Commentary Law and Policy

Our Current Approach to Sex Work: Flawed Laws, Flawed Policies, and Flawed Programs Will Not Right Our Wrongs

Meena Saraswathi Seshu

Freedom from abuse and violence is a human right that we will continue to fight for at every forum, including the Sex Worker Freedom Festival, which is on at Kolkata at the same time as the International AIDS Conference takes place in Washington DC.

Cross-posted in partnership from the HIV Human Rights blog and part of Rewire’s coverage of the International AIDS Conference, 2012.

Just two months back, I marched with hundreds of sex workers in India to demand justice for Anu Mokal. Anu, a sex worker, was picked up by the police at a bus stop one evening, charged with ‘soliciting’ customers at the bus stand, abused and beaten up. As a consequence, Anu, who was then four months pregnant, suffered a miscarriage.

With the support of a collective of sex workers, Anu filed a complaint against the policemen who assaulted her. But two months down the road, has her complaint progressed any further? No. Has the promised State inquiry into the incident taken place? Unlikely. If it has, the results have not been made known. Has Anu been given a fair hearing? Not that I know of. (Instead, while she was complaining, she was told that sex workers cannot be mothers). Have the policemen faced any action for assaulting a woman in a public place, an action that was witnessed by others? No.

Anu Mokal’s case is emblematic of the situation faced by the more than one million sex workers who live and work in India. On the one hand, they routinely face violence, including the violence of stigma. On the other, they are not able to rightfully claim their place in the sun as citizens, who deserve respect, dignity, justice, and rights – like any other citizen of our country. This is why the banner leading our march says:

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“The violence of stigma we dare to survive
Of dignity we dare to dream.”

Freedom from abuse and violence is a human right that we will continue to fight for at every forum, including the Sex Worker Freedom Festival, which is on at Kolkata at the same time as the International AIDS Conference takes place in Washington DC. (Come to Kolkata and support us, you guys!) But for now, I want to go a little deeper into this whole thing and show how flawed national laws, HIV policies and programs contribute to reducing freedoms for sex workers and depriving them of their daily rights.

To begin with, sex work is itself seen as a moral blot by all sections of society – from opinion makers in the media to the forces of law and order. I see this as ‘moral criminalization’, a situation in which public morality ‘criminalizes’ sex workers, regardless of their legal status. But when laws, policies and programs reflect this kind of thinking, the situation gets much worse.

We still have:

  • Flawed laws. For example, the Immoral Traffic Prevention Act of 1986 does not clearly distinguish adult sex work from trafficking. It reflects a world view in which sex work, trafficking and sexual violence are one and the same thing. This confused thinking results in a lack of justice for those who are trafficked and those who are not. Once the paradigm of trafficking stops dominating the legal framework, moral criminalization will stop and so will some of the violence against sex workers.
  • Flawed policies. On the one hand, policymakers acknowledge that it is effective to involve sex workers in peer-based HIV prevention programs – such programs show better results. On the other hand, policymakers do not acknowledge the structural factors that make sex workers vulnerable to HIV, including police violence and an absence of legal protection or rights. To quote from a 2002 Human Rights Watch, Epidemic of Abuse: Police Harassment of HIV/AIDS Outreach Workers in India“In practice, one branch of the government relies on the non-government sector to provide condoms and information to persons at high risk, while another branch of government – the law-enforcement establishment – abuses those who provide these services.” As Anu’s case shows, this tendency to give with one hand and take away with the other has not vanished in the decade since this report was published.
  • Flawed programs. Although we now have some HIV programs which centre on those in sex work and their health needs, we still have programs in which sex workers are seen as vectors of HIV and blamed for the HIV risks they face, programs which target sex workers not as human beings in themselves, but as ‘instruments’ to prevent HIV from spreading to their clients, and programs which reflect the thinking that immoral sex = sex workers = immoral disease.

