1. Joint Parliamentary Committee 24 May 2013 Sex Work Sector SWEAT
South African Sex Work Program, 2012 – Leveraging a Public Health & Human Rights Approach for HIV and Sex Work programming in South Africa
Joint Parliamentary Committee
24 May 2013
Sex Work Sector
SWEAT

2. Overview Programme principles Programme aims, objectives & outcomes
Activities
Scale-up
Monitoring & evaluation
Timeframe
Next steps

3. Sex workers & society Society usually views sex workers negatively
(in addition to lower social position and power of women & minority groups)
Moral judgment, criminalisation, stigma & discrimination
Marginalisation, exclusion & disempowerment
Generally speaking, society has a very negative attitude towards sex workers. This negative attitude is often in the context of the lower socioeconomic status of women and other minority groups.
The experiences moral judgement, social stigma and discrimination results in marginalisation, social exlusion and disempowerment.

4. Sex work in South Africa
Sex work is very common
Yet, all aspects of sex work are ILLEGAL
Contextual factors result in:
Marginalisation
Increased vulnerability to violence
No access to legal recourse
Discrimination prevents health & legal service access
Disempowerment limits ability to negotiate condoms
Unsafe working conditions & no workplace protections
Sex work is common, it occurs in every village, town and city in South Africa
Sex work takes place in a variety of settings:
In both formal and informal settings, like: brothels, massage parlours, road side, in taverns, truck stops, hostels and others
Sex work involves a diverse stakeholders:
Sex workers, clients, sex worker emotional partners, business owners and intermediaries
Sex work is ongoing despite ILLEGALITY of all aspects of sex work:
Selling sex, purchasing sexual services, owning a facility that provides sexual services etc.

5. Sex work in South Africa
Hostile environment
Social exclusion & marginalisation
Risk of arrest & extortion
No access to legal recourse
Disproportionately high risk for HIV infection
Conditions favouring HIV transmission
Unfavourable conditions for good health outcomes
Violence & rights abuses
Police harassment & violence
Sexual & physical assault
Poor understanding of rights
No workplace protections
Sex workers in South Africa live and work in hostile environments, endure high levels of human rights abuses and historically have not enjoyed the benefits of a responsive, non-discriminatory health system.
These elements contribute to the disproportionately high risk for HIV infection among sex workers, and for the transmission of HIV among them and their clients and sexual partners. Additionally, limited access to enabling health environments prevent good health outcomes among sex workers living with HIV.
Unresponsive health system
No national govt. led SW programme
Limited coverage of health services
Limited prevention commodities
Discrimination by health workers

6. Sex work & HIV in South Africa
HIV prevalence among female sex workers 60% - versus 25% among women (15-49 yrs)1
Female sex workers 4 times more likely to be HIV infected compared to women (15 – 49 yrs)1
Estimated 20% of all new HIV infections occur among sex workers2
1. Baral et. al. Burden of HIV among female sex workers in low-income and middle-income countries: a systematic review and meta-analysis Lancet 12 (3099).
2. SACEMA. Modes of Transmission Study. Report. Stellenbosch. 2010

7. South Africa’s National Response

8. Programme Principles Sex workers are equal citizens and have families
Sex workers’ rights and dignity must be respected
Sex workers are not victims by virtue of being sex workers
Sex work is a livelihood option
Sex worker ownership: “nothing about, us without us”
Evidence-informed response
Interventions should not do harm
Collective sex worker engagement, mobilisation and empowerment essential for success

9. Aims
Increase coverage & access to comprehensive HIV, STI & TB services for SW, their partners and families
Reduce violence and human rights abuses experienced by SW
Create enabling health & related systems for the realisation of Constitutional rights

10. Objectives
Reduce social & structural barriers to HIV, STI & TB prevention, care and impact
Reduce sexual transmission of HIV among SW
Sustain SW health and wellness
Strengthen the health system
Collect information & research to enable an effective HIV response

11. Expected outcomes
Reduction in human rights violations experienced by SW
SW-focused policy & programme inclusion across sectors
Empowered & capacitated sex workers
Established SW coalitions & networks
Capacitated health & law enforcement workers
Increased access to legal recourse for SW
Progression towards the decriminalisation of SW
Increased access to package of SW services
Increased access to services for SW partners & clients
Increased proportion of SW living with HIV on ART
Appropriate SW programme performance management
Improved commodity supply chain management
Evidence on new HIV-related advances for SW

