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Sex Workers

HP+ More recent Sex Workers publications are available.

  • In 2015, in order to examine the implications for key populations of reduced donor funding in Bangladesh and to provide guidance for future transitions, the USAID- and PEPFAR-funded Health Policy Project (HPP) conducted a desk review and 20 key informant interviews with civil society, local government, and international donors. The resulting case study offers lessons learned on how donors can ensure the resiliency of HIV programming for key populations while undergoing funding transitions.

  • In Barbados and Jamaica, the PEPFAR- and USAID-funded Health Policy Project (HPP) has delivered two-day stigma-reduction trainings to health facility staff. Adapted from a longer curriculum, the trainings comprehensively address stigma and discrimination by involving all health facility staff (including receptionists, pharmacists, nurses, and administration staff). HPP is also helping facility staff develop posted “codes of conduct” which outline the expectations for stigma-free services, regardless of HIV status, sexual orientation, or gender.

    The codes of conduct posters feature health facility staff photos and contact information for clients to report instances of discrimination. The codes of conduct are being rolled out across health facilities in Jamaica, Barbados, and other countries across the Caribbean.

  • Condom and lubricant (C/L) programming is a critical element of an evidence-based HIV prevention package for sex workers (SW), men who have sex with men (MSM) and transgender (TG) people, populations bearing a disproportionate burden of HIV in Africa. Policy impacts lubricant availability and access.The USAID- and PEPFAR-funded Health Policy Project adapted the Policy Assessment and Inventory Decision Model methodology in Burkina Faso, Togo, and Kenya to assess policies that impact SW/MSM/ TG access to services, including C/L, against international standards and best practices. This poster presents the methods and results of the study, and was prepared for the 20th International AIDS Conference in July 2014.

  • There is considerable uncertainty surrounding key population size and HIV prevalence estimates in Tanzania. To address this data gap, the USAID- and PEPFAR-funded Health Policy Project (HPP), the Ministry of Health and Social Welfare, and the Tanzania Commission for AIDS held a one-day workshop in Dar es Salaam in April 2014 to discuss and reach consensus among key stakeholders on key population estimates for mainland Tanzania. A Delphi method was used to seek consensus on the estimated size of and HIV prevalence among the three key populations in Tanzania: female sex workers, men who have sex with men, and people who use/inject drugs. The workshop processes and outcomes are summarized in this report. 

  • Given the importance of effective HIV-related programs for key populations in Kenya, several government entities, donors, and stakeholders expressed the need for country-specific data on the costs of providing oral pre-exposure prophylaxis (PrEP) to prevent HIV infection. Such data would contribute to the development of evidence-based oral PrEP policies and help ensure that the required resources are made available for appropriate implementation and scale-up. In collaboration with the National AIDS and STI Control Program and the Sex Worker Outreach Program, the Health Policy Project conducted a study to address the following questions: How much does it cost to provide oral PrEP to one sex worker for a year? And, how much would it cost to scale up oral PrEP to all sex workers country-wide? The findings show that the average, annual unit cost of providing oral PrEP to one sex worker is US$602 and the total cost to extend the intervention to all HIV-negative male and female sex workers in Kenya ranges from US$24 million to US$48 million, depending on coverage from 50 to 100 percent. The report concludes with recommendations for the Government of Kenya on factors to consider when planning any future scale-up of oral PrEP.

  • The Health Policy Project's final costing study entitled Estimating the Unit Cost of Providing a Minimum Package of HIV Services to Female Sex Workers and Men Who Have Sex with Men, provides useful information for national program planners, donors, and other stakeholders.It does now, however, include operational details on how these different stakeholders can use the study results for their individual planning, budgeting, and resource mobilization and/or allocation purposes. This companion guide provides details on how study results may be used to inform decision making at multiple levels.

  • The USAID-funded Health Policy Project (HPP) formed a study team to estimate the unit costs associated with a minimum package of HIV services for female sex workers (FSWs) and men who have sex with men (MSM).

    To support the use of the analysis and cost data presented in the final study, the HPP study team also identified the need to develop a companion user guide to provide policymakers and program planners with a practical, stepwise approach to using data for decision making and evidence-based HIV programs, services, and policies, that address the needs of people living with HIV (PLHIV), MSM, and FSWs in Côte d’Ivoire.

    Using a stepwise approach with accompanying tables and worksheets, the guide first explains the importance of calculating average costs using data analysis presented in the larger study. Next, it explains how to determine and use program reach to estimate annual unit costs for HIV programs. Finally, the reader is shown how to project programmatic and national annual costs for FSWs and MSM. 

