforts to alter social norms and male
behaviours led to a significant reduction in the sexual initiation of young men through
paid sex, helping bring about a sharp decline in the rate of new HIV infections89.
Address poverty and limited economic options
Although no person should be obliged to enter into sex work as a result of insecurity,
poverty, or coercion90, the majority of people who engage in sex work have few other
economic options91. Strategies that expand educational, economic and social opportunities,
especially for women and girls, represent an urgent necessity. Economic inequality is associated
with HIV risk92, and laws and policies that empower women to own property and
access schooling reduce that risk. Programmes are needed to address harmful employment
practices and to extend access to skills, credit and jobs. The United Nations has endorsed
the concept of ‘decent work’ as a vital path out of poverty93. Decent work sums up the
aspirations of people in their working lives—for opportunity and income; rights, voice and
recognition; family stability and personal development; and fairness and gender equality.94
Governments should prioritize strategies to create local employment opportunities for
women and girls. Focused programmes should be immediately developed in areas where
recruitment into sex work is active. In devising and implementing such strategies, policymakers
and programme planners should heed evidence of the effectiveness of initiatives
that provide livelihood skills, vocational training, local job creation and microfinance
to girls and young women95. Providing women and girls with opportunities for greater
ownership and control over economic assets empowers them to make their own choices
Wednesday, August 29, 2012
Addressing structural determinants of HIV
Many sex workers become involved in sex work while young, sometimes migrating from
rural areas to cities. Young migrants frequently move to the city to escape childhood
marriages or to assume responsibility for contributing to family income, sometimes as sole
providers. Measures are needed to prevent children and young people from being recruited
into sex work, including ensuring the availability of educational and work opportunities,
addressing family and social breakdown, increasing awareness of the health and other risks
associated with sex work, ensuring the availability of social protection safety nets (including
those required to mitigate the impacts of AIDS) and ensuring that all forms of child labour
are eliminated.
Addressing structural determinants of HIV risk and vulnerability is inevitably challenging,
as such approaches seek to alter complex and longstanding social, economic, political and
environmental factors80. While some may argue that structural interventions are too timeconsuming
or open-ended or that they divert resources from immediate HIV control
priorities, it is clear that the epidemic will not be reversed, nor will progress on HIV be
sustained, unless effective action is taken to address the structural factors that increase HIV
risk and vulnerability।
Gender equality, gender norms and relations
Gender inequality causes many women to enter sex work. Globally, most sex workers
are women or girls. With unequal access to education, employment, credit or financial
support outside marriage, women and girls often see sex work as one of the few options
available to support themselves81. Such economic pressures are compounded for women
whose husbands have died or abandoned them or who otherwise bear the primary burden
of supporting their families. Gender inequalities also result in stricter regulation of sexual
behaviour of women, girls, and men who have sex with men. Hypocrisy, denial, and taboos
associated with sex and sexuality impede effective programming on HIV and sex work.
An effective, sustainable response to HIV requires evidence-informed measures to address
the unequal relations between women and girls, men and boys, and men who have sex
with men82. Evidence-informed programmes to forge norms of gender equity should
be brought to scale, with particular attention to initiatives focused on men and boys83.
For example, programmes to promote dialogue and critical reflection among young men
regarding gender inequalities have been shown to significantly reduce their support for
inequitable gender norms, and to significantly increase condom use and decrease intimate
partner violence84. There is a much broader need for programmes that address norms and
practices concerning sexuality, marriage and reproduction; harmful cultural practices that
injure or disadvantage women; and the unequal access of women and girls to social, legal,
and political rights.85 Family and community structures should be strengthened to protect
young people from sexual exploitation. Religious leaders, educators and other community
leaders should be mobilized to advocate for a cultural environment that refuses to tolerate
sexual exploitation, including child marriage86
rural areas to cities. Young migrants frequently move to the city to escape childhood
marriages or to assume responsibility for contributing to family income, sometimes as sole
providers. Measures are needed to prevent children and young people from being recruited
into sex work, including ensuring the availability of educational and work opportunities,
addressing family and social breakdown, increasing awareness of the health and other risks
associated with sex work, ensuring the availability of social protection safety nets (including
those required to mitigate the impacts of AIDS) and ensuring that all forms of child labour
are eliminated.
Addressing structural determinants of HIV risk and vulnerability is inevitably challenging,
as such approaches seek to alter complex and longstanding social, economic, political and
environmental factors80. While some may argue that structural interventions are too timeconsuming
or open-ended or that they divert resources from immediate HIV control
priorities, it is clear that the epidemic will not be reversed, nor will progress on HIV be
sustained, unless effective action is taken to address the structural factors that increase HIV
risk and vulnerability।
Gender equality, gender norms and relations
Gender inequality causes many women to enter sex work. Globally, most sex workers
are women or girls. With unequal access to education, employment, credit or financial
support outside marriage, women and girls often see sex work as one of the few options
available to support themselves81. Such economic pressures are compounded for women
whose husbands have died or abandoned them or who otherwise bear the primary burden
of supporting their families. Gender inequalities also result in stricter regulation of sexual
behaviour of women, girls, and men who have sex with men. Hypocrisy, denial, and taboos
associated with sex and sexuality impede effective programming on HIV and sex work.
An effective, sustainable response to HIV requires evidence-informed measures to address
the unequal relations between women and girls, men and boys, and men who have sex
with men82. Evidence-informed programmes to forge norms of gender equity should
be brought to scale, with particular attention to initiatives focused on men and boys83.
For example, programmes to promote dialogue and critical reflection among young men
regarding gender inequalities have been shown to significantly reduce their support for
inequitable gender norms, and to significantly increase condom use and decrease intimate
partner violence84. There is a much broader need for programmes that address norms and
practices concerning sexuality, marriage and reproduction; harmful cultural practices that
injure or disadvantage women; and the unequal access of women and girls to social, legal,
and political rights.85 Family and community structures should be strengthened to protect
young people from sexual exploitation. Religious leaders, educators and other community
leaders should be mobilized to advocate for a cultural environment that refuses to tolerate
sexual exploitation, including child marriage86
Sex workers living with HIV
Sex workers living with HIV often find it especially difficult to leave sex work.
Comprehensive assistance should be readily available for HIV-positive sex workers,
including skills training, alternative livelihoods, and microfinance. There are many successful
examples of microcredit and microfinance programmes providing economic opportunities
for people living with HIV or to alleviate poverty among girls and women. Such
programmes use economic empowerment as a means to reduce stigma and discrimination
and expand life choices73. To date, however, only a few have specifically focused on meeting
the needs of sex workers74. Partnerships between local authorities and communities should
be strengthened to ensure sex workers living with HIV have equal access to HIV treatment,
care and support, as well as to available employment programmes. Every effort should be
made by governments, donors, civil society, sex worker organizations and the UN system to
ensure sex workers’ meaningful access to such programmes and services. Laws, policies, and
practices that diminish sex workers’ potential for their economic independence and social
inclusion must be reviewed and revised।
States should take measures to reduce the vulnerability, stigmatization and discrimination that
surround HIV and promote a supportive and enabling environment by addressing underlying prejudices
and inequalities within societies…
International Guidelines on HIV/AIDS and Human Rights 2006:55
HIV prevention efforts will not succeed in the long term unless the underlying drivers
of HIV risk and vulnerability are effectively addressed.75 The evidence base for structural
interventions is limited but there is wide recognition that these are a critical component
of combination prevention.76 Factors that commonly contribute to vulnerability to HIV
infection include gender inequality, discrimination and social exclusion77. These same
structural issues, together with poverty, mobility and displacement, may lead people to
engage in sex work and increase their vulnerability to HIV।
Addressing Societal Causes of HIV Risk and Vulnerability: Key Findings79
Long-term success in responding to the HIV epidemic will require sustained progress in
addressing human rights violations, gender inequality, stigma, and discrimination.
Significant investment in girls’ education, supported by policies mandating universal
primary and secondary education, would substantially reduce HIV risk and vulnerability
for women and girls.
Evidence-informed programmes to forge norms of gender equity should be brought
to scale, with particular attention to initiatives focused on men and boys.
National governments and international donors should prioritize strategies to
increase women’s economic independence and legal reforms to recognize women’s
property and inheritance rights.
All countries should ensure rigorous enforcement of antidiscrimination measures to
protect people living with HIV. The one third of countries that lack legal protections
against HIV-based discrimination should immediately enact such laws. Countries
should also protect populations most at risk from discrimination and ensure their
equal enjoyment of human rights.
Countries should include anti-stigma strategies as integral components of their
national AIDS plans, investing in a broad range of activities, including public
awareness and ”know your rights” campaigns, legal services for people living with
HIV, expansion of access to antiretroviral drugs, and expressions of national solidarity
in the HIV response.
Much stronger financial and technical support is needed for capacity-building for
organizations and networks of people living with HIV, and groups of people most at
risk of HIV infection.
Comprehensive assistance should be readily available for HIV-positive sex workers,
including skills training, alternative livelihoods, and microfinance. There are many successful
examples of microcredit and microfinance programmes providing economic opportunities
for people living with HIV or to alleviate poverty among girls and women. Such
programmes use economic empowerment as a means to reduce stigma and discrimination
and expand life choices73. To date, however, only a few have specifically focused on meeting
the needs of sex workers74. Partnerships between local authorities and communities should
be strengthened to ensure sex workers living with HIV have equal access to HIV treatment,
care and support, as well as to available employment programmes. Every effort should be
made by governments, donors, civil society, sex worker organizations and the UN system to
ensure sex workers’ meaningful access to such programmes and services. Laws, policies, and
practices that diminish sex workers’ potential for their economic independence and social
inclusion must be reviewed and revised।
States should take measures to reduce the vulnerability, stigmatization and discrimination that
surround HIV and promote a supportive and enabling environment by addressing underlying prejudices
and inequalities within societies…
International Guidelines on HIV/AIDS and Human Rights 2006:55
HIV prevention efforts will not succeed in the long term unless the underlying drivers
of HIV risk and vulnerability are effectively addressed.75 The evidence base for structural
interventions is limited but there is wide recognition that these are a critical component
of combination prevention.76 Factors that commonly contribute to vulnerability to HIV
infection include gender inequality, discrimination and social exclusion77. These same
structural issues, together with poverty, mobility and displacement, may lead people to
engage in sex work and increase their vulnerability to HIV।
Addressing Societal Causes of HIV Risk and Vulnerability: Key Findings79
Long-term success in responding to the HIV epidemic will require sustained progress in
addressing human rights violations, gender inequality, stigma, and discrimination.
Significant investment in girls’ education, supported by policies mandating universal
primary and secondary education, would substantially reduce HIV risk and vulnerability
for women and girls.
Evidence-informed programmes to forge norms of gender equity should be brought
to scale, with particular attention to initiatives focused on men and boys.
National governments and international donors should prioritize strategies to
increase women’s economic independence and legal reforms to recognize women’s
property and inheritance rights.
All countries should ensure rigorous enforcement of antidiscrimination measures to
protect people living with HIV. The one third of countries that lack legal protections
against HIV-based discrimination should immediately enact such laws. Countries
should also protect populations most at risk from discrimination and ensure their
equal enjoyment of human rights.
Countries should include anti-stigma strategies as integral components of their
national AIDS plans, investing in a broad range of activities, including public
awareness and ”know your rights” campaigns, legal services for people living with
HIV, expansion of access to antiretroviral drugs, and expressions of national solidarity
in the HIV response.
Much stronger financial and technical support is needed for capacity-building for
organizations and networks of people living with HIV, and groups of people most at
risk of HIV infection.
HIV programmes have a crucial role
Stigma and discrimination
As sex work is highly stigmatized in many societies, most sex workers face some degree of
stigma and discrimination. Male and transgender sex workers may face added stigma and
discrimination. Sex workers should be able to participate in all aspects of community life
free from economic, cultural, or social marginalisation, including sex workers living with
HIV. Building supportive environments and developing and strengthening strategic partnerships
can help reduce the stigma and discrimination sex workers face. HIV programmes
have a crucial role in assisting communities to identify and change stigmatizing attitudes
and behaviours related to HIV and sex work and to foster a spirit of tolerance and
inclusion. Health service personnel, law enforcement officers, the judiciary, social welfare
personnel should be specifically targeted for training and sensitisation.
Too often people engaged in sex work face rejection from their own communities. In
addition to mistreatment by clients and service providers, sex workers often risk rejection
at home. Upon returning to their communities, former sex workers may be banished,
victimized by sexual or physical violence, and have their property seized. Those who left
their communities at a young age to engage in sex work experience difficulty reintegrating
in their families and former friendship networks. People who sell sex in or near their homes may similarly face community disapproval, and/or violence from husbands,
partners or family members. The children of sex workers may also be subjected to stigma
and discrimination, adversely affecting their rights of access to education and health care.69
To reduce stigma and avert discriminatory practices, targeted community interventions for
social inclusion and capacity building should focus on women’s groups, community leaders
and religious leaders. Psychosocial support should be available for individuals who suffer
psychological distress as a result of the stigma associated with sex work.
As sex work is highly stigmatized in many societies, most sex workers face some degree of
stigma and discrimination. Male and transgender sex workers may face added stigma and
discrimination. Sex workers should be able to participate in all aspects of community life
free from economic, cultural, or social marginalisation, including sex workers living with
HIV. Building supportive environments and developing and strengthening strategic partnerships
can help reduce the stigma and discrimination sex workers face. HIV programmes
have a crucial role in assisting communities to identify and change stigmatizing attitudes
and behaviours related to HIV and sex work and to foster a spirit of tolerance and
inclusion. Health service personnel, law enforcement officers, the judiciary, social welfare
personnel should be specifically targeted for training and sensitisation.
Too often people engaged in sex work face rejection from their own communities. In
addition to mistreatment by clients and service providers, sex workers often risk rejection
at home. Upon returning to their communities, former sex workers may be banished,
victimized by sexual or physical violence, and have their property seized. Those who left
their communities at a young age to engage in sex work experience difficulty reintegrating
in their families and former friendship networks. People who sell sex in or near their homes may similarly face community disapproval, and/or violence from husbands,
partners or family members. The children of sex workers may also be subjected to stigma
and discrimination, adversely affecting their rights of access to education and health care.69
To reduce stigma and avert discriminatory practices, targeted community interventions for
social inclusion and capacity building should focus on women’s groups, community leaders
and religious leaders. Psychosocial support should be available for individuals who suffer
psychological distress as a result of the stigma associated with sex work.
effective programming on HIV and sex work
Strategic Partnerships
Partnerships at national, local and community levels should be strengthened to remove the
barriers that sex workers face to service access and enjoyment of their human rights. To
ensure effective programming on HIV and sex work, the UN should promote and support
regional, national, and local partnerships and/or coordinating structures, between judicial,law enforcement, health, and other government sectors, communities, organizations and
networks of sex workers, trade unions, women’s organizations, and other civil society
organizations. Such efforts can encourage the implementation of policies and programmes
to educate and train these and other constituencies and support monitoring and review
mechanisms that document and hold officials accountable for implementation of rights
based policies.67 At the community level, culturally sensitive advocacy and appropriate
education efforts should be directed towards opinion leaders and law enforcement authorities
to increase support for, and the success of, HIV interventions focused on sex workers.
