Introduction Access to HIV services as key component of HIV response among sex workers Vital elements of HIV prevention and care continuum HIV prevention testing and treatment Challenges to sex workers access to HIV related services in Europe ID: 573587
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Slide1
HIV prevention, testing and treatment – opportunities and barriers for sex workersSlide2
Introduction
Access to HIV services as key component of HIV response among sex workersVital elements of HIV prevention and care continuum (HIV prevention, testing and treatment)
Challenges to sex workers’ access to HIV related services in EuropeSlide3
Components of effective HIV responseSlide4
Addressing sex workers’ vulnerability to HIV through HIV-related services
Improved service coverage for sex workers could avert a substantial proportions of HIV infections both among sex workers and in the general population!
Health services should be made available to sex workers based on the principles of avoidance of stigma, non-discrimination and the right to health!
(Lancet, 2014; WHO, 2012, 2014)Slide5
HIV related services
HIV preventionHIV counselling and testingHIV treatment and care
HIV prevention and care continuum Slide6
HIV prevention
HIV prevention refers to various practices done to prevent the spread of HIV/AIDS
.HIV prevention is of key importance because it increases
one’s knowledge about HIV vulnerabilities,
enables individual to protect oneself from HIV infection and
creates demand for HIV testing, treatment and
care.Slide7
HIV prevention for sex workers
Promotion of male and female condoms and water-based lubricants
Targeted information, education and communication on HIV and STIsScreening, diagnosis and treatment of STIs
Post-exposure prophylaxis *
H
arm
reduction strategies for sex workers who use drugs:
needle and syringe programmes
opioid substitution therapy
evidence based substance use counselling
(WHO,
2013, 2014)Slide8
HIV prevention - challenges
Criminalisation and stigmatisation of sex workLimited availability of HIV prevention programmes for SWs
Discriminatory framework of service provisionNon-inclusive HIV prevention programming‘Criminalisation of condoms’Lack of access to
OSTSlide9
Limited availability of HIV prevention programming for SWs
Most
of the European countries report a policy or national strategy that promotes HIV prevention interventions for key populations at higher risk, including sex workers, but…
As reported by sex worker-led organisations, coverage of
HIV prevention
programmes
targeting
sex
workers is very low.
There is very little funding for comprehensive HIV prevention interventions.
In
most of the European countries HIV prevention services are provided on a local scale (
in capital,
big cities)
and target only female sex workers working outdoors.
e.g.
In Russia
only as much as 2-3% of sex workers were reached by any kind of HIV prevention and education in 2012.
In
2012, only 13% of sex workers in Greece have had any access to HIV prevention
.Slide10
Discriminatory framework of service provision
Lack of sex workers’ involvement in development of HIV programmingBiased and judgemental
attitudes among service providers Conditional access to HIV preventione.g.
In Sweden
outreach
workers refuse to provide sex workers with safer sex
supplies, education
on occupational health and safety
, and training
in negotiation of condom use with clients, since these are considered to facilitate, promote and legitimise involvement in sex work.
Some HIV service providers
encourage
sex workers
to exit sex work or only offer help to those
SWs who
directly declare willingness to cease selling
sex.Slide11
Non-inclusive HIV prevention programming
Limited number of services dedicated to: indoor sex workers
male and transgender sex workerssex workers who use drugsmigrant sex workersNarrowly defined and non-comprehensive services:
Guided by such goals as ‘increase in coverage’ or ‘condom distribution’, many HIV prevention programmes fail to provide SWs with interventions meeting their most pressing needs,
including the structural ones
. Slide12
Counter-
effective measures‘Criminalisation of condoms’
In some countries of the region condoms are being used as evidence against sex workers – police confiscate condoms and cite possession of condoms as justification to detain or arrest sex workers: Macedonia, France, RussiaIn several countries in Europe
police harass outreach workers
distributing condoms to sex workers: Tajikistan, Russia
Lack of access to Opioid Substitution Therapy
Currently OST is being legal
l
y prohibited in Russia, Turkmenistan and UzbekistanSlide13
HIV testing
The only way to know if a person is infected with HIV is for them to take an HIV test. HIV testing is critical, because it is the main route to enter into HIV
care.HIV tests are used to detect the presence of the
HIV in serum (blood),
saliva, or urine. Such tests may
detect:
Antibodies
produced by the body to fight HIV
(ELISA, Western blot, rapid tests)
Antigens
or
genetic material
related to the virus
(Antigen tests, Nucleic acid test/viral load test)
Rapid/express tests: finger-prick or mouth swab testsSlide14
HIV testing
Testing services should be voluntary and follow 5 rules (5 Cs):
informed consentconfidentiality (most, preferably, anonymity)c
ounselling (pre- and post-testing)
c
orrect tests results
c
onnection to care, treatment and prevention services
Members of key populations should be offered voluntary HIV testing every 6-12 months.