    The guide is available in English and French.

  • Stigma and discrimination against people living with HIV (PLHIV) and key populations, such as sex workers and men who have sex with men, reduces access to critical services, adversely affects health outcomes, and undermines human rights. Legal services, however, are poorly resourced in low- and middle-income countries, and access is often limited to the wealthiest people.

    Drawing on lessons learned from other contexts, the Health Policy Project (HPP) collated international best practices, research on legal codes and systems in Ghana, and consultations with key stakeholders to determine approaches to monitoring discrimination. Using this information, the report the describes internet- and text message-based platforms for reporting HIV-related discrimination to the Commission on Human Rights and Administrative Justice (CHRAJ), providing a mechanism for civil society organizations to report cases to CHRAJ, track case progress, and use data on stigma and discrimination to guide future advocacy on HIV- and other related policies in Ghana.

  • Effectively capturing and reporting discrimination data can help an organization or government administration gauge the level of discrimination in a country and ensure effective responses. However, there is currently no standard design for a discrimination monitoring and reporting system. In this report, the Health Policy Project brings together known international best practices; research on relevant, existing legal codes and systems in Ukraine; and information from consultations with key stakeholders to determine priorities and approaches for monitoring discrimination. The project also documents a process for defining the scope and scale of a potential system, which both incorporates these best practices as well as considers local needs, resources, and policy environments. The report serves as the beginning of a conversation on monitoring, reporting, and resolving cases of discrimination for vulnerable populations.

  • This brochure provides an overview of a web-based platform that civil society organizations in Ghana can use to report cases of discrimination to the country's Commission on Human Rights and Administrative Justice (CHRAJ). The system, developed with support from the USAID- and PEPFAR-funded Health Policy Project, links civil society to CHRAJ through case tracking, follow-up, and data reporting. The brochure provides information on why someone would submit a complaint, how to submit a complaint, and how to follow up on a complaint. It is meant solely for informational purposes. Step-by-step guidance on how to use the system is provided by the Discrimination Reporting System User Guide.

  • The Discrimination Reporting System User Guide outlines how civil society organizations in Ghana can use a web-based platform to report cases of discrimination to the country's Commission on Human Rights and Administrative Justice (CHRAJ). The system, developed with the support of the USAID- and PEPFAR-funded Health Policy Project, links civil society to CHRAJ through case tracking, follow-up, and data reporting. The user guide provides civil society organizations with a visual description of how to navigate the online system, submit complaints on behalf of clients, track the progress of complaints, and generate reports. It will be distributed to civil society organizations in Ghana that support people living with HIV and key populations.

  • As donor budgets for HIV have flat-lined, funding for HIV services and programming has decreased, particularly in countries with higher income status and concentrated HIV epidemics. To examine the impact of recent or ongoing PEPFAR funding transitions on key populations, the USAID- and PEPFAR-funded Health Policy Project (HPP) hosted a global consultation with key population civil society networks and developed case studies on PEPFAR’s transitions in four countries: Bangladesh, Botswana, China, and Guyana. The case studies offers lessons learned on how donors can ensure the resiliency of HIV programming for key populations while undergoing funding transitions.

    In addition, HPP developed the Readiness Assessment: Moving Toward a Country-led and –financed HIV Response for Key Populations. This guide is designed to assess the ability of a country’s stakeholders (including government, development partners, and civil society) to lead and sustain HIV epidemic control among key populations as donors transition to different levels and types of funding. The guide is a flexible tool that assesses readiness across four domains and focuses on the specific vulnerabilities of key populations.

  • Survey results in Dominica illustrated that key drivers of Stigma and Discrimination in health facilities (fear of HIV infection, negative attitudes and facility environment, including policy) are present across all levels of health facility staff, both medical and non-medical. HPP organized participatory analysis of the evidence and dissemination among health facility staff in order to promote reflection and to propel a sense of urgency to reduce stigma in the health setting. Baseline evidence provided a tool to motivate staff and policy makers to measurable improve services. Recommendations developed by the health care workers focus on a range of training suggestions including who, when, and how to strengthen capacity through training of health and auxiliary staff; and policy development strategies. They urged a call to action based on human rights and a professional obligation to provide equitable, quality services to all. The discussion and recommendations highlight the effectiveness of a participatory approach to data analysis to inform action. 