Community efforts should reinforce and monitor implementation of supportive policies
and laws developed at the national level.
Partnerships with sex workers and sex work community organizations, health professionals,
technical advisors, partners, families, and communities, will facilitate delivery of a comprehensive
package of effective, evidence-informed services.Partnership between sex workers, health services and law enforcement to
reduce violence
The Resourcing Health and Education Centre (RhED) in Melbourne, Australia and the
Scottish Prostitutes Education Project (SCOT-PEP), in Edinburgh, United Kingdom, provide
examples of effective working partnerships between sex workers, sex work projects, health
professionals and law enforcement agencies to reduce sex workers’ vulnerability to, and
experience of, crime and violence. A Remote Reporting Scheme encourages sex workers
to report crimes for both intelligence and investigation to the police through community
based organizations. An “Ugly Mug Scheme” provides an early warning system for sex
workers about potentially violent clients and other criminals, helping reduce their vulnerability
to violence.68
Partnerships at national, local and community levels should be strengthened to remove the
barriers that sex workers face to service access and enjoyment of their human rights. To
ensure effective programming on HIV and sex work, the UN should promote and support
regional, national, and local partnerships and/or coordinating structures, between judicial,law enforcement, health, and other government sectors, communities, organizations and
networks of sex workers, trade unions, women’s organizations, and other civil society
organizations. Such efforts can encourage the implementation of policies and programmes
to educate and train these and other constituencies and support monitoring and review
mechanisms that document and hold officials accountable for implementation of rights
based policies.67 At the community level, culturally sensitive advocacy and appropriate
education efforts should be directed towards opinion leaders and law enforcement authorities
to increase support for, and the success of, HIV interventions focused on sex workers.
Community efforts should reinforce and monitor implementation of supportive policies
and laws developed at the national level.
Partnerships with sex workers and sex work community organizations, health professionals,
technical advisors, partners, families, and communities, will facilitate delivery of a comprehensive
package of effective, evidence-informed services.Partnership between sex workers, health services and law enforcement to
reduce violence
The Resourcing Health and Education Centre (RhED) in Melbourne, Australia and the
Scottish Prostitutes Education Project (SCOT-PEP), in Edinburgh, United Kingdom, provide
examples of effective working partnerships between sex workers, sex work projects, health
professionals and law enforcement agencies to reduce sex workers’ vulnerability to, and
experience of, crime and violence. A Remote Reporting Scheme encourages sex workers
to report crimes for both intelligence and investigation to the police through community
based organizations. An “Ugly Mug Scheme” provides an early warning system for sex
workers about potentially violent clients and other criminals, helping reduce their vulnerability
to violence.68
International Guidelines on HIV/AIDS and Human Rights
Build Supportive Environments, Strengthen
Partnerships and Expand Choices
States should ensure, through political and financial support, that community consultation occurs in
all phases of HIV policy design, programme implementation and evaluation and that community
organizations are enabled to carry out their activities, including in the fields of ethics, law and human
rights, effectively.
International Guidelines on HIV/AIDS and Human Rights
Environments that support health promotion goals are created through concrete and
effective community action in setting priorities, making decisions, and planning and implementing
strategies to achieve better health. At the heart of this process is the empowerment
of communities—their ownership and control of their own endeavours and destinies61. Inthe context of sex work, community empowerment involves helping people in sex work
to come together for mutual assistance; removing barriers to full participation; respecting,
protecting and fulfilling human rights; combating stigma and discrimination; and strengthening
partnerships between government, civil society, and community actors to achieve the
most effective HIV responses.
The UN system has long recognized and supported the crucial contributions of community-
based organizations, including organizations of sex workers, towards the development
of innovative and effective HIV responses.62 The Office of the High Commissioner for
Human Rights emphasises that: “Development strategies should empower citizens, especially
the most marginalized, to articulate their expectations towards the State and other
duty-bearers, and take charge of their own development.”63 In the context of sex work,
community engagement and empowerment requires involving sex workers in the design,
research, implementation, monitoring, evaluation, of policies and programmes that affect
their lives and acknowledging that without their active engagement and involvement
efforts to provide universal access to HIV prevention, treatment, care and support will not
be optimally effective.
Building capacity in sex-worker networks and communities is part of a fundamental
commitment to the protection, promotion and respect of the human rights of sex workers.
Capacity-building includes provision of adequate funding and training for sex-worker
groups to develop and sustain organizational strength and expertise to effectively communicate
and share good practices with each other and externally. Community organizations
working with sex workers have an important role to play in supporting sex workers who
may be difficult for mainstream providers to reach, including undocumented migrants,
street workers and those working in informal sex work settings.64
Particular efforts are needed to ensure the involvement of people who sell sex but who do
not identify as sex workers in the design, research, implementation, monitoring and evaluation
of policies and programmes that address HIV and sex work.65 In nearly all countries
where the HIV epidemic has been reversed grass roots community organizations have been
at the heart of the national response66. Community groups, women’s organizations, governments,
donors and the United Nations share a responsibility to help empower all people
who engage in sex work, regardless of the circumstances in which sex work occurs.
Partnerships and Expand Choices
States should ensure, through political and financial support, that community consultation occurs in
all phases of HIV policy design, programme implementation and evaluation and that community
organizations are enabled to carry out their activities, including in the fields of ethics, law and human
rights, effectively.
International Guidelines on HIV/AIDS and Human Rights
Environments that support health promotion goals are created through concrete and
effective community action in setting priorities, making decisions, and planning and implementing
strategies to achieve better health. At the heart of this process is the empowerment
of communities—their ownership and control of their own endeavours and destinies61. Inthe context of sex work, community empowerment involves helping people in sex work
to come together for mutual assistance; removing barriers to full participation; respecting,
protecting and fulfilling human rights; combating stigma and discrimination; and strengthening
partnerships between government, civil society, and community actors to achieve the
most effective HIV responses.
The UN system has long recognized and supported the crucial contributions of community-
based organizations, including organizations of sex workers, towards the development
of innovative and effective HIV responses.62 The Office of the High Commissioner for
Human Rights emphasises that: “Development strategies should empower citizens, especially
the most marginalized, to articulate their expectations towards the State and other
duty-bearers, and take charge of their own development.”63 In the context of sex work,
community engagement and empowerment requires involving sex workers in the design,
research, implementation, monitoring, evaluation, of policies and programmes that affect
their lives and acknowledging that without their active engagement and involvement
efforts to provide universal access to HIV prevention, treatment, care and support will not
be optimally effective.
Building capacity in sex-worker networks and communities is part of a fundamental
commitment to the protection, promotion and respect of the human rights of sex workers.
Capacity-building includes provision of adequate funding and training for sex-worker
groups to develop and sustain organizational strength and expertise to effectively communicate
and share good practices with each other and externally. Community organizations
working with sex workers have an important role to play in supporting sex workers who
may be difficult for mainstream providers to reach, including undocumented migrants,
street workers and those working in informal sex work settings.64
Particular efforts are needed to ensure the involvement of people who sell sex but who do
not identify as sex workers in the design, research, implementation, monitoring and evaluation
of policies and programmes that address HIV and sex work.65 In nearly all countries
where the HIV epidemic has been reversed grass roots community organizations have been
at the heart of the national response66. Community groups, women’s organizations, governments,
donors and the United Nations share a responsibility to help empower all people
who engage in sex work, regardless of the circumstances in which sex work occurs.
Tuesday, August 28, 2012
source of new HIV infections, risking HIV transmission
Clients
The clients of sex workers reflect a cross-section of the population, representing all ages,
economic classes, and ethnic backgrounds. In some cases, sex work clients include women.
In many countries, men who buy sex represent the most important source of new HIV
infections, risking HIV transmission to their wives and partners58. HIV information and
services must be accessible for those who purchase sex. Specific education campaigns must
be developed with and for clients, who can be reached not only in sex work settings but
in other occupational and recreational environments. Successful service delivery strategies
for clients include those focusing on truck drivers; heavy transport; tourists and business
travellers; men who are separated from their families for long periods; migrants; uniformed
services, including police; construction, mining and infrastructure projects; or seafarers.
In devising strategies to reach sex work clients, programme planners should engage sex
workers, who can help identify settings where sex work occurs59. Clients who are reached
with educational and prevention programmes can become a positive force for demanding
safer sex. In addition to messages about safer sex, condom usage and health seeking behaviours,
programmes focused on clients should encourage clients to behave respectfully and
responsibly toward sex workers, and should include zero tolerance for violence and abuse.
Reaching the spouses and regular partners of clients is also important to effective HIV
prevention. Prevention strategies should use sexual and reproductive health services as an
entry point for HIV prevention, counselling, testing and referral services for women, men
and transgender people (including those providing prevention of mother-to-child transmission
and treatment for sexually transmitted infections).
The clients of sex workers reflect a cross-section of the population, representing all ages,
economic classes, and ethnic backgrounds. In some cases, sex work clients include women.
In many countries, men who buy sex represent the most important source of new HIV
infections, risking HIV transmission to their wives and partners58. HIV information and
services must be accessible for those who purchase sex. Specific education campaigns must
be developed with and for clients, who can be reached not only in sex work settings but
in other occupational and recreational environments. Successful service delivery strategies
for clients include those focusing on truck drivers; heavy transport; tourists and business
travellers; men who are separated from their families for long periods; migrants; uniformed
services, including police; construction, mining and infrastructure projects; or seafarers.
In devising strategies to reach sex work clients, programme planners should engage sex
workers, who can help identify settings where sex work occurs59. Clients who are reached
with educational and prevention programmes can become a positive force for demanding
safer sex. In addition to messages about safer sex, condom usage and health seeking behaviours,
programmes focused on clients should encourage clients to behave respectfully and
responsibly toward sex workers, and should include zero tolerance for violence and abuse.
Reaching the spouses and regular partners of clients is also important to effective HIV
prevention. Prevention strategies should use sexual and reproductive health services as an
entry point for HIV prevention, counselling, testing and referral services for women, men
and transgender people (including those providing prevention of mother-to-child transmission
and treatment for sexually transmitted infections).
Elimination of violence against sex workers
Elimination of violence against sex workers
Sex workers are often victimized by violence, including gender-based violence, perpetrated
by clients, controllers, managers of sex work establishments, law enforcement officers50 and
other government officials. Sex workers may also experience violence and discrimination
from intimate partners51, families, neighbours, partners and work colleagues.52 They are
sometimes coerced into providing sex to police in exchange for freedom from detainment,
arrest and fines53. Violence is associated with unprotected sex and heightened risk of HIV
transmission. All people selling sex must be protected from violence, coercion and other
forms of abuse, and be ensured of their rights to legal assistance and access to judicial and
extra-judicial mechanisms. Experience teaches that violence towards sex workers can be
reduced when law enforcement agencies, the judiciary, health services, and other arms of
government are engaged and cooperate fully with sex worker organizations and other civil
society groups.54 Actions to protect sex workers should include addressing clients’ misuse of
alcohol and consequent violence towards sex workers.55
Sex workers living with HIV
For sex workers living with HIV, the stigma surrounding HIV is compounded by the
stigma associated with sex work, which often further diminishes their access to essential
HIV services. Sex workers living with HIV require access to the standard of HIV
treatment, care and support services on a non-discriminatory basis. For sex workers who
test positive, support and quality counselling that addresses potential discrimination and
loss of income should be readily available. Education and encouragement about healthy
living and positive prevention56 can help protect their sexual and reproductive health and
well-being, avoid other sexually transmitted infections, delay HIV disease progression, avoid
development of resistant strains of HIV and opportunistic infections, and prevent further
transmission of the virus.
Increased access to antiretroviral therapy creates the need and opportunity for long term,
sustainable strategies that engage sex workers in life-long positive prevention. The success
of antiretroviral therapy in reducing illness and prolonging life can alter people’s perceptions
of risk, including by sex workers and their clients, underscoring the need to couple
treatment scale-up with the simultaneous expansion of access to focused HIV prevention
services. Antiretroviral treatment programmes, along with reproductive health and family
planning services, should promote correct and consistent condom use to reduce further
possibilities for HIV transmission.
Sex workers are often victimized by violence, including gender-based violence, perpetrated
by clients, controllers, managers of sex work establishments, law enforcement officers50 and
other government officials. Sex workers may also experience violence and discrimination
from intimate partners51, families, neighbours, partners and work colleagues.52 They are
sometimes coerced into providing sex to police in exchange for freedom from detainment,
arrest and fines53. Violence is associated with unprotected sex and heightened risk of HIV
transmission. All people selling sex must be protected from violence, coercion and other
forms of abuse, and be ensured of their rights to legal assistance and access to judicial and
extra-judicial mechanisms. Experience teaches that violence towards sex workers can be
reduced when law enforcement agencies, the judiciary, health services, and other arms of
government are engaged and cooperate fully with sex worker organizations and other civil
society groups.54 Actions to protect sex workers should include addressing clients’ misuse of
alcohol and consequent violence towards sex workers.55
Sex workers living with HIV
For sex workers living with HIV, the stigma surrounding HIV is compounded by the
stigma associated with sex work, which often further diminishes their access to essential
HIV services. Sex workers living with HIV require access to the standard of HIV
treatment, care and support services on a non-discriminatory basis. For sex workers who
test positive, support and quality counselling that addresses potential discrimination and
loss of income should be readily available. Education and encouragement about healthy
living and positive prevention56 can help protect their sexual and reproductive health and
well-being, avoid other sexually transmitted infections, delay HIV disease progression, avoid
development of resistant strains of HIV and opportunistic infections, and prevent further
transmission of the virus.
Increased access to antiretroviral therapy creates the need and opportunity for long term,
sustainable strategies that engage sex workers in life-long positive prevention. The success
of antiretroviral therapy in reducing illness and prolonging life can alter people’s perceptions
of risk, including by sex workers and their clients, underscoring the need to couple
treatment scale-up with the simultaneous expansion of access to focused HIV prevention
services. Antiretroviral treatment programmes, along with reproductive health and family
planning services, should promote correct and consistent condom use to reduce further
possibilities for HIV transmission.
sexual transmission of HIV and other sexually transmitted infections
Preventive commodities
Condoms, both male and female, are the single most effective available technology to
reduce the sexual transmission of HIV and other sexually transmitted infections43.
Condoms must be readily available for sex workers and their clients, either free or at low
cost, and conform to global quality standards. Condom access must be accompanied by
programmes that actively promote condom use, including the availability of water-based
lubricants and HIV education for sex workers, clients, owners of sex work establishments
and controllers. Programmes to reduce HIV transmission associated with sex work
should maximize successful negotiation of condom use, including through supporting
their use in formal sex work establishments, and through ensuring consistent supplies of
high-quality condoms in health settings, pharmacies and informal distribution points.
Drug and alcohol use, violence, exploitative management practices by brothel owners
and controllers, and harassment by law enforcement officers44 reduces the ability of sex
workers to negotiate condom use; governments and service providers should address
such factors to maximize the impact of condom programming focused on sex work.
