Table 3 Summary of evidence on HIV/STI and SRH policies and programmes for conflict-affected sex workers

Inter-Agency Working Group (IAWG) on Reproductive Health in Crises [55]

Inter-agency Field

Manual on

Reproductive

Health in Humanitarian

Settings

Refugee/IDPs

Sex worker sensitive HIV VCT programmes: Behaviours that put people at a higher risk of exposure to HIV, such as sex work or injecting drug use, also make people more susceptible to coercion, discrimination, violence, abandonment, incarceration or other negative consequences upon disclosure of an HIV-positive test. Healthcare providers require special training and supervision to uphold standards of informed consent and confidentiality for these populations. HIV VCT for these groups should be accompanied by the implementation of a supportive social, policy and legal framework.

Condom availability/distribution: Consult with local staff about how condoms can be made available in a culturally sensitive way, particularly for most at-risk groups, such as SWs and their clients, MSM, IDUs and young people. Ensure the consistent availability of quality male and female condoms. To see an effective reduction of HIV transmission through SW requires >90% compliance of correct use of condoms among SWs and their non-regular sex partners.

Spermicides: Not recommended for SWs, as they increase risk of HIV

SW specific services: Recommended at health service level, RH officers recommended to hot-spot areas where SWs congregate to

target interventions and services

STI screening: Service providers recommended to offer regular screening to people with frequent exposure to STIs, such as SWs

STI treatment: Presumptive treatment of SWs recommended at first visit followed by regular visits for speculum/bimanual

examination and Gram stain of cervical smear.

Right to equality and non-discrimination: Protected by providing access to STI services for the entire population, including adolescents, SWs and MSM, regardless of the legal status of prostitution and homosexuality in a country

Inclusion of SWs in programming: Involve vulnerable groups encouraged to be involved from the start in programme design,

implementation and monitoring.

Violence reduction strategies: Should be integrated in SW settings. Programmes recommended working with law enforcement to ensure SW’s ability to protect themselves and to ensure safer sex practices by their clients.

SW and child protection: Communities and SWs should be engaged in child protection policies and regulations.

Offer exit-strategies: Programmers encouraged to link SWs and their families to support mechanisms, including the provision of

assistance and incentives for women to leave sex work through a range of legal, economic and social services.

Address sex buyers: Work to change the behaviour of SWs’ clients (humanitarian staff, peacekeepers, police, general population)

HIV prevention for vulnerable groups: Involve groups from the start in programme design, implementation and monitoring; locate

programme activities in places frequented by the group (clubs, neighbourhoods, etc.); create safe virtual (telephone hotlines) or

physical (drop-in centres) spaces tailored to the group; train health and social workers to provide high-quality, client-friendly, HIV-related services; address structural barriers, including policies, legislation and customary practices, that discriminate against the group and prevent access and utilization of appropriate HIV prevention, treatment and care services.

UNAIDS Inter-Agency Task Team on Gender and HIV/AIDS (2001) [16]

HIV/AIDS, Gender and Conflict Situations

Refugee/IDPs

HIV/STI programmes: National governments, national and international NGOs and UN agencies encouraged to incorporate STI and HIV prevention measures into all humanitarian assistance. Donors strongly encouraged to support these interventions.

Conflict, displacement, HIV and gender inequality research: Assessments encouraged to be carried out, in collaboration between government and agencies, to determine the links these factors in each humanitarian situation. Steps encouraged to be taken to ensure that all humanitarian programmes are responsive to issues documented in these assessments.

Focus on women: All HIV/AIDS programmes and funding in conflict situations encouraged to address the disproportionate disease burden carried by women. Effective approaches include sensitisation, training and behaviour change communication programmes targeting men and boys as well as women and girls.

International guidelines for peacekeepers: Steps encouraged to be taken to ensure the implementation of internationally agreed guidelines for the prevention of HIV transmission during peacekeeping operations. Peacekeepers encouraged to receive training on women’s rights and gender-based violence as well as HIV prevention. Because peacekeepers have sometimes been implicated in abuses against women and girls, mechanisms of accountability encouraged to also be included.