Such laws, policies and programs increase the HIV risks that sex workers face, instead of decreasing them. They make sex workers powerless and more prone to taking higher risks, instead of empowering them to minimize these risks. So where do we go from here? We need to start seeing how HIV and human rights interact in the daily lives of sex workers. It’s not enough to give them condoms and information; we need to ensure they don’t routinely face violence – and to ensure they have access to justice if ever they do. We need to give them the right to lives free of violence. We need to take steps to reduce the stigma they dare to survive and give them the dignity of which they dare to dream.

I would have loved to share this message in Washington, DC at AIDS 2012 this year. But instead I will be in Kolkata, in solidarity with sex workers, who are determined not to let US immigration laws marginalize them even further.

Analysis Human Rights

Why It Might Not Be a Bad Thing if the Senate’s Human Trafficking Bill Dies (Updated)

Emily Crockett

Some advocates don’t think the Justice for Victims of Trafficking Act is worth trying to save in the first place. At best, they say, the JVTA has a few useful provisions and might give some more money to victims and services. At worst, it could make life more difficult for the vulnerable populations that the bill seeks to protect.

UPDATE, March 17, 12:45 p.m.: Senate Democrats blocked a motion to advance the trafficking bill on Tuesday. A motion to end debate and vote on the bill failed 55-43, with four Democrats joining Republicans to try to break the filibuster. Debate on the bill will continue.

Senate Democrats and Republicans have been bickering since last week over whose fault it is that they’re now fighting over abortion in what had been a popular, bipartisan human trafficking bill. The bill is set for a vote on Tuesday, but it’s likely to die in the reproductive health standoff.

Democrats say Republicans slipped anti-choice language into the Justice for Victims of Trafficking Act (JVTA) that would expand the already onerous Hyde Amendment—and how dare Republicans attack women’s health in a bill designed to help young victims of rape and abuse.

Republicans say Democrats should have known that the language was in this version of the bill from the start—and how dare Democrats hold up this crucial bill over what has been settled law for 39 years.

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The Hyde Amendment, a longstanding restriction on federal funding for abortion care, isn’t actually “settled law.” Its renewal is more of a yearly tradition, and the Republican add-on to JVTA would indeed expand its power and duration.

Some reproductive rights and justice advocates who are already campaigning to end Hyde, as well as anti-trafficking advocates who want Congress to move forward on their issue, have joined Democrats in condemning the Republican approach. They’re pushing for the Hyde language to be removed before discussion about the legislation continues.

But other advocates don’t think the JVTA is worth trying to save in the first place. They say that although the Hyde language is obviously a bad idea, that’s not the only problem with the bill. While domestic human trafficking is certainly an issue of national importance that affects thousands of people, these advocates say the JVTA in its current incarnation isn’t the right approach to combat it. 

At best, they say, the JVTA has a few useful provisions and might give some more money to victims and services. At worst, it could make life more difficult for the vulnerable populations that the bill seeks to protect.

A “Wrong-Headed” Approach

The JVTA has become “a stone soup of trafficking provisions,” Kate D’Adamo, national policy advocate at the Urban Justice Center’s Sex Workers Project, told Rewire. Similar bills have been introduced since 2006, she said, and the legislation has only gotten bigger and more unwieldy as more ideas have gotten thrown into the mix.

There are a few good elements, D’Adamo said. The JVTA provides for a federal advisory council made up of trafficking survivors, and it expands the FBI’s “Innocence Lost” mandate to include child labor trafficking as well as sex trafficking. D’Adamo said it’s “shocking” that the FBI hasn’t already done that, given how often minors face labor exploitation.

Unfortunately, D’Adamo said, these provisions are tacked on to a “rotten apple” of a bill that focuses too much on criminalization and too little on the needs of survivors.

Several provisions in the JVTA “prioritize the needs of the state, prosecution, and law enforcement over the needs of people who have experienced trafficking,” Alix Lutnick, senior research scientist with the Urban Health Program at RTI International, told Rewire in an email. “History has shown that it is not possible to prosecute or legislate our way out of this social issue.”

