 treatment.
The articles in this supplement argue for greater policy and programme support for efficient, scaled and targeted interventions with sex workers in order to improve control of HIV and related STI epidemics. At policy level, this includes structural interventions to increase condom use, reduce vulnerability and remove barriers to prevention and treatment. Implementation science shows how to identify areas where sex work takes place, design standardised packages of effective interventions, monitor progress and estimate outcomes—from programme participation to averted infections and retention on treatment. Sex workers should be involved as active participants in improving policies and programmes.
The fundamentals have been clear for decades. Interventions such as peer outreach, condom policies and programming, STI services and ART have long been shown to be feasible and effective, and are remarkably consistent across countries and regions.[12,13,20,21,26,28] Such direct interventions act proximally during sexual contact to reduce probabilities of transmission—condom use (by reducing exposure), STI treatment and ART (by shortening duration of infectiousness, reducing HIV cofactor effects, suppressing viral load). Structural interventions act synergistically, by changing conditions under which sex work takes place—reducing vulnerability, removing barriers and making direct interventions easier to adopt, more frequently applied or more effective.[13,22,23] Peer-based outreach and community mobilisation interventions facilitate both direct and structural interventions and provide a critical link between the sex worker community and health services.
Balance is important. Narrowly conceived programmes with single interventions—to increase condom use, for example, or test sex workers for HIV—run the risk of alienating sex workers and reducing impact. Programmes should thus strive to provide services that sex workers need and value, and to build trust by involving sex workers in decisions about how services are provided, especially those, like HIV testing, which may feel threatening. Experience shows that the more services meet sex workers’ perceived needs, the more likely they will be to utilise them and contribute actively to interventions. A mobilised community that trusts providers is a powerful platform on which to expand services.
Programmes should attempt to reach high coverage of the most active sex workers as most of the effect of interventions on HIV transmission is achieved by reaching those with the highest rates of partner change.[3,17] Determining eligibility based on level of risk is of course impractical and unethical to make on an individual basis—any sex worker who asks for services should receive them. On the other hand, programmes must decide how to allocate resources, beginning with decisions about which areas to target with outreach and peer interventions. High coverage is critical in areas with overt, full-time, high-volume sex work. The more difficult and resource-intensive task of identifying hidden, part-time sex workers—including ‘transactional’ sex—with few clients may be a secondary public health priority.
In summary, targeted treatment and preventions interventions with sex workers should be scaled up first and foremost in order to reduce the high HIV/STI burden and avert serious morbidity and mortality among sex workers themselves. Feasibility has been demonstrated as has the vital importance of such actions in controlling sexual transmission. The imperative for Africa is rapid scale-up of targeted prevention and treatment, linking outreach and facility-based services, and facilitated by policies and action to improve conditions that place sex workers at high risk and stand in the way of service access. The opportunity is a wealth of accumulated experience working with sex workers in diverse settings, in Africa as well as other regions, which can be tapped to make up for lost time. Elsewhere, even in countries with strong interventions and services for sex workers, an emerging challenge will be sustaining them in the face of declining global resources.
Sex work is an important driver of sexual transmission regardless of stage or classification of HIV epidemic. Yet, high-incidence transmission between sex workers and their clients can be interrupted.
The disproportionate burden of HIV borne by sex workers calls for expedited and facilitated access to appropriate services. Targeted prevention and treatment interventions should be scaled up first and foremost to reduce high HIV/STI burden and avert serious morbidity and mortality among sex workers themselves.
Experience from Asia has demonstrated the feasibility of protecting sex work, averting secondary transmission beyond sex workers and their clients, and, when implemented at sufficient scale, halting established HIV/STI epidemics. Feasibility and effectiveness have also been shown in Africa, but funding for interventions in sex work remains marginal and large-scale responses are rare.
Direct interventions should include peer-based outreach, condom programming and appropriate clinical services, and should be supported by structural interventions to reduce vulnerability, facilitate condom use and promote participation and ownership by sex workers.
Community mobilisation promotes sex worker participation and uptake of services, helps to overcome structural barriers and build a sustainable response. Provision of more comprehensive services addresses sex workers’ broader health and social needs and, in doing so, may also increase engagement and participation of sex workers, and cost-effectiveness of the response.