Successful prevention approaches also need to address condom use and negotiation
between sex workers and their regular partners.45
Linking and integrating services
Integrating HIV and sexual and reproductive health programmes can significantly reduce
HIV infection and improve the quality of life of people living with HIV46. Health care
workers, including those in primary health care settings and youth friendly services,
should be aware of and responsive to the specific health needs of sex workers and
clients, including regular testing and counselling; access to maternal and infant health
services; dual protection47; family planning, and mental health issues48. Service linkages
and integration should encompass sexual and reproductive health, including sexually
transmitted infection management and treatment services; tuberculosis programmes;
programmes to prevent mother-to-child HIV transmission; hepatitis prevention and
treatment services; psychosocial and mental health support, and referral to appropriate
services for women and children who are victims of trafficking and commercial sexual
exploitation49. Service hours and delivery strategies should be as flexible to address the
local sex work context.
Condoms, both male and female, are the single most effective available technology to
reduce the sexual transmission of HIV and other sexually transmitted infections43.
Condoms must be readily available for sex workers and their clients, either free or at low
cost, and conform to global quality standards. Condom access must be accompanied by
programmes that actively promote condom use, including the availability of water-based
lubricants and HIV education for sex workers, clients, owners of sex work establishments
and controllers. Programmes to reduce HIV transmission associated with sex work
should maximize successful negotiation of condom use, including through supporting
their use in formal sex work establishments, and through ensuring consistent supplies of
high-quality condoms in health settings, pharmacies and informal distribution points.
Drug and alcohol use, violence, exploitative management practices by brothel owners
and controllers, and harassment by law enforcement officers44 reduces the ability of sex
workers to negotiate condom use; governments and service providers should address
such factors to maximize the impact of condom programming focused on sex work.
Successful prevention approaches also need to address condom use and negotiation
between sex workers and their regular partners.45
Linking and integrating services
Integrating HIV and sexual and reproductive health programmes can significantly reduce
HIV infection and improve the quality of life of people living with HIV46. Health care
workers, including those in primary health care settings and youth friendly services,
should be aware of and responsive to the specific health needs of sex workers and
clients, including regular testing and counselling; access to maternal and infant health
services; dual protection47; family planning, and mental health issues48. Service linkages
and integration should encompass sexual and reproductive health, including sexually
transmitted infection management and treatment services; tuberculosis programmes;
programmes to prevent mother-to-child HIV transmission; hepatitis prevention and
treatment services; psychosocial and mental health support, and referral to appropriate
services for women and children who are victims of trafficking and commercial sexual
exploitation49. Service hours and delivery strategies should be as flexible to address the
local sex work context.
foundation’s national HIV/AIDS prevention
India – AVAHAN: Taking Empowerment with Sex Workers to Scale42
The Bill and Melinda Gates Foundation established Avahan (“call to action” in Sanskrit) as
the foundation’s national HIV/AIDS prevention initiative in India in 2003. To date, Avahan
has committed US$ 258 million, including US$ 23 million to support the capacity of the
Government of India to implement, monitor, and evaluate HIV prevention programmes.
The goal of Avahan is to prevent further HIV transmission in India by expanding access
to effective prevention programmes in the six states where infection rates are highest
and along the nation’s major trucking routes. Avahan targets people most vulnerable to
infection—sex workers, their clients and partners (including long-distance truck drivers),
high-risk men who have sex with men, and injecting drug users. Avahan works with 290 000
sex workers and injecting drug users and six million men who frequent sex workers.
Based in Delhi, Avahan comprises a team of foundation employees with private sector
and public health experience. The team works close to the ground, reviewing the initiative’s
impact and continually refining activities in consultation with the Government of
India, international organizations, and nongovernmental organizations.
The Bill and Melinda Gates Foundation established Avahan (“call to action” in Sanskrit) as
the foundation’s national HIV/AIDS prevention initiative in India in 2003. To date, Avahan
has committed US$ 258 million, including US$ 23 million to support the capacity of the
Government of India to implement, monitor, and evaluate HIV prevention programmes.
The goal of Avahan is to prevent further HIV transmission in India by expanding access
to effective prevention programmes in the six states where infection rates are highest
and along the nation’s major trucking routes. Avahan targets people most vulnerable to
infection—sex workers, their clients and partners (including long-distance truck drivers),
high-risk men who have sex with men, and injecting drug users. Avahan works with 290 000
sex workers and injecting drug users and six million men who frequent sex workers.
Based in Delhi, Avahan comprises a team of foundation employees with private sector
and public health experience. The team works close to the ground, reviewing the initiative’s
impact and continually refining activities in consultation with the Government of
India, international organizations, and nongovernmental organizations.
respect client confidentiality;AA
respect client confidentiality; avoid coercive and mandatory approaches (such as
mandatory medical treatment or procedures, forced rehabilitation or programmes implemented
by police or based on detention); and be designed with the full participation of the
affected community.
Health and social services should address the needs of migrant sex workers with or without
papers, refugees, internally displaced persons, asylum seekers and those from ethnic minorities.
Obtaining access to needed services may be especially challenging for people who lack
legal status and may be fearful of authorities. People with undocumented status should not
be refused service by providers or receive inadequate or incomplete treatment. Where sex
workers lack the language skills to request or comply with treatment regimens, cultural
mediators who provide translation and culturally sensitive counselling and support should
be available to help ease these access barriers41.
Service provision must be sufficiently flexible to address the diverse needs of all sex
workers and take account of the physical, social, legal and other local circumstances in
which sex is sold. For instance, women who sell sex but do not identify openly as sex
workers may avoid service settings specifically designed for sex workers and instead access
local primary health care services or maternal and child health services, which should be
capable of addressing their health needs in a non-judgmental manner. Providers should
be sensitised and accountable for providing respectful and high-quality services without
distinction including those who may sell sex. Sex workers who are also drug users require
additional support including access to drug-treatment and harm-reduction programmes.
mandatory medical treatment or procedures, forced rehabilitation or programmes implemented
by police or based on detention); and be designed with the full participation of the
affected community.
Health and social services should address the needs of migrant sex workers with or without
papers, refugees, internally displaced persons, asylum seekers and those from ethnic minorities.
Obtaining access to needed services may be especially challenging for people who lack
legal status and may be fearful of authorities. People with undocumented status should not
be refused service by providers or receive inadequate or incomplete treatment. Where sex
workers lack the language skills to request or comply with treatment regimens, cultural
mediators who provide translation and culturally sensitive counselling and support should
be available to help ease these access barriers41.
Service provision must be sufficiently flexible to address the diverse needs of all sex
workers and take account of the physical, social, legal and other local circumstances in
which sex is sold. For instance, women who sell sex but do not identify openly as sex
workers may avoid service settings specifically designed for sex workers and instead access
local primary health care services or maternal and child health services, which should be
capable of addressing their health needs in a non-judgmental manner. Providers should
be sensitised and accountable for providing respectful and high-quality services without
distinction including those who may sell sex. Sex workers who are also drug users require
additional support including access to drug-treatment and harm-reduction programmes.
obstacles to accessing HIV prevention
Removing structural barriers to universal access
Even where services are theoretically available, sex workers and their clients face substantial
obstacles to accessing HIV prevention, treatment care and support, particularly where sex
work is criminalised. Ensuring that sex workers and their clients have meaningful access
to essential services demands concerted action to overcome structural factors that limit
access. Stigma and discrimination must be effectively addressed36; violence and abuse of sex
workers must be reduced37; and legal barriers to participation should be revised38. Achieving
the changes in social and legal conditions that limit access to those services will take time,
but it is critical to implement needed legal and policy reforms now and to pursue these
actions with urgency and high-level support.
Providing services to documented and undocumented migrant sex workers
TAMPEP (European Network for HIV/STI Prevention and Health promotion Among Migrant
Sex Workers) operates in 25 countries in Europe. It specialises in combining research,
interventions, and the active participation of migrant sex workers. TAMPEP has mapped
the current trends of sex work in Europe for more than a decade and through its member
organizations provides support and services to migrant sex workers. TAMPEP is also active
in advising national governments on policies and programming for migrant sex workers.39
Information and education
Sex workers and clients should have access to high-quality educational opportunities.
Such programmes should be offered in a range of settings, not merely in sex work settings.
Information about HIV prevention, treatment, care and support is essential, but it is not
sufficient on its own to address the HIV-related needs of sex workers and their clients.
Effective learning takes place through dialogue and other participatory approaches that
are relevant to learners’ everyday lives and tailored to their specific language and concerns.
Information and education programmes should focus not only on the basics about HIV
risk, prevention, treatment and care, but also cover sexual health, rights, obligations, responsibilities
and opportunities for individual and collective action. Effective approaches require
the coordinated use of diverse methods, including peer outreach and education, facilitybased
counselling, print materials and mass media, and should always be age-specific,
gender-responsive, scientifically accurate and culturally appropriate.
Characteristics of effective services
Services must be available, accessible, acceptable and of high-quality40, in places and at times
that ensure their accessibility to sex workers and their clients. Integrated services increase
the number of entry points and expand coverage for a broader range of health and social
services. Service provision should not only address the needs of female sex workers but
also correspond to the specific needs of male and transgender sex workers, who are often
poorly served by existing providers. Services should provide the best available standard
Even where services are theoretically available, sex workers and their clients face substantial
obstacles to accessing HIV prevention, treatment care and support, particularly where sex
work is criminalised. Ensuring that sex workers and their clients have meaningful access
to essential services demands concerted action to overcome structural factors that limit
access. Stigma and discrimination must be effectively addressed36; violence and abuse of sex
workers must be reduced37; and legal barriers to participation should be revised38. Achieving
the changes in social and legal conditions that limit access to those services will take time,
but it is critical to implement needed legal and policy reforms now and to pursue these
actions with urgency and high-level support.
Providing services to documented and undocumented migrant sex workers
TAMPEP (European Network for HIV/STI Prevention and Health promotion Among Migrant
Sex Workers) operates in 25 countries in Europe. It specialises in combining research,
interventions, and the active participation of migrant sex workers. TAMPEP has mapped
the current trends of sex work in Europe for more than a decade and through its member
organizations provides support and services to migrant sex workers. TAMPEP is also active
in advising national governments on policies and programming for migrant sex workers.39
Information and education
Sex workers and clients should have access to high-quality educational opportunities.
Such programmes should be offered in a range of settings, not merely in sex work settings.
Information about HIV prevention, treatment, care and support is essential, but it is not
sufficient on its own to address the HIV-related needs of sex workers and their clients.
Effective learning takes place through dialogue and other participatory approaches that
are relevant to learners’ everyday lives and tailored to their specific language and concerns.
Information and education programmes should focus not only on the basics about HIV
risk, prevention, treatment and care, but also cover sexual health, rights, obligations, responsibilities
and opportunities for individual and collective action. Effective approaches require
the coordinated use of diverse methods, including peer outreach and education, facilitybased
counselling, print materials and mass media, and should always be age-specific,
gender-responsive, scientifically accurate and culturally appropriate.
Characteristics of effective services
Services must be available, accessible, acceptable and of high-quality40, in places and at times
that ensure their accessibility to sex workers and their clients. Integrated services increase
the number of entry points and expand coverage for a broader range of health and social
services. Service provision should not only address the needs of female sex workers but
also correspond to the specific needs of male and transgender sex workers, who are often
poorly served by existing providers. Services should provide the best available standard
The Principles of Effective HIV Prevention
access to high-quality primary health care, TB management, sexual and reproductive
health services, especially sexually transmitted infection management and prevention
of mother-to-child transmission;
access to alcohol and drug-related harm reduction programmes, including sterile
needles/syringes and opiate-substitution therapy; and,
integration of HIV services with all relevant welfare services, including social support
mechanisms for sex workers and their families.
Effective delivery of these essential services requires coordinated action by a range of
actors operating at different levels. Convening and facilitating collaboration among the
government and civil society partners to ensure the delivery of this coordinated action
is the responsibility of national authorities. The UN system should promote and support
the planning and delivery of this essential combination of actions on the scale required to
achieve universal access।
The Principles of Effective HIV Prevention, Treatment, Care and Support
The 2005 UNAIDS policy position paper on Intensifying HIV Prevention34 provides a
global framework to help guide all HIV prevention efforts and is reflected in UNAIDS’
response to HIV and sex work.35
The UNAIDS prevention framework is based on the following principles.
All HIV prevention, treatment, care and support efforts/programmes must have
as their fundamental basis the promotion, protection and respect of human rights
including gender equality.
HIV prevention, treatment, care and support programmes must be differentiated
and locally adapted to the relevant epidemiological, economic, social and cultural
contexts in which they are implemented.
HIV prevention, treatment, care and support actions must be evidence-informed,
based on what is known and proven to be effective and investment to expand the
evidence base should be strengthened.
HIV prevention, treatment, care and support programmes must be comprehensive
in scope, using the full range of policy and programmatic interventions known
to be effective.
HIV prevention is for life; therefore, both delivery of existing interventions as
well as research and development of new technologies require a long-term and
sustained effort, recognizing that results will only be seen over the longer-term
and need to be maintained.
HIV prevention, treatment, care and support programming must be at a coverage,
scale and intensity that is enough to make a critical difference.
Community participation of those for whom HIV prevention, treatment, care and
support programmes are planned is critical for their impact.
health services, especially sexually transmitted infection management and prevention
of mother-to-child transmission;
access to alcohol and drug-related harm reduction programmes, including sterile
needles/syringes and opiate-substitution therapy; and,
integration of HIV services with all relevant welfare services, including social support
mechanisms for sex workers and their families.
Effective delivery of these essential services requires coordinated action by a range of
actors operating at different levels. Convening and facilitating collaboration among the
government and civil society partners to ensure the delivery of this coordinated action
is the responsibility of national authorities. The UN system should promote and support
the planning and delivery of this essential combination of actions on the scale required to
achieve universal access।
The Principles of Effective HIV Prevention, Treatment, Care and Support
The 2005 UNAIDS policy position paper on Intensifying HIV Prevention34 provides a
global framework to help guide all HIV prevention efforts and is reflected in UNAIDS’
response to HIV and sex work.35
The UNAIDS prevention framework is based on the following principles.
All HIV prevention, treatment, care and support efforts/programmes must have
as their fundamental basis the promotion, protection and respect of human rights
including gender equality.
HIV prevention, treatment, care and support programmes must be differentiated
and locally adapted to the relevant epidemiological, economic, social and cultural
contexts in which they are implemented.
HIV prevention, treatment, care and support actions must be evidence-informed,
based on what is known and proven to be effective and investment to expand the
evidence base should be strengthened.
HIV prevention, treatment, care and support programmes must be comprehensive
in scope, using the full range of policy and programmatic interventions known
to be effective.
HIV prevention is for life; therefore, both delivery of existing interventions as
well as research and development of new technologies require a long-term and
sustained effort, recognizing that results will only be seen over the longer-term
and need to be maintained.
HIV prevention, treatment, care and support programming must be at a coverage,
scale and intensity that is enough to make a critical difference.
Community participation of those for whom HIV prevention, treatment, care and
support programmes are planned is critical for their impact.
Monday, August 27, 2012
Three Pillars of an Effective, Evidence-Informed Response to HIV and Sex Work
Three Pillars of an Effective, Evidence-Informed
Response to HIV and Sex Work
UNAIDS will base its efforts to address HIV and sex work on three essential pillars.