The JVTA establishes or enhances “specialized training programs” for officials like police officers, first responders, and prosecutors. But those training programs are “only as good as their content,” Lutnick said, and similar programs at the state level have proven themselves lacking.

She cited as an example California’s Proposition 35, which gives law enforcement officials a two-hour “specialized training program” featuring a video that perpetuates wrong ideas about sex workers. The video conflates all sex work with trafficking, Lutnick said, and doesn’t offer guidance on how to deal with transgender people, male sex workers, or any adult engaged in sex work.

The JVTA also creates or bolsters task forces that investigate child trafficking offenses and rescue victims. Task forces are a popular model for addressing human trafficking, but Lutnick said available data hasn’t proven that model to be effective.

Fewer than half of the 42 anti-trafficking task forces funded by the Office for Victims of Crime and the Bureau of Justice Administration since 2003 had high-quality data (meaning they regularly entered new cases into the system, provided individual-level information for at least one suspect or victim, and updated case information on a regular basis). Task forces have often been poorly monitored and coordinated and given ineffective guidance by officials.

Despite the tens of millions of dollars allocated to expanding trafficking task forces in recent years, Lutnick said, “It is not apparent how their expansion will result in more young people being identified.”

The biggest reforms in the JVTA aim to get tougher on traffickers. The bill uses an “end demand” strategy—the idea that there will be less sex trafficking if there is less demand for sex work—and makes patronizing or soliciting a minor a crime equal to trafficking itself.

It also funds both new law enforcement initiatives and victims’ services through a new “Domestic Trafficking Victims’ Fund.” Those funds would come from an extra $5,000 fine levied against people convicted of human trafficking, sexual exploitation, or “transportation for illegal sexual activity.”

There are potential civil rights complications with effectively expanding the definition of and prosecuting more people as traffickers. This would include, for instance, someone who genuinely didn’t know he was buying sex from an underage person. Some advocates point out that it could even target a friend of a sex worker trying to help that person out by giving him or her a ride to a job.

It’s also not clear whether the JVTA’s new victims’ fund would get anywhere close to the advertised $30 million from the new fines. Its funding for victims’ services and restitution is heavily dependent on whether convicted abusers are wealthy, and whether police catch enough of them.

“Most 21-year-old pimps don’t have $5,000 lying around,” D’Adamo said.

D’Adamo said that law enforcement already too often relies on “john stings” or vice raids, which might boost arrest counts but don’t actually do much to combat trafficking.

“A law-enforcement approach to human trafficking is completely wrong-headed,” said Darby Hickey, an analyst at Best Practices Policy Project and an advocate for sex workers.

Service providers say most victims don’t come to them as a result of law enforcement activity. For instance, a large number of D’Adamo’s clients at the Sex Workers Project escaped exploitation because one of their clients, the few contacts they had with the outside world, helped them out. Raids can create traumatic situations for sex workers and trafficked persons, who often have their civil rights violated in the process or come away with a deeper mistrust of law enforcement.

Making more patrons of sex work equal to traffickers in the law’s eyes, and making funding dependent on their arrests and convictions, will only increase the reliance on ineffective raids, D’Adamo said. There will be more people to arrest and convict and more incentive to arrest and convict them, but not more solutions to the deeper problems of trafficking.

Making Bad Options Worse

Not only is the law enforcement focus ineffective, advocates say; it could actively harm vulnerable youth.

Supporters of bills like the JVTA often focus on a particular vision of the people their legislation affects—namely, children who have been kidnapped or physically forced into brutal sex trafficking rings.

D’Adamo said lawmakers’ focus on child sex trafficking is much too narrow and sensationalized.

“One of the most gut-wrenching things that I hear people say is, ‘If I were a trafficking victim, maybe somebody would care about me, but right now I’m just a homeless mom.’”

