VANCOUVER, Canada – Of the many challenges women who make a living or augment their income through sex work confront, efforts to address one need sometimes seems to occur in isolation from others, presentations here highlighted today.
Consider, for example, the case of sex workers in Iran, who one presenter from that country said, his government prefers to refer to as “vulnerable women” in recognition of the stigma the term “sex worker” can carry. All the same, the business of sex work is criminalized there, with the result that being a vulnerable woman can lead to arrest. That was one of the stranger revelations, but by no means the only example of how views of sex workers can interfere with recognizing the realities that threaten their health, and drive HIV epidemics.
One presentation highlighting a financial survey among women who derive income from sex work in Côte d’Ivoire found participants expressing gratitude for an outreach that, they said, for once was not focused on HIV. At the same time, a series of other presentations in the same session highlighted that for many women involved in sex work, barriers to services block the path they need to travel between diagnosis with HIV and antiretroviral treatment.
The financial survey-focused presentation by Emily Namey of Family Health International began by noting that financial hardships drive women to enter sex work, which in turn puts them in the way of increased HIV risk. For that reason, the survey focused on finding “economic strengthening” strategies to support, and presumably help women out of sex work. At the same time, median income among women involved in sex work was higher than average in their communities. And, among the findings — tontines — informal lending cooperatives formed by women in sex work were one of the more functional parts of their financial lives.
From four South African cities — Port Elizabeth, Durban, Capetown, and Johannesburg, as well as in Lilongwe, Malawi, data shows overwhelming rates of HIV among women involved in sex work, who are often diagnosed, but are much less successful in attaining the treatment that would protect their health, as well as that of their children and sexual partners.
In Port Elizabeth, a South African city midway between Durban and Cape Town, HIV prevalence among women in a study from Johns Hopkins Center for Public Health and Human Rights was about 63 percent. Most women were diagnosed, reflecting the impact of community testing, Sheree Schwartz, presenting the findings, said. But treatment was, once again, where it fell apart — with mothers least likely of all to be on antiretroviral treatment. Universal antiretroviral coverage, and decentralized provision — in effect, efforts to match treatment to testing efforts — were among the recommendations there.
In Malawi, where as many as 70 percent of sex workers were estimated to be living with HIV, somewhere between 30 to 60 percent of those diagnosed are lost to follow up care between diagnosis and antiretroviral treatment. The most commonly reported barrier was an immune cell — or CD4 count — too high for treatment eligibility, which in Malawi is pegged at the current World Health Organization Guideline of 500. A mobile testing unit with a portable point-of-care CD4 test was the solution highlighted here. But the need for further implementation studies, and for health worker training, raise the question of whether new guidelines, making immediate treatment available to the women upon diagnosis, may be in place,sand a simpler solution, by the time the CD4 test hits the road.