2014

1. Combination HIV prevention for Female Sex Workers: What is the evidence? Linda-Gail Bekker, Leigh Johnson, Frances Cowan, Cheryl Overs, DonelaBesada, Sharon Hillier, Ward Cates Jnr. Desmond Tutu HIV Centre, S Africa School of Public Health, UCT, S Africa Centre for Sexual Health and HIV/AIDS Research, Zimbabwe Michael Kirby Centre for Public Health and Human Rights, Australia The Desmond Tutu HIV Foundation, S Africa University of Pittsburgh, USA FHI 360,USA 2014

2. 18 July …….we remember- “To deny people their human rights is to deny their very humanity……” “ We need bold initiatives to prevent new infections……”

3. Sex Workers and HIV Research • Immuno-pathogenenesis • Exposure without infection studies • Early microbicide trials • Nonoxynol –9 studies • Role of community participation • Thai 100% Condom uptake program • Good participatory guidelines • Early Pre-exposure prophylaxis trials.

4. FSW: What works for prevention? • Reviewed medical work(English) from 2000 to present related to Female Sex Worker (FSW) and HIV prevention (2300 articles). • Included Peer reviewed observational studies, RCTs, consensus papers and program reports. • Information specifically related to HIV Prevention in FSW sparse- • Inclusion criteria broadened to ensure a comprehensive understanding of potential HIV prevention interventions available.

5. Prevention Framework Risk level 5 : Environment Risk level 4 : Public policy Risk level 3 :Community Risk level 2 : Network Risk level 1 : Individual Tailored Combination Prevention

6. Tailored combination prevention • Effective prevention requires knowledge of SW setting and environment • Recognises SW autonomy and freedom to choose • Has full involvement of peers in design and implementation • Employs a layered combination approach • Includes careful monitoring and evaluation to measure impact and also any unanticipated harms….

7. Established Interventions • Condoms: • Male and female • condom-compatible lubricant • Access and cost • Voluntary testing and linkage to services. • Poor coverage in FSW but improving globally • Additional barriers: disclosure and fear issues. • Sex worker friendly health services, including sexual and reproductive health services. • STI treatment, contraception.

8. Voice from Zimbabwe…. In response : Sister with a Voice set up in 2009 by ZNAC. Now in 36 districts . ”The nurse said to me how can you, a sex worker even have high blood pressure, its high because of too much sex...you are wasting our drugs instead of us giving them to those who have proper high blood pressure caused by women like you when you take and infect their husbands and them eventually..."

9. Established Interventions • Economic strengthening and supplemental income. • Exploring conditional cash transfers • Behaviourchange through peer education and community-based counselling • Harm reduction in FSW-WID

10. Established Interventions: In a survey of its national programme in 2013, the Sex Workers Education and Advocacy Taskforce (Sweat) found that sex workers named the police as the perpetrators of violence 53% of the time. The late General Maswangane • Gender-based and police violence, stigma, and discrimination. • Rights, legal and protection services. • Community empowerment: • promotion of social cohesion and capital, inclusionand leadership skills. • Advocacy and community mobilization: • policy, programme, and services.

11. Newer Interventions • Post Exposure Prophylaxis services • Sexual assault, unintended exposures • Pre Exposure Prophylaxis services • Oral (PrEP) • Topical (microbicides) • SWF HIV care and treatment: • Antiretroviral treatment services • Prevention of vertical transmission

12. PrEP trials and protection estimates (TS= Transactional sex)

13. Factors associated with SW that may affect PrEP effectiveness

14. Newer interventions: Secondary prevention • Access to ARV Treatment critical for +SW health • Regular VCT and commencement of ART at earlier stages of infection (higher CD4 counts) • HPTN 052 : 96% reduction in HIV transmission between linked discordant couples where treated partner was suppressed on ART. • Important for HIV prevention in negative clients or intimate partners • Effective PMTCT services to reduce vertical transmission

15. Combination prevention: RSA case study. From 2015-2025 (Oral PrEP) (Topical PrEP)

16. Combination prevention: RSA case study. Effect of uptake and efficacy on % reduction in new HIV infections 2015-2025 Oral PrEP TasP

17. Prevention Framework 5:Know your SW epidemic, know your SW response

18. Prevention Framework 4: Policy reform and decriminalisation: safer working conditions; < police brutality; FSW empowerment

19. Prevention Framework 3: Community based and led services, advocacy and mobilisation: <stigma, discrimination. Peer led behaviour change

20. Prevention Framework 2: Networks : social, sexual, drug injection. STI control, condom promotion, harm reduction and reduction in GBV all important.

21. Prevention Framework 1: Behavioural and biomedical interventions: Condom usage, regular sexual and reproductive health care, VCT, PEP, PrEP (future of injectables, depot vaginal rings, rectal microbicides). Early Treatment for health and clients.

22. Conclusions • Effective HIV prevention interventions for FSWs have not been taken to scale in most parts of the world • Stigma and criminalization form barriers to existing effective interventions • FSW prevention packages MUST include SWs in design and implementation • Newer biomedical technologies should be additive to and not replacements for established interventions. • PrEP has been shown to be effective in men and women although sparse evidence in SWs. • ART critical for SWs living with HIV • Earlier ART in positive FSWs will benefit clients directly and FSW indirectly. • Tailored combination prevention interventions for FSWs are likely to have greatest benefit in SWs, clients and wider population.

23. Final word: “Where sex workers organize, where the police do not harass them and they are free to avail themselves of quality HIV services, sex workers have lower rates of STIs, more economic power and a greater ability to get education for their children”.The Global Commission on HIV and the law: Sex Workers 2012.

24. Thank You • Guest editors (Chris Beyrer, Jenny Butler, Anna-Louise Crago, SteffStrathdee) and Editors. • Co-authors: Leigh Johnson, Frances Cowan, Cheryl Overs, DonelaBesada, Sharon Hillier, Ward Cates Jnr. • Valuable comments: Cate Hankins, Ken Mayer, StefStrathdee, Chris Beyrer. • Visuals: Maria Stacey (SWEAT), Andy Lambert (TB/HIV). • Quote: Sisters with a Voice- Frances Cowan (Zim) • Funding: • The Bill and Melinda Gates Foundation • The United Nations Family Planning Association.