There is emerging evidence of how conflicts and disasters may lead to sex being sold or exchanged for accommodation, protection, food, gifts and other items or services. This can be attributed to many factors, including high levels of poverty, lack of livelihood opportunities, separation of families, breakdown in community support mechanisms and an increase in gender-based violence (GBV). Yet programmes addressing HIV and sex work in humanitarian settings are often poorly developed. HIV programmes typically follow generalised approaches, with insufficient attention being paid to those individuals and groups who are most vulnerable and at highest risk of acquiring and transmitting HIV and other sexually-transmitted infections (STIs).
Initial steps have been taken to address HIV and sex work in some refugee programmes in the East and Horn of Africa, Latin America and parts of Asia. Based on these experiences, and under the overall framework of the UNAIDS Guidance Note on HIV and Sex Work (1), UNHCR and UNFPA have developed a Technical Note as guidance for field staff and programme managers on addressing HIV and sex work in humanitarian situations. The primary objective is to inform humanitarian actors of steps that can be taken to reduce risk and vulnerability related to sex work.(2)
HIV and sex work
Sex work is an important driver of HIV transmission. Unprotected sex between clients and sex workers and between clients and their intimate partners contributes to increased risk of HIV transmission. Thus, sex workers and their clients are critical to an effective HIV response. Frequently, though, sex workers are marginalised and face widespread discrimination, reducing their participation in HIV prevention and their ability to access health, legal and social services. There is evidence that if sex workers are involved in the provision of services, both uptake and access usually improve. A growing number of countries that have scaled up interventions with sex workers have reported stabilisation, and even reversal, of their HIV epidemics.
Recognising these opportunities and challenges, UNAIDS promotes a human rights-based, evidenced-informed approach to HIV and sex work based on three pillars which have been adapted to meet needs in humanitarian settings:
Pillar 1: assuring universal access to comprehensive HIV prevention, treatment, care and support through planning and preparing to maintain services, implementing basic services in the emergency phase and building more comprehensive services as conditions stabilise.
Pillar 2: strengthening partnerships and expanding choices through working with sex workers to ensure supportive environments in which all sex workers can access the services they need.
Pillar 3: reducing vulnerability and addressing structural issues by ensuring protection, access to food, shelter and other basic needs together with related measures to prevent GBV and minimise pressure to enter sex work.
These pillars form the foundation for a comprehensive response to HIV and sex work and inform the recommendations presented in the Technical Note on HIV and Sex Work in Humanitarian Settings.
Sex work in humanitarian settings
The characteristics that define humanitarian emergencies, including conflict, social instability, poverty and powerlessness, can also facilitate the transmission of HIV. Power imbalances that make girls and women disproportionately vulnerable to HIV infection become even more pronounced during conflict and displacement. There may be increased pressure to engage in sex work. HIV risk for sex workers and clients may be increased due to lower condom use and increased violence.
The vulnerability of children to sexual exploitation and abuse is also heightened during humanitarian crises. While conditions, contributing factors and programmatic responses may overlap with those for adults, there are fundamental and important differences. The UNAIDS Guidance Note “affirms that all forms of involvement of children (defined as people under the age of 18) in sex work and other forms of sexual exploitation or abuse contravene United Nations conventions and international human rights law”. While improving conditions related to sex work is part of the response for adults, the programmatic response to sexual exploitation is protection and removal of the child from the conditions of exploitation.
Humanitarian settings present important opportunities for preventing HIV transmission. Forced displacement and humanitarian crises – whether associated with conflicts or natural disasters – usually involve armed groups, uniformed services and other men from within or outside the community whose presence often leads to an increase in sex work. In these settings, some sex workers openly sell sex whereas other sex workers prefer not to identify themselves as such, often working on a more part-time basis. As in non-humanitarian contexts, some sex workers will choose to continue in sex work while others would prefer economic empowerment opportunities to reduce their reliance on sex work. An important area of intervention is to educate law enforcement officials such as police personnel to be agents of change within their own communities, to respect the rights of sex workers and sensitise their peers on HIV prevention.
