Kathleen H. Reilly, MPH 6th IAS Conference on HIV Pathogenesis, Treatment and Prevention

1. Structural challenges of implementing HIV prevention interventions for commercial sex workers and their clients in China Kathleen H. Reilly, MPH 6th IAS Conference on HIV Pathogenesis, Treatment and Prevention Rome, Italy July 18, 2011

2. HIVCases in China Yunnan, Henan, Guangxi, Xinjiang, Guangdong and Sichuan Provinces account for 81% of all HIV cases in China HIV & AIDS in China. http://www.avert.org/aidschina.htm. Accessed June 23, 2011

3. Female Sex Workers and Health • Sex work is associated with the spread of STIs and HIV • In China, approximately 1% of FSWs are HIV positive • Spread of HIVfrom urban to rural areas is attributed to sex work • Drug use may compound the risk of HIV infection

4. FSWs as a Bridge Population • FSWs are a vulnerable group for HIV infection • FSWs can act as a bridge of HIV infection to the general population • FSWs may have steady boyfriends • Clients may be married or may have multiple sexual partners

5. Political and Cultural Challenges • Sex work is illegal, but widespread (estimated 1.8-3.8 million sex workers in China) • Barriers to reaching FSWs are stigma, economics, politics, and decentralized Chinese system • Mobility: many FSWs migrate within China and are difficult to follow

7. Political and Cultural Challenges • Chinese government is currently engaged in a crackdown on sex work • FSWs have conducted work in a ‘don’t ask don’t tell’ environment, the crackdown has influenced some to change locations • As sex work is driven underground it is more difficult for public health workers to locate and offer services and interventions to FSWs

8. Political and Cultural Challenges • The government is hesitant to create policies which appear to approve of sex work • Clients can be considered to have more economic power in the relationship • Lack of evaluation research regarding HIV intervention programs in China

9. Venues for Sex Work • Street • Massage parlors • Hair salons • Karaoke bars • Truck stops • Brothels • Escorts

10. Venue-based Outreach • High-end sex workers are often difficult to reach • Other types of sex workers may be difficult to reach • Students • Factory workers

11. Interventions and Challenges • STI clinics • FSWs may experience stigma from visiting a clinic exclusively for STIs • Clinics should be located in areas convenient to access and where FSWs would feel comfortable • Periodic outreach testing could be arranged for large sex work venues

12. Interventions and Challenges • Key stakeholders • Important to get buy-in from key stakeholders • public security • local agencies • venue owners (karaoke bars) • Public security can be an asset to a program instead of a threat

13. Interventions and Challenges • Sex work bosses • Typically do not migrate as much as FSWs • Often responsible for FSWs’ health • Can mandate FSWs to use condoms in commercial sex transactions • Can influence FSWs to get tested for HIV and STIs

14. Interventions and Challenges • Offering affordable testing and treatment • Budget limitations • Current standard is blood drawn ELISA with 2-4 week turnaround • Rapid tests have not been approved as a standard of care by the Chinese government • Feasibility studies are being conducted on using rapid tests among MSM in Beijing • Rapid tests are comparatively more expensive

15. Other Solutions? • Some countries have banned sex work • This may drive sex work underground, making safe sex promotion, treatment and monitoring more difficult • Many countries promote “harm reduction” strategies to encourage condom use and regular testing

16. Targeting Clients • Who are clients? • How do you reach clients? • Limited number of Chinese studies on commercial sex clients • Most studies use convenience sampling • Low- income clients are more likely to participate in studies • Interventions should promote positive attitudes towards condom use among clients

17. Other Commerical Sex Workers • The majority of interventions target FSWs, but there are other types of commercial sex workers to consider • Males selling to males • Males selling to females

18. Male Sex Workers • Like FSWs, MSWs also face stigma and discrimination • Intervention outreach methods will likely be quite different from interventions designed for FSWs • Venues may be different • More discreet locations such as parks, public bathrooms

19. Reducing Stigma in the Community • Stigma could be reduced by creating programs that include the general population • Decrease marginalization of sex work as an industry • Increase the familiarity and comfort with communicating about culturally difficult issues

20. Thank You! 谢谢！