Category 3: Implementation
Key components of HIV prevention interventions
To be most effective, HIV prevention in sex work settings should focus initially on the following three outcomes (see strategic framework):
- Safer sex and increased condom use
- Increased sex worker involvement and control over working and social conditions
- Reduced STI burden
Other services will likely be needed to respond to broader health and social needs. As projects develop, sex workers themselves should identify priorities. Service delivery issues include ensuring that interventions are accessible, acceptable and effective in the sex work context.
Frequently, a first step in building a safer environment is convincing sex workers that they can change conditions under which they live and work. The strengthening of peer networks to address HIV prevention can help build up sex workers' confidence. Even small successes as a result of community action can result in greater feelings of personal and collective power to take on other issues.
Initially, it may be necessary for projects to give substantial capacity-building, emotional and practical support to sex workers and peer leaders to help build up a sense of personal efficacy, community and solidarity, and so to facilitate community action (see Category 4). Sex workers often have a wide range of pressing concerns that affect their health, well-being and capacity for action both directly and indirectly. These may include worries about children, police harassment, exploitative working conditions, housing problems, domestic violence, migration status, HIV-related stigma. Financial pressures frequently limit sex workers' ability to consistently insist on safer sex.
Many projects have responded to these issues by engaging in advocacy at the local level, by organizing or making referrals to services, by setting up co-operatives and other financial services, by providing training on human rights and welfare issues, and by actively encouraging community action through the mobilization of peer networks.
Allgemeine schlussfolgerungen und empfehlungen - in German
Almene konklusioner og anbefalinger - in Danish
Algemene conclusies en aanbevelingen - in Dutch
Conclusões e recomendações gerais - in Portuguese
Allmänna slutsatser och ekommendationer ()
Conclusioni generali e raccomandazioni - in Italian
Recommendations et conclusions generales - in French
Conclusiones generales y recomendaciones - in Spanish
General conclusions and recommendations
Pathways to Partnership - Toolkit
Promoting safer sex and increased condom use
There are many ways of distributing and promoting condoms, including the use of peer educators and social marketing. Behaviour change communication methods - condom use demonstrations, videos, role plays, interactive workshops - can be used to build skills for effective safer sex negotiation as well as to provide information. In addition to condom use, projects can also promote non-penetrative methods of safer sex. Experienced peer educators or sex workers can be highly effective educators on this subject.
Since promotion of correct and consistent use of condoms will raise demand in most settings, it is important to ensure that an adequate and continuous supply of male latex condoms of high quality and at the lowest possible price can be maintained. Ask sex workers for feedback on condom quality and preferred size or brand. Where feasible, try to make water-based lubricants and female condoms available. Lubrication is especially important for male sex workers, and where anal sex is common. The female condom, a thin sheath of polyurethane that is placed in the vagina, has been approved as a family planning method and should be promoted. However, there is no firm scientific evidence so far that use of female condoms protects against HIV infection. Studies on this important issue are under way.
To be most effective, back up communication efforts with commodities (e.g. condoms, STI drugs, clean needles), services (e.g. STI management or HIV care and support services) and actions to build a more enabling environment for behaviour change (for example, by persuading brothel owners to support sex workers in insisting on the use of condoms, working with the police to reduce violence against sex workers). Where sex work is linked to injecting drug use it is important to promote harm reduction interventions including information and links to services.
Promoting condoms in clinics for sexually transmitted infections
The Female Condom - A guide for planning and programming
Condom use policies
Condom use policies mandate condom use in commercial sex settings and place responsibility for enforcement on sex work establishments rather than on individual sex workers. Successful programmes have been implemented at local ('safe houses' in Australia), municipal, regional and national levels (100% CUP in Philippines, Dominican Republic, Thailand, Cambodia).
100% Condom Use Programmes (CUP) require sex work establishment owners to ensure that all clients use condoms on their premises. Compliance is monitored in various ways, including monitoring of STI trends. High STI rates are considered evidence of a brothel's non-compliance with the condom use policy and sanctions can be taken against the brothel owner concerned. The strength of such 'structural' interventions is that consistent condom use becomes a work-place norm rather than being left up to individual sex workers to negotiate. Recent evidence indicates that the new social norms established within brothels can 'diffuse' to other less accessible sex work settings due to the mobility of sex workers and clients.