In fact, the best predictor of whether someone will end up a trafficking victim, D’Adamo said, is whether that person is already vulnerable or marginalized due to their poverty, homelessness, abuse, bad living situation, immigration status, or gender or sexual identity.

She talked about one violent trafficking ring that preyed upon transgender Latina women, who faced disproportionate levels of homelessness and isolation.

“One of the reasons why they pick those women—it’s easy to say, even if you know you’re going into the sex trade, ‘You might have a better life here, because look at what you have right now, and this could be better,’” D’Adamo said. “It’s not hard to exploit something that, at its core, is kind of true.”

In other words, traffickers would have a harder time recruiting and exploiting people who were less vulnerable to begin with. That’s why it’s more important to reduce the “supply” of trafficked sex labor (by reducing the homelessness and poverty that lead to it), some advocates say, than try to “end demand” by making a show of getting tougher on johns.

“We really need to think about our priorities,” D’Adamo said. “Do we want to lock up people based on fake stings, or do we want to actually fund the resources that keep people from getting into exploitative situations?”

People in true trafficking rings also aren’t the only ones who need aid, D’Adamo said, and they’re not the only ones who could be affected by the JVTA. 

At the Sex Workers Project, D’Adamo offers legal services to a broad range of people—from trafficking-ring victims, to homeless youth who trade “survival sex” for food or shelter, to club dancers or webcam performers who need help with custody battles.

The “survival sex” youth are D’Adamo’s biggest worry when it comes to the JVTA. They technically meet the government definition of being trafficked—automatically if they’re a sex worker under 18, and probably at any age if they’re engaged in survival sex, since feeling the need to trade sex for basic needs likely involves “coercion” that is “subtle or overt, physical or psychological.”

But these youth also have no good options and are just trying to get by, D’Adamo said. They may have run away from a horrible home life or an abusive foster care system. They are victimized by circumstance, but not necessarily by the kinds of criminals that Congress envisions when it passes bills like the JVTA.

Survival sex “might be the option that one person might be choosing, but they might be shoplifting the next day,” D’Adamo said. “They might be turnstile-jumping the next day, they might be sleeping on a subway car.”

And over-policing makes their bad options worse or more dangerous. For instance, D’Adamo said, JTVA’s “tough on crime” approach to johns might make fewer men willing to buy sex, but the ones who will are more likely to be a violent, criminal element.

Meanwhile, youth who have become afraid of police will often put up with more violence before they finally decide to come to the police about it.

“If we look at this as a criminal justice problem, our focus will always be on prosecuting the trafficker and not supporting the victim,” D’Adamo said.

“Idea Bills” vs. Saving Lives

Darla Bardine is the executive director of the National Network for Youth, an advocacy organization for homeless and disconnected youth.

Her nonpartisan organization doesn’t take a position on abortion one way or another, but Bardine still sent a letter on behalf of National Network for Youth to Sen. Patrick Leahy (D-VT) urging Congress to “remove the partisan piece” about abortion from the JVTA.

This moment of bipartisan cooperation in the Senate on what should be a nonpartisan issue is too important to waste, she said. Bardine’s letter, which referred to trafficking as a “dark mark on society,” called the JVTA “desperately needed.”

But her endorsement of the JVTA in an interview with Rewire was more lukewarm.

“We certainly don’t oppose the legislation,” she said.

She thinks the bill will give more “clarity” to prosecutors and law enforcement, and she likes the idea of increased money for victims’ services.

“I’m not convinced that it will actually result in millions of dollars like they say,” she said, “but fingers crossed!”

Bardine’s organization is much more interested, though, in a different bill: Leahy’s Runaway and Homeless Youth and Trafficking Prevention Act. It would reauthorize, update, and give more funding to the Runaway and Homeless Youth Act, a 40-year-old federal grant program funding street-level outreach and youth shelters around the country. That process is supposed to be done every five years, but it’s been overdue since 2013 due to congressional inaction.