Pillar 1: Assure universal access to comprehensive HIV prevention, treatment, care and support.
Pillar 2: Build supportive environments, strengthen partnerships and expand choices.
Pillar 3: Reduce vulnerability and address structural issues.
Each pillar is essential, and the three are mutually interdependent and should be coordinated
and implemented simultaneously. Each pillar permits and envisions short-term
measures and results, as well as longer-range structural measures that take longer to produce
effects। These need to be pursued in combination and with equal urgency.
Assure Universal Access to Comprehensive HIV
Prevention, Treatment, Care and Support
31 Monitoring the AIDS Pandemic Network (2004) AIDS in Asia: Face the facts. http://www.mapnetwork.org/docs/
MAPAIDSinAsia2004.pdf , UNAIDS (2006). Report on the Global AIDS Epidemic.
32 Rekart ML (2005) Sex-work harm reduction, The Lancet. Vol 366 No.9503 PP:2123-2134.
33 Overs C (2002) Sex Workers: Part of the Solution. An Analysis of HIV prevention programming to prevent HIV
transmission during commercial sex in developing countries.
Comprehensive, accessible, acceptable, sustainable, high-quality, user-friendly HIV
prevention, treatment, care and support must be urgently scaled up and adapted to
different local contexts and individual needs. Essential actions include:
actions to address structural barriers, including policies, legislation, and customary
practices that prevent access and utilisation of appropriate HIV prevention, treatment,
and care and support;
policies and programmes to ensure freedom from violence, abuse, and discrimination;
information for sex workers and their clients and others involved in the sex industry;
reliable and affordable access to commodities, including high-quality male and female
condoms, water-based lubricants, and contraceptives, and other requirements for
health, such as food, sanitation and clean water;
access to voluntary HIV testing and counselling, with treatment, effective social
support and care and for sex workers who test positive for HIV;
Consistent with the aim of universal access to HIV prevention, treatment, care and
support—formally endorsed in the 2006 Political Declaration on HIV/AIDS—
comprehensive, evidence-informed programmes for sex workers and their clients should
urgently be scaled up. Meeting the needs of key populations at higher risk of exposure to
HIV, such as sex workers and their clients, has also been shown to be highly cost effective31.
Sex workers have amply demonstrated their willingness and ability to be active partners
in such efforts32; where health and social services are provided and sex workers are actively
engaged in efforts to provide universal access to HIV prevention, treatment, care and
support, HIV incidence declines.33
States should...take measures necessary to ensure for all persons, on a sustained and equal basis, the
availability and accessibility of quality goods, services and information on HIV/AIDS prevention,
treatment, care and support, including antiretroviral and other safe and effective medicines, diagnostics
and related technologies for preventative, curative and palliative care of HIV and related opportunistic
infections and conditions. States should take such measures at both the domestic and international
levels, with particular attention to vulnerable individuals and populations.
Response to HIV and Sex Work
UNAIDS will base its efforts to address HIV and sex work on three essential pillars.
Pillar 1: Assure universal access to comprehensive HIV prevention, treatment, care and support.
Pillar 2: Build supportive environments, strengthen partnerships and expand choices.
Pillar 3: Reduce vulnerability and address structural issues.
Each pillar is essential, and the three are mutually interdependent and should be coordinated
and implemented simultaneously. Each pillar permits and envisions short-term
measures and results, as well as longer-range structural measures that take longer to produce
effects। These need to be pursued in combination and with equal urgency.
Assure Universal Access to Comprehensive HIV
Prevention, Treatment, Care and Support
31 Monitoring the AIDS Pandemic Network (2004) AIDS in Asia: Face the facts. http://www.mapnetwork.org/docs/
MAPAIDSinAsia2004.pdf , UNAIDS (2006). Report on the Global AIDS Epidemic.
32 Rekart ML (2005) Sex-work harm reduction, The Lancet. Vol 366 No.9503 PP:2123-2134.
33 Overs C (2002) Sex Workers: Part of the Solution. An Analysis of HIV prevention programming to prevent HIV
transmission during commercial sex in developing countries.
Comprehensive, accessible, acceptable, sustainable, high-quality, user-friendly HIV
prevention, treatment, care and support must be urgently scaled up and adapted to
different local contexts and individual needs. Essential actions include:
actions to address structural barriers, including policies, legislation, and customary
practices that prevent access and utilisation of appropriate HIV prevention, treatment,
and care and support;
policies and programmes to ensure freedom from violence, abuse, and discrimination;
information for sex workers and their clients and others involved in the sex industry;
reliable and affordable access to commodities, including high-quality male and female
condoms, water-based lubricants, and contraceptives, and other requirements for
health, such as food, sanitation and clean water;
access to voluntary HIV testing and counselling, with treatment, effective social
support and care and for sex workers who test positive for HIV;
Consistent with the aim of universal access to HIV prevention, treatment, care and
support—formally endorsed in the 2006 Political Declaration on HIV/AIDS—
comprehensive, evidence-informed programmes for sex workers and their clients should
urgently be scaled up. Meeting the needs of key populations at higher risk of exposure to
HIV, such as sex workers and their clients, has also been shown to be highly cost effective31.
Sex workers have amply demonstrated their willingness and ability to be active partners
in such efforts32; where health and social services are provided and sex workers are actively
engaged in efforts to provide universal access to HIV prevention, treatment, care and
support, HIV incidence declines.33
States should...take measures necessary to ensure for all persons, on a sustained and equal basis, the
availability and accessibility of quality goods, services and information on HIV/AIDS prevention,
treatment, care and support, including antiretroviral and other safe and effective medicines, diagnostics
and related technologies for preventative, curative and palliative care of HIV and related opportunistic
infections and conditions. States should take such measures at both the domestic and international
levels, with particular attention to vulnerable individuals and populations.
the grounds of real or perceived HIV status
The United Nations is mandated to uphold international human rights standards as
reflected in the Universal Declaration of Human Rights and other core human rights
instruments29. In addition to this overriding humanitarian imperative, experience has
demonstrated that effective HIV responses are grounded in the respect of human rights,
including non-discrimination on the grounds of real or perceived HIV status. Similarly,
the respect for the human rights of vulnerable populations is a precondition to their
involvement in national responses and the reduction of risk and harm.As human rights are universal, they apply to all people. Every human being is entitled to
the highest attainable standard of health, privacy, liberty and security, freedom of expression
and assembly, gender equality, freedom from violence and arbitrary arrest, free choice
of employment and just and favourable conditions of work, non-discrimination, and the
prohibition of forced labour, child labour and trafficking.
The UN system affirms the universality, inalienability and interdependence of rights,
and promotes and supports their application in practice, including for sex workers, their
clients and otherwise in the context of sex work, even where sex work is criminalised. The
recommendations outlined under each of the three pillars below are informed by, and aim
to consolidate the application of, the rights and responsibilities of those involved in sex
work. Within the international framework of human rights, a rights-based approach will be
applied according to the mandate of each member of the Joint United Nations Programme
on AIDS30.
Studies, as well as programmatic experience, have demonstrated the feasibility of
reducing HIV transmission associated with sex work. However, few national policies and
programmes adequately address the HIV-related needs of sex workers and their clients, or
their potential to contribute to national responses to HIV. States are encouraged to develop
the programmes needed to reduce HIV risk and vulnerability in the context of sex work.
The increasing mobility of people within and across national boundaries heightens the
importance of UN guidance on HIV and sex work that is based on universal principles
and that facilitates cross-border collaboration to achieve and sustain universal access to HIV
prevention, treatment, care and support for all people who need them.
reflected in the Universal Declaration of Human Rights and other core human rights
instruments29. In addition to this overriding humanitarian imperative, experience has
demonstrated that effective HIV responses are grounded in the respect of human rights,
including non-discrimination on the grounds of real or perceived HIV status. Similarly,
the respect for the human rights of vulnerable populations is a precondition to their
involvement in national responses and the reduction of risk and harm.As human rights are universal, they apply to all people. Every human being is entitled to
the highest attainable standard of health, privacy, liberty and security, freedom of expression
and assembly, gender equality, freedom from violence and arbitrary arrest, free choice
of employment and just and favourable conditions of work, non-discrimination, and the
prohibition of forced labour, child labour and trafficking.
The UN system affirms the universality, inalienability and interdependence of rights,
and promotes and supports their application in practice, including for sex workers, their
clients and otherwise in the context of sex work, even where sex work is criminalised. The
recommendations outlined under each of the three pillars below are informed by, and aim
to consolidate the application of, the rights and responsibilities of those involved in sex
work. Within the international framework of human rights, a rights-based approach will be
applied according to the mandate of each member of the Joint United Nations Programme
on AIDS30.
Studies, as well as programmatic experience, have demonstrated the feasibility of
reducing HIV transmission associated with sex work. However, few national policies and
programmes adequately address the HIV-related needs of sex workers and their clients, or
their potential to contribute to national responses to HIV. States are encouraged to develop
the programmes needed to reduce HIV risk and vulnerability in the context of sex work.
The increasing mobility of people within and across national boundaries heightens the
importance of UN guidance on HIV and sex work that is based on universal principles
and that facilitates cross-border collaboration to achieve and sustain universal access to HIV
prevention, treatment, care and support for all people who need them.
A number of complex factors may also contribute to entry into sex work
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Understanding Sex Work and Its Links with HIV
Understanding Sex Work and Its Links with HIV
Sex workers include “female, male and transgender adults and young people7 who receive
money or goods in exchange for sexual services, either regularly or occasionally…”8. Sex
work varies between and within countries and communities. Sex work may vary in the
degree to which it is more or less “formal” or organized, and in the degree to which it is
distinct from other social and sexual relationships and types of sexual-economic exchange9.
Where sex work is organized, controllers10 and managers generally act as clearly-defined,
power-holding intermediaries between the sex worker and client, and often between both
and local authorities. Self-employed sex workers usually find their clients through independent
means, increasingly through mobile telephones and the internet11, and may be
recruited or excluded from settings where an organized system is in place. Individuals maysell sex as a full-time occupation, part-time, or occasionally to meet specific economic
needs (such as education costs, or in a family financial crisis). Others are trafficked or
coerced into selling sex. Many people who exchange sex for money or goods do not selfidentify
as sex workers12, and do not seek nor have access to HIV prevention, treatment,
care and support advice or services for sex workers, including in humanitarian and postconflict
settings13.
The settings in which sex work may occur range from brothels or other dedicated
establishments to roadsides, markets, petrol stations, truck stops, parks, hotels, bars,
restaurants and private homes, and may be recognizable or hidden. Sex work settings may
cater to local communities or primarily involve transient, migrant and mobile populations
of both sex workers and clients. Depending on their individual circumstances, sex workers
may be further victimized by discriminatory gender-based attitudes, violence, and sexual
exploitation, and by membership in other populations that are highly vulnerable to HIV
exposure, such as men who have sex with men and injecting drug users14. Policies and
programmes to address the links between HIV and sex work must recognize the social and
geographic diversity of sex work, as well as the rapid changes that may occur in patterns of
sex work, including types of transactional sex15, and in sex work settings.16
The conditions in which sex work occurs may have a profound impact on HIV risk
and vulnerability17. While some sex work settings have served as excellent venues for
HIV-prevention programmes, many others neither promote safer sex nor protect sex
workers from violence perpetrated by clients, law enforcement officers, gangs, establishment
owners or controllers. In addition, debt-bondage, low pay and inadequate living conditions
may further compromise the health and safety of sex workers. Where sex workers are able
to assert control over their working environments and insist on safer sex, evidence indicates
that HIV risk and vulnerability can be sharply reduced. Excellent examples of community
organized HIV-prevention programming for sex workers include AVAHAN (India),
Clinque de Confiance (Cote d’Ivoire), CONASIDA (Mexico), DAVIDA (Brazil), Durjoy
Nari Shango (Bangladesh), EMPOWER (Thailand), FIMIZORE (Madagascar), Durbar
Mahila Samanwaya Committee (India), SWING (Thailand) and TAMPEP (Europe)18In many countries, laws, policies, discriminatory practices, and stigmatizing social attitudes
drive sex work underground, impeding efforts to reach sex workers and their clients with
HIV prevention, treatment, care and support programmes. Sex workers frequently have
insufficient access to adequate health services; male and female condoms and water-based
lubricants; post-exposure prophylaxis following unprotected sex and rape; management
of sexually transmitted infections, drug treatment and other harm reduction services19;
protection from violence and abusive work conditions; and social and legal support.
Inadequate service access is often compounded by abuse from law enforcement officers.
Documented and undocumented migrants working in sex work often face particularly
severe access barriers as a result of linguistic challenges, exclusion from the services that are
available locally, and minimal contact with support networks. Even where HIV information
and services are accessible to sex workers, such services often fail to comply with human
rights standards20 and insufficiently engage clients, the controllers and managers of sex work
or take account of the local social and cultural context.
Similarly, in many countries, official policies principally focus on reducing or punishing
the suppliers while ignoring the consistent demand for paid sex.21 The demand for sex
work may be affected by social and cultural norms and individual circumstances, including
work-related mobility and spousal separation; social isolation and loneliness; access to
disposable income22; and attitudes based on harmful gender norms, including a desire for
sexual dominance and sense of entitlement, which may manifest in sexual and economic
exploitation and violence against sex workers. When addressing HIV in the context of
sex work, policies and programmes should not only focus on the needs of sex workers
themselves but also address factors that contribute to the demand for paid sex.
Sex workers include “female, male and transgender adults and young people7 who receive
money or goods in exchange for sexual services, either regularly or occasionally…”8. Sex
work varies between and within countries and communities. Sex work may vary in the
degree to which it is more or less “formal” or organized, and in the degree to which it is
distinct from other social and sexual relationships and types of sexual-economic exchange9.
Where sex work is organized, controllers10 and managers generally act as clearly-defined,
power-holding intermediaries between the sex worker and client, and often between both
and local authorities. Self-employed sex workers usually find their clients through independent
means, increasingly through mobile telephones and the internet11, and may be
recruited or excluded from settings where an organized system is in place. Individuals maysell sex as a full-time occupation, part-time, or occasionally to meet specific economic
needs (such as education costs, or in a family financial crisis). Others are trafficked or
coerced into selling sex. Many people who exchange sex for money or goods do not selfidentify
as sex workers12, and do not seek nor have access to HIV prevention, treatment,
care and support advice or services for sex workers, including in humanitarian and postconflict
settings13.