Key strategies for response
It is important to work on multiple levels and across sectors to reduce risk and vulnerability related to HIV while protecting the safety and human rights of affected populations. By being aware of conditions that heighten vulnerability and risk, humanitarian actors can take steps to ensure services and support are in place to protect the human rights of sex workers and their clients, minimise risks of HIV transmission and meet the broader health and social needs of sex workers. The Technical Note outlines steps to protect populations and prevent unwanted entry into sex work. Its recommendations reflect experience from many different settings and are adaptable to local conditions and cultural contexts. The starting point for all these interventions is engagement with sex workers and communities.
The steps set out in the box belowillustrate how sex work can be addressed in humanitarian settings. Most activities are extensions of health or protection services that should be implemented as part of the humanitarian response. Additional attention to sex work may involve very little extra effort but can yield important results in terms of protecting the rights of the population and averting HIV morbidity and mortality.
Key activities per phase
1. Integrate HIV and sex work into contingency planning
- Identify existing sex worker networks and programmes
- Map services and develop contingency plans for rapid restoration if disrupted
2. Expedite registration, risk identification and protection
- Identify those most at risk: single-parent, female-headed and child-headed households, unaccompanied minors
- Ensure protection and establish GBV services
- Promote codes of conduct
3. Ensure safe shelter and access to food and basic necessities
4. Provide basic SRH (sexual and reproductive health) and HIV services
- Implement MISP (Minimal Initial Service Package)(3)
- Establish basic STI services within SRH and outpatient clinics
- Implement basic HIV services
5. Start outreach
- Use contacts to begin mapping and engagement with sex workers
- Identify sex-work venues, distribute condoms and information
6. Build supportive environments and partnerships
- Establish peer groups and support sex worker-led approaches
- Strengthen existing women’s groups to reach non self-identified sex workers
- Conduct rapid assessments and plan interventions
7. Reinforce protection
- Strengthen prevention of GBV and sexual exploitation
- Find ways to involve men
8. Expand comprehensive HIV and SRH services including STI services
9. Expand targeted services
- Support transition of peer activities to broader community mobilisation
- Strengthen venue-based and special clinics for identified sex workers
- Work with clients to reduce demand for unprotected paid sex
10. Provide social/economic/legal services
- Strengthen legal protection
- Establish self-regulatory boards
- Increase livelihood and educational opportunities for the most vulnerable
- Prepare for appropriate durable solutions, especially for most vulnerable
In Kenya and Uganda, UNHCR and implementing partners have worked closely on developing programmes with sex workers, based on sustainable and improved comprehensive services including HIV and reproductive health, community social services and livelihood interventions. In both cases there is evidence that much can be achieved within a six-month period: sex worker-led organisations and peer groups were established, confidential and respectful health-care services were provided and protection systems strengthened. These examples illustrate how the active engagement and involvement of sex workers is not only possible but also leads to improved quality of HIV prevention measures.
In Sierra Leone, the Women in Crisis Movement (WICM), an NGO supported by UNFPA, is devoted to empowering war-affected adolescents and young girls through a combination of vocational training and creation of cooperative employment. WICM has developed a two-year vocational training programme helping girls and young women at two sites who actively chose to leave sex work. Combining vocational training with income-generating activities and the inclusion of sexual and reproductive health as an integrated component in the training programmes allowed them to have access to education, acquire skills and to increase their economic independence.
Interventions to respond to HIV and sex work in humanitarian settings are both necessary and feasible, even during an emergency. In situations where comprehensive HIV programmes have already been established but where sex workers have not yet been reached, a basic set of sustainable multisectoral activities can be established within six months. The integration of HIV into the humanitarian clusters remains a major challenge. Although HIV is recognised as a cross-cutting issue, it is, unfortunately, all too often seen as the domain of the health sector only.
Jennifer Butler (firstname.lastname@example.org), Priya Marwah (email@example.com), Cecile Mazzacurati (firstname.lastname@example.org) and Richard Steen (email@example.com) work for UNFPA. Ann Burton (firstname.lastname@example.org) and Marian Schilperoord (email@example.com) work for UNHCR.
(2) This guidance is being field tested and will be available for distribution by the end of 2010 on the websites of UNHCR and UNFPA.