Republicans in this session of Congress have blocked Leahy’s bill because of its non-discrimination clause for LGBT youth. Bardine said that provision is crucial because up to 40 percent of homeless youth are LGBT, primarily because their families reject them, and it’s been documented that not all LGBT youth are treated appropriately or welcomed into the government-funded programs designed to help them.

Darby Hickey of Best Practices Policy Project noted that Republicans have set the tone of the legislative debate over trafficking for 15 years.

Hickey says the dominant voices in the trafficking debate are “an alliance between conservative Christians, who see this as part of their ‘save the children, save the women’ crusade, and anti-sex-work feminists—as well as people who are doing the real anti-human trafficking work, who have been trying to do harm reduction and get the right thing done.” But these latter advocates, Hickey said, “have a less powerful bargaining position in all of these negotiations.”

Leahy has proposed his bill as an amendment to the JVTA. Others have proposed amendments that bolster services or further protect survivors from prosecution. It’s not clear whether any of them will get a vote.

The congressional stalling has real consequences, Bardine said. Until the Runaway and Homeless Youth Act is reauthorized, homeless youth can’t benefit from a number of other improvements. The reauthorization would let homeless youth stay in emergency shelters longer; give shelter staff additional training to screen for sex or labor trafficking; and collect updated data on homeless youth to help serve them better.

Crucially, the reauthorization will also increase funding from $115 million to $165 million. That’s still woefully inadequate to address the “horrendous” turn away rates at existing centers, Bardine said, or to build them in the many communities that don’t have them at all. But it’s a badly needed funding increase that could make homeless youth less vulnerable to the pressures that lead to trafficking and other exploitation.

The JVTA is really just “an idea bill,” Bardine said, meaning that it is largely untested. “That’s why our focus is the Runaway and Homeless Youth and Trafficking Prevention Act, because it’s not an idea. It’s an existing 40-year federal program that saves lives.”

“Our hope is that leadership will just focus on what we agree upon and get all this better legislation through and be productive for once,” she said.

Analysis Human Rights

The Evidence Is In: Decriminalizing Sex Work Is Critical to Public Health

Anna Forbes & Sarah Elspeth Patterson

Why are researchers only just beginning to recognize the connection between the decriminalization of sex work and HIV? And why is the trend toward criminalizing populations involved in the sex trades increasing in the United States—moving in the opposite direction from other countries?

During the 2014 International AIDS conference, The Lancet medical journal released a series of articles focused exclusively on HIV and sex work. One study by Kate Shannon et al., demonstrates that decriminalization of sex work could reduce HIV infections by 33 to 46 percent over the next decade. Shannon’s team showed that “multi-pronged structural and community-led interventions” are essential to promoting the human rights of sex workers, as well as improving their access to HIV prevention and treatment. Dr. Chris Beyrer, the researcher who coordinated this Lancet series, told AIDS conference participants that “[e]fforts to improve HIV prevention and treatment by and for people who sell sex can no longer be seen as peripheral to the achievement of universal access to HIV services and to eventual control of the pandemic,” drawing an irrefutable line between the social, legal, and economic injustices sex workers face and their subsequent vulnerability to HIV.

The Lancet series authors join many other prominent public health voices in identifying the decriminalization of sex work as vital to preventing the spread of human immunodeficiency virus (HIV) and of acquired immune deficiency syndrome (AIDS). For two decades, sex workers rights’ activists throughout the world have pushed human rights, public health, and HIV and AIDS response leaders to recognize that they, along with people who inject drugs and men who have sex with men, are “key populations” without whom an effective HIV and AIDS response is impossible. In 2012, the World Health Organization (WHO) declared that “all countries should work toward decriminalization of sex work and elimination of the unjust application of non-criminal laws and regulations against sex workers.” In South Africa (with the largest population of people living with HIV in the world), the National AIDS Council is urging its government to decriminalize sex work—a demand that advocates and health policy professionals are making in dozens of other countries as well. Amnesty International, Human Rights Watch, and the UN’s Global Commission on HIV and the Law all endorse this position. The latter points out “the impossibility of governments stigmatizing people on one hand, while simultaneously actually helping to reduce their risk of HIV transmission or exposure on the other.”

