During the 2014 International AIDS conference, The Lancet medical journal released a series of articles focused exclusively on HIV and sex work. One study by Kate Shannon et al., demonstrates that decriminalization of sex work could reduce HIV infections by 33 to 46 percent over the next decade. Shannon’s team showed that “multi-pronged structural and community-led interventions” are essential to promoting the human rights of sex workers, as well as improving their access to HIV prevention and treatment. Dr. Chris Beyrer, the researcher who coordinated this Lancet series, told AIDS conference participants that “[e]fforts to improve HIV prevention and treatment by and for people who sell sex can no longer be seen as peripheral to the achievement of universal access to HIV services and to eventual control of the pandemic,” drawing an irrefutable line between the social, legal, and economic injustices sex workers face and their subsequent vulnerability to HIV.

The Lancet series authors join many other prominent public health voices in identifying the decriminalization of sex work as vital to preventing the spread of human immunodeficiency virus (HIV) and of acquired immune deficiency syndrome (AIDS). For two decades, sex workers rights’ activists throughout the world have pushed human rights, public health, and HIV and AIDS response leaders to recognize that they, along with people who inject drugs and men who have sex with men, are “key populations” without whom an effective HIV and AIDS response is impossible. In 2012, the World Health Organization (WHO) declared that “all countries should work toward decriminalization of sex work and elimination of the unjust application of non-criminal laws and regulations against sex workers.” In South Africa (with the largest population of people living with HIV in the world), the National AIDS Council is urging its government to decriminalize sex work—a demand that advocates and health policy professionals are making in dozens of other countries as well. Amnesty International, Human Rights Watch, and the UN’s Global Commission on HIV and the Law all endorse this position. The latter points out “the impossibility of governments stigmatizing people on one hand, while simultaneously actually helping to reduce their risk of HIV transmission or exposure on the other.”

Sex work has been decriminalized in New Zealand and one province (New South Wales) in Australia leaving sex work businesses subject to standard occupational health and safety regulations. Law enforcement treats the sale of sex as it does any other business, without any intrusion or interruption unless existing laws are being violated.

Decriminalization has resulted in higher rates of condom use and enables sex workers to organize community-based health practices that demonstrably improve health and reduce HIV risk. It also makes it possible for sex workers to report and for the police to address illegal acts as they occur, such as assault, theft of services, employment of minors, or client coercion. In this decriminalized setting, sex workers can be strong allies in the fight against trafficking, intimate partner violence, and child abuse since they can report incidents to the police and social service agencies without putting themselves at risk of arrest.

So, why is the HIV-AIDS field only just beginning to recognize the connection between the decriminalization of sex work and HIV? And why is the trend toward criminalizing populations involved in the sex trades increasing in the United States—moving in the opposite direction from other countries? The following are three contributing factors.

Conflating Sex Work With Trafficking

Public debate around sex work in the United States increasingly focuses on people who have been trafficked or otherwise coerced into the sex trade. Anti-trafficking advocates conflate sex work (people choosing to sell sexual services from among employment options available to them) with trafficking (people being forced into the sex industry against their will). Laws that criminalize all people selling sex (voluntarily or involuntarily) violate the rights of the former and undermine efforts to identify and assist the latter. The Global Commission on HIV and the Law states unequivocally that, “Sex work and sex trafficking are not the same. The difference is that the former is consensual, whereas the latter is coercive.”

A commentary by Steen et al. in the recent Lancet series notes that “repressive and counterproductive police action,” including the arrest and incarceration of trafficking victims for the purposes of “rescue,” has overtaken far more effective responses in several countries. The understandable, but destructively over-simplified, mandate to “rescue and restore” sex workers is also being imposed in public health settings where providers are now charged with identifying and intervening with potential victims of trafficking in the sex trade. Certainly, health-care providers have a duty to watch for and help patients in abusive situations of all kinds. They also have a duty to understand the complexities of human experience, respond to patient-identified needs, and maintain that patients are experts of their own lives, whatever that may look like.

Lack of Access to Health Care for Sex Workers

Providing access to health-care services targeted to consumers’ needs is a vital part of any country’s HIV response. Without it, those most in need of prevention, care, and treatment are least likely to get it.

In a 2010 survey, 53 percent of medical students said they were not adequately trained to address their patients’ sexual issues comfortably. Far fewer professional medical curricula explicitly prepare students to understand that they will encounter sex workers as patients who, like all other patients, are individuals with a wide range of experiences, backgrounds, and needs that can best be treated with patient-centered care.