  • St. Kitts and Nevis is implementing an intervention package to achieve “stigma-free” HIV services. This brief summarizes the results from a survey of health facility staff to inform the intervention, and review of these data in a participatory workshop with health sector stakeholders. The National AIDS Programme is leading the implementation effort with technical support from the University of the West Indies (UWI) and the USAID- and PEPFAR-funded Health Policy Project (HPP). The package includes: a comprehensive survey of all health facility staff; training for health staff and NGO leaders on stigma reduction in health facilities; development of policies and facility Codes of Conduct to reduce HIV stigma; routine monitoring of stigma and discrimination; and where possible, tracking progress on treatment adherence and uptake of testing, treatment, and prevention. The package is part of a regional initiative led by the Pan Caribbean Partnership Against HIV/AIDS (PANCAP) and facilitated by HPP and UWI to apply a jointly agreed framework for effective stigma reduction in health facilities.

  • This two-day training was adapted from the USAID- and PEPFAR-funded Health Policy Project’s 2013 document, Understanding and Challenging HIV and Key Population Stigma and Discrimination: Caribbean Facilitator's Guide. The overall training objectives are

    1. To foster an understanding of how stigma and discrimination towards men who have sex with men and other key populations affects the HIV epidemic
    2. To increase understanding of the different identities of sexual minorities
    3. To increase understanding of how stigma and discrimination towards men who have sex with men impedes access to health services

  • Discrimination against people living with HIV and key populations is a common and challenging problem. A year ago, the Commission on Human Rights and Administrative Justice (CHRAJ) in Ghana launched a web-based system to provide a simple way for reporting HIV- and key population–related discrimination with help from the USAID and PEPFAR-supported Health Policy Project (HPP). This brief describes the outcomes of the discrimination reporting system after one year and ways forward. 

    Click here to read a blog on HPP's work on the CHRAJ stigma and discrimination reporting portal.  

  • A new study released by the Health Policy Project, examines the experience of stigma and discrimination among male and female sex workers and how these experiences affect sex workers’ utilization of health services. Measuring the prevalence of four types of stigma: anticipated, witnessed/heard, experienced, and internalized; the study revealed that over 80 percent of male sex workers and over 70 percent of female sex workers avoided or delayed needed health services in the year preceding the survey. This and other findings provide critical evidence for the need to address stigma and discrimination to both improve health outcomes of and control the HIV among the key populations most affected by HIV.

  • In Jamaica, Woman Inc., with support from the Health Policy Project (HPP), implemented a pilot project to assess the feasibility of integrating screenings and referrals for gender-based violence (GBV) with clinical services for HIV and other sexually transmitted infections. The links between GBV and HIV are widely acknowledged, but relatively few people access services for GBV, especially women and key populations with high HIV burdens such as men who have sex with men and sex workers. The pilot project involved gender training for healthcare providers and community agencies, adaptation and implementation of a GBV screening tool, and mapping and strengthening of GBV referral systems. The findings, summarized in this brief, indicate that the pilot enhanced the capacity of HIV healthcare providers to improve access to GBV support services and better meet the needs of their patients, especially women and key populations.

  • Countries in West Africa (WA) have made significant progress in addressing the HIV epidemic. However, HIV prevalence among sex workers (SWs) and men who have sex with men (MSM) remains high, and data are unavailable for transgender (TG) populations. Services that meet the needs of SWs, MSM, and TG are often unavailable outside of major cities. Stigma and discrimination (S&D) against key populations impact service uptake and increase migration, making it harder to reach these populations. Policies—such as laws, national strategies, and operational procedures—impact service availability and uptake. To inform decisionmakers and improve access to HIV-related services for mobile SWs, MSM, and TG populations in West Africa, the USAID- and PEPFAR-funded Health Policy Project (HPP) conducted an analysis of key policies in countries along the Abidjan-Lagos corridor and Burkina Faso.

  • Through this case study, the USAID- and PEPFAR-funded Health Policy Project (HPP) seeks to share Thailand’s experience implementing the AIDS Zero Portal (AZP) and its initial impact at the national and provincial levels. The AZP offers a potential model for other countries looking to institutionalize and leverage information systems as part of their routine monitoring and evaluation, strategic planning, and resource allocation efforts.

  • For people living with and affected by HIV, stigma and discrimination within health facilities are serious barriers to healthcare access and engagement. Researchers have documented numerous instances worldwide of people living with HIV receiving substandard care or being deterred from seeking care. Although progress has been made in training and other interventions to reduce HIV-related stigma in healthcare facilities, these programs have not been institutionalized as routine practice or implemented on a large scale. Moreover, the tools for measuring stigma tend to be lengthy and time-consuming to administer, thus infeasible for use in facilities.