Sex work takes place in many contexts and takes many forms, from overt and full-time to part-time and ‘transactional’. While any sex worker who seeks services should receive them, programmes should prioritise coverage of overt, high-volume sex work as a first step to interrupting transmission and controlling epidemics.
Implementation of both direct and structural interventions should be supported by community mapping and monitoring involving sex workers, where confidentiality and data protection are ensured.
The articles in this supplement argue for greater policy and programme support for efficient, scaled and targeted implementation of interventions with sex workers in order to improve control of HIV and related STI epidemics.
Wrote the paper: RS GD TW MG EM.
3. Brunham RC, Plummer FA (1990) A general model of sexually transmitted disease epidemiology and its implications for control. Med Clin North Am 74: 1339–1352.
11. Vassall A, Chandrasekar S, Pickles A, Beattie T, Shetty G, Bhattacharjee P, et al. (2014) Community mobilization and empowerment interventions as part of HIV prevention for female sex workers in Southern India: a cost-effectiveness analysis. PLoS One. In Press.
12. Vuylsteke BL, Das A, Dallabetta G, Laga M (2009) Preventing HIV among Sex Workers; Mayer KH, Pizer HF, editors. HIV Prevention: a comprehensive approach. London: Academic Press.
20. World Health Organization, United Nations Population Fund, Joint United Nations Programme on HIV/AIDS, Global Network of Sex Work Projects, The World Bank (2013) Implementing comprehensive HIV/STI programmes with sex workers: practical approaches from collaborative interventions; World Health Organization UNPF, Joint United Nations Programme on HIV/AIDS, Global Network of Sex Work Projects, The World Bank, editor. Geneva: World Health Organization.
39. Mishra S, Moses S, Boily MC, McKinnon LR, Williams JR, Alary M, et al. (2014) The rationale for focusing on sex work programmmes in the response to HIV across sub-Sharan Africa: a systematic review, meta-analysis, and mathematical modelling study. PLoS One. In Press.
52. Tenni B, Thomson N (2014) Arresting HIV: Fostering partnerships between sex workers and police to reduce HIV risk and promote prefessionalization within policing institutions. PLoS One. In Press.
Shawn Harrison, Sean Hagan, and Jared Clark, Soil Born Farms
Shawn Harrison and Marco Franciosa, cofounders of Soil Born Farms, grew up in urban areas (Sacramento and Los Angeles respectively), yet both were drawn to agriculture. The two met in 1997 during a yearlong apprenticeship at the UC Santa Cruz Center for Agroecology & Sustainable Food Systems. In 2000, they left a handwritten note in the mailbox of a Sacramento resident asking if they could use her land to grow food in exchange for some of the harvest. The following day a deal was struck, and since then, Soil Born Farms has expanded to two urban farms, the 25-acre American River Ranch (which includes Mile 16 of the American River Parkway) in Rancho Cordova, and the one-and-a-half acre Farm on Hurley Way in Sacramento. The farms' work falls within three primary categories: certified organic food production, hands-on education, and food access.
Soil Born Farm grows organic flowers, fruit, and vegetables; its main crops include multiple varieties of lettuce, carrots, beets, kales, collards, Asian greens, potatoes, tomatoes, summer and winter squash, melons, onions, garlic, corn, peaches, nectarines, pluots, radishes, turnips, kohlrabi, broccoli, and cabbage.
To educate local youth about agriculture and nutrition, approximately 1,500 students from Sacramento area schools visit the farms through Discovery field trips and their Exploration series. Students who participate in the farms' Youth Corps education program visit the farm between four to ten times over the course of the academic year. Soil Born Farms also runs an apprenticeship program where aspiring farmers learn how to run a farm, and both of their current farm managers started in the apprenticeship program.
As well as hosting students, Soil Born Farms brings farm practices to local schools. At North Sacramento's Grant High School, Soil Born helps the Grant Environmental Organization (G.E.O.) with programs based out of its school garden and cooking classroom. Soil Born also works with area schools on garden development and teacher training. To get local produce into schools, Soil Born Farm is making inroads with other community partners to provide 250 flats of local strawberries a week to the Sacramento City School District school lunch program.
As for the future? "We would