Halting and reversing HIV epidemics in Asia by interrupting transmission in sex work: experience and outcomes from ten countries

Abstract

HIV epidemics spread rapidly through Asian sex work networks two decades ago under conditions of high vulnerability, low condom use, intact male foreskins and ulcerative STIs. Experiences implementing interventions to prevent transmission in sex work in ten Asian countries were reviewed. All report increasing condom use trends in sex work. In the seven countries where condom use exceeds 80%, surveillance and other data indicate declining HIV trends or low and stable HIV prevalence with declining STI trends. All four countries with national-level HIV declines among sex workers have also documented significant HIV declines in the general population. While all interventions in sex work included outreach, condom programing and STI services, the largest declines were found in countries that implemented structural interventions on a large scale. Thailand and Cambodia, having controlled transmission early, are closest to providing universal access to HIV care, support and treatment and are exploring HIV elimination strategies.

Keywords::

• HIV
• sex work
• STI
• structural interventions

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Erratum

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• • Rapid control of sexual transmission is feasible under different conditions. Initial successes in Thailand, West Bengal and Cambodia led some to conclude that targeted strategies were feasible only in places with highly organized, establishment-based sex work. Experience from China, India, Mongolia, Nepal and more recent developments from Cambodia and Thailand show, however, that models are adaptable to places where sex work is less structured and/or street-based;

• • Interventions in sex work are highly efficient, capable of population-level impact by reaching a relatively small proportion of the population. Successful examples share several components – peer outreach, condoms and STI services – and are driven by sound public health principles. Despite differences in implementation, all have found ways to reach sex workers with relevant, effective services and, increasingly, to involve them as part of the solution;

• • Structural interventions can change fundamental conditions of sex work and greatly enhance the effect of other interventions. Large decreases in curable STIs and reversal of HIV epidemics have occurred following national implementation of 100% condom use programmes. Community-led structural interventions have enabled sex workers to address a range of conditions from low condom use to violence;

• • Interventions with sex workers and other vulnerable, marginalized populations require ‘enabling environments’ that facilitate outreach and access to services. Criminalization of sex work, misguided anti-trafficking measures and other law enforcement efforts that increase vulnerability and drive sex workers underground may have unrecognized negative public health effects. Country experience argues for decriminalization of sex work to advance public health objectives;

• • HIV responds to comprehensive STI control efforts. The fastest growing HIV epidemics all initially took off in areas with poor control of other STIs. Ulcerative STIs including chancroid and syphilis were strongly associated with HIV transmission and rapid control of these infections preceded HIV declines;

• • Effective STI/HIV control must reach adequate levels of coverage in order to have impact, and be sustained over time. Relaxation of control measures can lead to rapid rebound transmission of STIs, and increased spread of HIV. Good quality, accessible STI services contribute to maintaining control, and regular STI reporting permits monitoring of sexual transmission trends;

• • Wider availability of ART has likely contributed to declining HIV trends in recent years. This may increase as eligibility criteria for ART are revised, admitting more people into treatment earlier. There is a high potential for complementarity with targeted primary prevention efforts in sex work. Offering earlier ART to sex workers may result in further reductions of HIV transmission.

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