HIV vulnerabilities of sex workers in Europe

Introduction Basic facts and figures of the HIV epidemic at the global and European level Dynamic of HIV epidemic among sex workers of all genders globally and in the European region Concept of ‘key population’ Factors contributing to sex workers’ vulnerability to HIV

HIV/AIDS HIV - Human Immunodeficiency Virus == AIDS - Acquired Immunodeficiency Syndrome HIV prevalence – the percentage of population living with HIV infection HIV incidence – the annual number of new infections that occur in a population

HIV epidemic globally – fast facts Since the beginning of the epidemic, around 78 million people have become infected with HIV and 39 million people have died of AIDS-related illnesses. In 2013, there were 35 million people living with HIV. An estimated 0.8% of adults aged 15–49 years worldwide are living with HIV. Worldwide, 2,1 million people become newly infected with HIV in 2013. In 2013, 1,5 million people died from AIDS-related causes worldwide. The burden of the HIV epidemic varies considerably between countries and regions. (WHO, 2014)

HIV epidemic globally – fast facts (WHO, 2013)

HIV epidemic among sex workers Since the beginning of the HIV epidemic sex workers of all genders bear a disproportionate burden of HIV: The overall HIV prevalence among non- transgender female sex workers is estimated at 11,8%. Female sex workers are 13,5 times more likely to be living with HIV than other women in reproductive age.

Global epidemiology of HIV among FSW The global burden of HIV in FSW in 2013 79 countries (mostly low- and middle-income) n = 437 025 FSW white ~ countries which do not collect data on HIV prevalence among SW (Beyrer et al., Lancet, 2014)

Global epidemiology of HIV among FSW Regional variations: Sub-Saharan Africa – 36,9% (29,3%) Eastern Europe – 9,1% Latin America and Caribbean - 6,1% Asia - 5,2% Middle East and North Africa - 1,7% (Baral et al., 2013)

Global epidemiology of HIV among male and transgender sex workers Very limited data on HIV prevalence among male and transgender sex workers! HIV prevalence rates among male and transgender sex workers appear to be even higher than among female sex workers (11,8%): 14% prevalence rates for male sex workers (data from 51 countries) 27,3% prevalence rates for transgender women sex workers (data from 14 countries) (Baral et al., Lancet, 2014; Poteat et al., Lancet, 2014)

Epidemiology of HIV among sex workers in Europe HIV prevalence among non- transgender female sex workers in Europe varies significantly depending on the country and ranges from 0.2% in Germany, through > 2% in Croatia and Poland, 5% in Uzbekistan, 8% in Italy, 13% in Ukraine and Portugal, to almost 20% in Latvia. (ECDC, 2013; World Bank, 2013)

Epidemiology of HIV among male and transgender sex workers in Europe HIV prevalence rates among male and transgender sex workers are higher than in female sex workers (very scarce data…): HIV rates among male sex workers: e.g. 2% in the Czech Republic, almost 10% in the UK and Belgium, 15% in Russia and 16.7% in Kyrgyzstan, over 20% in the Netherlands and Germany HIV rates among transgender sex workers: e.g. 20% in the Netherlands, 22% in Spain, 27% in Italy (ECDC, 2013; World Bank, 2013)

Sex workers as a key population Key populations: populations which bear higher burdens of HIV infection than the general population men who have sex with men people who inject drugs people in prisons and other closed settings transgender people sex workers [people living with HIV] Estimates by the UNAIDS suggest that as many as 50% of all new infections worldwide occur in people from key populations.

Sex workers as a key population Key populations are defined as groups who, due to specific higher-risk behaviours, are at increased risk of HIV irrespective of the epidemic type or local context. Also, they often have legal and social issues related to their behaviours that increase their vulnerability to HIV. (WHO, 2014) Sex workers as a key population – two perspectives: at high risk of acquiring HIV infection due to multiple sexual partners, inability to negotiate consistent condom use with clients, STIs, other overlapping risk-behaviours (e.g. injecting drug use, hormone and silicone injections) disproportionately affected by HIV due to a range of social and structural factors which contribute to increased odds of HIV infection and overall vulnerability to HIV

What social and structural factors contribute to sex workers’ vulnerability to HIV?

Social and structural factors which contribute to sex workers’ vulnerability to HIV Legal environment laws and regulations governing sex work law enforcement strategies other laws which affect sex workers (sub-populations) Social environment social attitudes towards sex workers social and economic reality in which sex workers live and work Work environment work settings work ‘reality’ management practices and policies

Legal environment Factors increasing HIV vulnerability: Criminalisation of sex work and other punitive laws governing sex work (criminalisation of third parties, clients, brothels, etc.) Other by-laws targeting sex workers (e.g. non-criminal offences against ‘public peace and order’) Repressive law-enforcement strategies and policing (raids, arrests and detentions, incarceration, police violence and extortion, etc.) Anti-trafficking laws and policies, repressive migration laws Criminalisation/penalisation of drug use, same sex practices, gender identity, cross-dressing, etc. Lack of laws protecting sex workers (labour rights, anti-discriminatory provisions, recognition of non-normative gender identities and behaviours, etc.)

Social environment Factors increasing HIV vulnerability : Sex work-related stigma and discrimination Other overlapping layers of stigma and discrimination (e.g. to transphobia, homophobia, xenophobia, drug use related stigma) Violence and abuse by non-state actors Social marginalisation and isolation Economic insecurity and disempowerment Residential instability Mobility and migration (both international and internal) Other…

Work environment Factors increasing HIV vulnerability: Unsafe and unfavourable work settings Lack of control over one’s working environment Coercion, exploitation, limited autonomy Violence by clients, managers, operators Isolation and lack of peer-support Unsupportive venue-based policies and practices Lack of occupational health and safety measures Other…

How much could HIV infections be averted? (Lancet, 2014)