Sex Work, HIV/AIDS, and Human Rights

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Sex Work, HIV/AIDS, and Human Rights

Context

Although sex work has a long history in nearly every culture and society, sex workers have been rarely, if ever, free from persecution, stigma, and violence. In some countries, notably in Western Europe,government oﬃcials and policymakers have worked with sex workers and their representatives in an eﬀort to ease discrimination and improve access to health care and other social services. Such eﬀorts have at times been slow and inconsistent; they are, however, major accomplishments compared with most nations elsewhere in the world.

In Central and Eastern Europe and Central Asia,for example,sex workers remain among the most marginalized members of society. Policymakers and authorities view them as nuisances to be ignored or immoral lawbreakers rather than as individuals who can and should be protected from violence and receive social and economic assistance and support. At the same time, the surging HIV/AIDS epidemic in the region places sex workers at increasingly greater risk of infection not only from HIV,but also from other potentially debilitating conditions related to sex work and drug use.

This report provides an overview of these and other important issues that sex workers face in the region as well as to the political, economic, and social factors that inﬂuence policies and attitudes toward sex workers. It focuses primarily on existing laws and policies and their consequences from the perspective of HIV prevention and treatment. The report also oﬀers recommendations designed to uphold sex workers’ human rights and remove barriers that reduce their ability or willingness to obtain access to consistent and equitable health care and other social services.

Statement of principles

The eﬀorts of CEEHRN and its allies with and on behalf of sex workers are based on the following deﬁnitions, principles, and goals:

•Sex work is deﬁned as the unforced sale of sexual services for money or goods between consenting adults. Sex work includes street prostitution, escort service, telephone sex service, pornography, exotic dancing, and others.
Sex workers should have the same rights and responsibilities as all other workers, and as every other citizen and resident.
Protection of sex workers’ rights is crucial for eﬀective harm reduction, HIV/AIDS prevention, and treatment eﬀorts at all levels—individual, community, and national. To ensure protection of these rights, sex workers should be able to work legally.

Sex Work, HIV/AIDS, and Human Rights in Central and Eastern Europe and Central Asia

Barriers preventing access to health, social, and drug treatment services need to be removed to improve the health and social well-being of sex workers.
Activities related to sex work between consenting adults should be decriminalized.All national criminal laws relating to adult prostitution should be repealed.All regional and local regulations targeting sex workers to prosecute the practice of their trade should be repealed.
Sex workers and other community members should have an active role in designing commercial regulations of the sex trade.
Targeted, pragmatic, and comprehensive social programs must be developed in consultation with sex workers and implemented to improve relations between the police and sex workers as well as between sex workers and the community at large..
Targeted, pragmatic, and comprehensive public health programs must be developed and implemented with the involvement of sex workers to raise awareness about safer sex; safer drug use; and HIV/AIDS prevention, treatment, and support.
Governments throughout Central and Eastern Europe and Central Asia should review and revise accordingly existing laws and policies in the realms of illicit drug use and sex work with the goal of adopting policies in which their human rights commitments are upheld. These commitments include agreements such as the UN Declaration of Commitment on HIV/AIDS,the UN Millennium Declarations,the Convention on the Elimination of All Forms of Discrimination against Women, the Convention on Economic,Social and Cultural Rights,and other instruments of international human rights law.
There is no reason to delay reform that helps protect the health and rights of sex workers and, by extension, society at large. The time to act is now!

Geographic focus

For the purposes of this report, the term “Central and Eastern Europe and Central Asia” or“CEE/CA” refers to all of the countries of the former Soviet Union as well as those in Central and Eastern Europe that previously were communist states. To varying extent, all of them have adopted market-based economies. Most are also democracies, although in some democracy exists in name only. The following 27 countries are part of the region of CEE/CA as deﬁned by this report: Albania, Armenia, Azerbaijan, Belarus, Bosnia and Herzegovina, Bulgaria, Croatia, the Czech Republic, Estonia, Georgia, Hungary, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, FYR Macedonia, Moldova, Poland, Romania, Russia, Serbia and Montenegro, Slovakia, Slovenia, Tajikistan, Turkmenistan, Ukraine, and Uzbekistan.

Note on terminology

The terms “sex worker” and “prostitute” are used interchangeably in this report to refer to individuals whose economic livelihood consists of accepting money in exchange for sex.

In the context of sex work in this report, “abolition” refers to an approach that aims to eliminate all forms of paid sex through legal prohibition;“decriminalization” refers to the repeal of all laws that criminalize the action of taking money for sex; and “regulation” refers to an intermediate approach that regards prostitution as inevitable and not explicitly prohibited, but nevertheless in need of special social controls and regulations.

Acronyms and abbreviations used in this report

AFEW AIDS Foundation East-West
ART antiretroviral treatment
CCM Country Coordinating Mechanism
CEDAW Convention on the Elimination of All Forms of Discrimination against Women
CEE/CA Central and Eastern Europe and Central Asia
CEEHRN Central and Eastern European Harm Reduction Network
DFID Department for International Development (U.K. government aid agency)
EU European Union
FSU former Soviet Union
GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria
HCV hepatitis C
HOPS Healthy Options Project Skopje
IDU injecting drug user
IHRD International Harm Reduction Development Program
OHI Open Health Institute
OSI Open Society Institute
PSI Population Services International
STI sexually transmitted infection
UHRA Ukrainian Harm Reduction Association
UNAIDS Joint United Nations Programme on HIV/AIDS
UNDP United Nations Development Programme
UNESCO United Nations Education, Scientiﬁc and Cultural Organization
UNICEF United Nations Children’s Fund
USAID U.S.Agency for International Development
VCT voluntary counseling and testing
WHO World Health Organization

Sex Work, HIV/AIDS, and Human Rights in Central and Eastern Europe and Central Asia

Executive summary

Social and economic disarray in the wake of the dissolution of the Soviet Union severely limited many women’s ability to support themselves, thus precipitating a surge in the number of sex workers across Central and Eastern Europe and Central Asia (CEE/CA). Soon thereafter, drug use and HIV/AIDS began reaching epidemic proportions in several countries of the region, notably in the former Soviet Union. This report, based on a comprehensive survey of organizations working with sex workers throughout CEE/CA,oﬀers sobering proof that in most parts of the region,the plight of sex workers grows bleaker every day due to a lethal combination of economic desperation, surging health risks, discrimination, and violence.

As this report makes clear,these three developments—growing prevalence of sex work,drug use, and HIV—are increasingly intertwined. Sex workers are more likely to engage in high risk behaviors that greatly increase the possibility of HIV transmission, such as injecting drugs and unprotected sex.At the same time,they have limited access to the kind of services and assistance that can help them address these risk behaviors. This report illustrates how current policies and legislation fail to protect sex workers.National drug policies,including prohibition or restriction of harm reduction services; discrimination at health care services; police corruption; and wide- scale traﬃcking of women all serve to further marginalize sex workers. In cases where sex work is not technically illegal, it is still not tolerated and discrimination pervades. Such attitudes greatly impede sex workers’ access to public health services, including drug treatment and HIV prevention services. These multiple vulnerabilities are also further compounded by underlying social issues such as lack of education and economic opportunities.

The aim of this report is to raise awareness on the key concerns and issues aﬀecting sex workers to enable planning and implementation of appropriate health and social policies. The report focuses on the following: HIV/STI epidemiological history and trends in the CEE/CA region; behavioral practices in relation to sex work; relevant national legislation and policies, including human rights, and their enforcement; and existing services for sex workers in the region.

The ﬁndings suggest that as the HIV/AIDS epidemic gathers steam throughout much of CEE/CA, improving the health and well-being of sex workers becomes more critical than ever. Evidence indicates that the HIV epidemic in the region is currently concentrated among speciﬁc population groups such as injecting drug users (IDUs) and sex workers.The overlap between sex work and drug use doubles sex workers’ vulnerability to acquisition and transmission of HIV. Targeted HIV interventions for sex workers and IDUs are needed to tackle HIV and prevent it from becoming a generalized epidemic. The health and safety of all citizens thus depends on working with and for sex workers to help them protect themselves from harm. This will require a greater commitment among all members of society to accept and support the provision of comprehensive, pragmatic services for those most in need. It also depends on the recognition that enforcing international human rights standards is a cornerstone of eﬀorts to remove stigma and discrimination and enable the full participation in society of all people.

This report is grounded in the understanding that sex workers have the rights to health and social support as do all members of society. This belief is at the heart of the recommendations derived from this report, summarized into the following categories: for policymakers, for health authorities, for law-enforcement authorities, for service providers, and for researchers.

The successful implementation of the recommendations speciﬁed in the report rely not only on policymakers and service providers,but also on the ability of sex workers to advocate for their own rights.In order for this to happen more consistently,obstacles that prevent sex workers from organizing among themselves into working collectives or unions need to be removed. As sex workers feel more comfortable and less fearful in general,they are able to work together more closely and consistently to advocate for their rights.As much as anything else, this development could have the most positive eﬀect on their own health and the health of those in their lives. (More extensive information about the recommendations may be found in Section 5, “Conclusions and Recommendations”.)

Recommendations for policymakers

Government oﬃcials from across the spectrum should summon greater levels of political will and commitment to address social marginalization, economic exclusion, and violence within broader governance.
Mechanisms should be initiated, preferably in cooperation with human rights groups and civil society, to enhance the independent monitoring of human rights agreements; protect the rights of vulnerable populations; and punish violators.
Repressive national legislation regarding drug use and the provision of eﬀective interventions, such as harm reduction services, should be revised to reﬂect pragmatic, compassionate policies. Most importantly, harsh penalties for drug use should be eliminated because they restrict the ability and willingness of those at risk to obtain information and services to protect their own health and the health of those around them.
Sex work should be decriminalized, and other national policies that negatively aﬀect sex workers’ human rights and access to health services should be revised or eliminated.
Sex workers’ involvement in all government-organized HIV/AIDS and human rights initiatives should be made a priority and guaranteed.