The settings in which sex work may occur range from brothels or other dedicated
establishments to roadsides, markets, petrol stations, truck stops, parks, hotels, bars,
restaurants and private homes, and may be recognizable or hidden. Sex work settings may
cater to local communities or primarily involve transient, migrant and mobile populations
of both sex workers and clients. Depending on their individual circumstances, sex workers
may be further victimized by discriminatory gender-based attitudes, violence, and sexual
exploitation, and by membership in other populations that are highly vulnerable to HIV
exposure, such as men who have sex with men and injecting drug users14. Policies and
programmes to address the links between HIV and sex work must recognize the social and
geographic diversity of sex work, as well as the rapid changes that may occur in patterns of
sex work, including types of transactional sex15, and in sex work settings.16
The conditions in which sex work occurs may have a profound impact on HIV risk
and vulnerability17. While some sex work settings have served as excellent venues for
HIV-prevention programmes, many others neither promote safer sex nor protect sex
workers from violence perpetrated by clients, law enforcement officers, gangs, establishment
owners or controllers. In addition, debt-bondage, low pay and inadequate living conditions
may further compromise the health and safety of sex workers. Where sex workers are able
to assert control over their working environments and insist on safer sex, evidence indicates
that HIV risk and vulnerability can be sharply reduced. Excellent examples of community
organized HIV-prevention programming for sex workers include AVAHAN (India),
Clinque de Confiance (Cote d’Ivoire), CONASIDA (Mexico), DAVIDA (Brazil), Durjoy
Nari Shango (Bangladesh), EMPOWER (Thailand), FIMIZORE (Madagascar), Durbar
Mahila Samanwaya Committee (India), SWING (Thailand) and TAMPEP (Europe)18In many countries, laws, policies, discriminatory practices, and stigmatizing social attitudes
drive sex work underground, impeding efforts to reach sex workers and their clients with
HIV prevention, treatment, care and support programmes. Sex workers frequently have
insufficient access to adequate health services; male and female condoms and water-based
lubricants; post-exposure prophylaxis following unprotected sex and rape; management
of sexually transmitted infections, drug treatment and other harm reduction services19;
protection from violence and abusive work conditions; and social and legal support.
Inadequate service access is often compounded by abuse from law enforcement officers.
Documented and undocumented migrants working in sex work often face particularly
severe access barriers as a result of linguistic challenges, exclusion from the services that are
available locally, and minimal contact with support networks. Even where HIV information
and services are accessible to sex workers, such services often fail to comply with human
rights standards20 and insufficiently engage clients, the controllers and managers of sex work
or take account of the local social and cultural context.
Similarly, in many countries, official policies principally focus on reducing or punishing
the suppliers while ignoring the consistent demand for paid sex.21 The demand for sex
work may be affected by social and cultural norms and individual circumstances, including
work-related mobility and spousal separation; social isolation and loneliness; access to
disposable income22; and attitudes based on harmful gender norms, including a desire for
sexual dominance and sense of entitlement, which may manifest in sexual and economic
exploitation and violence against sex workers. When addressing HIV in the context of
sex work, policies and programmes should not only focus on the needs of sex workers
themselves but also address factors that contribute to the demand for paid sex.
AIDS to reduce HIV risk and vulnerabilityA
Sound, evidence-informed measures to address sex work constitute an integral component
of an effective, comprehensive response to HIV. The Guidance Note provides clarification
and direction regarding approaches by the Joint United Nations Programme on HIV/
AIDS to reduce HIV risk and vulnerability in the context of sex work. It provides a policy
and programmatic emphasis that rests on three interdependent pillars: (a) access to HIV
prevention, treatment, care and support for all sex workers and their clients; (b) supportive
environments and partnerships that facilitate universal access to needed services, including
life choices and occupational alternatives to sex work for those who want to leave it; and
(c) action to address structural issues related to HIV and sex work.
Further, it is firmly built on human rights principles supporting the right of people to
make informed choices about their lives, in a supportive environment that empowers them
to make such choices free from coercion, violence and fear. This Guidance Note affirms
the human right to the liberty and security of person recognising each individual’s agency
over her/his body and sexuality, as well each individual’s right not to be trafficked or
held in slave-like conditions. It also affirms that all forms of the involvement of children
(defined as people under the age of 18) in sex work and other forms of sexual exploitation
or abuse contravenes United Nations conventions and international human rights law6.
of an effective, comprehensive response to HIV. The Guidance Note provides clarification
and direction regarding approaches by the Joint United Nations Programme on HIV/
AIDS to reduce HIV risk and vulnerability in the context of sex work. It provides a policy
and programmatic emphasis that rests on three interdependent pillars: (a) access to HIV
prevention, treatment, care and support for all sex workers and their clients; (b) supportive
environments and partnerships that facilitate universal access to needed services, including
life choices and occupational alternatives to sex work for those who want to leave it; and
(c) action to address structural issues related to HIV and sex work.
Further, it is firmly built on human rights principles supporting the right of people to
make informed choices about their lives, in a supportive environment that empowers them
to make such choices free from coercion, violence and fear. This Guidance Note affirms
the human right to the liberty and security of person recognising each individual’s agency
over her/his body and sexuality, as well each individual’s right not to be trafficked or
held in slave-like conditions. It also affirms that all forms of the involvement of children
(defined as people under the age of 18) in sex work and other forms of sexual exploitation
or abuse contravenes United Nations conventions and international human rights law6.
Sunday, August 26, 2012
on HIV and Sex Work
UNAIDS Guidance Note
on HIV and Sex Work
The development of the UNAIDS Guidance
Note on HIV and Sex Work benefited from
the contributions of the UNAIDS Reference
Group on HIV and Human Rights and the
Global Working Group on HIV and Sex
Work Policy. The Guidance Note was also
informed by a series of consultations that
occurred between 2006 and 2008, including
the Global Technical Consultation on HIV
and Sex Work; a regional consultation
for Latin America and the Caribbean;
subregional consultations in southern Africa
and the Caribbean; national consultations
in China, Malawi, Peru, Thailand and
Zimbabwe; and subnational consultations
and discussions in Kenya, Nepal and the
Pacific Island Countries. The specific needs
of populations of humanitarian concern
were informed by consultations in southern
Eastern Europe. The UNAIDS Guidance
Note further benefited from the Informal
Briefing for the High Level Meeting on
AIDS, held in April 2008 focusing on HIV
and sex work.
This Guidance Note has been
developed to provide the UNAIDS
Cosponsors and Secretariat with a coordinated
human-rights-based approach
to promoting universal access2 to HIV
prevention, treatment, care and support
in the context of adult sex work. In
a world where the overwhelming
majority of HIV infections are sexually
transmitted, sex workers and their
clients are at heightened risk of HIV,
in large measure as a result of a larger
number of sex partners. Vulnerability to
HIV as a result of sex work extends to
women, men, and transgender people.
Although the links between sex work
and HIV vulnerability have been
recognized since the earliest days of
the epidemic, surveys indicate that sex
workers have inadequate access to HIV
prevention services3, and it is believed that their access is even more limited for appropriate
treatment, care and support. To date, the HIV response has devoted insufficient attention
and resources to efforts to address HIV and sex work, with less than 1% of global funding
for HIV prevention being spent on HIV and sex work4. The epidemiological data on
HIV infection rates among sex workers and their clients reflects the failure to adequately
respond to their human rights and public health needs. Recent studies continue to confirm
that in many countries sex workers experience higher rates of HIV infection than in most
other population groups
on HIV and Sex Work
The development of the UNAIDS Guidance
Note on HIV and Sex Work benefited from
the contributions of the UNAIDS Reference
Group on HIV and Human Rights and the
Global Working Group on HIV and Sex
Work Policy. The Guidance Note was also
informed by a series of consultations that
occurred between 2006 and 2008, including
the Global Technical Consultation on HIV
and Sex Work; a regional consultation
for Latin America and the Caribbean;
subregional consultations in southern Africa
and the Caribbean; national consultations
in China, Malawi, Peru, Thailand and
Zimbabwe; and subnational consultations
and discussions in Kenya, Nepal and the
Pacific Island Countries. The specific needs
of populations of humanitarian concern
were informed by consultations in southern
Eastern Europe. The UNAIDS Guidance
Note further benefited from the Informal
Briefing for the High Level Meeting on
AIDS, held in April 2008 focusing on HIV
and sex work.
This Guidance Note has been
developed to provide the UNAIDS
Cosponsors and Secretariat with a coordinated
human-rights-based approach
to promoting universal access2 to HIV
prevention, treatment, care and support
in the context of adult sex work. In
a world where the overwhelming
majority of HIV infections are sexually
transmitted, sex workers and their
clients are at heightened risk of HIV,
in large measure as a result of a larger
number of sex partners. Vulnerability to
HIV as a result of sex work extends to
women, men, and transgender people.
Although the links between sex work
and HIV vulnerability have been
recognized since the earliest days of
the epidemic, surveys indicate that sex
workers have inadequate access to HIV
prevention services3, and it is believed that their access is even more limited for appropriate
treatment, care and support. To date, the HIV response has devoted insufficient attention
and resources to efforts to address HIV and sex work, with less than 1% of global funding
for HIV prevention being spent on HIV and sex work4. The epidemiological data on
HIV infection rates among sex workers and their clients reflects the failure to adequately
respond to their human rights and public health needs. Recent studies continue to confirm
that in many countries sex workers experience higher rates of HIV infection than in most
other population groups
Condom education and promotion must be accompanied
Plug the supply and resource gaps. It is critical that a regular supply of condoms be
guaranteed by national programmes and supported by the donor and non-governmental
organization communities. Male and female condoms should be available to everyone who
needs them, whenever and wherever they want them. Condom education and promotion
must be accompanied by a stable and affordable supply of condoms. Coordinated and
collective actions at global and national levels (between donors, national governments
and the private sector) are required to improve commodity purchasing and distribution.
6. Improve impact measurement. Condom-promotion programmes need to have
programme effectiveness measured, regardless of the group being targeted. Other than
Senegal, Thailand, Uganda and, possibly, Cambodia, there are still too few examples
of low- and middle-income countries that have successfully halted and begun reversing
their epidemics. Trends in the parameters of condom use in countries (e.g., distribution
numbers, consistent condom use with casual and regular partners) should be vigilantly
monitored and the effects on HIV transmission assessed. For example, there are
encouraging findings from a study among 18–24-year-old young men in a South African
township that showed significant impact at the general population level of consistent
condom use on HIV, herpes simplex-2, and genital ulceration. Young men who used
condoms consistently were two to three times less likely to be infected with HIV and to
have genital ulceration 46.
Behavioural information on the proportion of people in different populations in a country
who consistently use condoms with various types of partners is a key to tracking the
effects of condom programming on HIV incidence, although methodological challenges
remain. Condom promotion aimed at the general population should ideally include
measurement of trends in the numbers of sexual partners (especially casual partners and
among the young). Research should focus on establishing the level of condom use that
is required to make a difference in incidence and prevalence rates in different epidemic
situations.
Whatever the challenges to ensuring condom access, availability and correct and
consistent use, the promotion of condoms is a strategy that must be used to the best
advantage. There are so few effective tools to prevent HIV transmission that there is
no leeway to forego any of them—least of all the one that, arguably, provides the best
chance of success।
guaranteed by national programmes and supported by the donor and non-governmental
organization communities. Male and female condoms should be available to everyone who
needs them, whenever and wherever they want them. Condom education and promotion
must be accompanied by a stable and affordable supply of condoms. Coordinated and
collective actions at global and national levels (between donors, national governments
and the private sector) are required to improve commodity purchasing and distribution.
6. Improve impact measurement. Condom-promotion programmes need to have
programme effectiveness measured, regardless of the group being targeted. Other than
Senegal, Thailand, Uganda and, possibly, Cambodia, there are still too few examples
of low- and middle-income countries that have successfully halted and begun reversing
their epidemics. Trends in the parameters of condom use in countries (e.g., distribution
numbers, consistent condom use with casual and regular partners) should be vigilantly
monitored and the effects on HIV transmission assessed. For example, there are
encouraging findings from a study among 18–24-year-old young men in a South African
township that showed significant impact at the general population level of consistent
condom use on HIV, herpes simplex-2, and genital ulceration. Young men who used
condoms consistently were two to three times less likely to be infected with HIV and to
have genital ulceration 46.
Behavioural information on the proportion of people in different populations in a country
who consistently use condoms with various types of partners is a key to tracking the
effects of condom programming on HIV incidence, although methodological challenges
remain. Condom promotion aimed at the general population should ideally include
measurement of trends in the numbers of sexual partners (especially casual partners and
among the young). Research should focus on establishing the level of condom use that
is required to make a difference in incidence and prevalence rates in different epidemic
situations.
Whatever the challenges to ensuring condom access, availability and correct and
consistent use, the promotion of condoms is a strategy that must be used to the best
advantage. There are so few effective tools to prevent HIV transmission that there is
no leeway to forego any of them—least of all the one that, arguably, provides the best
chance of success।
Consistent condom use is essential for HIV
Address critical misperceptions. The correct and consistent use of condoms in
stable relationships continues to be a challenge. This issue, as well as the continued
promotion of condom use with casual partners, must be directly addressed. In addition
to promoting the use of condoms with regular partners through traditional mass media
and small media channels, it is important to reinforce it through voluntary counselling
and testing networks. Couples and others who may assume it is already too late to
adopt safer sexual practices must be encouraged and supported to use condoms through
post-test and ongoing counselling. Consistent condom use is essential for HIV-positive
persons who choose to remain sexually active.
HIV prevention programmes need to regularly draw from the findings of operational
research on how consistent condom use for key groups in different settings can be
achieved.
4. Draw on the synergistic interaction of interventions. With the continued rise in
the spread of the epidemic across all regions, HIV prevention programmes must include
a wide range and mix of interventions that are tailored to the country’s epidemiological
and cultural situation. This should include, but not be limited to, education on the
‘ABCs’ of prevention, treatment and care of STIs, voluntary counselling and testing
services, harm reduction, and addressing discrimination and stigmatization.
Promoting sexual abstinence or reduction in the number of sexual partners does not
preclude the promotion of condoms. All prevention programmes have the responsibility
to provide people with complete and accurate information so that they are able to make
informed choices. Providing accurate information includes avoiding overstating the
effectiveness of condoms, such as saying that sex with a condom is “safe sex” (instead
of “safer sex”), and telling the truth about condoms (i.e., that they are highly effective
when used correctly and consistently).
Successful programmes that encourage delayed sexual onset and partner reduction can
also help people to be aware of the importance of condom use whenever they do not
meet these objectives. Monitoring the outcomes of these programmes can provide useful
insights for optimal calibration of the mix of prevention interventions.
stable relationships continues to be a challenge. This issue, as well as the continued
promotion of condom use with casual partners, must be directly addressed. In addition
to promoting the use of condoms with regular partners through traditional mass media
and small media channels, it is important to reinforce it through voluntary counselling
and testing networks. Couples and others who may assume it is already too late to
adopt safer sexual practices must be encouraged and supported to use condoms through
post-test and ongoing counselling. Consistent condom use is essential for HIV-positive
persons who choose to remain sexually active.
HIV prevention programmes need to regularly draw from the findings of operational
research on how consistent condom use for key groups in different settings can be
achieved.
4. Draw on the synergistic interaction of interventions. With the continued rise in
the spread of the epidemic across all regions, HIV prevention programmes must include
a wide range and mix of interventions that are tailored to the country’s epidemiological
and cultural situation. This should include, but not be limited to, education on the
‘ABCs’ of prevention, treatment and care of STIs, voluntary counselling and testing
services, harm reduction, and addressing discrimination and stigmatization.
Promoting sexual abstinence or reduction in the number of sexual partners does not
preclude the promotion of condoms. All prevention programmes have the responsibility
to provide people with complete and accurate information so that they are able to make
informed choices. Providing accurate information includes avoiding overstating the
effectiveness of condoms, such as saying that sex with a condom is “safe sex” (instead
of “safer sex”), and telling the truth about condoms (i.e., that they are highly effective
when used correctly and consistently).