When sex workers receive demeaning and unprofessional treatment in health-care settings, they see health-care providers as an extension of the larger system that criminalizes them. A survey by the New York City-based Persist Health Project found that few sex workers disclosed their occupation to their health-care provider; only one study participant reported a positive experience after doing so. As one respondent explained, “I think for security reasons, I don’t usually disclose. Mainly because I don’t trust doctors … I sort of treat them like law enforcement.” Another noted that most health-care providers “have no clue who you are, no clue about your background, you can’t read them or know that they’re not going to try to lecture you or give you a stink-eye.”

St. James Infirmary, a peer-based occupational safety and health clinic for sex workers in San Francisco, corroborates these findings. Of their incoming patients, 70 percent had never previously disclosed their occupation to a medical provider for feared of bad treatment. Providing sex-worker friendly health care requires training health-care workers appropriately and supporting services designed specifically with and for the communities they serve.

Violence Risk Exacerbated by Criminalization

People usually envision a sex worker as someone soliciting on the street, but only about 20 percent of U.S. sex workers are street-based. The vast majority see clients in other venues including massage parlors, brothels, apartments they share with other sex workers, or a client’s hotel room. Many connect with clients online.

HIV risk is high among street-based sex workers who experience high levels of violence at the hands of clients and abusive law enforcement personnel. One important way they reduce this risk is assessing a potential client before getting into his car—looking for signals that he might be violent and relaying his license number to a colleague in case the worker disappears. This assessment time is also used to negotiate price and condom use. Law enforcement crack-downs compel sex workers to complete their negotiations quickly (in order to avoid arrest), depriving them of the time needed for assessment and negotiation.

Street-based sex workers have little or no protection if a client becomes violent or refuses to use a condom. Of the street-based workers surveyed in The Lancet study by Shannon et al., 25 percent reported being pressured by clients to have sex without a condom. Those working in remote areas (such as industrial parks) to escape local policing were three times more likely to report being pressured into having sex without a condom than the study population overall. The recent Lancet series data also shows that, in some countries, up to one-third of sex workers do not carry an adequate supply of condoms due to “condoms as evidence” policies that allow police to seize a sex worker’s condom supply and use it as evidence of their intent to engaged in sex work—a widely-used policy in several U.S. cities. 

Getting From Here to There 

Punitive laws against sex work are in place in 116 countries, including the United States, creating, according to the Open Society Foundations, “a state-sanctioned culture of stigma, discrimination, exploitation, and police and client violence against sex workers.”

Decriminalizing sex work in the United States is a long and challenging process, but there is a path to follow. The 1988 ban on federal funding for syringe exchange remained in place for 20 years and, after briefly lifting it in 2009, the Obama administration agreed to its reinstatement in 2011 at Congress’ insistence. Advocacy pressure to overturn it continues.

Thanks to the efforts of dedicated researchers and activists during the two decades between 1988-2009, public health professionals, medical institutions and virtually everyone working in the HIV-AIDS field learned why harm reduction practices are essential. Services to people who use drugs began to improve, although they are still inadequate, primarily because they are grossly under-funded. Progress has been made.

The U.S. National Institutes of Health (NIH) issued a consensus statement that addressed the need for syringe exchange but also observed that “[p]rograms targeting sex workers have been highly efficacious in other countries, but [in the U.S., programs] will encounter cultural and political barriers.” The public silence maintained on this issue for the last 17 years is emblematic of those barriers.

But sex workers’ rights organizations in most U.S. cities, though heavily marginalized, have not been silent. They are struggling to end “condoms as evidence” practices, train health-care providers, find or establish sex worker-friendly health-care services, and demand their rightful place as invaluable allies in ending human trafficking and preventing the spread of HIV. Like the harm reductionists who set up the first syringe exchange sites in the United States, they need the support of mainstream sexual and reproductive health advocates willing to learn from them and join them. Like the early harm reductionists, they need the rest of us to bring our money, skills, and political support this human rights struggle.

We can’t stop HIV in the United States without sustainable and long-term solutions to end the arrest, detention, and incarceration of sex workers in the United States, as well as end the violations against sex workers within the correctional system. A meta-analysis of more than 800 other studies and reports, published in the recent Lancet series, listed abuse experienced by sex workers as including “homicide; physical and sexual violence, from law enforcement, clients, and intimate partners; unlawful arrest and detention; discrimination in accessing health services; and forced HIV testing.” It added “protection of sex workers is essential to respect, protect, and meet their human rights, and to improve their health and well-being.”

Expert voices in support of community-led, sex worker-centered health care in the fight against HIV are becoming more and more numerous. When will the mainstream HIV and AIDS organizations and women’s health advocacy communities join loudly in this demand?