Recommendations for health authorities

HIV testing must be voluntary and conﬁdential for all individuals, including sex workers, IDUs, and others at high risk for contracting the virus.
Harm reduction services, including needle/syringe exchange, should be available at all public health facilities.
Migrants should have improved access to public health services.
Policies and procedures in health care delivery that discriminate against IDUs and sex workers should be identiﬁed and removed.

Sex Work, HIV/AIDS, and Human Rights in Central and Eastern Europe and Central Asia

Recommendations for law-enforcement authorities

• Policies should be implemented to help stem harassment and abuse of sex workers by the police.

• All members of the police and other law-enforcement entities should receive regular training on issues related to HIV, drug use, and the legal and human rights of all individuals, especially sex workers and other vulnerable groups. Police should also be expected to refer—but never in a coercive or threatening manner—sex workers and IDUs to programs, projects, and shelters where they can receive appropriate assistance.

Recommendations for service providers

• Programs targeting sex workers in general and speciﬁc groups within sex worker populations need to be expanded and diversiﬁed.

• Service providers should seek to establish better links with human rights organizations/ activists and other stakeholders in the region as part of an enhanced eﬀort to monitor violations.

• Better program monitoring and evaluation would be a useful step toward improving planning and service delivery in general.

Recommendations for external donors

• Donors, especially foreign development agencies, need to base their response and funding on the real situation on the ground and on scientiﬁc evidence—and not on domestic ideological considerations in their own countries.

• Staﬀ at multilateral and bilateral aid entities—as well as public health system employees at all levels—should be encouraged to speak up in response to perceived mismanagement, misallocation of priorities, and discrimination. They should be able to note their objections conﬁdentially and without risk of reprisals such as dismissal.

• The policies and programs of various donors should be better organized and coordinated to ensure continuity of service, especially in countries where service provision depends mostly on donor assistance.

Recommendations for researchers

• Researchers, scientists, national governments, and multilateral organizations should collaborate on the establishment of professional, sustainable research teams that publish more speciﬁc and accurate data on the HIV/AIDS epidemic and vulnerable populations, including sex workers, in CEE/CA.

• The effects of decriminalization of sex work should be carefully analyzed, and the results made widely available. Special attention should be paid to experiences in other countries of the region (notably Hungary and Latvia).

INTRODUCTION

Sex Work, HIV/AIDS, and Human Rights in Central and Eastern Europe and Central Asia

Following the collapse of the Soviet Union some 15 years ago, the countries of Central and Eastern Europe and Central Asia (CEE/CA) experienced complex political, economic, and social changes in the 1990s that helped precipitate a signiﬁcant rise in the number of people involved in sex work (Lowndes et al, 2003). The upheavals related to economic transition led to an increase in unemployment and a sharp decline in living standards; in many countries of the region, women were the ﬁrst ones to lose their jobs and ﬁnd themselves desperately trying to adjust to an environment in which the state no longer provided jobs or a basic level of ﬁnancial assistance. Although the economies of some nations in CEE/CA, especially those that have joined the European Union (EU) or expect to do so shortly, have grown rapidly in recent years, high levels of unemployment, violence against women, and lack of an adequate child support infrastructure are more or less present in every country of the region.According to a 2000 report from the United Nations Education, Scientiﬁc and Cultural Organization (UNESCO), out of 26 million jobs that vanished in the decade after 1989, more than half―14 million―were women’s jobs (UNESCO, 2000).

One of the main consequences has been that in many countries of the region, sex work represents the only way for signiﬁcant numbers of young women to earn a living. In South Eastern Europe,for example,the diﬃcult economic situation and lack of employment has meant that the sex industry is the primary area of work for women and adolescent girls traﬃcked from other countries (UNHCR,UNICEF,2002).In Kyrgyzstan,CentralAsia,women without education or professional training have few if any other options to support themselves (Kurmanova, 2004). For Baltic countries such as Latvia, economic changes caused by restoration of independence and the expansion of tourism and foreign investment, coupled with the continued high level of unemployment and corruption,are believed to be among the key explanations as to the increased level of women’s involvement in commercial sex work.There is hope that many of the underlying factors, notably unsettled social welfare systems, will be addressed in nations linked to the EU. Other countries in the region,meanwhile,face a far bleaker future in terms of increasing income- generating opportunities and raising living standards, especially for women.

In the meantime,public health indicators remain depressed.The concurrent and interlinked rise in drug use and HIV transmission represents a particularly grave challenge. HIV rates have skyrocketed in most of the region since the mid-1990s,when the virus ﬁrst made its appearances among communities of injecting drug users (IDUs). Sex work and injecting drug use in the region overlap: many sex workers inject drugs and many drug users, especially female, exchange sex for drugs or money to support their habit.Ongoing debates in epidemiological literature and policy forums center on whether sex workers represent a“bridging population”that can facilitate HIV transmission between communities of IDUs and the “general population”. There is of yet no ﬁrm conclusion to this debate.Many analysts believe that the level of unprotected sex among sex workers may be lower than among the general population (Europap/Tampep, 1999), while others argue that the potential of heterosexual transmission of HIV from sex workers to their male clients is dangerously high (Lowndes et al, 2003). Regardless, it is clear from both a public health and human rights perspective that protecting the so-called general population cannot and should not be the only aim of and expected beneﬁt from increasing access to health care and HIV/STI prevention and treatment services among sex workers and drug users. The division into these groups exists only in epidemiological terminology; in real life, sex workers and drug users are integrated members of overall society, and protecting their health is an important goal in itself.

As daunting and potentially lethal as they are, HIV and sexually transmitted infections (STIs) are of course not the only health and welfare issues of constant concern to sex workers. They face violence on a daily basis and have limited or nonexistent legal protection.As in most other countries of the world, state policies addressing issues of sex work in the region are rarely driven by pragmatism, scientiﬁc evidence, and human rights concerns; instead, they are often restrictive and based on moral prejudice. Even when sex work is not technically illegal, it is frowned upon and its practitioners discriminated against and shunned by much of society. These attitudes greatly impede sex workers’ access to public health services, including treatment for drug dependence as well as HIV prevention and treatment information and services. They also place sex workers in a position where their basic human rights can easily be violated and protection of these rights becomes diﬃcult if not impossible.

The results of the surveys underpinning this report are shocking not only for the sheer number of people they translate into,but also for what they indicate about the desperation faced bymanywomen.Muchof theregion,especiallyinCentralAsia,comprisesculturallyconservative countries in which women who engage in any sex act outside of marriage are frequently abused, shunned, and ostracized by their families and society overall. That they would turn to—or be forcedinto—sexworkprovidessomeof thestrongestproof possiblethatmanynations’socialand economic safety nets have frayed into irrelevance.Young women engaged in sex work are among the most vulnerable members of male-dominated societies from every perspective imaginable.

1.1 Background to the report

In an eﬀort to determine the eﬀectiveness of existing services for sex workers in the region, CEEHRN initiated a pilot region-wide survey among 26 harm reduction programs in 15 countries in March 2003. The research focused on legal regulation, epidemiology, and services for sex workers. The results of this small-scale survey demonstrated that

• programs lack knowledge about national legal regulations of sex work;

• in most countries, sex work is formally criminalized and/or sex workers are informally discriminated against through law-enforcement practices;

• services for sex workers are limited in scope and number; and

• criminalization of sex work is one of the main obstacles to eﬀectively providing services for sex workers. (Jiresova, 2003)

The survey’s conclusions were discussed at a CEEHRN strategic planning meeting in 2004, during which it was decided to undertake policy assessments in diﬀerent areas and to develop recommendations for policy improvement, including sex work regulation. As identiﬁed then, the main objectives of the project were to review the following in CEE/CA nations: HIV/STI epidemiological history and trends;behavioral practices in relation to sex work;relevant nationallegislation and policies, including those dealing with human rights, and their enforcement; and existing services for sex workers in the region.This report compiles the results of that review and oﬀers a comprehensive snapshot of the important issues that directly aﬀect sex workers across the legal, political, social, economic, and health spectrums.

1.2 Report structure

Section 1 introduces the project,outlines its aims and scope,and provides a brief description of methodology.

Section 2 gives an overview of the extent and diﬀusion of HIV and STIs associated with sex work and injecting drug use in CEE/CA. It summarizes HIV and STI case reports; HIV and STI prevalence derived from selected studies of sex workers; estimates of the size of sex worker populations; demographic data on sex workers; rates and trends of injecting drug use; and injecting and sexual risk behaviors among sex workers in the region.

Section 3 summarizes international treaties and provisions that are intended to regulate— or can be interpreted as inﬂuencing—responses to sex work at the international and national levels. It also discusses more general issues related to human rights; provides information on traﬃcking; considers the various forms of regulation of sex work in CEE/CA countries, from direct prohibition to explicit allowance of sex work; and includes a brief review of published and original data on human rights violations against sex workers.

Section 4 focuses on service provision for sex workers in the region. It reviews existing projects,target groups,and sources of funding; attempts to assess service coverage; and discusses existing advocacy eﬀorts, including self-organizing of sex workers, which are geared toward increasing the amount and scope of eﬀective services.

Section 5 includes recommendations for improving policies aﬀecting sex workers as well as general and speciﬁc service provision.