Successful programmes that encourage delayed sexual onset and partner reduction can
also help people to be aware of the importance of condom use whenever they do not
meet these objectives. Monitoring the outcomes of these programmes can provide useful
insights for optimal calibration of the mix of prevention interventions.
How can we move condoms and HIV prevention forward?
How can we move condoms and HIV prevention forward?
Despite the experience of the past two decades, many questions remain unanswered
regarding the promotion, use and effectiveness of condoms. Objective and unbiased
research is needed and should, ideally, make it easier for condom programmes to ensure
an appropriate mix of prevention approaches that include condom promotion for key
populations at higher risk, promoting consistent condom use in stable relations, and
securing a regular supply of condoms to all who need them.
1. Build on the condom’s advantage. Condom promotion is an essential part of HIV
prevention programmes, both for key populations with high risk of HIV exposure and
for the general population. The use of condoms by those living with HIV enables them
to continue having a healthy and safer sex life. For sex workers in every country in the
world, condoms represent the only real option for reducing the risk of contracting and
transmitting HIV. Other groups whose risk of exposure is high include injecting drug
users and their sexual partners, and heterosexuals with many sexual partners or with a
high turnover of partners. Targeted condom promotion addresses the need for condom
availability at critical delivery points.
2. Condom promotion for the general population can encourage people to think and
talk about HIV prevention; it also helps to make safer sex the norm. Condom promotion
programmes have had the greatest impact on prevalence rates when introduced early in
a country’s epidemic and when they are accessed and used consistently by populations
at higher risk of HIV exposure. Condom promotion also yields other benefits, such as
preventing unintended pregnancy and reducing the transmission of other STIs.
Operational research is needed to determine both how condom promotion can best
be integrated into combination approaches to reduce sexual transmission of HIV and
to better understand the interactions that take place between different programme
components. It is essential that condom promotion programmes, while using successful
condom social marketing techniques to reduce common fears and misperceptions in the
general population, also target priority populations. In addition, such programmes must
incorporate approaches that create a more supportive sociocultural climate by providing
balanced arguments on the benefits of condom use versus its risks.
Despite the experience of the past two decades, many questions remain unanswered
regarding the promotion, use and effectiveness of condoms. Objective and unbiased
research is needed and should, ideally, make it easier for condom programmes to ensure
an appropriate mix of prevention approaches that include condom promotion for key
populations at higher risk, promoting consistent condom use in stable relations, and
securing a regular supply of condoms to all who need them.
1. Build on the condom’s advantage. Condom promotion is an essential part of HIV
prevention programmes, both for key populations with high risk of HIV exposure and
for the general population. The use of condoms by those living with HIV enables them
to continue having a healthy and safer sex life. For sex workers in every country in the
world, condoms represent the only real option for reducing the risk of contracting and
transmitting HIV. Other groups whose risk of exposure is high include injecting drug
users and their sexual partners, and heterosexuals with many sexual partners or with a
high turnover of partners. Targeted condom promotion addresses the need for condom
availability at critical delivery points.
2. Condom promotion for the general population can encourage people to think and
talk about HIV prevention; it also helps to make safer sex the norm. Condom promotion
programmes have had the greatest impact on prevalence rates when introduced early in
a country’s epidemic and when they are accessed and used consistently by populations
at higher risk of HIV exposure. Condom promotion also yields other benefits, such as
preventing unintended pregnancy and reducing the transmission of other STIs.
Operational research is needed to determine both how condom promotion can best
be integrated into combination approaches to reduce sexual transmission of HIV and
to better understand the interactions that take place between different programme
components. It is essential that condom promotion programmes, while using successful
condom social marketing techniques to reduce common fears and misperceptions in the
general population, also target priority populations. In addition, such programmes must
incorporate approaches that create a more supportive sociocultural climate by providing
balanced arguments on the benefits of condom use versus its risks.
the Global Fund to fight AIDS,
Resources to meet the demand
Resources to meet demand for condoms come from domestic government sources
and out-of-pocket expenditures; multilateral agencies, including the United Nations
Population Fund (UNFPA) and the World Bank Multi-Country AIDS Programme
(MAP); the Global Fund to fight AIDS, TB, and Malaria; the private sector (foundations,
employers, international nongovernmental organisations) and bilateral donors. Donors
provided 3.574 billion condoms in 2002, at a cost of US$ 94.9 million. Condom funding
peaked in 1996 when international funding of condoms was at US$ 68 million, but it
subsequently declined to US$ 40 million annually in 1999 and 2000.Part of this decline may be attributed to policy changes in the United
States, which substantially cut donations from 800 million condoms in
1992 to 300 million a year in 2000. While many developing countries
now provide and promote condoms as part of their HIV prevention
strategies, many of the poorest countries still depend on assistance
provided through bilateral and multilateral funding. Such cutbacks are
sorely felt in the places where condoms are most needed।
Getting condoms to those who need them most
The rise in the need for condoms is fuelled by increasing HIV
prevalence in many developing countries, by large numbers of people
beginning sexual activity, and by a growing interest in contraceptive
use. However, sexually active young people (especially young women)
are regularly and repeatedly denied information about, and access to,
condoms. This means that misconceptions (such as the belief that
condoms do not protect against HIV infection) are not corrected.
If condoms are to be used at all, and especially if they are to be used
consistently, then it is clearly important that people have access to them
and that they be able to afford them. A reliable supply and distribution
system for those who need condoms is essential. Numerous surveys
cite non-availability of condoms at the time of sexual interactions as a
main reason for non-use 44.
Experience has shown that, when condoms are available and affordable,
people use them. Decreasing condom prices in Brazil in the early 1990s
resulted in a massive increase in the numbers of condoms purchased.
The increase in condom accessibility and availability promoted by
the Ford Foundation in South Africa (through mass distribution and
vending machines in workplace toilets) increased uptake 25-fold 45.
The gender aspects of condom use are undoubtedly the most difficult
hurdles to overcome. Until men and women share equal decisionmaking
power in their interpersonal relationships, the female
condom will provide women with greater opportunities for protecting
themselves from HIV and STIs than the male condom. Research studies
in South Africa, Thailand, the United States and Zambia indicate that
a greater number of sexual acts are protected when female condoms are available as a supplement to male condoms, although more investigation is needed
to confirm these findings
Resources to meet demand for condoms come from domestic government sources
and out-of-pocket expenditures; multilateral agencies, including the United Nations
Population Fund (UNFPA) and the World Bank Multi-Country AIDS Programme
(MAP); the Global Fund to fight AIDS, TB, and Malaria; the private sector (foundations,
employers, international nongovernmental organisations) and bilateral donors. Donors
provided 3.574 billion condoms in 2002, at a cost of US$ 94.9 million. Condom funding
peaked in 1996 when international funding of condoms was at US$ 68 million, but it
subsequently declined to US$ 40 million annually in 1999 and 2000.Part of this decline may be attributed to policy changes in the United
States, which substantially cut donations from 800 million condoms in
1992 to 300 million a year in 2000. While many developing countries
now provide and promote condoms as part of their HIV prevention
strategies, many of the poorest countries still depend on assistance
provided through bilateral and multilateral funding. Such cutbacks are
sorely felt in the places where condoms are most needed।
Getting condoms to those who need them most
The rise in the need for condoms is fuelled by increasing HIV
prevalence in many developing countries, by large numbers of people
beginning sexual activity, and by a growing interest in contraceptive
use. However, sexually active young people (especially young women)
are regularly and repeatedly denied information about, and access to,
condoms. This means that misconceptions (such as the belief that
condoms do not protect against HIV infection) are not corrected.
If condoms are to be used at all, and especially if they are to be used
consistently, then it is clearly important that people have access to them
and that they be able to afford them. A reliable supply and distribution
system for those who need condoms is essential. Numerous surveys
cite non-availability of condoms at the time of sexual interactions as a
main reason for non-use 44.
Experience has shown that, when condoms are available and affordable,
people use them. Decreasing condom prices in Brazil in the early 1990s
resulted in a massive increase in the numbers of condoms purchased.
The increase in condom accessibility and availability promoted by
the Ford Foundation in South Africa (through mass distribution and
vending machines in workplace toilets) increased uptake 25-fold 45.
The gender aspects of condom use are undoubtedly the most difficult
hurdles to overcome. Until men and women share equal decisionmaking
power in their interpersonal relationships, the female
condom will provide women with greater opportunities for protecting
themselves from HIV and STIs than the male condom. Research studies
in South Africa, Thailand, the United States and Zambia indicate that
a greater number of sexual acts are protected when female condoms are available as a supplement to male condoms, although more investigation is needed
to confirm these findings
Are condom supplies sufficient and reaching those who need them?A
Are condom supplies sufficient and reaching
those who need them?
Condom promotion and distribution programmes have grown
significantly since the beginning of the AIDS epidemic. Despite
this, it is estimated from a survey of 70 countries that only 18% of risky
sex acts in low and middle income countries in 2003 were protected
by condom use 42. In this survey, a risky sex act is defined as one with
a casual partner or with spouse, if at least one partner has contacts
with outside partners. UNFPA estimates that 8 billion condoms were
needed in 2000 for HIV/STI prevention alone, and that, by 2015, at
least 18.6 billion condoms will be needed (Figure 2) 43. These figures
exclude condoms needed for family planning purposes, and assumethat the condoms would, in any case, not be used consistently. Excluding the costs of
delivery, distribution, promotion or other services, it would have cost US$ 239 million
to procure the minimum number of condoms (8 billion) needed in 2000. This cost is
estimated to increase to US$ 557 million by 2015.
There are two important questions regarding condom supply:
• Are there sufficient resources to meet the demand?
• Are the available supplies of condoms reaching the people who need them most?
those who need them?
Condom promotion and distribution programmes have grown
significantly since the beginning of the AIDS epidemic. Despite
this, it is estimated from a survey of 70 countries that only 18% of risky
sex acts in low and middle income countries in 2003 were protected
by condom use 42. In this survey, a risky sex act is defined as one with
a casual partner or with spouse, if at least one partner has contacts
with outside partners. UNFPA estimates that 8 billion condoms were
needed in 2000 for HIV/STI prevention alone, and that, by 2015, at
least 18.6 billion condoms will be needed (Figure 2) 43. These figures
exclude condoms needed for family planning purposes, and assumethat the condoms would, in any case, not be used consistently. Excluding the costs of
delivery, distribution, promotion or other services, it would have cost US$ 239 million
to procure the minimum number of condoms (8 billion) needed in 2000. This cost is
estimated to increase to US$ 557 million by 2015.
There are two important questions regarding condom supply:
• Are there sufficient resources to meet the demand?
• Are the available supplies of condoms reaching the people who need them most?
How can condom promotion programmes be more effective?
These studies demonstrate that lower age seems to be one of the strongest predictors
of condom use. At the same time, there remain a number of obstacles to ensuring that
young people use condoms. Myths, fears and misperceptions about condoms among
young people, combined with inaccessibility to supplies, severely weaken prevention
practices among 15–24-year-olds, yet this is the age group hit hardest by the epidemic
in many settings. Structural barriers such as gender norms and roles, social stigma,
and lack of access to youth friendly health services constitute additional major factors
undermining the capacity of young people to protect themselves from HIV infection.
Top-level commitment is needed to put in place policy and programmatic interventions
aimed at young people, which back up prevention education with access to prevention
tools।
How can condom promotion programmes be more
effective?
High rates of condom use have been achieved, at least for casual sexual partnerships,
in some of the countries hardest hit by AIDS. This has not invariably led to a
demonstrable fall in the rate of HIV infection because of the timing of their introduction,
the target population and the level of coverage. For example, it is estimated that overall
provision of condoms in Africa in 1999 amounted to only 4.6 per man per year 42.
It is quite possible that HIV prevalence would have risen even faster in some countries
if condom use had not increased. But the current situation raises many questions, such
as the following:
• What level of condom use is necessary to control and roll back a generalized
heterosexual epidemic?
• In settings reporting high rates of condom use, are condoms being used
consistently and correctly enough to have the desired impact?
• At what point is condom use only with casual sexual partners no longer good
enough?
• How can high rates of condom use in steady sexual partnerships be achieved
when HIV prevalence in the general population is high?
These questions remind us that the number of condoms distributed is not the sole
indicator of success of an HIV prevention programme. In addition to measuring condom
uptake and condom use, we need to ask ourselves what exactly should be measured.
From an epidemiological point of view, rates of condom use are essential indicators in
UNAIDS
22
situations where exposure to HIV is more likely, such as sex between
new, nonsteady or casual partners. Most condom use studies tend to
focus on this indicator. However, condom use with regular partners is
also an important indicator of successful condom promotion and must
be included in monitoring and evaluation efforts.
The examples of Senegal and Thailand indicate that the introduction
of condom-promotion programmes early in the epidemic strengthens
HIV prevention. High rates of condom use among populations
at higher risk of HIV acquisition, before an epidemic spreads to
the general population, may account for successful control of the
epidemic. In countries where the HIV epidemic has spread to the
general population, high rates of consistent condom use among the
general population will be needed over an extended period of many
years before an effect on prevalence rates can be detected.
The available evidence clearly shows that a dramatic increase in
condom use can make, and over the past two decades has made, a
difference. This has occurred in a variety of geographic regions
and cultures and has far exceeded what many sceptics would have
believed possible even a few years ago. People can be and have been
convinced of the need to use condoms, supporting the argument that
for many people condoms represent an acceptable, viable strategy for
HIV control
of condom use. At the same time, there remain a number of obstacles to ensuring that
young people use condoms. Myths, fears and misperceptions about condoms among
young people, combined with inaccessibility to supplies, severely weaken prevention
practices among 15–24-year-olds, yet this is the age group hit hardest by the epidemic
in many settings. Structural barriers such as gender norms and roles, social stigma,
and lack of access to youth friendly health services constitute additional major factors
undermining the capacity of young people to protect themselves from HIV infection.
Top-level commitment is needed to put in place policy and programmatic interventions
aimed at young people, which back up prevention education with access to prevention
tools।
How can condom promotion programmes be more
effective?
High rates of condom use have been achieved, at least for casual sexual partnerships,
in some of the countries hardest hit by AIDS. This has not invariably led to a
demonstrable fall in the rate of HIV infection because of the timing of their introduction,
the target population and the level of coverage. For example, it is estimated that overall
provision of condoms in Africa in 1999 amounted to only 4.6 per man per year 42.
It is quite possible that HIV prevalence would have risen even faster in some countries
if condom use had not increased. But the current situation raises many questions, such
as the following:
• What level of condom use is necessary to control and roll back a generalized
heterosexual epidemic?
• In settings reporting high rates of condom use, are condoms being used
consistently and correctly enough to have the desired impact?
• At what point is condom use only with casual sexual partners no longer good
enough?
• How can high rates of condom use in steady sexual partnerships be achieved
when HIV prevalence in the general population is high?
These questions remind us that the number of condoms distributed is not the sole
indicator of success of an HIV prevention programme. In addition to measuring condom
uptake and condom use, we need to ask ourselves what exactly should be measured.