12. Ultimate impact
Removal of structural barriers & legal reform to allow realisation of rights & effective responses
Reduction in new HIV infections among SW and their partners
Reduction in HIV and TB related deaths among SW
High quality, efficient & responsive health system
Evidence-informed policy & programming

13. NATIONAL SEX WORK PROGRAMME LOGIC MODEL

14. NSWP activities (1) Mobilisation & engagement Service provision
HIV/STI/TB services
SW needs assessment
SRH services
SW-led organisation establishment
Psychosocial services
Alcohol & drug support services
SW capacity building
Safe space establishment
Access to justices
Services to address exploitation
Network establishment

15. NSWP activities (2) Communication Structural reform Sensitisation
Health & rights
Health systems & community strengthening
Sensitisation
Health workers
Information
Law enforcers
Monitoring & Evaluation
Advocacy
Surveillance
Human rights
Research
Access to justice
Decriminalisation

16. Context 1:
Hot Spot!
Large population in relatively contained, urban area.

17. Context 2:
Large population, rural or focussed on particular contextual element, mobile and tend to be reached only at work (truck stop, mine etc)

18. Context 3:
General context: smaller population or unknown population size, generalised area, contextually varied

19. SERVICE PACKAGE MATRIX
Context i
Service delivery model ii
Package of services iii
Metropolitan area
High concentration of SW
Specialist sex worker clinics
(NGO-govt. partnership)
e.g. Essen St clinic
extended hours
established networks
mobile services
1. Condoms & lubricant
2. PEP
3. STI/TB diagnosis & management
4. HIV, testing, treatment, care & support
5. Psychosocial services & risk reduction
6. Referral for substance abuse
7. Reproductive & sexual health
8. IEC materials
9. Safe spaces & peer-led mobilisation
Sex worker ‘hot spots’
Sex-worker focused services
(NGO or govt. provided)
e.g., truck stops
Includes sex worker clients
Includes mobile services
1. Services described above (1 – 9)
2. Services for sex worker partners (1 -5, 9)
3. Mobile services ( 1 – 4, 9)
Other areas
HTA clinics
Sex-worker friendly services
Outreach work & primary health care package, provided in a sensitised manner
i. Context assessed through location mapping & needs assessment, defined by SW concentration
ii. Peer led outreach, education, linkage to services & support provided in all contexts

20. Service delivery 1:
Hot Spot!

21. Service delivery 2:
Large population, rural or focussed on particular contextual element, mobile and tend to be reached only at work (truck stop, mine etc)

22. Service delivery 3:
General context: smaller population or unknown population size, generalised area, contextually varied

23. Peer-led activities
Sex worker peers understand contexts & complexities of industry
Sharing of knowledge, skills & building capacity between peers
Key to success of sex work programmes in India
Collective mobilisation and empowerment can lead to change
Peer progression model – career pathing of SW peers
Approach builds on Quality Assurance Standards for Peer Education & Outreach Workers for High Risk Vulnerable populations in South Africa

24. What is the innovation? Evidence informed programming
Mobilisation - Sex worker targeted (not accidental, hidden or unknown)
Fit for purpose=fit for context
Sex worker peer educators
Sex worker community strengthening
Up-scaling successful interventions
Health worker sensitisation
Advocacy / human rights approach
Co-ordinated

25. Monitoring & Evaluation
Under development, based on logic model
Inputs into national M&E framework
National Level (SANAC)
Impact & outcome indicators
Bio-behavioural surveys required
Audits of specific programme elements
Local level (implementers)
Process indicators
Include quality indicators
Include SW satisfaction surveys

26. TIME FRAME:

27. Sex work programme next steps
Refine implementation model & cost
SW ratification & input on programme
Formalise role of the SW TWG
Initiate capacity building of health care workers & organisations ahead of scale-up

28. Contact us sallys@sweat.org.za 021 4487875
Sex Worker Help line:
Or please-call-me

29. PARTNERSHIPS FOR SW INTERVENTIONS