Appendices at the end of the report contain extensive information and data presented in table format. The charts and tables are referred to throughout the report.

1.3 Methodology

The analysis was carried out in four stages: expert consultation; literature review; survey of projects; and expert follow-up consultation to develop recommendations.

Stages 1 and 4: Stakeholders were contacted and asked to provide information and observations about past and ongoing research and other relevant information on sex work, its relationship to drug use, and existing services oﬀered to sex workers. Experts and stakeholders from the following entities were contacted via email and listservs:

• harm reduction programs that work with sex workers

• country oﬃces of UNAIDS and other UN agencies

• human rights organizations at international, regional, and domestic levels

• international organizations and NGOs working in the ﬁeld, such as the Open Society Institute’s International Harm Reduction Development Program (IHRD), EUROPAP, TAMPEP, and AIDS Foundation East-West (AFEW)

INTRODUCTION

At the ﬁnal stage of the report (Stage 4), these stakeholders were contacted again and asked to provide feedback and to assist in the development of policy recommendations.

Stage 2: CEEHRN staﬀ and consultants reviewed reports and information obtained from stakeholders as well as published English- and Russian-language research literature, abstracts from recent international conferences (including the International AIDS Conference and the International Conference of Drug-Related Harm), international agency and country assessment reports, and centrally registered HIV-surveillance data.

The literature searches for Section 2 of this report were undertaken on two electronic databases, Medline (OVID) and the International Bibliography of the Social Sciences.

English and Russian Internet resources were widely used to gather reports and current papersprovidingregionalandinternationalperspectives.Giventhatdocumentationonsexwork, drug use, and HIV/AIDS is limited or often edited extensively prior to public dissemination, “grey literature”provided by experts was also analyzed.

Stage 3: A survey focusing on issues not covered by existing literature was carried out. A standardized survey instrument was developed to collect national and program data on:

• legal regulations of sex work;

• epidemiological data on HIV, STIs and oﬃcial and estimated number of sex workers, including drug injectors;

• demographic proﬁle of sex workers;

• behavioral data on sex work and drug use;

• human rights of sex workers and their recognition and upholding by police, clients, and mass media;

• medical services for sex workers, including access to diagnostics and treatment of HIV and STIs;

• operations and eﬀectiveness of existing low-threshold services for sex workers;

• peer education and support; and

• self-support groups, including advocacy organizations.

The questionnaire was submitted to some 20 national respondents throughout the CEE/CA region. Each respondent was responsible for at least one, and in some cases two or more, of the 27 countries to be covered in the report. Data and responses were provided for the following 24 of the 27 countries: Armenia, Azerbaijan, Belarus, Bosnia and Herzegovina, Bulgaria, Croatia, the Czech Republic, Estonia, Georgia, Hungary, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, FYR Macedonia, Moldova, Poland, Romania, Russia, Serbia and Montenegro, Slovakia, Tajikistan, Ukraine, and Uzbekistan. For various reasons, including lack of access, data were not collected for Albania, Slovenia, and Turkmenistan.

For the most part, national and program respondents collected data between July–October 2004. Data collection generally consisted of analyzing routine monitoring reports and national surveillance information. Methods of data collection and surveillance diﬀered across individual countries, a situation that makes it diﬃcult to obtain direct, systematic cross-country comparisons. However, although the information and data collected may not be appropriate for in-depth analysis, they met the report’s overall goal of providing reasonably descriptive detail of sex work in each country.

Percentages presented in this report’s narrative have been rounded to the nearest whole number, except with exceptionally small numbers or when speciﬁcally indicated otherwise.As a result, percentages may not add up to 100.

1.4 Structural and analytical limitations

CEEHRN acknowledges that both men and women are regularly involved in the provision of sexual services. The organization recognizes the important health and human rights issues aﬀecting male sex workers in the CEE/CA—in addition to injecting drug use, these include the criminalization of homosexual behavior (legislation that is still present in some of the region’s countries) and the high risk of HIV/STI transmission among men who have sex with men. However, this study targeted women only, primarily because evidence from the ﬁeld indicates that the great majority of commercial sex workers in the region are women. CEEHRN recommends that additional research and analysis of male sex work be made a top future priority of organizations focusing on sex work issues in the region.

Duetocertainlimitationsof thisresearch(suchasﬁnancialandlackof legalexpertiseamong national respondents),this report was not intended to be a comprehensive in-depth legal analysis of national legislation. Furthermore, there was neither space in the survey nor expertise among respondents to directly consider parallel issues related to service provision, such as housing and income security, or to closely examine speciﬁc issues related to access to various services.

Sex Work, HIV/AIDS, and Human Rights in Central and Eastern Europe and Central Asia

Sex Work and Associated Risk Behaviors

This section provides an overview of the extent and diffusion of HIV and STIs associated with sex work and injecting drug use in Central and Eastern Europe and Central Asia. It summarizes HIV and STI case reports; HIV and STI prevalence derived from selected studies of sex workers; estimates of the size of sex worker populations; demographic data on sex workers; rates and trends of injecting drug use; and injecting and sexual risk behaviors among sex workers in the region.

Extent of sex work in CEE/CA

Nearly all countries in CEE/CA have experienced an increase in sex work,largely stemming from economic necessity, in the wake of the collapse of the Soviet Union (Konings, 1996; Loseva and Nashkhoev, 1999; Platt, 1998; AIDS Info share, 2001).The rise in explicitly commercial sex work has occurred concurrently with a growing emphasis on the economic value of sexual relations in general, a development that reﬂects widening diﬀerentials in wealth (Renton et al., 1998). Many individuals have undoubtedly proﬁted during the ongoing transitions to market-based economies, but the living standards of the majority, and in particular women, have declined.

The sex industry appears to be growing especially rapidly in the countries of Central Asia, which are the poorest parts of the former Soviet Union (UNAIDS-CAR, 2000). One report from the late 1990s indicated that 1 in 4 women in Kazakhstan would engage in sex work at some time in her life (Thomas, 1997). This estimate was supported a couple of years later by ﬁndings from a survey conducted by a pedagogical institute in Almaty; about 40% of respondents reported having at some time accepted ﬁnancial remuneration for sex (Schonning and Buzurukov, 1999).

The available evidence clearly indicates that sex work is a common phenomenon in the region. However accurate estimates on the number of sex workers are diﬃcult to obtain for a number of reasons, including the transient nature of sex work and of sex worker populations; ambiguous deﬁnitions as to what constitutes sex work; and the often-murky legislation regarding sexworkthatprevailsintheregion.Therefore,thesefactorsshouldbeconsideredwhenreviewing respondent-derived data in Table 7 (in the Appendices),which summarize recent estimates of the number of women involved in sex work and sex work prevalence.

SEX WORK AND ASSOCIATED RISK BEHAVIORS

Structure of sex work

Evidence from the published literature and from the project reports suggest that in CEE/CA and elsewhere, the sex work industry can be roughly divided into three distinct levels or types: street workers, apartment workers, and hotel (“elite”) workers.

Street workers. The “lowest” and most dangerous level includes women who work on the streets, often in bus and railway stations. They are most likely to inject drugs, have lower rates of condom use, and be migrant workers, all factors that tend to isolate them from HIV and sexually transmitted infection (STI) prevention and care services. As a result, risky behaviors such as injecting drug use and unprotected sex are relatively high, as are rates of HIV and STI infection.

Apartment workers.The second group consists of women who usually work in groups under a manager, often a woman. They operate from apartments, saunas, or on the street. This type of sex work is more formalized and professional. Injection drug use is less common,and if it occurs it is more likely to be concealed from clients and management. Members of this group are also more likely to have greater access to treatment for STIs, although this access tends to be limited to private care services (Konings, 1996).

Sex Work, HIV/AIDS, and Human Rights in Central and Eastern Europe and Central Asia

Categories of sexual partners

Sex workers routinely have sex with both paying customers and individuals who do not pay. Unlike the former, members of the latter category are generally people with whom sex workers interact on a regular basis; some may be boyfriends or husbands, others are casual friends or acquaintances. The level and extent of risky behaviors on the part of sex workers often diﬀer greatly depending on the partner’s category.Sex workers are less likely to use condoms with non- paying customers for numerous psychological, emotional, and physical reasons ranging from implicit trust to a desire to have a child.Whatever the reasons for this dichotomy in condom use, one of its major consequences is increased risk of HIV transmission to and from non-paying customers.This risk is further heightened by the fact that often there is little diﬀerence in rates of injecting drug use between paying and non-paying partners.

HIV cases in the region

Sex Work, HIV/AIDS, and Human Rights in Central and Eastern Europe and Central Asia

the majority of HIV cases to date have been associated with injecting drug use—itself a rapidly growing epidemic, especially among young people, in countries marked by weak economies, falling living standards,and deteriorating health and social services.Heroin and other opioids are widely available and relatively inexpensive because most countries are located along major drug- transit routes toWestern Europe fromAfghanistan,where most of the world’s opium poppies are grown. Recent estimates indicate that over 75% of oﬃcially registered HIV cases are attributable to injecting drug use in Belarus, Estonia, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Moldova, Russia, Tajikistan, and Uzbekistan.

In 2002,the number of new HIV cases reports declined for the ﬁrst time in Russia and Ukraine, a development linked to a reported decrease in cases among IDUs.There is some evidence to suggest that this does not represent a true decline but rather a decline in the number of HIV tests conducted among IDUs.Data are unclear as to the current signiﬁcance of sexual transmission of HIV.However, public health observers and experts generally believe sexual transmission is a major concern for the future, especially among the sexual partners of IDUs and among IDUs involved in sex work.

