Effective HIV & SRH Responses Among Sex Workers and other Key Populations Module 4: Critical Enablers

Session 1 Critical Enablers CREATING ENABLING ENVIRONMENTS FOR KEY POPULATIONS

2 Demand For SRH, GBV, HIV services Supply Quality equitable services Added value of community Enabling environments Laws, Policy, Law enforcement practices Critical enablers

WHO Consolidated guidelines: Essential health interventions  Condom & lubricants  Harm reduction including NSP, OST  HIV testing and counselling  HIV treatment and care  SRH = FP, MCH/PMTCT  Prevention and management of co-infections including viral hepatitis  TB and mental health 3

WHO Consolidated guidelines:Essential strategies for an enabling environment 3

Punitive laws and human right abuses are costing lives, wasting money and stifling the global AIDS response. -- Global Commission on HIV and the Law (2012 ) 3

Laws & policies that may impede effective HIV and SRH responses  Criminalization of sex work, sex between men, drug use  Punitive law enforcement practices, including confiscation of condoms as evidence of sex work  Focus on HIV testing STILL requires informed consent  Not mandatory, compulsory or coerced testing  Denial of identification documents or of service if not in the correct province or district 3

Legal and Policy Conflicts  Criminalizing KPs behaviours increases vulnerability to HIV:  Fuels stigma & discrimination  Undermines access to health services  Legitimizes violence, harassment and extortion  Limits carrying of condoms for fear of arrest  Police ‘crackdowns’ including raids, harassment and violence against Key Populations at the hands of law enforcement disperses populations and undermines access to services 3

Road of resources 3 October 2012 July 2013 July 2014 December 2012 January 2015

Sex Work and the Law in Asia & Pacific 2012  Analysis of laws and human rights environment and their impact on effective HIV responses among sex workers in 48 countries  Evidence based tool to support governments, UN agencies and sex worker communities to prioritize and implement strategies to address legal and human rights challenges  Defines an agenda for country level action 3

Decriminalisation of sex work would have the greatest effect on the course of HIV epidemics across all settings. -- Lancet series

Legal environments, human rights & HIV Legal Environments, Human Rights and HIV Responses among men who have sex with men and transgender people in Asia and the Pacific – an Agenda for Action 3

Community- empowerment-based responses to HIV in sex workers were consistently associated with significant reductions in HIV and STIs, and increases in condom use. -- Lancet series

Lessons from the Asia Pacific region 3

What does it cover?  Eleven detailed case studies on HIV and sex work programmes and advocacy from seven countries in the region o Bangladesh, China, Fiji, India, Myanmar, Nepal, Thailand.  An analysis of the key lessons learned for delivering and scaling up evidence and rights-based responses, based on experience in the region. 3

Examples from the region 3 OrganizationFocusCountry TOPScaling up an integrated approach to SRH and HIV prevention, testing, treatment and care Myanmar Dark BlueHIV prevention, treatment and care for male and transgender sex workers China SWINGSex worker organizational development; Partnership with police to foster law enforcement practices that protect rights and supports effective HIV programming Thailand Lily Women’s Wellness Center HIV prevention, treatment and care for ‘low fee’ sex workers China

Examples from the region 3 OrganizationFocusCountry VAMP PlusImproving access to HIV testing, treatment and care for sex workers living with HIV India USHA CooperativeEconomic empowerment: financial cooperative - savings and loans India Durjoy Nari Sangha Preventing and addressing violence against sex workers Bangladesh Blue Diamond Society Advocacy and leadership development for law reform, programmes for legal education and legal services for men who have sex with men and transgender communities Nepal

Examples from the region 3 OrganizationFocusCountry VAMP PlusImproving access to HIV testing, treatment and care for sex workers living with HIV India USHA CooperativeEconomic empowerment: financial cooperative - savings and loans India Durjoy Nari Sangha Preventing and addressing violence against sex workers Bangladesh Blue Diamond Society Advocacy and leadership development for law reform, programmes for legal education and legal services for men who have sex with men and transgender communities Nepal

VAMP Sex Workers’ Collective 3

VAMP: Improving access to HIV testing, treatment & care for sex workers living with HIV  Facilitating access to HIV testing & treatment through outreach, counselling and accompanied referral  Community care and safety net through advocacy for treatment, determining eligibility, adherence and other aspects of wellbeing such as shelter and nutrition.  A safe space to discuss social and legal issues affecting sex workers and their families for collective action. 3

Lessons from experience 3 Family planning and full range of SRH and HIV outcomes Improving access to maternal child health / PMTCT and HIV Treatment Meeting the broader SRH needs of sex workers make ‘people sense’, achieving SRH and HIV outcomes Rapid testing in convenient location / hours Trained community counsellors Commitment to confidentiality Community based VCT improves uptake Build sex workers’ confidence to test Improve treatment literacy Facilitate access to HIV treatment Effective HIV treatment scale up & realizing the preventive benefits of treatment requires investing in community based programmes that:

Durjoy Nari Sangha | Bangladesh Sex worker organization: Multifaceted anti-violence programme 3

Outcomes  Reduced violence  Increased reporting of violence  Improved understanding of rights  Increased access to legal, health and social systems 3

SWING: Thailand Building community and working with police 3

“We placed police cadets as our interns, hoping that we would make allies and friends and that would help us stop and address the violence.” Surang Janyam, Director of SWING 3

SWING: Innovative partnerships with police  Each year new recruits were placed with SWING for a 3 week training period  Cadets worked alongside SWING staff :  Promoting condoms and teaching English at drop-in centers  Receiving orientation in outreach and counseling skills  Participating in police station simulations at the SWING office to experiment with ways of approaching police. 3