Sexual violence programming: Programmes encouraged to be designed to support the victims of sexual violence through medical care, counselling, support groups and related activities. Health service packages for girls and women who have been raped encouraged to include post-exposure HIV prophylaxis.

Military HIV/STI programming: Programmes encouraged to be undertaken to improve HIV/STI awareness and treatment within the regular military and rebel forces, where these are systematically demobilised. This will have important impacts on sexual health risks to civilians from ex-combatants. Civilians, including SWs near military installations, encouraged be included in these awareness raising and treatment programmes.

UNHCR (2010) [67]

HIV and sex work in refugee

situations: A practical guide to launching interventions

an issue affecting women, men, girls, boys and communities

Conflict-affected SWs

This guide is intended to assist those working to slow transmission of HIV and other STIs in humanitarian settings. The focus is on intervening where HIV has the potential to spread quickly – with SWs and their clients.

Practical, step-by step activities are recommended for addressing HIV in sex work within refugee situations, including:

1. Sensitization and buy-in: Engage agencies responsible for refugees, community groups, and leaders.

2. Identification, hotspot mapping and snowballing: Collect baseline and risk information, provide condoms, and assess need through snowball sampling, mapping hotpots, and estimating numbers of SWs and clients.

3. Protection: Support registration, ensure safe access to basic needs, and reinforce GBV prevention and child protection activities

4. Profiling and case management: Gain deeper understanding of sex work in the community, identify those most at vulnerable/risk, and develop case management plans to address urgent problems

5. Forming Multi-Functional teams (MFTs): Guide programme implementation, identify roles and responsibilities, strengthen partnerships, and ensure coordination and monitor progress

6. Building peer-led systems with SWs: Meet and review programme objectives, introduce verbal contract about participation in peer group, ask SWs to choose their leaders and agree to meet regularly, provide peer leaders with training, condom education, promotion and distribution kits

7. Health services: Assess services looking at HIV/STI-related areas, advocate and ensure SWs have access to non-judgmental services

8. Male and venue-based interventions: Engage men and boys, and offer simple venue-based interventions

9. Monitoring

UNFPA & UNHCR – Burton et al. (2010) [3]

Addressing HIV and sex work

Conflict-affected SWs

Interventions to respond to HIV and sex work in humanitarian settings are both necessary and feasible, even during an emergency. In situations where comprehensive HIV programmes have already been established but where SWs have not yet been reached, a basic set of sustainable multisectoral activities can be established within six months.

Key Activities per phase include:

Preparedness

1. Integrate HIV and sex work into contingency planning: Identify existing SW networks and programmes, map services, and develop contingency plans for rapid restoration if disrupted

Emergency phase

2. Expedite registration, risk identification and protection: Identify those most at risk, ensure protection, establish GBV services, and promote codes of conduct

3. Ensure safe shelter and access to food and basic necessities

4. Provide basic SRH and HIV services: Implement MISP, establish basic STI/SRH services and outpatient clinics, and implement basic HIV services

5. Start outreach: Begin mapping and engagement with SWs, identify sex-work venues, and distribute condoms and information

Stabilised phase

6. Build supportive environments and partnerships: Establish peer groups, support SW-led approaches, strengthen existing women’s groups to reach non self-identified SWs, conduct rapid assessments, and plan interventions

7. Reinforce protection: Strengthen prevention of GBV and sexual exploitation, and find ways to involve men

8. Expand to comprehensive HIV and SRH services including STI services

9. Expand targeted services: Support transition of peer activities to broader community mobilisation, strengthen venue-based and special clinics for identified SWs, and work with clients to reduce demand for unprotected paid sex

10. Provide social/economic/legal services: Strengthen legal protections and establish self-regulatory boards, increase livelihood and educational opportunities for the most vulnerable, and prepare for appropriate durable solutions

Inter-Agency Task Team on HIV and Young People (n.d) [12]

HIV Interventions

for Young People

in Humanitarian

Emergencies

Conflict-affected youth

Provision of basic health care and support: Providing basic health care and support to younger, most-at-risk groups, such as people who inject drugs (PWID), SWs and MSM. Special attention is needed to address the needs of younger age groups, particularly during the minimum response stage.