SEX WORK AND ASSOCIATED RISK BEHAVIORS

prevalence in this region may be 10 times higher than indicated by oﬃcially registered cases.The primary mode of HIV transmission in the region is sexual—except in Serbia and Montenegro, where a majority of cases to date are associated with injecting drug use.

HIV prevalence remains relatively low in Central Asia and the Caucasus, but it is rising more quickly in these countries than anywhere else in the CEE/CA region.As in South Eastern Europe, the actual number of people living with HIV in Central Asia is thought to be several times larger than oﬃcially registered. In Uzbekistan, for example, a total of 3,596 cases were registered at the end of 2003; UNAIDS, meanwhile, estimated that at least 11,000 people were living with HIV in Uzbekistan by then.

With the possible exception of some countries in Central Europe,lack of political leadership and HIV-related stigma and discrimination are major impediments to the development and implementation of eﬀective HIV/AIDS policies and strategies in CEE/CA. Marginalized populations such as IDUs, sex workers, men who have sex with men, and Roma continue to be at greatest risk for contracting HIV. Many members of these groups remain unable or unwilling to access adequate health care or HIV prevention and treatment services because of outright discrimination (such as denial of care) or fear of harassment from authorities.

Overall HIV prevalence data are summarized in Table 1 in the Appendices. HIV infections associated with sex work are discussed later in this section.

STI cases in the region

Rates of most major STIs,including chlamydia,gonorrhea,and syphilis,soared across much of the region in the 1990s before leveling oﬀ at levels much higher than in most of the rest of the world. This represents a worrying trend for at least two important reasons. Firstly, the presence of STIs increases the likelihood of contracting HIV; secondly, high rates of STI are indicative of risk sexual behaviors.

Most public health oﬃcials are especially concerned about the increase in syphilis, which if left untreated can have adverse eﬀects on an individual’s long-term health. Relatively high rates of syphilis—over 100 cases per 100,000 population—have been reported in recent years within the general population in many CEE/CA countries, including Belarus, Bosnia and Herzegovina, Estonia,Kazakhstan,Moldova,Russia,and Ukraine.In the decade after the collapse of the Soviet Union,the rate of syphilis among the general population reached 277 cases per 100,000 in Russia; in Ukraine, 148 per 100,000; in Moldova, 198 per 100,000; and in Belarus, 199 per 100,000.2 The highest increase in STI rates in CentralAsia occurred in Kazakhstan,with a marked increase also noted in Kyrgyzstan.In the countries of South Eastern Europe,the reported rates of syphilis have been relatively low and stable since 1990.

Between 1998 and 2003, syphilis diagnoses declined throughout the region, but the notiﬁcation of syphilis among rural populations is still growing. (A summary of syphilis cases in CEE/CA is presented in Table 2 in the Appendices.)

Sex Work, HIV/AIDS, and Human Rights in Central and Eastern Europe and Central Asia

HIV infections associated with sex work

The number and percentage of HIV infections attributable to sex work across the region are diﬃcult to determine with a signiﬁcant degree of accuracy.For one thing,deﬁnitions of what constitutes “sex work” and a “sex worker” are not standardized across the region. In Russia, for example, the term used in national surveillance data for sex worker is “persons with casual sex partners”,which is not speciﬁc enough to make any systematic inferences about the nature of the sex work.

It is also likely that existing data massively underestimate the number of HIV cases related to sex work, a situation directly linked to stigma, discrimination, inconsistent legal status, and substandard health care services.Both sex workers and clients may fail to disclose their behavior because they are ashamed or frightened of the possible consequences, such as denial of services, harassment,or incarceration.These threats may also act as a deterrent to get tested for HIV or to seek treatment for HIV-related conditions or STIs.

For these reasons,the data—summarizing national surveillance of HIV case reports among sex workers in the region—presented in Table 4 in the Appendices should be interpreted with caution. Even with this caveat, it is evident that HIV prevalence among sex workers far exceeds negligible levels from just a decade ago.Estimates in Table 4 suggest that HIV prevalence among sex workers in Russia,for example,has increased from 0% in 1995 to 0.1% nationally (Ladnaya et al., 2002) and was as high as 15% in 2000 in Moscow alone (Pokrovsky, 2000-2001).

Similar estimates from Ukraine show a marginal increase in HIV cases attributable to sex work, from 0.6% in 1998 (of n=54,166) to 0.8% in 1999 (of n=29,034) (Dehne and Kobyshcha, 2000). It is diﬃcult to determine what proportion of HIV cases may be related to sexual transmission by an injecting drug use because the percentage of sex workers who inject drugs is not speciﬁed.Although there is a lack of systematic or reliable data,reports fromAlbania suggest that the number of people infected with HIV increased by 100% in 2000, the majority of whom were females traﬃcked for prostitution abroad (Hazizaj et al., 2002).

Sex work and injecting drug use

Reports from harm reduction projects surveyed indicated that a high proportion of sex workers, especially those who work in the streets, were involved in drug use. Estimates from Russia ranged from 24% of sex worker clients injecting drugs in Nizhny Novgorod, 47% in Krasnoyarsk, 80% in Barnaul, and 95% in St. Petersburg. In Balakovo, a local harm reduction project estimated that 29% of sex workers accepted drugs as payment for sex work. A separate study in St. Petersburg estimated that there were as many as 11,100 female IDUs who were also sex workers (Benotsch et al., 2004).

Injecting risk behaviors

Sex workers who inject drugs are undoubtedly at a greater risk of negative health eﬀects than their non-drug using counterparts.Risks include overdose,increased chance of contracting HIV and other blood-borne diseases through needle/syringe sharing as well as sexual transmission, and multiple vulnerabilities associated with police harassment and violence from clients.A study in Togliatti, Russia indicated that sex worker IDUs were more likely than non sex workers or male IDUs to report injecting with a used needle or syringe; they were also more likely to inject on a daily basis (Platt et al., 2005). In St. Petersburg, a survey of 100 female IDUs indicated that 37% had exchanged sex for money or drugs,and that 44% had shared injecting equipment in the previous four weeks (Benotsch et al., 2004).

Data from projects surveyed for this report also indicate high levels of risky injecting behaviors.In Krasnoyarsk,Russia,100% of sex workers reported sharing injecting paraphernalia,and 71% reported ever injecting with a used needle or syringe (n=~638). In St. Petersburg, 44% of a sample of sex workers (n=unknown) reported at least occasionally injecting with a used needle or syringe.In Vilnius,Lithuania,drawing up opiates from a communal pot was said to be common alongside injecting with used needles and syringes.

A rapid assessment report from Serbia and Montenegro also indicated risky injecting behavior among sex workers involved in injecting drug use. Of the 22% of sex workers in the assessment (n=116) who were currently injecting drugs, four-ﬁfths reported sharing their drug- injecting equipment. In Belgrade, all of the sex workers aged 15 to 19 who were injecting drugs reported sharing their equipment (Rhodes et al.,2004). Project data from Belgrade indicated that 20% of drug-injecting sex workers inject with used needles and syringes.

Sex work and condom use

For most sex workers, including those who do not inject drugs, the main potential HIV transmission mode is through unprotected sex. Condom use can drastically reduce this risk. However, studies suggest that condom use among sex workers in the region is inconsistent and inﬂuenced primarily by the organizational context of sex work.Researchers in Russia have noted that sex workers operating from hotels or through agencies were likely to be better educated about safer sex and in a better position to negotiate condom use than those working from the street (Platoshina and Chaika, 1995; Kungurov et al., 1999; Dehne and Kobyshcha, 2000; AIDS Infoshare, 2001). In Riga, Latvia, one study showed that knowledge of condom use remained low among sex workers working in railway stations and on the streets, and that most did not visit health services (Kurova et al., 1998).

In several rapid assessment studies, individuals providing services to sex workers in Central Asia have also reported inconsistent condom use among their clients (Kurmanova, 1999; Kurmanova, 2000; Schonning and Buzurokov, 1999; Oostovegels, 2001).In Karaganda,Kazakhstan, respondents estimated that regular condom use among their clients was between 30% and 40%. In Kazakhstan, reports suggest that the majority of male clients refuse to use condoms (Thomas,

1996). An assessment of sex workers in Shimkent indicated that 75% did not use condoms regularly (Rodina and Valieva, 2002).

In some cities and countries, condom availability is limited or otherwise diﬃcult to ensure on a regular basis. Various economic factors also appear to inﬂuence condom usage by sex workers.In Turkmenistan,for example,condoms can be obtained free from a polyclinic,but only for persons who are registered as a user of the service (Kurmanova, 1999).

Project data indicated that street sex workers across the region consistently agree to work without a condom in exchange for additional money. Other reasons included pressure from clients, sometimes involving violence; low levels of awareness of the risks of HIV and STI transmission, especially among young sex workers and those on the street; the eﬀects of drug use in clouding decision-making; and a lack of peer support among other sex workers in terms of reinforcing condom use.

Sex Work, HIV/AIDS, and Human Rights in Central and Eastern Europe and Central Asia

use was relatively consistent among customers but irregular or infrequent among boyfriends and casual partners (Tchoudomirova et al.,1997).Similarly,a survey of sex workers in Georgia showed high proportions of condom use with clients but not with non-paying regular partners. In that survey,72% of respondents reported always using condoms with clients and 95% reported using a condom with their last client; however, only 18% reported using a condom during their most recent sexual act with a non-paying regular partner (Stvilia et al., 2003).