    To address these issues, an international team of researchers developed and piloted a brief, globally standardized questionnaire for measuring stigma and discrimination in health facilities. This tool can help facilitate routine monitoring of HIV-related stigma as well as the expansion and improvement of programming and policies at the health-facility level.

    Based on the pilot's findings, two final questionnaires are now available: a brief version for program evaluation and a comprehensive version for research purposes. Each questionnaire can be used for high-prevalence or low-prevalence settings.

  • The PANCAP Stigma Framework was developed with assistance from the USAID- and PEPFAR-supported Health Policy Project in response to regional and national requests made to PANCAP for direction on responding to stigma and discrimination in the Caribbean. Stigma and discrimination continue to be key drivers of the Caribbean HIV epidemic and are major obstacles to effective responses. Their impact on Caribbean health and development is wide ranging. HPP provided technical and financial support for PANCAP partners with experience in reducing stigma and discrimination to review existing frameworks and Caribbean tools to inform the drafting of a comprehensive approach. A small group of technical experts from HPP drafted the initial framework to meet the needs of small countries, island states, and emerging nations. This framework has initially engaged and will serve to strengthen the capacity of national HIV programs to develop, implement, and monitor effective policies and programs, and to address HIV in a sustainable manner at the national level. The PANCAP Stigma Framework is built on three components, health and development, collective empowerment, and social justice and gender equality, which are crucial in addressing the Caribbean response to HIV-related stigma and discrimination. 

  • Males who have sex with males (MSM), transgender (TG) people, and sex workers (SWs) are at higher risk for HIV transmission than other individuals, even in generalized epidemics. Structural and policy issues have created barriers for MSM/TG/SWs in seeking services and adopting individual and community harm reduction strategies. Published by the Health Policy Project and the African Men for Sexual Health and Rights (AMSHeR), with support from the United States Agency for International Development (USAID) and US President’s Emergency Plan for AIDS Relief (PEPFAR), the Policy Analysis and Advocacy Decision Model for HIV-Related Services: Males Who Have Sex with Males, Transgender People, and Sex Workers is a collection of tools that helps users assess and address policy barriers that restrict access to HIV-related services for MSM/TG/SWs.

    Designed to help country stakeholders build a public policy foundation that supports access to and implementation and scale-up of evidence-informed services for MSM/TG/SWs, the Decision Model helps to clearly identify and address policy barriers to services. Its policy inventory and analysis tools draw from the extensive body of international laws, agreements, standards, and best practices related to MSM/TG/SW services, allowing the assessment of a specific country policy environment in relation to these standards. This customizable, in-depth, and standardized approach will build stakeholders’ capacity to identify incremental, feasible, near-term opportunities to improve the legal environment and the resulting quality of and access to services for MSM/TG/SWs while long-term human rights strategies are implemented.

    A companion decision model geared specifically toward people who inject drugs (Policy Analysis and Advocacy Decision Model for HIV-Related Services: People Who Inject Drugs) is also available in English and Russian. 

  • The Policy Analysis and Advocacy Decision Model for Services for Key Populations in Kenya provides stakeholders—including policy makers, service providers, and advocates—with tools to assess and advocate policies that govern accessibility and sustainability of services for key populations (men who have sex with men, sex workers, people who inject drugs, and transgender people). By comparing existing Kenyan policies to the global normative guidelines and best practices, the model reveals gaps and challenges in implementation. This document, prepared by the USAID and PEPFAR-funded Health Policy Project for the National AIDS Control Council of the Ministry of Health, analyzes more than 120 policy and program documents related to HIV and key populations.  It also makes policy recommendations for enhanced service scale-up and uptake by key populations in Kenya. 