(WHO 2012, 2014)Slide15
HIV testing
HCT services for sex workers should be provided in variety of settings:Health facilities, e.g.:
STI clinicsHepatitis and TB clinicsAntenatal clinics(Community) testing sites/outreach
Controversy
: in some European countries rapid home-use HIV kits enabling self-testing are also being made available: Northern Ireland, Russia, United Kingdom and FranceSlide16
HIV testing - challenges
Limited number of (community) testing sites/outreach targeting sex workersStigma and discrimination in testing facilities
Lack of confidentiality/ anonymity in HCT servicesMandatory HIV testing Repressive HIV-related laws and regulationsSlide17
Lack of confidentiality/anonymity in HCT services
It has been reported that:In several
European countries of the region, admission to free HCT is conditional on the presentation of valid identification
documents: Georgia, Romania, Turkey
Even if HIV testing is delivered
anonymously once
a person is diagnosed with HIV, their identity
is
revealed
to
public health
institutions: Sweden
HIV test results are being shared with
third
parties, including the police, authorities, family members, sex workers’ clients, other members of the sex worker community: Kyrgyzstan, Russia, Ukraine Slide18
Mandatory HIV testing
Condition of engagement in sex work
In several European countries which implemented a regulatory approach to sex work, such as Austria, Greece, Hungary, Latvia and Turkey, periodic compulsory screenings for HIV and other STIs are attached to the procedure of sex worker
registration.
e.g.
Latvia
: STI and HIV screening every month/three months
Austria
(Vienna): weekly tests for STIs, once in 3 months for HIV
Hungary
: compulsory HIV and STI examination every three monthsSlide19
Mandatory HIV testing
Initiated by the law-enforcement agencies
In some European countries where sex work is penalised, sex workers
are being
forced to undergo testing for HIV and other STIs during police raids or following
detention. Such practices have been documented in Kyrgyzstan, Macedonia, Romania, Russia, Tajikistan, Ukraine.
e.g.
Kyrgyzstan
:
over
30% of
sex workers have been subjected to screenings for HIV and
STIs
in the course of arrests following police
sweeps
Macedonia
: in 2008,
30
Macedonian sex workers were
forced
to undergo medical examinations for HIV and hepatitis B and
C after the arrest
Tajikistan
: in 2014, circa 500 sex workers were tested for HIV
during
police raids and imprisonmentSlide20
Repressive HIV-related laws and regulations
Criminalisation of:HIV transmission
sexual act that results in HIV transmissionHIV exposuresexual act that puts sex partner at risk of HIV infection
HIV non-disclosure
non-disclosure of one’s HIV status followed by a sexual act that results in HIV transmission or puts the sex partner at risk of HIV transmission
or non-disclosure of one’s HIV status to the sexual partner (whether or not risk appears)
In countries without HIV specific
legislation, prosecutions possible under different laws criminalising
:
e.g. transmission
of contagious
diseases, STI, causing
injury to health,
grievous
bodily
harm, poisoning, manslaughter.Slide21
Repressive HIV-related laws and regulations
HIV-related laws are also being used against migrant sex workers:
In such countries as Moldova, Russia, Kazakhstan and Turkmenistan sex workers diagnosed with HIV are being arrested and deported to their home countries.[Some European countries have also implemented restrictions on residence
and entry for people living with
HIV:
Cyprus, Russia and
Uzbekistan.]Slide22
HIV treatment
HIV treatment (ART) involves using antiretroviral drugs (ARVs) which reduce the
reproductivity of HIV in body and allow to rebuild one’s immune system. CD4 cells - white
blood/immune cells destroyed by HIV
CD4 count
– number of CD4 cells in one’s blood; the smaller the number, the weaker the immune system is (average = 500-1200
cells/mm
3
)
Viral load
-
the level of HIV in
one’s blood; the higher viral load, the weaker the immune system is (undetectable = 50 copies of the HIV virus per ml of blood; high = 50,000 copies per ml). ART helps to supresses the viral load.Slide23
HIV treatment
WHO guidance on when people should start HIV treatment (2013):Slide24
HIV treatment
HIV treatment also includes the treatment of opportunistic infections and cancers that affect people living with
HIV, e.g.:Tuberculosis (TB)Hepatitis B & CSTIs and cervical cancerCryptococcal
infection
Comprehensive HIV treatment and care also requires addressing nutrition and mental health needs of people living with HIV.Slide25
HIV treatment
Universal access to HIV treatment is recognised as an indispensable element in achieving the full realisation of the right of everyone to the enjoyment of the highest attainable standards of health.