Internal and external migration in the context of sex work

Nearly all projects surveyed for this report said that a substantial proportion—often more than half—of their clients were migrants from rural areas,regional cities,or other countries in the region. Migrants are usually more likely than natives to be vulnerable to harassment and abuse from authorities and clients, often because they are reluctant to report violations (they may be illegal immigrants) or are unfamiliar with their surroundings.Their isolation may be exacerbated by a lack of family assistance or social support network, which also increases the possibility that they are unaware of services, such as harm reduction projects, that may be available to them. In many areas,a disproportionate percentage of sex workers are composed of women from socially and economically marginalized ethnic groups from within the country, such as Roma in several nations in Central and Eastern Europe, or from poorer neighboring countries (Central Asian women working in Russia and Central Europe).

In most countries of the region, women tend to migrate from poorer rural areas, work for a few months, and then return home with their earnings (Lakhumalani, 1997; Platt, 1998; Loseva and Nashkhoev, 1999; Dehne and Kobyshcha, 2000; AIDS Infoshare, 2001; Naskhoev, 2002). This pattern is reﬂected in the project data showing high numbers of sex workers in capital cities. Project reports suggested that there were between 30,000 and 150,000 sex workers in Moscow; at least 20,000 in St. Petersburg;10,000-20,000 in Minsk,Belarus;7,000-8,000 inYerevan,Armenia;and 6,000 in Tashkent, Uzbekistan (see Table 7 in the Appendices). Projects also reported seasonal ﬂuctuations of sex work, particular in port cities such as Odessa (Ukraine) and in capital cities.Street sex work in the region is also aﬀected by seasonal changes;there is generally less work during the winter months.

SEX WORK AND ASSOCIATED RISK BEHAVIORS

Any discussion of human rights is useful only when one important caveat is clearly stated and understood: at a very basic level, human rights laws and agreements are largely worthless if not enforced. All CEE/CA countries have signed most, if not all, of the relevant international human rights agreements and have national laws on the books that forbid the withholding or violation of key rights to any individual.In many of these nations,however,especially those that were once part of the Soviet Union, human rights structures and enforcement mechanisms are weak, ineﬃcient, or simply ignored. The overall human rights records of some governments— notably Belarus,Russia,Turkmenistan,and Uzbekistan—are appalling and may in fact be getting worse for a variety of reasons.In these and an even greater number of countries of the region,the rights of sex workers and other marginalized groups such as IDUs are routinely trampled upon, with predictably dire consequences.

Few doubt that human rights laws and agreements are necessary to serve as a framework in which to implement rights provisions.However,the ongoing denial of these rights on the ground clearly indicates that it is equally if not more important for the rights guaranteed therein to be enforced comprehensively and consistently by all—especially governments, law enforcement, and service providers. The most consistent and passionate advocates are usually those aﬀected directly. Therefore, a key strategy for those working with sex workers should focus on creating the conditions for the eﬀective mobilization of sex workers, IDUs, and others whose rights are denied or violated consistently. They are their own best advocates when it comes to seeking policy reform and change, even in countries that seem ossiﬁed and rigid. The quality and scope of service provision for sex workers are also likely to be improved only when they are able and willing—ideally by forming coalitions of like-minded and supportive individuals and organizations—to identify what they need and why reform is necessary not only for them, but for society in general.Ensuring the health and well-being of the population at large is contingent upon improving the health and rights of those most at risk.

International treaties

Many of the issues discussed in this report are referred to directly or indirectly in various human rights declarations and standards that are commonly accepted across the region—and are generally considered to be universal in nature, applicable to all individuals. They include the right to the highest attainable standard of health in relation to sexuality; the right to health and family planning; the right to life, freedom, integrity, and security; the right not to be assaulted or exploited sexually; the right not to be tortured or to be the object of cruel, inhuman, degrading punishment or treatment; the right not to be subject to sex-based discrimination; the right to privacy; the right to bodily integrity; and the right to pursue a satisfying and safe sexual life.

Several human rights treaties and other documents establish these universally applicable rights. With few exceptions, all of them have been signed by every country in the world, including those in CEE/CA. The agreements include the UN’s Universal Declaration of Human Rights; the International Covenant on Civil and Political Rights; the International Covenant on Economic, Social and Cultural Rights; and the Convention on the Elimination of All Forms of Discrimination against Women. Two other agreements, the European Convention on Human Rights (and its ﬁve protocols) and the European Convention for the Prevention of Torture and Inhuman and degrading treatment and Punishment,do not apply to countries outside of Europe, including those in Central Asia.

Article 12 of the International Covenant on Economic, Social, Cultural and Political Rights recognizes the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. Furthermore, it outlines steps to be taken by member states to achieve the full realization of this right, including the implementation of measures designed to prevent the spread of disease and the elimination of discrimination in access to health care and treatment for all.The covenant includes sexual and reproductive health in this right and encourages gender equity. HIV/AIDS and most other diseases are not mentioned speciﬁcally in this covenant, but many analysts and policymakers have suggested that the agreement should be interpreted to include prevention, treatment, and care services for HIV/AIDS as a health right.

As indicated speciﬁcally in this agreement and at least tacitly in many other international human rights conventions, reproductive and sexual rights are essential for women and men to exercise their right to health. These rights include freedom of choice on the numbering and spacing of children and the forms of contraception; consistent and unimpeded access to information about reproductive services; the right to be protected from sexual harassment and It should be noted that policymakers and government oﬃcials in a signiﬁcant number of countries around theworld,especiallyculturallyconservativeones,donotnecessarilyacceptoragreewithallof theserights— depending on how they are interpreted. For example, many people consider abortion to be a reproductive right,but abortion is banned or discouraged in several nations,including some in CEE/CA.

Sex Work, HIV/AIDS, and Human Rights in Central and Eastern Europe and Central Asia

The intentions of this convention’s framers may have been well-meaning,but the agreement has signiﬁcant limitations. For one thing, although it recognizes the diﬃculties inherent in regulating consensual adult prostitution, it fails to acknowledge the diﬀerences between forced and voluntary prostitution—and therefore is rooted in the belief that sex work should end. In this respect it shares a fundamental ﬂaw with some other international, regional, and national agreements designed to protect women; in their zeal to prohibit or limit behavior that may be dangerous to women, many protocols deny women the right to choose how they can and wish to make a living.

Many women are not coerced into sex work. Instead, they opt to engage in it for a variety of reasons that may or may not have to do with economic self-suﬃciency, independence, or ﬁnancial desperation.Whether for moral or health reasons,banning sex work is not generally an appropriate strategy and may even be counterproductive. Many women’s rights to employment may be limited, and prohibition often pushes such behavior further underground, thus further jeopardizing sex workers’health and limiting their ability to advocate for their rights.

Additional information about the UN’s Fourth World Conference on Women may be found online at www.un.org/womenwatch/daw/beijing/index.html.

A list of the states that are party to the convention may be found online at www.unhchr.ch/html/menu3/b/treaty11a.htm.

LEGAL REGULATIONS OF SEX WORK AND THE HUMAN RIGHTS OF SEX WORKERS

disparity and to help ensure successful HIV/AIDS prevention eﬀorts. In 1997, the Asia Paciﬁc Women’s Consultation on Prostitution adopted a statement in which human rights activists, academics,and lawyers urged governments to“recognize and validate the reality of women who are working in prostitution”, and deﬁned all labor performed by women in the sex industry as work. In 2004, members of the European Committee on Women’s Rights and Gender Equality agreedtoprotectthelegalrightsof sexworkers,andstatedthatanynewlegislationonprostitution must include these rights.

Unfortunately, such enlightened language is missing from many high-proﬁle international humanrightsagreements.Anotherexampleofthepotentiallynegativeconsequences—towomen’s rights—of otherwise well-meaning agreements may be found in the United Nations Protocol to Prevent, Suppress, and Punish Traﬃcking in Persons. Adopted in 2000, this convention created a clear and distinct global deﬁnition of traﬃcking in human beings. In Article 3, traﬃcking is deﬁned as “the recruitment, transportation, transfer, harboring or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or beneﬁts to achieve the consent of a person having control over another person, for the purpose of exploitation”. The protocol’s condemnation of coerced sex work is laudable. However, it did little to deﬁne unforced prostitution or to proclaim the necessity of recognizing and safeguarding sex workers’human rights.

Also of particular relevance to issues discussed in this report is the Convention on the Elimination ofAll Forms of Discrimination againstWomen (CEDAW),which is a.A broad-based non-discriminationtreaty,CEDAWrequiresstateparties(includingallCEE/CAcountries)totake all appropriate measures to remove obstacles and to foster the conditions necessary for women to realize their full potential as the equals of men. This convention also pays special attention to the issue of traﬃcking, with Article 6 mandating that all state parties “take all appropriate measures, including legislation, to suppress all forms of traﬃc in women”.

Furthermore, General Recommendation 19 in CEDAW calls upon states to take measures to combat gender-based violence, which can impair the ability of women to access their human rights and fundamental freedoms—including the right to life; the right not to be subject to torture or cruel, inhuman, or degrading treatment or punishment; the right to legal protection; the right to liberty and security of person; the right to equal protection under the law; and the right to the highest attainable standard of health. Recommendation 19 recognizes the need for special protection of “prostitutes”because of their particular vulnerability to violence.CEDAW’s GeneralRecommendation24,meanwhile,emphasizestheimportanceof statestocloselyconsider the societal determinants of health, paying particular attention to the health needs and rights of women belonging to vulnerable and disadvantaged groups, including migrant women and women engaged in sex work.

