A retreat from human rights? A reflection on sex work’s place in contemporary HIV prevention

ABSTRACT

In 2012, the World Health Organization guidelines for HIV prevention recommended the decriminalisation of sex work as their number one good practice. Although human rights language played a key role in the international scientific and activist endorsement of the WHO policies, since then there have been few initiatives in terms of advancing the kinds of structural and political changes endorsed. In this Commentary, we reflect on sex work’s place in the broader field of the biomedicalization of responses to HIV. The analysis is based on literature reviews and our research trajectories, including preliminary results from a qualitative study on the implementation of PrEP in Rio de Janeiro, Brazil. We argue that sex workers occupy an ambiguous and less visible role in current AIDS policies, and that such policies are increasingly characterised by their prioritisation of biomedical approaches over structural factors. These shifts should be understood as part of a broader, global hegemony of clinical responses to HIV prevention and the continuation of a neoliberal discourse around human rights, without adequate investment in the material conditions necessary to guarantee these rights.

KEYWORDS:

• Sex work
• HIV/AIDS
• PrEP
• human rights
• biomedicalization

Acknowledgments

We would like to thank Luiza Bastos, Claudia Mora and Livia Fraga for their support in the literature review and/or fieldwork, as well as Richard Parker, Carmen Logie and the two anonymous reviewers by their insightful and generous comments and suggestions.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Notes

1 As defined by UNAIDS in 2010

Combination prevention relies on the evidence informed, strategic, simultaneous use of complementary behavioural, biomedical and structural prevention strategies (…) [that] operate on different levels (e.g. individual, relationship, community, societal) to address the specific, but diverse needs of the populations at risk of HIV infection. (2010, p. 5)

2 The review of academic output on PrEP research, among gay/MSM, trans women and cisgender female sex workers, was conducted by Luiza Bastos, Mauro Brigeiro and Simone Monteiro. It followed database and descriptors selection, inclusion and exclusion criteria and a blind selection. The five databases used were PubMed, LILACS, Scielo, ProQuest and JSTOR. The search was guided by the combination of descriptors selected from MeSH and articles published between 2010 and 2019 in English, Spanish and Portuguese were selected. The abstracts were stored in the reference management software Mendeley.

3 Coordinated by Simone Monteiro, the full study name is‘The Biomedicalization of the response to AIDS: access of gays, trans women, travestis and prostitutes to PEP and PrEP in the metropolitan area of Rio de Janeiro’. Interviews were conducted from June of 2019 to February of 2020, and all participants provided signed informed consent. The study was approved by the Fiocruz Internal Review Board (number 16076619.2.0000.5248) and received support from the INOVA Program at Fiocruz (2019–2020).

4 Most common primary topic categories were: HIV/STIs, Drug Use, Violence, Policy and Legal Context, Sexual and Reproductive Health, Clients, Sex Industry, Activism/NGOs, Internet/Media. It is important to note that this means that stigma was not the primary focus of the articles. The review did not analyse to what extent either stigma or human rights were discussed or mentioned as part of a series of vulnerability factors in the articles published.

5 ImPrEP is an international HIV prevention project and trial that includes offering PrEP to 7.500 MSM and trans women in Brazil, Mexico and Peru. Cisgender female sex workers were not included in it or the previous large international PrEP trial that also included Brazil, called iPrEx that was supported by the National Institutes of Health from 2007 to 2011 and included seven countries: Brazil, Ecuador, Peru, South Africa, Thailand, and the United States.