Lessons: Communities vital role in partnering across sectors health, justice 3 Address law enforcement practice that undermine effective HIV & SRH health outcomes e.g. Police Directives that support HIV/SRH responses; non confiscation of condoms – Myanmar, Cambodia Improve key populations knowledge of rights and access to legal services Operationalize effective working partnerships between KPs and health, public security and justice sectors

Know your rights + access to justice  People need to know their legal rights and be able to access the legal system to enforce them  Community legal education:  Rights and avenue for redress to address: violence and discrimination  Know your rights when dealing with police e.g when arrested, detained  Access to legal services:  community-based and government legal aid services  train and support community paralegals 3

Stigma and Discrimination 3 A significant barrier to access of services by Key Populations remains stigma and discrimination. Past experiences or fear of stigma and discrimination make people reluctant to access services or not disclose information that would ensure they get the care they need when they do reach health services.

Stigma and Discrimination: Solutions  Peer outreach workers can play a vital role in working with health sector partners to:  understand the barriers their communities face  help connect people to services and make those services more responsive to what communities need  Examples:  Health services provided in Drop In Centers  Peer workers in health settings  Peer workers accompanied referrals to health services  Community/ health sector problem solving for a  Involve communities in health sector training 3

Gender Based Violence  Gender based violence (GBV) has been internationally recognised as a violation of human rights  Violence against key populations is both:  A violation of human rights  Increases key population’s vulnerability to HIV infection 3

The Right(s) Evidence The Right(s) Evidence – sex work, violence and HIV in Asia A multi-country qualitative study  Evidence based tool to support governments, UN agencies and sex worker communities to prioritize and implement strategies to address violence against sex workers  Research conducted in Indonesia (Jakarta), Myanmar (Yangon), Nepal (Kathmandu) and Sri Lanka (Colombo) 3

Violence increases HIV risk violence  Violence affects the ability to negotiate condom use.  Rape and gang rape perpetrators rarely use a condom.  Genital injuries and STIs increase likelihood of HIV transmission 3

Key Findings  Sex workers experience extreme violence at work, in their neighborhoods, and in their homes  122 of 123 participants had experienced violence in their work setting.  This violence is physical, sexual, emotional and economic. In this study it included:  theft, physical assault, rape, gang rape and sexual extortion in exchange for release from custody or to avoid arrest. 3

Key Findings  Police and clients were the most commonly reported people who used violence against sex workers.  Violence by police and other state officials was also reported in custodial settings.  Criminalization increases exposure to police violence. 3

Police violence & criminalization create climate of impunity 3 Exposure to police Police violence Reluctance to report Impunity Continuing violence Criminalization

Number of participants reporting violence to police by site & gender 3

3 Laws and policies affect sex workers

Intimate partner violence  Intimate partners were the most common perpetrators of violence outside the work setting  Some of the most severe injuries reported in this study, including permanent disability and disfigurement were caused by intimate partners.  55 of 76 female participants, half the male participants and one- third of transgender participants had experienced intimate partner violence  The most serious instances were reported by female and transgender participants. 3

Factors that decrease sex workers’ risk of violence and HIV  Safe workplaces with well-defined workplace safety frameworks, decent work conditions and responsive owners/managers.  Information on rights & access to complaints mechanisms  Collectivization, strong sex worker networks & access to knowledge and skills to conduct sex work safely  Learning from past experiences how to keep safe  Access to healthcare services that are non-stigmatising and non-discriminatory. 3

Factors that increase sex workers’ risk of violence and HIV  Criminalization of sex work and same-sex sexual acts, and law enforcement practices exacerbated the incidence of violence by police personnel and clients by:  Giving police broad powers to arrest and detain sex workers (some of the most serious violence occurred in custody)  Creates client of impunity  Pushing sex work underground into less safe venues  Reducing sex workers’ ability to negotiate safe sex work practices  Increasing stigma and discrimination 3

Factors that increase sex workers’ risk of violence and HIV  Culture of impunity: Failure to prosecute perpetrators of violence against sex workers undermines access to justice and normalizes violence against sex workers.  Stigma and discrimination allows violence against sex workers  Gender inequality whereby violence is used to uphold and reinforce harmful gender norms and maintain existing power relations. 3

Recommendations Report has detailed recommendations in five key areas: 1.Reform punitive laws, policies and law enforcement practices to protect sex workers’ rights, including the right to be free of violence 2.End impunity of those who commit violence against sex workers 3.Strengthen sex workers’ access to justice, and empower sex workers with information about their rights 3

Recommendations 4. Recognize sex work as legitimate work and ensure that sex workers have legally enforceable rights to occupational health and safety protection 5. Improve sex workers’ access to sexual and reproductive health, HIV and gender-based violence services Full & summary report: violence-and-hiv-asia-multi-country-qualitative-study 3

Policy Brief: Sex Work, Violence & HIV in Asia - From Evidence to Safety  Brief of evidence for action drawn from:  The Right(s) Evidence: Sex Work, Violence and HIV in Asia, 2015  The Lancet Special Series on Sex work and HIV, 2014  Consolidated Guidance on HIV prevention, treatment & care for Key Populations, 2014 Policy Brief: Sex Work, Violence and HIV in Asia - From Evidence to Safety work-violence-and-hiv-asia-evidence-safety 3

Creating a safe working environment Working Conditions, Occupational Health and Safety and Rules of Entertainment Services Enterprises, Establishment and Companies, Cambodia (2014) The proclamation covers: Workplace safety Rights and benefits including overtime Prohibitions on forced labour and violence against entertainment workers. 3