1. Strengthening Programmes among Sex Workers: Lessons from the region under the key elements of a harm reduction approach

2. Regional Experience & Good Practice UNFPA, UNAIDS & APNSW (2012) HIV & Sex Work Collection 2

3. Regional Experience & Good Practice The HIV and Sex Work Collection 3 “There is considerable experience in this region about what works in delivering HIV prevention, treatment and care programmes” (UNFPA, UNAIDS & APNSW, 2012, p6)

4. Regional Experience & Good Practice The HIV and Sex Work Collection The purpose of the HIV and Sex Work Collection is to:  Document and share programming and advocacy experience  Provide detailed case studies that illustrate the ways in which programmes and advocacy interventions were designed and delivered to elements of a comprehensive response  Identify lessons learned, gaps, challenges and key considerations for strengthening and scaling up comprehensive and effective responses in the region 3

5. Regional Experience & Good Practice The HIV and Sex Work Collection It is a valuable resource:  For programming managers, implementers and service providers  To guide policy makers and development partners in planning and allocating resources for strengthening and scaling up effective interventions  To advance advocacy efforts for a comprehensive response that focuses on evidence and rights based interventions. 3

6. Regional Experience & Good Practice The HIV and Sex Work Collection  Presents eleven key elements of a comprehensive response to HIV in the context of sex work  Strategic Investment demands the address of social enablers and enabling policies  Document presented in two sections:  Part 1: Key lessons learned, gaps and challenges in delivering and scaling up evidence and rights based responses in the Asia-Pacific region  Part 2: Presents 11 detailed case studies on HIV and sex work interventions 3

7. Key elements of harm reduction approach to HIV & sex work 1.HIV prevention and SRH, HCT, access to treatment, care and support services 2.Enabling legal, policy and social environment 3.Mobilize, empower and involve sex worker communities 4.Address underlying causes of vulnerability to HIV:  prevent and reduce violence  economic empowerment & social protection  address stigma and discrimination in access to health services 3

8. Element 1: Comprehensive HIV prevention & SRH services  Access to male and female condoms and water-based lubricant  Peer based outreach and education including tailored plain- language/visual resources, individual and group support  Sexual and reproductive health (SRH) services including STI diagnosis and treatment, dual method contraception, family planning,  HIV testing and counseling (HCT) with direct connection to treatment, care and suppot for PLHIV 3

9. Element 1: Comprehensive HIV prevention & SRH services  Access to HIV and TB treatment, care and support  Access to alcohol and drug related harm reduction including needle and syringe programmes and opioid substitution treatment, effective drug treatment programmes 3

10. Element 1: Comprehensive HIV prevention & SRH services  Integration of HIV and SRH services essential to HIV prevention and universal access to reproductive health  to prevent unintended pregnancies and  ensure access to antenatal care including PMTCT  Why broader SRH for sex workers:  Low levels condom use with non-commercial sexual partners  Condoms are less effective in preventing unintended pregnancy compared with other forms of contraception  Evidence of high unmet contraceptive need  Prevalence of violence against sex workers, increasing risk 3

11. Element 1: Comprehensive HIV prevention & SRH services Why SRH for sex workers?  Condom breakages more common among sex workers given frequency of sexual intercourse  High level of sexual violence  HIV testing in Maternal Child Health (MCH) services often not reaching pregnant sex workers 3

12. Element 2: Enabling legal & policy environment – Impact of criminalization  HIV and SRH services alone are not enough  Sex Work & The Law in Asia and the Pacific found laws that criminalize sex work increase vulnerability to HIV:  Fuels stigma and discrimination  Undermines access health services because of fear or experience of discrimination  Legitimizes violence, harassment and extortion  Limits carrying of condoms for fear of arrest 3

13. Element 2: Consistent calls for decriminalization of sex work Punitive laws and human right abuses are costing lives, wasting money and stifling the global AIDS response Global Commission on HIV and the Law  Consistent findings that criminalization of sex work hinders HIV responses to HIV & calls to decriminalize sex work:  Global Commission on HIV and the Law, July 2012  Sex work and the Law in Asia and Pacific, October 2012  Commission on AIDS in Asia, 2008 3

14. Element 2: Lessons on impact of decriminalization  New Zealand, decriminalized sex work in 2003:  Removal of criminal penalties, reduces corruption  Implemented workplace health and safety standards o Obligation on sex work businesses and sex workers to promote and adopt safer sex practices o Ministry of Health in charge of inspection and enforcement, not police  Provided sex workers access to legal redress to resolve work related disputes and employment discrimination 3

15. Element 2: Lessons on impact of decriminalization New Zealand Parliamentary review found:  Increased confidence & well being among sex workers  Improved working conditions & ability to negotiate safer sex standard in sex industry  High condoms use  HIV prevalence among sex workers very low  Decriminalization has not lead to increase in numbers of sex workers 3 Annah Pickering, Manager of the Auckland Region, New Zealand Prostitutes Collective, presenting on benefits of decriminalization in New Zealand, Sex Workers Freedom Festival, July 2012