The 100% CUP has been credited with achieving very high rates of condom use and with significantly reducing the prevalence of STIs and HIV in countries such as Thailand and Cambodia.
Condom use policies should be adapted to local conditions, reinforce other interventions and include the following components:
- Involvement and commitment of a range of stakeholders
- Regular examination and treatment of STI in sex workers
- Availability and accessibility of condoms
- Effective behaviour change communication through a variety of channels to make condom use the social norm
- Outreach activities to reinforce the messages of the programme
In 100% CUP, as in all programmes, it is important to establish mechanisms to involve sex workers in planning and implementation and to ensure that their rights are respected at all times. A recent WHO/UNAIDS evaluation of the 100% CUP in Cambodia acknowledged its successes while recommending strengthening of community development components.
Experiences of 100% Condom Use Programme in selected countries of Asia
STI HIV 100% Condom Use Programme in Entertainment Establishments
Guidelines for scaling-up the 100% condom use programme. Experience from Cambodia
Responding to Questions About the 100% Condom Use Programme
Reducing STI burden
Sex workers are frequently exposed to STIs in their work, yet often face difficulties accessing health care services. STIs cause serious problems (such as pelvic inflammatory disease, infertility, ectopic pregnancy) in addition to making it easier for HIV infection to take place. For these reasons, effective STI services adapted to sex workers' needs are an essential component of HIV prevention interventions. It would not be sufficient to provide STI services without addressing other health needs of sex workers, however.
There are many advantages to providing clinical services as part of the package of interventions offered to sex workers. Sex workers may have more confidence in a project if they are receiving respectful services of high quality from the same people as are promoting prevention. Such services can be more easily adapted to sex workers' needs and the quality of service can be more easily ensured. In other cases it may be more feasible to establish linkages and referrals with pre-existing services, recognizing that they may need some adaptation or additional training in order to meet the needs of sex workers and clients.
Services need to be acceptable and accessible to sex workers. Sex workers have reported various barriers to seeking help from formal services, including stigma and discrimination by staff, poor quality treatment, high cost, inaccessible locations or inconvenient working times, and because of the fear of being exposed, reported, deported or imprisoned. In addition, sex workers may have irregular and unpredictable working times and lifestyles, making it hard to keep appointment times or to follow treatment regimes. These issues are especially relevant for mobile and migrant sex workers and their clients.
Appropriate services can be developed by training staff and monitoring attitudes and quality of treatment, by setting up special clinical services for sex workers/clients at convenient times and locations, by arranging special sessions within mainstream services at times that are convenient, by subsidizing or providing free treatment, or by setting up mobile clinics or providing on-site services. Peer educators should always be involved in promoting services.
Guidelines for the management of STI in female sex workers
These are guidelines for public health specialists and health professionals on how to develop or improve STI services for female sex workers. The report includes sections on clinical care, HIV counselling and testing, education for behaviour change, promoting the use of condoms and social services. The guidelines were written to inform the STI management component of 100% condom use programmes.
Contents and Preface. Guidelines for the Management of Sexually Transmitted Infections
Introduction, STI associated syndromes. Guidelines for the Management of STI
Specific infections. Guidelines for the Management of Sexually Transmitted Infections (Chapter 3)
Increasing sex worker involvement and control
Vulnerability to HIV is largely shaped by social factors that lie outside an individual's control. Consequently, a concerted effort should be made to tackle these factors and to build more supportive or 'enabling' environments for sexual health. Actions to build enabling environments can be taken at individual, local or higher levels. Two approaches that have proven successful are:
- community mobilization to empower sex workers to change conditions that contribute to vulnerability and risk.
- condom use policies that transfer primary responsibility for condom use from individual sex workers to establishments where they work.
It can take time to change deep-seated social norms and structures. Most community intervention start slowly but even small changes can make a big difference. Let the community set the agenda. There are many examples where sex workers - often starting with HIV prevention work - have become more empowered and have mobilized to create safer and less exploitative living and working conditions.
Other health and social services
Sex workers have other health care needs as well, and efforts should be made to provide other services. Priorities should be identified by sex workers themselves. Commonly, these include:
- HIV counselling, testing, care and treatment;
- prevention of mother-to-child transmission of HIV;
- family planning and antenatal services;
- general health services;
- harm reduction services for drug users;
- social welfare and legal services.