From an epidemiological point of view, rates of condom use are essential indicators in
UNAIDS
22
situations where exposure to HIV is more likely, such as sex between
new, nonsteady or casual partners. Most condom use studies tend to
focus on this indicator. However, condom use with regular partners is
also an important indicator of successful condom promotion and must
be included in monitoring and evaluation efforts.
The examples of Senegal and Thailand indicate that the introduction
of condom-promotion programmes early in the epidemic strengthens
HIV prevention. High rates of condom use among populations
at higher risk of HIV acquisition, before an epidemic spreads to
the general population, may account for successful control of the
epidemic. In countries where the HIV epidemic has spread to the
general population, high rates of consistent condom use among the
general population will be needed over an extended period of many
years before an effect on prevalence rates can be detected.
The available evidence clearly shows that a dramatic increase in
condom use can make, and over the past two decades has made, a
difference. This has occurred in a variety of geographic regions
and cultures and has far exceeded what many sceptics would have
believed possible even a few years ago. People can be and have been
convinced of the need to use condoms, supporting the argument that
for many people condoms represent an acceptable, viable strategy for
HIV control
Saturday, August 25, 2012
greatest risk for HIV infection
Among young people
Condom use among young people is especially important because the young are often
at greatest risk for HIV infection and have the least access to condoms. Moreover,
young people are establishing patterns of sexual behaviour that may last a lifetime. One
indicator often used to examine condom use among the youngest sexually active persons
is to ask whether a condom was used during their first ever sexual encounter. Rates as
high as 77% are reported in France and 68% in England. But developing countries such
as Brazil (48%) and Mexico (43%) also have a high proportion of young people who say
they used a condom the first time they had sex39.
Demographic and health surveys (DHS) show that young age is a strong predictor of
condom use, except apparently among young MSM, for whom condom use may be
lower in some settings. DHS data from 27 countries in Africa and Latin America showed
higher rates of condom use at last high risk sex for 15–24 year olds compared to 25–29
year olds in every country40. High risk sex was defined as sex with a non-marital, noncohabiting
partner. Figure 1 shows the results from selected African countries in studies
conducted between 1994 to 2001 among 15–24 year old young men and women.
Condom use among young people is especially important because the young are often
at greatest risk for HIV infection and have the least access to condoms. Moreover,
young people are establishing patterns of sexual behaviour that may last a lifetime. One
indicator often used to examine condom use among the youngest sexually active persons
is to ask whether a condom was used during their first ever sexual encounter. Rates as
high as 77% are reported in France and 68% in England. But developing countries such
as Brazil (48%) and Mexico (43%) also have a high proportion of young people who say
they used a condom the first time they had sex39.
Demographic and health surveys (DHS) show that young age is a strong predictor of
condom use, except apparently among young MSM, for whom condom use may be
lower in some settings. DHS data from 27 countries in Africa and Latin America showed
higher rates of condom use at last high risk sex for 15–24 year olds compared to 25–29
year olds in every country40. High risk sex was defined as sex with a non-marital, noncohabiting
partner. Figure 1 shows the results from selected African countries in studies
conducted between 1994 to 2001 among 15–24 year old young men and women.
In the sex industry
In the sex industry
Experience throughout the developing world confirms that the greatest changes in
sexual behaviour have taken place among sex workers and their clients. Thailand’s
100% Condom Use Programme achieved nearly universal use of condoms in its large
sex industry. After an intensive campaign of condom promotion and distribution in
brothels, a survey found that the proportion of female sex workers who said that they
always use condoms during commercial sex rose from 14% in 1989 to over 90% in
1994 32,33. Another study found that consistent condom use among brothel-based sex
workers went up from 87% in 1993 to 97% in 1996 34.
Evaluations of HIV programmes and randomized trials in various parts of the world
reveal that some of the most effective prevention programmes have taken place in
sex-worker settings. Post-intervention in a randomized trial in Mumbai, India, 70%
of women reported using condoms at least sometimes and 28% said they used them
always. These proportions compared to 53% and 0% respectively for women in control
brothels who did not receive the intervention. HIV incidence was 5% per year in the
intervention group, versus 16% per year in the control group, with similar differences
in the incidence of other STIs 35. In the Democratic Republic of the Congo in 1994, an
HIV-prevention programme for sex workers increased consistent condom use from
11% to 68% and decreased HIV incidence from 11.7% per year to 4.4% per year, with
parallel decreases in other STIs 36. In Senegal in 1999, 94% of sex workers reported
using a condom the last time they had sex with a regular client and 98% with a new
client 37. In Kampala, Uganda, in 2001, 99% of female sex workers reported using a
condom when they last had intercourse 38. Unfortunately, these success stories are by
no means typical of all parts of the developing world. Nevertheless, they demonstrate
that very high rates of condom use in commercial sex are achievable.
Experience throughout the developing world confirms that the greatest changes in
sexual behaviour have taken place among sex workers and their clients. Thailand’s
100% Condom Use Programme achieved nearly universal use of condoms in its large
sex industry. After an intensive campaign of condom promotion and distribution in
brothels, a survey found that the proportion of female sex workers who said that they
always use condoms during commercial sex rose from 14% in 1989 to over 90% in
1994 32,33. Another study found that consistent condom use among brothel-based sex
workers went up from 87% in 1993 to 97% in 1996 34.
Evaluations of HIV programmes and randomized trials in various parts of the world
reveal that some of the most effective prevention programmes have taken place in
sex-worker settings. Post-intervention in a randomized trial in Mumbai, India, 70%
of women reported using condoms at least sometimes and 28% said they used them
always. These proportions compared to 53% and 0% respectively for women in control
brothels who did not receive the intervention. HIV incidence was 5% per year in the
intervention group, versus 16% per year in the control group, with similar differences
in the incidence of other STIs 35. In the Democratic Republic of the Congo in 1994, an
HIV-prevention programme for sex workers increased consistent condom use from
11% to 68% and decreased HIV incidence from 11.7% per year to 4.4% per year, with
parallel decreases in other STIs 36. In Senegal in 1999, 94% of sex workers reported
using a condom the last time they had sex with a regular client and 98% with a new
client 37. In Kampala, Uganda, in 2001, 99% of female sex workers reported using a
condom when they last had intercourse 38. Unfortunately, these success stories are by
no means typical of all parts of the developing world. Nevertheless, they demonstrate
that very high rates of condom use in commercial sex are achievable.
Among men who have sex with men
Among men who have sex with men (MSM)
Clear evidence that people can be convinced to use condoms, and that condoms can be
a successful public health strategy for HIV prevention, has been documented among
MSM and sex workers. In San Francisco, condoms were heavily promoted from the
beginning of the epidemic by public health officials and by leaders of the local gay
community 28. Incidence rates for all STIs fell substantially, and annual HIV incidence
rates fell from double digits in the early 1980s to less than 1% after 1985 29.
There have been similar increases in condom use among MSM in many places in
industrialized countries. However, this has not necessarily been true in developing
countries. Where condom use among MSM remains low, this has more often been
due to lack of effort than to failure of condom promotion campaigns. HIV prevention
programmes in many countries have not given MSM the prevention and care services
that they warrant. This may be because of outright discrimination and stigmatization or
because of a belief that MSM are hard to reach. Yet, concerted efforts targeted at MSM
have usually been successful in increasing condom use. In Salvador, Brazil, for example,
consistent condom use during anal sex increased from 81% to 97% in MSM following participation in safer-sex workshops30. Recent epidemiological and behavioural data
show a rise in unprotected sex among a small but significant proportion of MSM in
developed countries coinciding with widespread access to accessible antiretroviral
(ARV) treatment regimens 31. Findings in many industrialized countries that show lower
condom use among young MSM, combined with growing complacency among those
on ARV treatment, demonstrate the need to revitalize and sustain primary prevention
messages aimed at promoting protected sex for MSM in high-income countries.
Clear evidence that people can be convinced to use condoms, and that condoms can be
a successful public health strategy for HIV prevention, has been documented among
MSM and sex workers. In San Francisco, condoms were heavily promoted from the
beginning of the epidemic by public health officials and by leaders of the local gay
community 28. Incidence rates for all STIs fell substantially, and annual HIV incidence
rates fell from double digits in the early 1980s to less than 1% after 1985 29.
There have been similar increases in condom use among MSM in many places in
industrialized countries. However, this has not necessarily been true in developing
countries. Where condom use among MSM remains low, this has more often been
due to lack of effort than to failure of condom promotion campaigns. HIV prevention
programmes in many countries have not given MSM the prevention and care services
that they warrant. This may be because of outright discrimination and stigmatization or
because of a belief that MSM are hard to reach. Yet, concerted efforts targeted at MSM
have usually been successful in increasing condom use. In Salvador, Brazil, for example,
consistent condom use during anal sex increased from 81% to 97% in MSM following participation in safer-sex workshops30. Recent epidemiological and behavioural data
show a rise in unprotected sex among a small but significant proportion of MSM in
developed countries coinciding with widespread access to accessible antiretroviral
(ARV) treatment regimens 31. Findings in many industrialized countries that show lower
condom use among young MSM, combined with growing complacency among those
on ARV treatment, demonstrate the need to revitalize and sustain primary prevention
messages aimed at promoting protected sex for MSM in high-income countries.
Persons in steady sexual relationships
Persons in steady sexual relationships
A high proportion of HIV transmission takes place between steady partners. Therefore,
not using condoms or using them inconsistently can be a problem. This is particularly
true in settings with high HIV prevalence, where the likelihood that a partner may be
infected is raised।
There are barriers, of course, to using condoms with steady partners or in stable
relationships. Trust, power inequalities, and the desire for children are common issues
among married couples which can discourage condom use 21. Studies in Kenya and
Zambia show that, while marriage increases the frequency of sex, it decreases condom
use and can severely restrict women’s ability to protect themselves from infection. The
association of condom use with casual or commercial sex persists as a barrier because
it reinforces the misperception that protection against STIs or HIV is not needed with
regular sexual partners. However, there is growing evidence in many countries of the
risk of HIV infection within marriage. In a recent study in India, 90% of women being
treated for STIs had only one lifetime partner, and 14% were HIV-positive. In Kisumu,
Kenya and Ndola, Zambia, adolescent married girls age 15–19 years were found to
have higher levels of HIV infection than non-married sexually active girls the same age,
demonstrating that not only is marriage not protective in some settings, but it actually
can increase risk22.
It would seem to be rational behaviour for HIV-serodiscordant couples to use condoms.
However, most studies of serodiscordant couples reveal low condom use: 17% reported
regular condom use in Rwanda23, 24% in Haiti24, and 33% in Zambia25. Condom use has
been reported to be more frequent in HIV-serodiscordant couples where the woman is
the HIV-positive partner than in relationships where the man is HIV-positive
A high proportion of HIV transmission takes place between steady partners. Therefore,
not using condoms or using them inconsistently can be a problem. This is particularly
true in settings with high HIV prevalence, where the likelihood that a partner may be
infected is raised।
There are barriers, of course, to using condoms with steady partners or in stable
relationships. Trust, power inequalities, and the desire for children are common issues
among married couples which can discourage condom use 21. Studies in Kenya and
Zambia show that, while marriage increases the frequency of sex, it decreases condom
use and can severely restrict women’s ability to protect themselves from infection. The
association of condom use with casual or commercial sex persists as a barrier because
it reinforces the misperception that protection against STIs or HIV is not needed with
regular sexual partners. However, there is growing evidence in many countries of the
risk of HIV infection within marriage. In a recent study in India, 90% of women being
treated for STIs had only one lifetime partner, and 14% were HIV-positive. In Kisumu,
Kenya and Ndola, Zambia, adolescent married girls age 15–19 years were found to
have higher levels of HIV infection than non-married sexually active girls the same age,
demonstrating that not only is marriage not protective in some settings, but it actually
can increase risk22.
It would seem to be rational behaviour for HIV-serodiscordant couples to use condoms.
However, most studies of serodiscordant couples reveal low condom use: 17% reported
regular condom use in Rwanda23, 24% in Haiti24, and 33% in Zambia25. Condom use has
been reported to be more frequent in HIV-serodiscordant couples where the woman is
the HIV-positive partner than in relationships where the man is HIV-positive
Can people be convinced to use condoms?
Can people be convinced to use condoms?
No matter how effective condoms may be, they can have little impact
in preventing HIV if people do not use them. There is growing
evidence that in key populations at higher risk of HIV exposure, such as
men who have sex with men (MSM) and sex workers and their clients,
people can be persuaded to use condoms. In these groups, both increases
Condoms areabout 90%effective wheused correctlyand consistently.
If the risk oftransmissionis one in500 withouta condom,it would bereduced to onein 5000 when a
condom is used.in condom use and high rates of condom use have been documented. Global experience
shows that the use of condoms is often not consistent, whether in the general population,
among persons in steady relationships, or in key populations at risk of HIV infection General population
Promoting widespread condom use in the general population is a greater challenge than
promoting it in specific populations, such as sex workers and their clients. Furthermore,
it is not easy to measure the success of condom promotion efforts directed at the general
population. Statistics on the number of condoms distributed give some idea of the scope
of the effort but do not indicate what proportion of the population, particularly those at
highest risk, is consistently using condoms. Most surveys do not identify key populations
at highest risk and do not ask about high-risk settings where condom use could make
a difference to transmission. For instance, in epidemics concentrated among specific
segments of the population (e.g. MSM and sex workers), high condom use would make
a substantial difference, regardless of the rate of condom use in the general population.
Numerous studies show high rates of condom use in the general population of various
developing countries. Data collected by the Brazilian Ministry of Health showed that 63%
of men and 69% of women reported using a condom during their last sexual encounter
with a casual partner 18. In a 1999 study in Zimbabwe, over 70% of men reported using a
condom the last time they had high-risk sex 19. However optimistic the trends in condom
use are, the rise in condom use generally applies only to a tiny fraction of all sexual
encounters in these countries. Condom use is much lower in rural areas, and condom
promotion has had little impact in the context of steady sexual relationships. Across
all regions of the world, the poor results of promotion efforts to encourage consistent
condom use within regular partnerships highlight this as one of the major challenges in
condom promotion
No matter how effective condoms may be, they can have little impact
in preventing HIV if people do not use them. There is growing
evidence that in key populations at higher risk of HIV exposure, such as
men who have sex with men (MSM) and sex workers and their clients,
people can be persuaded to use condoms. In these groups, both increases
Condoms areabout 90%effective wheused correctlyand consistently.
If the risk oftransmissionis one in500 withouta condom,it would bereduced to onein 5000 when a
condom is used.in condom use and high rates of condom use have been documented. Global experience
shows that the use of condoms is often not consistent, whether in the general population,
among persons in steady relationships, or in key populations at risk of HIV infection General population
Promoting widespread condom use in the general population is a greater challenge than
promoting it in specific populations, such as sex workers and their clients. Furthermore,
it is not easy to measure the success of condom promotion efforts directed at the general
population. Statistics on the number of condoms distributed give some idea of the scope
of the effort but do not indicate what proportion of the population, particularly those at
highest risk, is consistently using condoms. Most surveys do not identify key populations
at highest risk and do not ask about high-risk settings where condom use could make
a difference to transmission. For instance, in epidemics concentrated among specific
segments of the population (e.g. MSM and sex workers), high condom use would make
a substantial difference, regardless of the rate of condom use in the general population.