16. Element 2: Lessons on impact of decriminalization  In the State of New South Wales, Australia similar lessons:  Successful in reducing opportunities for police corruption  Improved coverage of health promotion programmes and rights protection for sex workers  Highest rates of condom use among sex workers anywhere in the world (exceeding 99%) and consistently low STI prevalence  Workplace health and safety guidelines applied  No evidence of increased frequency of sex work  Net savings for the criminal justice system 3

17. Progress: Supportive laws, policy & practices in the region  Ministry of Interior, Cambodia directive to police that condoms will not be used as evidence for arrest  Order of Government of Myanmar that police not to confiscate condoms  Legislation in Fiji and Papua New Guinea (PNG) make it unlawful to deny a person access to condoms or other means of protection from HIV 3

18. Progress: Supportive laws, policy & practices in the region  Laws in Cambodia, Fiji, Lao PDR, PNG, the Philippines and Viet Nam offer some protections in areas such as:  prohibition of compulsory testing  rights to confidentiality  protection from HIV related discrimination  Rules of Social Security Fund, Thailand enable sex workers to access state social security benefits for sickness, disability, and a pensions if they make financial contributions 3

19. Element 2: Progress: Supportive laws, policy & practices in the region  Supreme Court decisions in Bangladesh, India and Nepal and the constitutional court of Taiwan have explicitly recognized the human rights of sex workers  Karmaskar case, 2011, Supreme Court of India directed the government to consider providing ration cards and voter identity cards to sex workers 3

20. Element 3: Lessons in mobilizing & empowering sex workers  Evidence from HIV & Sex Work Collection shows community mobilization & empowerment central to:  Effective peer outreach and social mobilization  Addressing barriers to service access including stigma and discrimination, building community demand & confidence to access services 3

21. Element 3: Lessons in mobilizing & empowering sex workers  Innovative approaches to prevent and address violence against sex workers and advocate for law reform & tackle law enforcement practices that violate sex workers’ rights and undermine effective HIV responses  Strong links between empowering sex workers and effectively addressing the causes of HIV vulnerability:  strongest programming and advocacy in the region is led by sex worker community organizations 3

22. Elements 3 & 4: Lessons in preventing & addressing violence  Violence against sex workers pervasive and significantly associated with sexual health risk, including reduced condom use and increased risk of STI/HIV  Durjoy Nari Sangha, is a sex worker organisation in Bangladesh with a member of 3,500  Durjoy has pioneered a remarkable multifaceted anti-violence programme to:  prevent violence by mobilizing and building capacities of sex workers and community partners, including clients, police, local business men, and religious leaders 3

23. Elements 3 & 4: Lessons in preventing & addressing violence  mitigate violence by ensuring that sex workers who experience violence can access legal, health and protection support services  respond to violence by tackling barriers to reporting violence and improve responsiveness of law enforcement and judiciary.  Durjoy’s programme has demonstrated:  reduction in incidence of violence  increased understanding of rights among sex workers  increased reporting of violence and  improved access to legal and health services and social systems 3

24. Elements 3 & 4: Lessons in preventing & addressing violence  Strengthen partnerships between sex workers and key stakeholders at local level: police, venue and brothel owners, community leaders, clients of sex workers, lawyers, human rights institutions, and health care service providers  Build capacity of sex workers to:  case manage incidences of violence, including counselling and referral for health, legal and psychological support  document experiences of violence for advocacy  Address stigma, exclusion and marginalization of sex workers through community based education campaigns 3

25. Elements 3 & 4: Lessons in addressing barriers to services  Dark Blue is a Lesbian, Gay, Bisexual, Transgender (LGBT) community organization in Tianjin China  Started addressing the unmet HIV and sexual health needs of male and transgender sex workers in 2008  Dark Blue now has 9 full-time staff and 31 outreach workers  Provides a wide range of services and programmes:  Community based drop-in-centers with HIV and STI testing and treatment facility  Peer outreach and education services including internet-based radio and chat-room programmes for health information & referrals  Outreach in sex clubs and bathhouses now key site for HIV and STI prevention, HIV testing and on-site treatment of some STIs such as Syphilis 3

26. Elements 3 & 4: Lessons in addressing barriers to services  Dark Blue investing in building strong partnerships with Tianjin Provincial Government Centre for Disease Control and Prevention (CDC), government health service providers and owners of sex clubs/ bathhouses has been critical to success:  Club owners support access to sex clubs – condoms and lubricant, rapid HIV and STI testing & some STI treatment in venue  CDC recognizes Dark Blue can reach male and transgender sex workers and support their public health efforts by encouraging testing and treat early 3

27. Elements 3 & 4: Lessons in addressing barriers to services  Peer outreach and services in sex clubs and bathhouses significantly increased reaching men who have sex with men, including male and transgender sex workers – 9,000 in 2010 to 20,000 in 2011  CDC provides Dark Blue with rapid test kits  As a result of rapid HIV testing drop in centers and in sex clubs HIV testing has more than doubled: 2,163 people tested at on- site VCT in 2009 rising to 4,501 in 2011  Dark Blue’s work with CDC government health service providers has helped ensure non-discriminatory & confidential services sex worker has improved service uptake including HIV treatment 3