Sex Work, HIV/AIDS, and Human Rights in Central and Eastern Europe and Central Asia

seeking to reduce stigma and discrimination against those engaged in it. Where sex work is criminalized,7 sex workers’concerns about safety, security, and physical and psychological abuse are not integrated into the public legal and health sectors. When their activity is illegal or not regulated,sex workers often avoid any contact with law enforcement out of fear of persecution or harassment.Decriminalization of sex work is the ﬁrst key step to eﬀectively and comprehensively applying the international human rights framework to sex workers.

One additional international agreement of relevance to sex work is the International Convention on the Protection of the Rights of All Migrant Workers and Members of Their Families, which was adopted by the UN General Assembly in December 1990 and entered into force upon its 20th ratiﬁcation in 2003. Although it does not speciﬁcally mention sex workers or prostitution, the agreement provides a broad deﬁnition of what constitutes a migrant worker and draws a distinction between migrant workers who are lawfully working within the host state and those in“irregular” situations (illegal). The convention obliges the state parties to guarantee all migrant workers, regardless of their legal status, a limited selection of social, economic, and cultural rights.All should have the right to non-discrimination with respect to remuneration and conditions of work, and the right to participate in trade unions. This is not a very widely ratiﬁed agreement at this point; as of June 2005, just 30 states worldwide had acceded to it or ratiﬁed it, including four from CEE/CA: Azerbaijan, Bosnia and Herzegovina, Kyrgyzstan, and Tajikistan. Ultimately, though, the convention’s ability to help protect the rights of migrant sex workers will be greatly enhanced in countries where sex work itself is legalized.

Someobserversbelievethatgreaterprotectionof therightsof sexworkerswouldbeobtained through a special UN-level international declaration that would contain an overall acceptable deﬁnition of sex work and would spell out the international human rights pertaining to sex work—and call upon governments to decriminalize sex work. Others, meanwhile, believe that such a strategy is unnecessary because CEDAW and the International Covenant on Economic, Social, Cultural and Political Rights in particular provide adequate protections for sex workers, assuming their provisions are enforced. They also express concern that a special overarching UN declaration might in fact be counterproductive given the current opprobrium-inﬂuenced political and social climate regarding sex work. In their opinion, the declaration would likely be much weaker than intended, thus undercutting the rights established by the other two existing conventions.

National regulations of commercial sex work

Laws and policies address sex work in a variety of diﬀerent ways,from regulating individual sex work itself to seeking to prohibit organized sex work. In many CEE/CA countries where sex work itself is not criminalized, the practice of prostitution is eﬀectively rendered impossible through restrictions on organizing, advertising, and living oﬀ the proceeds of sex work.Actions taken in the name of these restrictions often lead to unlawful detention, extortion, and other violations of sex workers’rights.

LEGAL REGULATIONS OF SEX WORK AND THE HUMAN RIGHTS OF SEX WORKERS 39

These regulations appear to indicate that sex workers in Latvia are better oﬀ when compared to other countries in the region, but this may not necessarily be true since police raids and client violence continue to occur. In a 2002 survey, 86% (n=162) of sex worker respondents in Latvia reported sexual violence toward them; this compared with 98% (n= 154) in Lithuania and 46% (n= 158) in Estonia (Kalikov, 2002). These data reinforce concerns regarding the fact that the information contained on oﬃcial health cards is not considered completely conﬁdential, as indicated by regulations requiring information-sharing among medical examiners and the police. Drug-use behavior is likely to be noted on the card, for instance, which could prompt arrest or harassment by the police. Such a fear could conceivably dissuade some sex workers from applying for an oﬃcial health card and continuing to work outside the system,thus limiting their regular exposure to the health care system.

Although sex work has not been a criminal oﬀense in Hungary since 1993, a law regulating sex work was enacted only in 1999. The basic rules are outlined in the“Act About the Organized Crime and Related Areas” (Act 1999:LXXV, Section 7-11). According to the act, sex work is not punishable under the law, with the following conditions:

Similar to Latvia, local governments in Hungary have the authority to designate so- called tolerance zones where sex workers can work, provided the sex work activity in the local community (village, town, or city) is“common”or multitudinous. Local governments must designate such zones if the number of people living in the area is above 50,000 and sex work activity is continuous. Sex work is basically legal within these tolerance zones. Local governments cannot designate tolerance zones in“protected areas”(such as schools, universities, museums, childcare institutions, state administration oﬃces, religious institutions, or diplomatic institutions) or in neighborhoods surrounding these areas.

Sex Work, HIV/AIDS, and Human Rights in Central and Eastern Europe and Central Asia

As in other countries of the region, the Hungarian Criminal Code punishes pimps and brothel-keepers. Brothel maintenance is punishable by up to ﬁve years in prison, and from two to eight years if minors are employed. Pimping can entail imprisonment for up to three years and/or a ban from the geographical area.

According to the Hungarian Civil Liberties Union, which was the national respondent for this survey, the biggest problem with the regulation of sex work in Hungary is that the local governmentsrefusetodesignatetolerancezones,withsomepilotexceptions.Thereasonisusually connected to the resistance among members of local communities who are concerned about real estate prices. Sometimes the big cities have competence problems as well. In Budapest, the main local government (the Budapest mayor’s oﬃce) is prepared to designate tolerance zones, but the individual districts identiﬁed oppose this move. This leads to situations in which sex workers are being ﬁned regularly, with ﬁne accumulations leading to conditional prison sentences. Local human rights organizations and the Hungarian Prostitutes Association insist that every local government that does not designate a tolerance zone is breaking the law, but as of yet they have not been widely successful in their advocacy eﬀorts.

Conclusive in-depth studies of the laws’ impact on national public health have yet to be conducted in either Latvia or Hungary. Studies indicate, however, that similar approaches to street sex work in countries such as Australia have improved health indicators among sex workers and their clients (Morton et al., 2002). Meanwhile, other studies indicate that certain aspects of policies in Latvia and Hungary—such as mandatory HIV/STI testing and regular breaches of sex workers’ privacy when their medical records are shared with the police—may further marginalize sex workers and worsen their access to STI treatment (Dehne, 2000). This once more emphasizes the importance of observing all human rights standards,such as access to voluntary and conﬁdential testing and treatment, when implementing innovative public health policies.The following sub-section focuses on the broader aspects of human rights in the context of sex work in CEE/CA.

LEGAL REGULATIONS OF SEX WORK AND THE HUMAN RIGHTS OF SEX WORKERS

Police ﬁnd numerous grounds for harassing sex workers,with documentation-related issues being the most common rationale. Most such oﬀenses, such as lack of proper identiﬁcation documents and residency permits, are minor ones that usually entail a court-ordered ﬁne. However, sex workers are often detained illegally and whatever documents they might have are taken away, which renders them further vulnerable in future police raids. Sex workers who use drugs are particularly vulnerable during police raids. In many cases, police who are looking to make their quotas of drug-related arrests—one of the most insidious consequences of harsh drug policies—plant drugs on a sex worker who is a user.

But equally often,police do not even bother ﬁnding an excuse to harass sex workers or extort bribes—both are done as a matter of course.Even in countries where sex work is decriminalized, sex workers assume that they have to pay oﬀ police oﬃcers with money or sexual services.

The spectrum of police violations reported by national respondents or found in literature is impressiveanddispiriting,rangingfromverbalabuseandcompulsorytestingtoillegaldetentions, sexual exploitation and torture, including rape and multiple assaults. In the following anecdote, a sex worker in Uzbekistan captured a wide range of possible violations of human rights that sex workers face on a daily basis:

Say you work the highway. A police truck approaches.You are grabbed and forced inside. Of course, they [the police] curse you all the way.You spend some time in that truck because they drive you all over the city looking for others. Then they bring you to ROVD [a police station operated by the District Department for Interior Aﬀairs], right in the hands of the superior at the anti-drugs and prostitution department. It’s important to behave yourself, as otherwise you will probably be beaten. Police make you write why you were on the highway“prostituting yourself”. They maintain you should admit in writing that you are a prostitute. Sometimes this is when you can try and bribe the oﬃcer with an oﬀer of free sex… After you have admitted in writing, they can either let you go but keep your passport, or bring you to the STI clinic for compulsory tests. In the STI clinic, if you test positive for one thing or another, you can end up staying there for up to 30

days, and you have to pay for treatment. Of course you are tested for HIV. If you are“clean”, then police pick you up from the STI clinic and return you to ROVD again. Then you have to write yet another paper saying that you will pay the administrative ﬁne and will not work as a prostitute any longer. The court decides whether or not to ﬁne you. After this you are a free bird. The police will not touch you for at least three days on the highway, because the STI clinic will not take you again in such a short period of time.

— a sex worker from Tashkent, Uzbekistan

Sex Work, HIV/AIDS, and Human Rights in Central and Eastern Europe and Central Asia

Two-thirds(66%)of sex workers surveyed by the Vilnius Addictive Disorders Center in Lithuania testiﬁed that they had experienced physical violence from police. In Nizhny Novgorod,Russia,the Oblast AIDS Center reported that every third sex worker interviewed had experienced some kind of violence, and 21% explicitly reported police brutality.

Detentions based on lack of documents. In Bulgaria, as in other countries in the region, the police reportedly arrest large numbers of sex workers on the grounds of passport control.This is perceived as an admissible, even socially desirable action on the part of the authorities (Arsova, 2000).The situation is perhaps most dire for sex workers in Russia,where the system of“propiska” (residency requirements) is strictly enforced in many cities.This system mandates the placement of a stamp in one’s internal passport that indicates he or she is allowed to reside in the area; the lack of such a stamp frequently provides police with the grounds for arresting or detaining sex workers.

