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• W2018584918 abstract "However little else they have in common, both Moses and contemporary public health professionals would agree on 1 thing: sex workers have been integral to the spread of sexually transmitted infections (STIs) since biblical times.1 Given such diversity of ideological views linking sex workers to disease (“contagion” for some, source of “infection” for others), we should not be surprised that the targeting of sex workers has marked the socio-medico history of STIs.2 If the need to target sex workers has not been a matter of dispute, the intent of targeting—surveillance, health interventions, moral reform, quarantine, or punishment—has been a source of public health and political tensions. Rwanda is the most recent site of polarized imperatives to target sex workers. As the public health community deliberates 2 recently released reports3,4 that examine the role of sex work in the country's human immunodeficiency virus (HIV) epidemic, national legislators deliberate a bill to criminalize “the profession of prostitution,” with steep fines and multiyear prison terms (Draft Penal Code on prostitution in Rwanda, adopted by the Parliament on December 23, 2009, and presently under debate in the Senate). The accompanying article in this journal5 reporting HIV incidence rates in a cohort of Rwandan sex workers thus enters a knotty terrain of public health scrutiny and moral-legal wrangling. In this context, its value in timeliness matches its scientific merit. First, to its scientific and public health strengths. The study contributes to a critically important (but not particularly abundant) literature on HIV incidence in general and sex worker populations in Africa.6 The Rwanda cohort (N = 397) was young (half, ≤24 years of age), but experienced in sex trade (half, >3 years of sex work). In the first 12 months of follow-up, 13 new HIV infections occurred with an incidence rate of 3.5 infections per 100 person years. This is lower than the HIV incidence in many other African sex worker cohorts.6 The sparsity of incident infections (N = 13) limits analysis and interpretation. The self-reported behavioral data also defy ready interpretation, but are, nonetheless, intriguing. For example, HIV incidence was highest among women who tested frequently for HIV rather than among women who reported the highest number of sex partners or the highest frequency of sex. Despite the statistical limitations, the finding that a higher proportion of repeat testers reported having an HIV-infected partner fits in with our current debates on the epidemiologic impact of partnership concurrency versus discordant couples.7,8 Overall, the study cohort represents a group of women at high sexual risk, confirmed not only by the burden of STI but also by the incidence of pregnancy, a rate of more than 25 pregnancies per 100 women years. The original cohort had excluded women who intended to become pregnant in the first year; hence, we can assume that many of these pregnancies were unintended. Though 75% of the women reported using male condoms for dual protection against both HIV/STDs and unintended pregnancy, findings of the study suggest that condom use was inconsistent. More comprehensive and integrated HIV, STI, and family planning services in interventions oriented to sex workers would help address this situation. To deliver the most effective combination of services, we also need more evidence on the safety and effectiveness of long-acting methods of contraception (hormonal implants, intrauterine devices) in female populations at high risk of HIV/STDs.9 For the field of HIV prevention, the Rwanda study is particularly timely and pertinent. The world has recently been encouraged by studies showing that both topical and oral preexposure prophylaxis with antiretrovirals can reduce the risks of HIV acquisition in high-risk populations.10,11 Findings on the HIV and STD incidence, the pregnancy rate, and the cohort retention rate (especially encouraging at 96%) provide helpful information about an additional population that might be considered for future prevention trials. Incidence findings such as these will be equally important in guiding effective resource allocations to support programs and strategies designed to avert the greatest number of new infections. Reducing infectiousness by treating HIV-infected persons, as well as reducing susceptibility to infection in HIV-negative core-transmitter and bridge populations, will both be a key.12 In an increasingly challenging funding environment,13 targeting our programs for the greatest prevention impact will be critical. Specific to targeting sex workers, the Rwanda HIV/AIDS (MOT) analysis3 reveals an important definitional challenge. Recognizing a difference between full-time commercial sex and more episodic transactional sex, the MOT model presents findings on the following 2 sex worker categories: (1) commercial sex workers and (2) commercial and transactional sex workers combined. In making this distinction, the model assumes that transactional sex involves fewer sex partners (126 per year) compared to commercial sex (520 sex partners per year). Simply acknowledging different levels of women's engagement in the sex trade produces very different projections. Over a 12-month period and using medium size population estimates, the Rwandan MOT model attributes 7% of all new infections to the combined sex worker group versus 27% to the commercial sex worker group; using high population size estimates, the range is even greater: 7% versus 46%, respectively. Rwanda's MOT findings quantify a long-standing qualitative concern about conceptualizations of sex workers in public health research.14 By contextualizing the exchange of sex for money or material goods within broader understandings of social networks and culturally mediated gender relations, several socio-cultural studies in sub-Saharan Africa15–18 challenge some implicit assumptions about sex work in many public health studies. Specifically, such socially thick descriptions19 of sex and material exchange impel us to qualify more precisely what counts as “commercial” and who counts as a “client.” The inclusion criteria of the accompanying article serve as an example.5 Women were included in the cohort if they (1) had exchanged sex for money at least once in the last month, or (2) had multiple sex partners and had sexual intercourse at least twice a week, or (3) both. But do the behaviors at the parameters of this definition really constitute “sex work?” Do exchanges of money, however infrequent and in whatever context, necessarily qualify as sex work? Do all women with 2 sex partners and who have sex with at least 1 of them twice a week qualify as sex workers? Defining the point at which material exchange or multipartnering constitutes “sex work” is in the end an unavoidable judgment call. But rather than being petty semantics, we contend that continued definitional imprecision in epidemiologic studies undermine the interpretive value and clarity of research on the role of sex workers in the spread of STIs. Whether in a concentrated or generalized epidemic, sex workers constitute a population where a disproportionate level of new HIV infections is being transmitted. The challenge for epidemiology is to better capture in its methods the complexity of sex work as a multipatterned social dynamic. A more complete and nuanced comprehension of the organization and structure of sex work20 will help to refine measures of risk within the trade. Attempts to understand the relationship between risk and intensity of engagement in the sex trade is one promising approach. For instance, Rwanda's 2010 Bio-behavioral Surveillance Survey Among Female Commercial Sex Workers4 demonstrated higher HIV prevalence in women reporting 100% of their income from sex work compared to women reporting alternative sources of income that supplement their earnings from sex work. Multidisciplinary modes of inquiry will further our understanding of the complexity of the sex trade and variable risk within it.20 Keeping the science and the programs close together will deliver better knowledge and improved targeting strategies in high-risk interventions. A preoccupation with sex worker definitions is not exclusive to public health scientists and practitioners. In response to the Chamber of Deputies passing the bill to criminalize sex work in Rwanda, the Deputy Speaker of Parliament says, “There is no way you will charge someone for practicing prostitution without a clear basis.”21 An opponent of the bill, the Deputy Speaker elaborates: “Why aren't we asking how these women get in this situation? What is society's role in educating and helping them with prevention and treatment?” (verbal communication with Deputy Speaker, Jean-Damascéne Ntawukuliryayo, December 15, 2010). Fortunately for Rwanda's enlightened legislators, between the MOT study,3 the Bio-behavioral Surveillance Survey,4 and this most recent article,5 a substantial evidentiary base exists describing risk levels and risk behaviors among sex workers in Rwanda. Together, these studies provide a sound basis to advocate for a favorable policy environment for sex worker interventions. They also offer important insights that should provoke an effort to enhance our understanding of sex work as a complex social phenomenon, to refine the definitions of sex work used in our research, and to target approaches in our HIV prevention interventions." @default.
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• W2018584918 title "Sex Worker Studies: The Science, Semantics, and Politics of Targeting Our HIV Prevention Response" @default.
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