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HIV prevention, testing and treatment – opportunities and

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.

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HIV prevention, testing and treatment – opportunities and






Presentation on theme: "HIV prevention, testing and treatment – opportunities and"— Presentation transcript:

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