Coercion for sex. The national respondent from Bosnia and Herzegovina reported several cases of rape by police. Many cases of this type of police brutality and intolerance allegedly occurred in a zone between two cantons (or regions) of the country.Police from another canton reportedly forced street sex workers residing in a diﬀerent canton to provide them with free sexual services. The same respondent also reported that sex workers working in night clubs and bars also faced sexual coercion from police oﬃcers posing as clients. The respondent noted that policemen in the country often have mutual agreements with bar owners in which the owners oﬀer the services of the bar’s sex workers in exchange for not reporting that prostitution occurs there. (Prostitution is illegal in Bosnia and Herzegovina.)

A research study among sex workers in Moscow, Russia (n=242) concluded that 18% had been raped by the police (Nashkhoev, 2002). In Georgia, out of 160 interviewed street-based sex workers, 42% (n=67) reported experiencing either sexual or physical violence over the previous year. The youngest, those under the age of 19, suﬀered the most: 50% of those surveyed said they had experienced sexual or physical abuse. Overall, only 42 were willing to identify the perpetrator; of them, 26% identiﬁed the police (Stvilia et al., 2003).

A common feature of many post-Soviet countries—the system of “subotnik”—has been described earlier in this report earlier (Section 2.4). This type of obligatory free sexual services to the police is often reported in literature (Lakhumalani, 1997; Platt, 1998; AIDS Infoshare, 2001; Andrushak et al., 2000) and was mentioned in several country reports.

Bribes and extortion. Although pimping and soliciting are mainly illegal in most of the countries surveyed, police corruption is also alleged by some to extend to organized sex work. For example, in Kazakhstan, a Human Rights Watch report discussed witnesses’ claims that police oﬀered pimps protection from criminal prosecution in exchange for monetary payments and free sexual services (Human Rights Watch, 2003).

Similar developments were reported by a local NGO that works to protect the legal rights of sex workers in Bishkek,Kyrgyzstan.The most common problem cited by sex workers centered on rights’ violations on the part of law enforcement agencies and the police—with most clients complaining about money extortion and illegal detention (Tais Plus, 2004).

AreportfromRussia,wheresexworkisanadministrativeoﬀense,notedhighlevelsof extortion. Policemen reportedly based their demands for bribes and sexual services on laws regulating “petty hooliganism”or for failing to possess the correct documents.(Lowndes et al,2003).

LEGAL REGULATIONS OF SEX WORK AND THE HUMAN RIGHTS OF SEX WORKERS

Displacement of sex workers. Law-enforcement policies directed against street prostitution rarely reduce its overall frequency; instead, they merely lead to geographic redistribution across parts of the same town or city. Such displacement places sex workers under greater risk because they often may not know their new area or clients who frequent it. The policies also increase the likelihood that sex workers will need to work later at night, in more isolated and therefore dangerous areas, to avoid police attention. In turn, this is yet another reason that sex workers are particularly vulnerable to violence. The following anecdote from Kyrgyzstan provides a straightforward account of how displacement occurs and some of its consequences:

The police took with them two girls who they claimed did not work in the “right place”. The police were very straightforward and said they needed money. The pimp paid. Now the girls are very afraid of police, in part because they will not let them work at all…

— volunteer report, Tais-Plus, Kyrgyzstan

Respondents from Poland also mentioned unwarranted and illegal deportation of sex workers from Poland by the police.

Compulsory HIV/STI testing. In the mid-1990s, at the height of one of the world’s periodic HIV/AIDS panics, legislation mandating testing for HIV and STIs and prescribing criminal charges for transmission of sexual diseases was common in many CEE/CA countries. Most of theselawshavebeeneasedorabolished,buttraditionsof “legallyenforcedhealth”andimproperly close links between health services and police remain strong.10 Forced testing of arrested sex workers for STIs and HIV, as well as their hospitalization for compulsory STI treatment, has been reported in many countries, including Russia (Lowndes et al., 2003; Lakhumalani, 1997; Platt, 1998; AIDS Infoshare, 2001). Compulsory testing is so grounded in some of the countries’ HIV/AIDS responses that sometimes service providers do not identify it as such. For example, an AIDS center in a Russian city reported the following in the survey:“Compulsory testing and treatment are absent. Meanwhile there is obligatory HIV testing for STIs patients, for IDUs, and at receipt in pre-detention.”[Emphasis added by editors]

The Palmira project from Kyrgyzstan reported that in the wake of police raids, obligatory HIV testing is often carried out (and without pre-test counseling). Respondents from Poland mentioned cases in which sex workers were asked to show their HIV/STI test results to the police.

According to AFEW, some of these harsh laws still remain, and are enforced, in parts of Central Asia.A rapid assessment report carried out in 2000 among sex workers in Dushanbe, Tajikistan indicated that Articles 125 and 126 of the Criminal Code are frequently used as a basis for arresting or detaining sex workers.Article 125 prohibits an individual from knowingly infecting another person with HIV;Article

126 prohibits knowingly infecting another person with an STI.According to the 2000 study, charges of violating one or both of these articles had been brought every year against at least one female in the sex industry.At that point, no cases had ever been brought before the court; however, such legislation may discourage a sex worker from seeking testing and treatment services because the crime requires that the accused know his or her diagnosis. Moreover, obtaining access to public-sector STI or HIV/AIDS servicesrequirestheregistrationof positivediagnoses,adevelopmentthatcanincreasethelikelihoodof hospitalization, contact tracing, and possible job loss. (AFEW, 2003a)

Sex Work, HIV/AIDS, and Human Rights in Central and Eastern Europe and Central Asia

LEGAL REGULATIONS OF SEX WORK AND THE HUMAN RIGHTS OF SEX WORKERS

In Kazakhstan, over 60% of street sex workers reported violence from clients.According to one study inVilnius,Lithuania,86% of sex workers reported being sexually abused by at least one client over a 12-month period in 2003.

In Georgia, out of 160 interviewed female street sex workers, 42% (n=67) reported experiencing either sexual or physical violence over the previous year. The highest percentage (50%) of them were 18 years old or younger. Only 42 out of the 160 surveyed said they were willing to identify the perpetrator; of them, 52% said the violence was committed by a client.

One of the sex workers asked us to help her deal with the policeman who was violating her and her colleagues’ rights. He would always beat them, blackmail them, and use their services for free. Together with the sex worker, two staﬀ social workers from“Tanadgoma” [an NGO that works with sex workers] contacted the head of the local Human Rights Committee and

Respondents from Tallinn, Estonia reported that TV ﬁlm footage of a police raid of sex workers openly showed the faces of those arrested, without obtaining their consent, and did not provide sex workers with the means to conceal their identities.

Thereareindicationsthatthesituationmaybechanginginapositiveway.Manyrespondents mentioned a slight decrease in identity breaches by mass media over the past several years; respondents from Croatia, for example, reported that when journalists write stories about sex work,they are increasingly trying to protect them by using made-up names.In Kazakhstan,most media agencies reportedly emphasized protecting the identities of sex workers so that they can work with them in the future.

LEGAL REGULATIONS OF SEX WORK AND THE HUMAN RIGHTS OF SEX WORKERS

If you are an addict, this means it is over. I was staying at a tuberculosis clinic. My tuberculosis should have been operated [on]. As soon as they found out that I was an addict, I was refused.

— Zhenya (female)

The doctors’ attitude is defeating.When I went to the ﬁrst hospital, the doctor treating me said,“All addicts, absolutely all, are sick with AIDS even if nothing is found in the blood samples. Nobody will look after you. Get yourself a nurse, a nanny.” Their attitude is full of disgust and alienation. They do not want to communicate with you, nothing at all…

— Galina (female)

Many sex workers say they rarely trust specialized health providers because of expensive or unnecessary charges for their services. In addition, they often distrust state medical facilities because of the perceived or real assumption that such facilities sometimes provide inaccurate diagnoses as part of an eﬀort to extort money from patients. The following anecdote is from a sex worker in Georgia:

They give us inaccurate test results because they think that because we are sex workers we have a lot of money. Medical doctors just earn extra money when they identify us as sex workers.When I took another test at a diﬀerent clinic, where I am not recognized as a sex worker, the results were diﬀerent from the ones received during the [previous] testing.

— reported by the NGO“Tanadgoma”, Tbilisi, Georgia

The reluctance of some sex workers to visit state clinics may also stem from perceived or real poor quality of services, which is often a consequence of the depleted and resource-starved state of health systems in many CEE/CA countries.The following two quotes from NGOs in the region illustrate that situation:

The system of the dispensaries at the moment is in a very poor economical situation and very often they don’t have the necessary medical consumable materials.

— Health and Social Development Foundation, Soﬁa, Bulgaria

In Romania it is quite hard for anyone to receive good quality services from the public medical institutions. It does not matter if you have a medical insurance, a job or if you are still studying. For adequate services it is necessary to pay extra (tips) to the medical staﬀ. The discriminatory

situation is towards everyone and it does not matter if you are sex worker, drug user, migrant and so on.

— ARAS, Bucharest, Romania

Furthermore,the police reportedly are also often involved in bringing sex workers to clinics for compulsory testing and treatment.As might be expected,this has had the eﬀect of increasing the desire of sex workers to avoid any interaction with both the police and with health care professionals.

Most respondents mentioned that free HIV testing was rarely consensual. They also noted that pre- and post-test counseling was provided sporadically,if ever,unless sex workers attended specialized clinics linked to harm reduction or HIV prevention projects.The same was true with regardtoSTItesting.InBulgaria,forexample,STItestingandtreatmentwereoﬀeredbypublicSTI clinics,but it was neither free nor anonymous.Respondents from Belarus reported that although sex workers had free access to STI testing and treatment,the latter was not anonymous—and sex workers consequently rarely disclosed their profession.

