The historic launch of the South African National Sex Worker HIV Plan in March 2016 was a clear message that the country is serious about addressing the needs of sex workers and their high risk of exposure to HIV, pregnancy, sexually transmitted infections (STIs) and human rights violations. In a country where constitutional rights are paramount, no group or individual should be refused full rights to services and justice.
A wide range of government departments, nongovernmental and research organisations, civil society and the South African National Aids Council (Sanac) secretariat worked together to establish consensus on all aspects of the plan.
The document explains that sex worker programmes are critical and that criminalising sex work drives workers underground and away from services, increases stigma and creates obstacles to accessing health services. It asserts that the current legal environment in which sex work is criminalised reduces workers' power and renders them more vulnerable.
Research in 2013, commissioned by Sanac and carried out by the Sex Workers Education & Advocacy Taskforce, estimated that there were 153 000 sex workers in the country. A subsequent study by Sanac, the health department and the University of California San Francisco found that almost 60% of those surveyed in three cities were living with HIV.
One in three workers were HIV infected by the age of 24 and less than a third of HIV-positive sex workers surveyed were on treatment, the 2014 study revealed. Modelled estimates of HIV incidence published in 2014 in the medical journal The Lancet show that women sex workers and their clients account for about 6% of heterosexual HIV transmissions in South Africa.
National efforts to arrest new HIV infections will not succeed if new infections in sex workers are not stopped. Sex workers are also at risk of other STIs, including syphilis, gonorrhoea, and the human papilloma virus, which has been shown to cause cervical cancer.
Almost one in five (18%) of women sex workers surveyed in Johannesburg and Cape Town had syphilis – rates that were among the highest in Southern Africa, the 2014 University of California San Francisco study found.
Government policy documents, such as the National Strategic Plan for HIV, TB and STIs 2017-2022, suggest that control of these epidemics can only be achieved if sex workers have access to health programmes. Treatment of HIV and STIs is highly effective at stopping onward transmission.
It has now been proven that, because antiretrovirals decrease the amount of virus in HIV-positive people's bodies, they make people far less likely to transmit the virus – 96% less likely, according to the HPTN 052 study, which was published in 2016 in the New England Journal of Medicine.
But sex work is criminalised and therefore negatively viewed by many healthcare workers. Meanwhile, there are few health services geared towards sex workers and their needs. As a result men, women and transgender sex workers are often excluded from health systems or reluctant to seek care, increasing social inequities and their vulnerability to illness.
This criminalisation is in direct conflict with global and national efforts to increase HIV prevention, testing and treatment services among sex workers to stop new infections and prevent deaths. This includes government's ongoing provision of the HIV prevention pill to workers also known as pre-exposure prophylaxis (PrEP). PrEP can reduce a person's chances of contracting HIV by between 44% and more than 90%, depending on how well it's taken, studies have shown.
PrEP could cut new HIV infections among South African sex workers by up to 40%, the 2014 The Lancet study found. And providing antiretrovirals to sex workers living with HIV could prevent almost a quarter of new infections among their clients.
Decriminalising sex work globally could avert 33% to 46% of HIV infections among women sex workers and their clients in the next decade, argued the research.
With this in mind, Sanac worked with sex workers to review the evidence and develop a national plan rooted in human rights to overcome barriers to healthcare. This document states that we should "secure a commitment for decriminalisation of sex work which enables access to services" – a recommendation informed by evidence provided by the Sanac technical working group of experts on sex work that supported decriminalisation as the best legal framework to support the attainment of goals set out by the national strategic plan.
The final published version of the latest national strategic plan on HIV, TB and STIs is silent on the decriminalisation of sex work, but it does not contradict the country's HIV plan for sex workers. In fact, it says that implementation of national strategies to reduce HIV among sex workers should be scaled up.
We believe the South African National Sex Worker HIV Plan 2016-2019 still directs the country's response to sex workers. The Sanac secretariat remains in solidarity with sex workers as well as the national sex work technical working group and sex worker advocacy organisations.
We continue to support eff orts towards securing political commitment for the decriminalisation of sex work to achieve public health goals and to safeguard human rights and, in doing so, ensuring the full roll-out and implementation of the National Sex Worker HIV Plan.
On May 26, the South African Law Reform Commission released its recommendations on possible law reforms to address sex work.
The commission did not put forth decriminalisation as an option. We see this as an opportunity to re-engage the national sex work technical working group. We also see this as a chance to raise the profile of discussion and debate on the issue of law reform and to bring stakeholders together to discuss meaningfully the realities of being a sex worker in a criminalised environment.
As a country, we can all do more to confront the harsh realities of sex work by focusing on supportive human rights activities such as sensitising police and health workers about sex workers' rights and improving the ability of both sex workers and activists to better document, report and prosecute perpetrators of abuse or discrimination.
We must urgently work with government to ensure police no longer use the possession of items such as condoms, lubricant, and antiretrovirals as evidence of sex work and grounds for confiscation and arrest.
Sanac will continue to advocate for an environment that will enable us to fully and efficiently implement the National Sex Worker HIV Plan.
Connie Kganakga is the acting chief executive of the Sout African National Aids Council.
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