Sex work has been decriminalized in New Zealand and one province (New South Wales) in Australia leaving sex work businesses subject to standard occupational health and safety regulations. Law enforcement treats the sale of sex as it does any other business, without any intrusion or interruption unless existing laws are being violated.

Decriminalization has resulted in higher rates of condom use and enables sex workers to organize community-based health practices that demonstrably improve health and reduce HIV risk. It also makes it possible for sex workers to report and for the police to address illegal acts as they occur, such as assault, theft of services, employment of minors, or client coercion. In this decriminalized setting, sex workers can be strong allies in the fight against trafficking, intimate partner violence, and child abuse since they can report incidents to the police and social service agencies without putting themselves at risk of arrest.

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So, why is the HIV-AIDS field only just beginning to recognize the connection between the decriminalization of sex work and HIV? And why is the trend toward criminalizing populations involved in the sex trades increasing in the United States—moving in the opposite direction from other countries? The following are three contributing factors.

Conflating Sex Work With Trafficking

Public debate around sex work in the United States increasingly focuses on people who have been trafficked or otherwise coerced into the sex trade. Anti-trafficking advocates conflate sex work (people choosing to sell sexual services from among employment options available to them) with trafficking (people being forced into the sex industry against their will). Laws that criminalize all people selling sex (voluntarily or involuntarily) violate the rights of the former and undermine efforts to identify and assist the latter. The Global Commission on HIV and the Law states unequivocally that, “Sex work and sex trafficking are not the same. The difference is that the former is consensual, whereas the latter is coercive.”

A commentary by Steen et al. in the recent Lancet series notes that “repressive and counterproductive police action,” including the arrest and incarceration of trafficking victims for the purposes of “rescue,” has overtaken far more effective responses in several countries. The understandable, but destructively over-simplified, mandate to “rescue and restore” sex workers is also being imposed in public health settings where providers are now charged with identifying and intervening with potential victims of trafficking in the sex trade. Certainly, health-care providers have a duty to watch for and help patients in abusive situations of all kinds. They also have a duty to understand the complexities of human experience, respond to patient-identified needs, and maintain that patients are experts of their own lives, whatever that may look like.

Lack of Access to Health Care for Sex Workers

Providing access to health-care services targeted to consumers’ needs is a vital part of any country’s HIV response. Without it, those most in need of prevention, care, and treatment are least likely to get it.

In a 2010 survey, 53 percent of medical students said they were not adequately trained to address their patients’ sexual issues comfortably. Far fewer professional medical curricula explicitly prepare students to understand that they will encounter sex workers as patients who, like all other patients, are individuals with a wide range of experiences, backgrounds, and needs that can best be treated with patient-centered care.

When sex workers receive demeaning and unprofessional treatment in health-care settings, they see health-care providers as an extension of the larger system that criminalizes them. A survey by the New York City-based Persist Health Project found that few sex workers disclosed their occupation to their health-care provider; only one study participant reported a positive experience after doing so. As one respondent explained, “I think for security reasons, I don’t usually disclose. Mainly because I don’t trust doctors … I sort of treat them like law enforcement.” Another noted that most health-care providers “have no clue who you are, no clue about your background, you can’t read them or know that they’re not going to try to lecture you or give you a stink-eye.”

St. James Infirmary, a peer-based occupational safety and health clinic for sex workers in San Francisco, corroborates these findings. Of their incoming patients, 70 percent had never previously disclosed their occupation to a medical provider for feared of bad treatment. Providing sex-worker friendly health care requires training health-care workers appropriately and supporting services designed specifically with and for the communities they serve.

