Efforts to prevent HIV usually consist of proactive interventions — but when it comes to sex workers, leaving them alone might be the best prescription of all. A study presented by researchers at the 20th International AIDS Conference in Melbourne this week determined that decriminalizing sex work would have “the greatest effect on the course of HIV epidemics” across the world.
Female sex workers in low- and middle-income countries are more than 13 times as likely to contract HIV than women outside the industry, and are at high risk of transmitting the virus to others. In order to lower HIV rates worldwide, researchers at the conference argued, countries should make improving the circumstances of sex workers a top priority.
The study, which was published by the British medical journal The Lancet as the first in a series partly funded by the United Nations Population Fund, found that criminalization makes sex workers more likely to be beleaguered or abused by police and less likely to use condoms or seek treatment for HIV and other diseases.
Using a statistical model informed by previous surveys, the researchers calculated the potential diminishment in HIV infections over the next ten years in three cities — Vancouver, Canada; Mombasa, Kenya; and Bellary, India — should they decriminalize the trade. They found that this policy would lower HIV’s prevalence among sex workers in Vancouver by 37 percent, by 33 percent in Mombasa, and by 46 percent in Bellamy.
“We did a systematic review of the literature of the past five years,” Steffanie Strathdee, director of the University of California at San Diego’s Global Health Initiative and one of the paper’s authors, told VICE News. “Our evidence from the modeling supports full decriminalization.”
Public health advocates hailed the study’s conclusion.
“It highlights, for the first time, the intimate connection between a criminalized status and the risks that are associated with it,” Marine Buissonniere, director of the Open Society Public Health Program, told VICE News.
The World Health Organization earlier this month called for decriminalizing the “behavior of key populations” at risk for HIV.
“In places where sex work is criminalized you tend to find a community that is extremely vulnerable and marginalized, where they are subject to abuse in the healthcare system and more generally don’t enjoy the same set of human rights,” said Buissonniere. “When a country criminalizes either sex work or drug use it tends to push people underground and away from services.”
Though countries like the Netherlands and Germany have legalized sex work in defined contexts, and nations like Denmark have decriminalized it in certain circumstances (soliciting on the street is still illegal), the only two places in the world to have fully decriminalized it are New Zealand the Australian state of New South Wales. The distinction is important — decriminalization removes all “prostitution-specific regulations imposed by the state,” while legalization introduces new laws and regulations that are less punitive. In the latter framework, sex workers without proper permits or access are still forced to work underground.
“Legalization actually replicates some of the same problems that criminalization does,” Strathdee said. “The perspective is about taxes and control and not about human rights. Even in legalized environments there are police crackdowns.”
Countering a common concern voiced against reform, the number of sex workers in New Zealand hasn’t changed significantly since the profession was decriminalized in 2003. In New South Wales, which decriminalized sex work in 2009, sex workers actually have a lower prevalence of HIV than in the rest of the country.
Strathdee and her colleagues criticized not only laws against sex workers but also alternative policies, like criminalizing the purchase of sexual services alone — the so-called “Swedish model” against clients established by Sweden in 1999. Several European nations have adopted such laws, and legislators in Canada are considering a similar statute.
European advocacy groups have contended that clients in countries that use the Swedish model are less likely to report dangerous circumstances or the suspicion that workers are being abused or trafficked.
“If a john comes across a sex worker who is being trafficked, they may be frightened themselves to report because of their risk of arrest,” said Strathdee. “Nothing short of full decriminalization would bring these benefits.”
Complicating matters is the limited recourse sex workers have to law enforcement to report trafficking and abuses. Police harassment can discourage sex workers from seeking medical treatment or using condoms.
Kholi Buthelezi, a former sex worker who is the national coordinator of Sisonke, an organization of sex workers South African (where 60 percent of sex workers are believed to have HIV), described police in her country as a constant source of harassment and abuse.
“Sex workers are forced to empty bags, and if they find condoms they can use them as evidence to detain them,” Buthelezi told VICE News.
Police can hold sex workers for days on unclear charges or simply for being outside with condoms. In some situations, she said, they will destroy the HIV medication of sex workers or deny them medicine while in custody, seemingly just because they can. Missed doses can increase symptoms, the likelihood of transmission, and could lead to the sex worker developing drug-resistance.
In the worst cases, officers will inflict sexual violence.
“Some sex workers will say no to them and will get raped,” Buthelezi said, noting the obvious difficulty of sex workers pressing charges against police. “Decriminalization will reduce trafficking and HIV rates in any country, I’m positive.”
The problem isn’t limited to the developing world. It took until this year for the NYPD to limit the use of condoms as evidence in prostitution cases.
Advocates of criminalization and the Swedish model emphasize the need to stop sex trafficking, but they fail to enlist sex workers in the effort.
“What we’re seeing is sex workers are certainly the best ally in identifying who has been trafficked,” Buissonniere said. “If you look at situations where sex workers are empowered and not criminalized, where sex workers have worked together along with police, they are ensuring the safety of the community at large.”
Though the study’s findings on female sex work were applauded, the dearth of data on male and transgender sex workers was apparent. These groups are marginalized even within the world of sex work.
The Melbourne conference, marred by the deaths of at least six attendees in the crash of Malaysian Airline Flight 17 in eastern Ukraine, ends on Friday.
Follow Samuel Oakford on Twitter: @samueloakford
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