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‘Treatment as Prevention’: How might the game change for sex workers?

by Cheryl Overs

The recent Lancet publication of the HPTN 052 study has shown unequivocally that initiation of anti-retroviral treatment (ART) by people with HIV substantially protects their HIV-uninfected sexual partners from acquiring HIV infection, with a 96 percent reduction in risk of HIV transmission.[1]

The announcement in June is a welcome confirmation of what many already suspected – that ART is prevention. The word ‘game-changer’ was, not surprisingly, all over the internet within hours of the publication of the announcement of the closure of the trial. But so were questions about where this leaves the existing approaches to HIV prevention and promotion of sexual and reproductive health. Sex worker advocates immediately recognised that this new evidence could have a significant effect on both the actual conduct of commercial sex and on the programmes, public health policy and legal frameworks around it.

A resources shift away from certain cornerstones of HIV prevention could be disastrous for sex workers in respect of both health and human rights outcomes. Condoms, information, sexual and reproductive health services and social support are crucial protection to limit other illnesses, exploitation, abuse and unwanted pregnancies. The greatest risk concerning sex workers is that condom use will be abandoned or become even more difficult to negotiate. As knowledge that ‘treatment is prevention’ reaches sex workers and their clients, demand for unprotected commercial sex may result from confidence that even if a sex worker is HIV-positive she/he is likely to be on ART, and thus not infectious. This is particularly likely where governments make testing and treatment for sex workers mandatory. Crafting messages to encourage testing and treatment as a prevention strategy without discouraging condom use is an enormous challenge. There is also a risk of ART being pressed on sex workers for whom it is not needed or even as pre-exposure prophylaxis.

While sex workers’ organisations support HIV testing and ART, they have consistently pointed to barriers to sex worker access to ART, including discrimination, financial costs, violence, loss of livelihood, lack of nutrition and housing and appalling treatment by health care workers. This is especially so where the food supply is insecure, where sex work is highly criminalised or stigmatised and where the price of treatment for opportunistic infections is unaffordable. It applies in particular to migrant sex workers.
 
This extraordinary finding that treatment is prevention obviously produces no automatic change to the social, economic and political context in which public health activity takes place. But it means it is more urgent than ever to eliminate the barriers that have limited the efficacy of existing prevention methods. In addition, we must avoid shifting HIV programming and resources to HIV testing “by numbers”– an approach that poses great challenges to confidentiality and quality of care, as has been raised by the Sonagachi Project in a recent submission to the Commission on HIV and Law.

Sex workers need to respond to the change in the prevention/treatment dynamics by identifying what approaches work for them and demanding that governments and health agencies include those approaches into the scaling up of testing and treatment. Addressing legal and other structural barriers is essential. The only way to achieve this is with the involvement of sex workers and with the removal of laws that threaten sex workers’ human rights.

Testing policy is another key issue for sex workers. Sex worker groups should resist shifts toward routine and provider-initiated testing where conditions suggest it may become yet another abusive practice, and embrace it where the following conditions exist:

  • Recognition of sex work  as an occupation and that sex workers should have the same legal rights as other citizens;
  • Adequate health care, education, food and shelter for sex workers and their families;
  • Universal access to HIV treatment care and support;
  • Respectful, rather than stigmatising, behaviour by health service providers;
  • Affordable, confidential and ethical HIV and STI screening;
  • Registration and funding of sex workers’ organisations; absence of violence and arbitrary detention by police; guaranteed access to the best available HIV care and treatment.

If my suggestion that these conditions are necessary for ARV treatment to function effectively as HIV prevention for sex workers, the goal is still to make those conditions a reality so in some sense the game may not have changed very much at all.

 

 

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