Violence Risk Exacerbated by Criminalization

People usually envision a sex worker as someone soliciting on the street, but only about 20 percent of U.S. sex workers are street-based. The vast majority see clients in other venues including massage parlors, brothels, apartments they share with other sex workers, or a client’s hotel room. Many connect with clients online.

HIV risk is high among street-based sex workers who experience high levels of violence at the hands of clients and abusive law enforcement personnel. One important way they reduce this risk is assessing a potential client before getting into his car—looking for signals that he might be violent and relaying his license number to a colleague in case the worker disappears. This assessment time is also used to negotiate price and condom use. Law enforcement crack-downs compel sex workers to complete their negotiations quickly (in order to avoid arrest), depriving them of the time needed for assessment and negotiation.

Street-based sex workers have little or no protection if a client becomes violent or refuses to use a condom. Of the street-based workers surveyed in The Lancet study by Shannon et al., 25 percent reported being pressured by clients to have sex without a condom. Those working in remote areas (such as industrial parks) to escape local policing were three times more likely to report being pressured into having sex without a condom than the study population overall. The recent Lancet series data also shows that, in some countries, up to one-third of sex workers do not carry an adequate supply of condoms due to “condoms as evidence” policies that allow police to seize a sex worker’s condom supply and use it as evidence of their intent to engaged in sex work—a widely-used policy in several U.S. cities. 

Getting From Here to There 

Punitive laws against sex work are in place in 116 countries, including the United States, creating, according to the Open Society Foundations, “a state-sanctioned culture of stigma, discrimination, exploitation, and police and client violence against sex workers.”

Decriminalizing sex work in the United States is a long and challenging process, but there is a path to follow. The 1988 ban on federal funding for syringe exchange remained in place for 20 years and, after briefly lifting it in 2009, the Obama administration agreed to its reinstatement in 2011 at Congress’ insistence. Advocacy pressure to overturn it continues.

Thanks to the efforts of dedicated researchers and activists during the two decades between 1988-2009, public health professionals, medical institutions and virtually everyone working in the HIV-AIDS field learned why harm reduction practices are essential. Services to people who use drugs began to improve, although they are still inadequate, primarily because they are grossly under-funded. Progress has been made.

The U.S. National Institutes of Health (NIH) issued a consensus statement that addressed the need for syringe exchange but also observed that “[p]rograms targeting sex workers have been highly efficacious in other countries, but [in the U.S., programs] will encounter cultural and political barriers.” The public silence maintained on this issue for the last 17 years is emblematic of those barriers.

But sex workers’ rights organizations in most U.S. cities, though heavily marginalized, have not been silent. They are struggling to end “condoms as evidence” practices, train health-care providers, find or establish sex worker-friendly health-care services, and demand their rightful place as invaluable allies in ending human trafficking and preventing the spread of HIV. Like the harm reductionists who set up the first syringe exchange sites in the United States, they need the support of mainstream sexual and reproductive health advocates willing to learn from them and join them. Like the early harm reductionists, they need the rest of us to bring our money, skills, and political support this human rights struggle.

We can’t stop HIV in the United States without sustainable and long-term solutions to end the arrest, detention, and incarceration of sex workers in the United States, as well as end the violations against sex workers within the correctional system. A meta-analysis of more than 800 other studies and reports, published in the recent Lancet series, listed abuse experienced by sex workers as including “homicide; physical and sexual violence, from law enforcement, clients, and intimate partners; unlawful arrest and detention; discrimination in accessing health services; and forced HIV testing.” It added “protection of sex workers is essential to respect, protect, and meet their human rights, and to improve their health and well-being.”

Expert voices in support of community-led, sex worker-centered health care in the fight against HIV are becoming more and more numerous. When will the mainstream HIV and AIDS organizations and women’s health advocacy communities join loudly in this demand?