Numerous studies show high rates of condom use in the general population of various
developing countries. Data collected by the Brazilian Ministry of Health showed that 63%
of men and 69% of women reported using a condom during their last sexual encounter
with a casual partner 18. In a 1999 study in Zimbabwe, over 70% of men reported using a
condom the last time they had high-risk sex 19. However optimistic the trends in condom
use are, the rise in condom use generally applies only to a tiny fraction of all sexual
encounters in these countries. Condom use is much lower in rural areas, and condom
promotion has had little impact in the context of steady sexual relationships. Across
all regions of the world, the poor results of promotion efforts to encourage consistent
condom use within regular partnerships highlight this as one of the major challenges in
condom promotion
Consistent condom use A population may
transmission during penetrative sex by about 90%. Thus, the best
estimate that may be deduced from all these studies is that condoms
used correctly and consistently reduce the risk of transmission by
about 90%. With perfect use, effectiveness may be even higher,
though not 100%.
It is important to clarify that an effectiveness of 90% does not mean
that HIV transmission will take place in 10% of sexual acts where
condoms are used. In fact, the risk of transmission is much lower.
If the risk of sexual transmission is one in 500 without a condom, it
would be reduced to one in 5000 when a condom is used.Consistent condom use
A population may use large numbers of condoms but the impact will
be limited if the persons who use them most do not do so consistently.
There is little evidence that using condoms sometimes (but not always)
provides any greater protection than not using condoms at all. In fact,
one study from Uganda found that individuals who sometimes used
condoms were at higher risk of infection than those who never used
them, perhaps because they were more risky in other aspects of their
sexual behaviour, such as the number of partners they had 17.
In analysing overall data on condom use, it is critical to determine who
is using condoms. In a situation where overall condom use in general
is high, but condom use is low in those few encounters where it could
make a measurable difference, condom promotion must become more
focused. This could occur, for example, if those at highest risk of HIV
infection have lower rates of condom use, while people at low risk
have higher rates of condom use.
estimate that may be deduced from all these studies is that condoms
used correctly and consistently reduce the risk of transmission by
about 90%. With perfect use, effectiveness may be even higher,
though not 100%.
It is important to clarify that an effectiveness of 90% does not mean
that HIV transmission will take place in 10% of sexual acts where
condoms are used. In fact, the risk of transmission is much lower.
If the risk of sexual transmission is one in 500 without a condom, it
would be reduced to one in 5000 when a condom is used.Consistent condom use
A population may use large numbers of condoms but the impact will
be limited if the persons who use them most do not do so consistently.
There is little evidence that using condoms sometimes (but not always)
provides any greater protection than not using condoms at all. In fact,
one study from Uganda found that individuals who sometimes used
condoms were at higher risk of infection than those who never used
them, perhaps because they were more risky in other aspects of their
sexual behaviour, such as the number of partners they had 17.
In analysing overall data on condom use, it is critical to determine who
is using condoms. In a situation where overall condom use in general
is high, but condom use is low in those few encounters where it could
make a measurable difference, condom promotion must become more
focused. This could occur, for example, if those at highest risk of HIV
infection have lower rates of condom use, while people at low risk
have higher rates of condom use.
How effective are condoms?
How effective are condoms?
Compelling international evidence has been gathered by the US
Department of Health and Human Services and the United
Nations Population Fund which shows that consistent use of latex
male condoms is a highly effective method for preventing HIV
transmission. Scientific research by the US National Institutes
of Health and World Health Organization (WHO) found “intact
condoms…are essentially impermeable to particles the size of
sexually transmitted disease pathogens, including the smallest
sexually transmitted virus”.
Four meta-analyses of condom effectiveness put the range at
69–94% 13, 14, 15, 16. Conclusive evidence from studies of serodiscordant
couples (where one partner is HIV-positive and the other is
not) shows that using a condom reduces the probability of HIV
Compelling international evidence has been gathered by the US
Department of Health and Human Services and the United
Nations Population Fund which shows that consistent use of latex
male condoms is a highly effective method for preventing HIV
transmission. Scientific research by the US National Institutes
of Health and World Health Organization (WHO) found “intact
condoms…are essentially impermeable to particles the size of
sexually transmitted disease pathogens, including the smallest
sexually transmitted virus”.
Four meta-analyses of condom effectiveness put the range at
69–94% 13, 14, 15, 16. Conclusive evidence from studies of serodiscordant
couples (where one partner is HIV-positive and the other is
not) shows that using a condom reduces the probability of HIV
Reproductive health programmes
Reproductive health programmes for young people vary in their
approach. Some are fairly explicit (e.g., by demonstrating the correct
use of condoms). Most, however, are basically conservative in their
approach and encourage delay in sexual initiation and limiting the
number of one’s partners. Some studies indicate that more explicit
approaches that include skills training—i.e., how to use condoms
correctly and how to negotiate their use with partners—may produce
greater reductions in sexual risk than programmes that provide only
information11,12. However, even the more explicit condom promotion
programmes for adolescents seldom emphasize ‘eroticizing safer sex’.
This approach is more commonly taken in prevention programmes
aimed at key populations at risk, such as men who have sex with men
or sex workers and their clients.
If protected or safer sex is promoted as part of an array of means, which
also include abstinence, and partner reduction, aimed at preventing
sexual transmission of HIV, there is greater likelihood that strategies will
complement and mutually reinforce each other. In different situations,
the emphasis placed on each strategy will differ in accordance with
epidemiological, contextual and behavioural evidence.
approach. Some are fairly explicit (e.g., by demonstrating the correct
use of condoms). Most, however, are basically conservative in their
approach and encourage delay in sexual initiation and limiting the
number of one’s partners. Some studies indicate that more explicit
approaches that include skills training—i.e., how to use condoms
correctly and how to negotiate their use with partners—may produce
greater reductions in sexual risk than programmes that provide only
information11,12. However, even the more explicit condom promotion
programmes for adolescents seldom emphasize ‘eroticizing safer sex’.
This approach is more commonly taken in prevention programmes
aimed at key populations at risk, such as men who have sex with men
or sex workers and their clients.
If protected or safer sex is promoted as part of an array of means, which
also include abstinence, and partner reduction, aimed at preventing
sexual transmission of HIV, there is greater likelihood that strategies will
complement and mutually reinforce each other. In different situations,
the emphasis placed on each strategy will differ in accordance with
epidemiological, contextual and behavioural evidence.
Friday, August 24, 2012
The ABCs of HIV Prevention
The ABCs of HIV Prevention
(A) Abstinence refers to not engaging in sexual intercourse
Sexual expression is a natural and healthy part of life, however, for certain
periods during one’s life, one may choose to abstain from all sexual expression
or from higher-risk activities such as penetrative sexual intercourse. Prevention
strategies encouraging delay of sexual initiation or debut help young people
to postpone sexual intercourse until they have developed the personal and
social skills that will enable them to practise protected intercourse. The goal of
delay-oriented programmes is to facilitate the development of young people’s
capacities for informed decision-making regarding their sexual health, including
the prevention of pregnancy and sexually transmitted infections (STIs), including
HIV. Whether abstinence occurs as a delay of sexual debut or as adoption of
a period of abstinence at a later stage, access to information and education
about alternative safer sexual practices is critical to avoid HIV infection on sexual
initiation or resumption of sexual activity.
(B) Being safer by being faithful to one’s partner or reducing the number of
sexual partners
The lifetime number of sexual partners is a very important predictor of HIV
infection. Thus, having fewer sexual partners reduces the risk of HIV exposure.
However, strategies to promote faithfulness among couples do not necessarily
lead to lower incidence of HIV unless neither partner has HIV infection and both
are consistently faithful.
(C) Condom use refers to consistent and correct use of condoms, both
male and female
Effective condom promotion within a combination prevention strategy must
involve the equally important and interrelated components of informed choice,
empowerment, supportive environment, demand and supply. To meet the
needs and socioeconomic conditions of all population groups, greater access
to, and availability of, condoms should be ensured through diverse channels,
including free distribution, commercial sale and social marketing programmes.
Condoms need to be actively promoted among sexually active young people
and other populations at higher risk of HIV exposure such as sex workers and
their clients, men who have sex with men (MSM), and people with HIV and their
partners. Studies conducted by the US National Institutes of Health and the US
Centers for Disease Control and Prevention (CDC) have found that, without
access to condoms, other prevention strategies lose much of their potential
effectiveness. In addition, for young people, condom education and promotion
are most effective within the context of life-skills education to help them make
responsible decisions related to sexual behaviour and reproductive health.
(A) Abstinence refers to not engaging in sexual intercourse
Sexual expression is a natural and healthy part of life, however, for certain
periods during one’s life, one may choose to abstain from all sexual expression
or from higher-risk activities such as penetrative sexual intercourse. Prevention
strategies encouraging delay of sexual initiation or debut help young people
to postpone sexual intercourse until they have developed the personal and
social skills that will enable them to practise protected intercourse. The goal of
delay-oriented programmes is to facilitate the development of young people’s
capacities for informed decision-making regarding their sexual health, including
the prevention of pregnancy and sexually transmitted infections (STIs), including
HIV. Whether abstinence occurs as a delay of sexual debut or as adoption of
a period of abstinence at a later stage, access to information and education
about alternative safer sexual practices is critical to avoid HIV infection on sexual
initiation or resumption of sexual activity.
(B) Being safer by being faithful to one’s partner or reducing the number of
sexual partners
The lifetime number of sexual partners is a very important predictor of HIV
infection. Thus, having fewer sexual partners reduces the risk of HIV exposure.
However, strategies to promote faithfulness among couples do not necessarily
lead to lower incidence of HIV unless neither partner has HIV infection and both
are consistently faithful.
(C) Condom use refers to consistent and correct use of condoms, both
male and female
Effective condom promotion within a combination prevention strategy must
involve the equally important and interrelated components of informed choice,
empowerment, supportive environment, demand and supply. To meet the
needs and socioeconomic conditions of all population groups, greater access
to, and availability of, condoms should be ensured through diverse channels,
including free distribution, commercial sale and social marketing programmes.
Condoms need to be actively promoted among sexually active young people
and other populations at higher risk of HIV exposure such as sex workers and
their clients, men who have sex with men (MSM), and people with HIV and their
partners. Studies conducted by the US National Institutes of Health and the US
Centers for Disease Control and Prevention (CDC) have found that, without
access to condoms, other prevention strategies lose much of their potential
effectiveness. In addition, for young people, condom education and promotion
are most effective within the context of life-skills education to help them make
responsible decisions related to sexual behaviour and reproductive health.
prominence of commercial sex in HIV transmission
The difference in programme emphasis between use of condoms and reduction in the
number of sexual partners appears more related to differences in local epidemiology—
namely differences in the prominence of commercial sex in HIV transmission—than to
differences in philosophy.
These two countries’ responses to the HIV epidemic were based on correct assessment
of the main factors driving their epidemics and an understanding of local sociocultural
characteristics. Thailand’s emphasis on condom use in sex work venues would not have
worked in Uganda as this factor was not driving the Ugandan epidemic. A Ugandanstyle
programme emphasizing partner reduction for the general population probably
would not have worked well in Thailand. In both cases, what did work was a determined,
multisectoral effort that enlisted broad public support and responded to local realities।
Condoms and the combination behavioural
change approach
The continuing debate on the place and role of condom promotion in HIV prevention
programmes particularly for young people has generated mixed messages. These tend
to confuse young people and constrain consensus as to what works for youth. This
controversy illustrates concern about the interactions between condom promotion,
on the one hand, and other behavioural change approaches (particularly those aimed
at sexual abstinence) on the other. At the root of this concern is a fear that condom
promotion may increase sexual activity and may encourage people to have more sexual
partners9.
Reproductive health programmes for young people, including sexual health education,
have been investigated extensively to determine whether condom education and
promotion have, in fact, resulted in young people switching from abstinence to
sexual activity with condoms. A review in 2002 identified 41 studies that examined
programmes with condom education components. These programmes were based in
schools or in the community, or were carried out through the mass media, workplaces
or health facilities10. Almost all resulted in improved knowledge and attitudes, and
many produced an increase in contraceptive use. Seven of the programmes showed a
significant impact in the direction of reduced sexual risk (in terms of delayed sexual
initiation or reduced number of sexual partners). It may be noted that most of these
studies did not specifically focus on condom promotion interventions.
This conclusion reinforces the need for a range of prevention options for young people,
covering the full spectrum of sexual behaviour. It is important to offer adolescents
choices for HIV prevention. This combination behavioural change approach has been
labelled as ABC—i.e., Abstinence, including delay of sexual initiation or debut, Being
safer by being faithful to one’s partner or reducing the number of sexual partners, and
correct and consistent Condom use (see box). Providing information and education on
a range of safer sexual behaviours is consistent with current empirical evidence of the
diversity of young people’s sexual behaviours.
number of sexual partners appears more related to differences in local epidemiology—
namely differences in the prominence of commercial sex in HIV transmission—than to
differences in philosophy.
These two countries’ responses to the HIV epidemic were based on correct assessment
of the main factors driving their epidemics and an understanding of local sociocultural
characteristics. Thailand’s emphasis on condom use in sex work venues would not have
worked in Uganda as this factor was not driving the Ugandan epidemic. A Ugandanstyle
programme emphasizing partner reduction for the general population probably
would not have worked well in Thailand. In both cases, what did work was a determined,
multisectoral effort that enlisted broad public support and responded to local realities।
Condoms and the combination behavioural
change approach
The continuing debate on the place and role of condom promotion in HIV prevention
programmes particularly for young people has generated mixed messages. These tend
to confuse young people and constrain consensus as to what works for youth. This
controversy illustrates concern about the interactions between condom promotion,
on the one hand, and other behavioural change approaches (particularly those aimed
at sexual abstinence) on the other. At the root of this concern is a fear that condom
promotion may increase sexual activity and may encourage people to have more sexual
partners9.
Reproductive health programmes for young people, including sexual health education,
have been investigated extensively to determine whether condom education and
promotion have, in fact, resulted in young people switching from abstinence to
sexual activity with condoms. A review in 2002 identified 41 studies that examined
programmes with condom education components. These programmes were based in
schools or in the community, or were carried out through the mass media, workplaces
or health facilities10. Almost all resulted in improved knowledge and attitudes, and
many produced an increase in contraceptive use. Seven of the programmes showed a
significant impact in the direction of reduced sexual risk (in terms of delayed sexual
initiation or reduced number of sexual partners). It may be noted that most of these
studies did not specifically focus on condom promotion interventions.
This conclusion reinforces the need for a range of prevention options for young people,
covering the full spectrum of sexual behaviour. It is important to offer adolescents
choices for HIV prevention. This combination behavioural change approach has been
labelled as ABC—i.e., Abstinence, including delay of sexual initiation or debut, Being
safer by being faithful to one’s partner or reducing the number of sexual partners, and
correct and consistent Condom use (see box). Providing information and education on
a range of safer sexual behaviours is consistent with current empirical evidence of the
diversity of young people’s sexual behaviours.
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