28. Elements 3 & 4: Lessons in addressing barriers to services  Tingim Laip Project in Papua New Guinea employs current and past sex workers as Field Officers  These women and transgender people do outreach and accompanied referrals  Some work in the clinics, greeting new clients, helping them communicate with other staff (breaking down language, class, clan barriers)  They bring refreshment packs as the waiting time can be long and this means that new clients don’t walk away without getting service 3

29. Elements 3 & 4: Lessons in addressing barriers to services  One Field Worker, Marcia, sweeps the clinic each morning at the start of the day – she says that this ‘menial’ task demonstrates respect for the clients coming in and shows other staff that she respects the sex worker clients  Marcia is living with HIV and is very skilled in providing treatments information and support for newly-diagnosed people  She also does house visits, reminding people to come back to get their treatments refils 3

30. Elements 3 & 4: Lessons in addressing barriers to VCT access & uptake  Viet Nam: 43.8% of sex workers had an HIV in the last 12 months and knew the result (2010-2011 reporting period)  SWING Thailand, TOP Myanmar, Dark Blue China demonstrate increase in VCT uptake with:  Availability of rapid testing  Services at suitable hours and community locations, such as drop in centers, convenient for & trusted by sex workers  Professionally trained community counsellors  Demonstrated commitment to voluntary and confidentiality services 3

31. Elements 3 & 4: Lessons in economic empowerment  Financial insecurity compromises sex workers’ ability to insist on condoms for fear of losing business  Access to secure savings and loans  Improve access to social protection:  Life skills, education and training to expand options for viable livelihood/ income generation  Social insurance and assistance e.g. ration cards  Affordable housing schemes  Build skills to manage finances 3

32. Elements 3 & 4: Lessons in economic empowerment  Durbar Mahila Samanwaya Committee (DMSC) is a collective of 65,000 sex workers in West Bengal, India  DMSC found:  Sex workers denied access to bank accounts because of lack of papers  Commonly cheated of savings through use of unregulated financial institutions  DMSC created the USHA Cooperative, now the largest sex workers led financial institution in Asia 3

33. Elements 3 & 4: Lessons in economic empowerment USHA Cooperative, West Bengal, India  Significant success in improving sex workers’ control over their finances and expand their economic options  Membership of over 16,000 sex workers  Savings accounts and fixed deposits, with tie-in product with the Life Insurance Corporation of India 3

34. Elements 3 & 4: Lessons in economic empowerment  Between 4,000 – 5,000 members receive low cost loans annually  Vocational training and support for business development  USHA has one of the best loan recovery rates in West Bengal - over 90%  An annual turnover of US $ 2.7 million and capital assets of more than US $ one million  USHA member’s registration cards used to obtain voter ID cards and rations cards, enabling sex workers to access other civil entitlements 3

35. Sources: Lessons from the region  Sex Work and the Law in Asia the Pacific UNDP & UNFPA October 2012:  analysis of laws, policies and law enforcement practices and their impact on human rights and HIV responses among sex workers in 48 countries in Asia and the Pacific  defines an agenda for action at country level  The HIV and Sex Work Collection: Innovative responses in Asia and the Pacific, UNFPA, UNAIDS and Asia Pacific Network of Sex Workers (forthcoming December 2012):  Documents 11 programmes from 7 countries  Provides an analysis of key lessons from experience in the region 3

36. Key resources  Sex Work & the Law in Asia & the Pacific, UNDP & UNFPA, Cot 2012  Sex Work & Violence: Understanding Factors for Safety & Protection – Desk Review of literature from and about the Asia Pacific region, UNFPA, UNDP, APNSW, Partners for Prevention, May 2012  The HIV and Sex Work Collection: Innovative responses in Asia and the Pacific, UNFPA, UNAIDS & Asia Pacific Network of Sex Workers, forthcoming, Dec 2012  UNAIDS Guidance Note on HIV and Sex Work, updated March 2012  Global Commission on HIV and the Law: Risks, Rights and Health, July 2012  HIV in Asia and the Pacific: Getting to Zero, UNAIDS 2011 3

37. Key resources 3  Meeting the Contraceptive Needs of Key Populations Affected by HIV in Asia: An Unfinished Agenda, Petruney, T.et al, June 2012  Effectiveness of Peer Education Interventions for HIV Prevention in Developing countries: A Systematic review and meta-analysis, Medley A. et al, 2009  Sex worker-led structural interventions in India: A case study on addressing violence in HIV prevention through Ashodaya Samithi collective in Mysore, Reza-Paul, S. et al, 2012  What makes a structural intervention? Reducing vulnerability to HIV in Community settings, with particular reference to sex work, Evan, C. et al, Aug 2012