It has been recognised as one of the United Nations’ Millennium Development Goal 6b: (by 2010) achieve universal access to treatment for HIV/AIDS for
all
those who need it.
Key populations living with HIV should have the same access to antiretroviral therapy as other populations!
All pregnant sex workers should have the same access for prevention of mother-to-child transmission of HIV and follow the same recommendations as other women!
(WHO, 2014)Slide26
HIV treatment - challenges
Punitive legal frameworks governing sex work
Repressive laws affecting sub-populations of sex worker communityUnsupportive social environment: social and economic marginalisation, discrimination, stigma, violenceCriminalisation of HIV transmission and exposure
Detrimental and judgmental treatment in health care settings
Discrimination in access to health care settings
Institutional exclusion from health care services
Limited access to ARV medicinesSlide27
Prejudice-based exclusion for health care settings
It is reported that in numerous medical facilities providing HIV treatment and care, negative and disapproving approaches toward sex workers are expressed in judgmental and paternalistic attitudes, open hostility and reluctance,
or even refusal to prescribe antiretroviral and other treatments despite no
contraindications.Slide28
Structural exclusion for health care settings
In many European countries, access to public health services, including
ART and care, is linked to individual’s legal, insurance and residence status. Many sex workers who are not able to meet these requirements are effectively excluded from public health
system:
Sex workers without identity documents
Sex workers without health/ medical insurance
(bond to employment status)
International migrant sex
workers
(without official residence
or work
permit, non-EU citizens)
Internal migrants sex workers Slide29
Availability and accessibility of medicines
Limited access to effective ARV treatments:
poor medicine registration, supply and distribution systemshortage of supplies low
investments in the health care
sector
high
costs of safe and effective
medicines
Stock-outs of ART:
R
eported in Albania
, Belarus, Georgia, Macedonia, Russia, and
Ukraine
Serious concern in
Armenia, Bulgaria,
Estonia,
Romania,
and Tajikistan
(ECDC, 2013)Slide30
Retention in care - challenges
Adherence – taking HIV medicines every day
according to prescription.Prevents virus from multiplyingImproves health outcomesReduces the risk of drug resistance
Main causes of treatment interruptions among sex workers:
p
olice raids, arrests, detention, imprisonment
violence by state and non-state actors
s
tigma related to HIV-status
d
iscrimination in health care settings
high mobility
stock-outs of medicationsSlide31
ARV related prevention
(Early) treatment as prevention
HIV prevention methods that use antiretroviral treatment to decrease the chance of HIV transmissionPost-exposure prophylaxisPEP is an intervention that uses ARVs to reduce the likelihood of HIV infection after possible
exposure (
recommended to sex workers
!
[WHO, 2012]
)
Pre-exposure
prophylaxis
PrEP
is a method of HIV prevention, which involves people who are HIV-negative taking ARVs (
Truvada
) on daily basis to reduce their risk of becoming
infectedSlide32