  • This USAID-funded assessment, conducted in Togo, is the second country application of the Health Policy Project (HPP) and African Men for Sexual Health and Rights (AMSHeR) Policy Analysis and Advocacy Decision Model for HIV-Related Services: Males Who Have Sex with Males, Transgender People, and Sex Workers (Beardsley et al., 2013). The current application of the Decision Model in Togo complements the pilot application conducted in 2012 in Burkina Faso. It was designed as an in-depth policy analysis of the legal, regulatory, and policy environment related to sex workers (SW), men who have sex with men (MSM), and prison populations in Togo to uncover gaps in policy and practical challenges to policy implementation. Beginning in June 2013, the HPP principal investigator, a legal expert from AMSHeR, and a team of local consultants conducted a document review and assessment. The team collected an inventory of 116 source policy and program documents and previous policy and program research related to HIV and/or key populations. Upon completion of the inventory, the team conducted 21 key informant interviews to examine the policy environment and assess dissemination and implementation of current policies, particularly gaps in dissemination and implementation that pose barriers to service access for key populations. The HPP policy analysis and key informant interviews confirmed that positive changes related to HIV prevention, care, and treatment are occurring in Togo. Initial steps are being taken to develop policies that recognize key populations and aim to improve access to services for them. Significant opportunities exist to further progress, including the USAID-funded Regional Project for the Prevention and Care of HIV/AIDS in West Africa (PACTE-VIH) and open support from the president of Togo and the permanent secretary for the National AIDS Council. However, critical gaps in policy, dissemination, and implementation remain and are highlighted in this report.

    Read the brief on this topic.

  • In Côte d'Ivoire (CdI), the Health Policy Project (HPP) supported national institutions to estimate the unit cost of HIV programs targeting key populations such as males who have sex with males and sex workers. This final report provides estimates for the cost of delivering HIV services to key populations in CdI as well as projections of how costs could change over time in varying scenarios of program scale-up and service packages. These results can be used by stakeholders at all levels of the country to better plan and budget for HIV service delivery.

  • This poster presents the results of a study on measuring HIV stigma among all levels of health facility staff. A tool developed by international program implementing agencies, university and non-university based researchers, the global network of people living with HIV (GNP+), and UNAIDS was field-tested to refine it and create a brief questionnaire that can be used s a standalone survey or a module in a broader HIV survey for health facility staff. The poster was presented by staff of the USAID- and PEPFAR-funded Health Policy Project at the 17th International Conference on AIDS and STIs in Africa in December 2013, in Cape Town, South Africa.

  • Stigma and discrimination (S&D) remain critical barriers to achieving HIV prevention, care, and treatment targets, including zero new HIV infections and zero AIDS-related deaths. In Jamaica and elsewhere in the Caribbean, S&D falls hardest on key populations, including men who have sex with men (MSM) and sex workers (SW) and undermines access to testing and treatment.

    The Key Population Challenge Fund (KPCF) project aimed to improve the quality of and access to stigma-free HIV testing and counseling (HTC) services for key populations. Through this initiative, the Health Policy Projected (HPP) implemented a stigma-reduction toolkit for facility-based healthcare providers. Project outcomes included cultivating an enabling environment for key populations and the development of facility-level codes of conduct.

  • The response to HIV and AIDS is an integral component of efforts to improve social and economic conditions in Ghana and Côte d’Ivoire. Available data suggest that HIV prevalence rates among key populations, particularly female sex workers (FSWs) and men who have sex with men (MSM), are several times higher than the national averages for both countries. These groups also face additional barriers to social acceptance and access to services, compared with the general population. Accordingly, Ghana and Côte d’Ivoire each completed a Strategic Framework to guide interventions and service delivery specifically for key populations. The frameworks propose a package of services that includes HIV prevention; HIV treatment, care, and support; and psychosocial support and legal services. This brief describes the costing analysis conducted by HPP and in-country stakeholders to provide country-specific costing data on key populations to provide an evidence base for policy-making processes.

  • As part of its overall effort to promote evidence-based policies, decision making, planning, and advocacy, the Health Policy Project has worked with the Ghana AIDS Commission (GAC) and other important  stakeholders to conduct a costing study of services to key populations in Ghana (males who have sex with males and female sex workers). This will ensure that Ghana has country-specific costing data available. The study team collected information from service providers at eight purposively selected facilities and from program managers at the regional and central levels. The costing data are now being used to update Ghana's Goals Model and for planning, budgeting, and decision-making purposes (e.g, in conjunction with the development of Global Fund proposals and development of operational plans and budgets). In addition, one of the purposes of analyzing unit costs is to understand what is driving costs and identify areas where there is potential to gain efficiencies and reduce costs without negative impacts on quality.

    The report does not include specific operational details on how each of these different levels may use study results for their individual planning, budgeting and resource mobilization, and/or allocation purposes. The accompanying Estimating the Unit Costs of Providing Key HIV Services to Female Sex Workers and Males Who Have Sex with Males in Ghana: A Data Use Guide summarizes key findings from the study and provides specific details on how study results may be best used to inform the evidence base for the Ghana HIV program.