LEGAL REGULATIONS OF SEX WORK AND THE HUMAN RIGHTS OF SEX WORKERS

“Tais Plus” from Kyrgyzstan also reported that over a three-year period its staﬀ knew of only three cases in which sex workers sought to prosecute illegal law-enforcement practices. In 2000, a sex worker wrote a legal complaint about a police oﬃcer who was extorting money from her. But she ultimately withdrew her complaint in the face of pressure from the police and conﬁdentiality breaches. In another case, a legal appeal from a sex worker was registered in March 2003,but no resolution had occurred as of 16 months later.According to“Tais Plus”,there are two main reasons that sex workers are reluctant or unwilling to seek legal assistance. One is administrative—they lack the identiﬁcation documents required to launch a proceeding. The other, which is more philosophical, stems from many sex workers’ deﬁant rejection of the need for any protection or assistance from the justice system. This stance may in fact be an example of “legal realism” on their part, considering how unlikely or substandard protection would be in the ﬁrst place.

The police often exploit sex workers’ low level of legal awareness to extort bribes and spread fear among this highly marginalized population.Raising their legal awareness is therefore highly important, and it may also have the eﬀect of increasing the visibility of crimes against them. At the same time, pressure should be placed on the police and other law-enforcement agencies (including the judiciary) to uphold their responsibility to protect all citizens in a forthright and non-discriminatory manner. They should be subject to signiﬁcant disciplinary action when violations are uncovered―and those who report violations should be able to do so conﬁdentially.

Sex Work, HIV/AIDS, and Human Rights in Central and Eastern Europe and Central Asia

As reported by the national respondent in Hungary,the anti-prostitution movement in that country has grown stronger in recent years. The “Movement for a Prostitution-free Hungary” gets serious media coverage and public support. In 2004, for example, the biggest Hungarian daily newspaper rejected an opinion piece submitted by the Hungarian Civil Liberties Union in response to two large pieces in the newspaper that outlined the paper’s explicit anti-prostitution stance.

Hostile public attitudes represent a major obstacle to the implementation of comprehensive services for sex workers.According to a survey conducted of organizations working with and for sex workers in three countries of Central Asia (Kyrgyzstan, Tajikistan, and Uzbekistan), negative public opinion was identiﬁed as a key factor that hindered their ability to provide services and support for sex workers and other marginalized groups, including IDUs (AFEW, 2003). In these nations and elsewhere in CEE/CA, women expressed shame and guilt for being involved in sex work, emotions that are largely determined by predominant social mores. It is undeniably diﬃcult to seek out and expect human rights protections when living and working in societies in which one’s behavior is condemned harshly, regardless of the circumstances.

Brief history of harm reduction for sex workers

Nearly all international health organizations agree that harm reduction should be one of the most important elements of all national plans and strategies to ﬁght HIV/AIDS.As deﬁned by the International Harm Reduction Development program (IHRD) of the Open Society Institute (OSI),“Harm reduction is a pragmatic and humanistic approach to diminishing the individual and social harms associated with drug use especially the risk of HIV infection. It seeks to lessen the problems associated with drug use through methodologies that safeguard the dignity, humanity and human rights of people who use drugs.”11 This deﬁnition refers speciﬁcally to drug use, but harm reduction is generally used to apply to strategies employed to reduce the health and social harm from any potentially risky behavior, not just drug use.

With varying intensity by country, harm reduction strategies have been employed in the region since the early 1990s. The ﬁrst harm reduction projects focused on HIV prevention and other services for IDUs. Before long, though, it became clear that many sex workers were using the services, a perhaps unsurprising development given the strong correlation between sex work and drug use. In recognition of the need to provide more targeted harm reduction services to sex workers, IHRD funded a pilot initiative for sex workers in CEE/CA in 2000. The initiative started with 33 organizations in 12 countries: Belarus, Bulgaria, Estonia, Latvia, Lithuania, Poland, Romania, Russia, Slovakia, Turkmenistan, Ukraine, and Uzbekistan. In just the ﬁrst six months, more than 6,500 sex workers were reached at least once and provided with harm reduction information about HIV, STIs, and drug use. Approximately 6,200 (95%) of them were engaged more than once with follow-up information, education, counseling, and referrals. More than 5,100 sex workers were reported to be participating in needle and syringe exchange services (IHRD and OSI, 2001).

The number of harm reduction projects targeting sex workers and/or other high-risk sub- groups increased steadily after 2000.A needs assessment study by CEEHRN in 2002 identiﬁed

This deﬁnition and additional information about harm reduction may be found on the website of OSI’s International Harm Reduction Development Program at www.soros.org/initiatives/ihrd.

Sex Work, HIV/AIDS, and Human Rights in Central and Eastern Europe and Central Asia

42 projects targeting sex workers among 174 members of the network at that time. (In that year,CEEHRN started a thematic sub-network to facilitate exchange between projects working with sex workers.) A review in 2003 identiﬁed 37 projects targeting sex workers in Russia only (Platt and Montgomery,2003).A wider CEEHRN survey of needle exchange programs focusing on data from that same year identiﬁed 237 harm reduction programs from 27 countries in the region, with 85 speciﬁcally identifying sex workers as a key target group, if not the primary one (CEEHRN, 2004).

Funding

This report originally was not intended to consider funding and sources of funding.In the course of information-gathering, however, it became clear that certain limitations in service provision stem primarily or at least partly from donor policies and conditions.Also,a previous CEEHRN needs assessment survey of 26 organizations working with sex workers, conducted in 2003, revealed that ﬁnancial constraints represented one of the most important barriers to the development of eﬀective services and achieving eﬃcient coverage of the target populations (Jiresova, 2003).

For the reasons stated above,this report’s authors decided to review available information on sources of funding in the region.One source was a 2004 survey from CEEHRN that covered 237 needle exchange programs in 27 countries of CEE/CA; a total of 85 of the programs explicitly targeted sex workers. Based on an examination of their operation and performance indicators in 2003, it was determined that almost half of harm reduction programs in the region were partially or fully funded by country authorities. National or local funding covered most expenses of the programs in some countries, including Croatia, the Czech Republic, Lithuania, and Poland. In those countries and elsewhere, direct national or local monetary or in-kind support constituted an important contribution to some projects that still largely relied on external donors.

The main external donors in the region in 2003, as reported by these 85 organizations,12 included (in order of input13): IHRD (58 projects), USAID (nine projects), DFID (six projects), and OHI (four projects). Other funders included UNAIDS, UNDP, and the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM).

Sex Work, HIV/AIDS, and Human Rights in Central and Eastern Europe and Central Asia

Commission on Narcotics and Drugs and has also asked the UN Oﬃce on Drugs and Crime to remove from its website materials related to needle exchange.

These policies and developments threaten the stability of many harm reduction programs in CEE/CA because many governments look to the United States for guidance about how best to respond to the HIV/AIDS epidemic. It may be that U.S. domestic political concerns have the eﬀect of further disrupting the fragile and far-too-limited system of services currently available for sex workers and other marginalized groups in resource-poor regions—countries that are, unlike the United States at the moment, struggling to deal with looming public health catastrophes related to HIV/AIDS.

4.4 Target groups

Most of the projects surveyed in this report provide services primarily to female sex workers. Project“Vstrecha” from Minsk, Belarus is the only one focusing on male sex workers. Seven other projects cover this sub-group as a part of a broader sex work population; they include projects in Minsk, Belarus; Soﬁa and Varna, Bulgaria; Osh, Kyrgyzstan; Strumica, Macedonia; Bucharest, Romania; Bratislava, Slovakia; and Dushanbe, Tajikistan.

Demographic characteristics of project clients are presented in detail in Section 2 of this report.Most of the clients are women aged 20-30 who work on the street.Among the surveyed projects, 56% reported considering IDUs as a speciﬁc group of sex workers. (More detailed data regarding the percentage of sex worker IDUs covered by the projects are presented in Section 2 and in Table 8 in the Appendices.) The majority of the projects reported that a large proportion (often at least 50%) of their clients were migrants from rural areas, regional cities or other countries in the region (see Table 9 in the Appendices).

4.5 Service coverage

There is no commonly accepted precise deﬁnition of the word “coverage” in the contextofserviceprovision.(Broadlyspeaking,itisoftenusedtorefertotwointertwined things: the extent to which targeted individuals in a delineated community have access to and utilize services; and the scope of such services.) Also, there are no particular international recommendations as to what constitutes eﬀective coverage of sex worker populations. However, in 2000 the UNAIDS Task Force for HIV Prevention among IDUs in Central and Eastern Europe set a target of 60% coverage for harm reduction programs in the countries of the former Soviet Union. Many analysts consider this percentage to be at or near the threshold necessary to halt the transmission of HIV in a speciﬁc community, especially closely integrated ones such as IDUs.

Respondents from Armenia, Georgia, Kyrgyzstan, Russia, Tajikistan, Ukraine, and Uzbekistan reported instances of compulsory testing of HIV and STIs in their countries, mostly in the cases when sex workers were found to be injecting drugs and during police raids. In addition, forced HIV testing of STI patients was reported in Nizhny Novgorod, Russia.

In Latvia, a report prepared in April 2002 by the Drug Law and Health Policy Resource Network noted that although HIV testing is voluntary and protected under Latvian law, there were some incidents when medical oﬃcials conducted HIV tests without patients’ permission. Furthermore, as noted in Section 3, sex workers are required to undergo regular medical examinationsinLatviaandHungary,countriesinwhichcommercialsexworkislegalbuthighly regulated. In both nations, therefore, HIV testing is in reality not voluntary and anonymous for sex workers. This situation directly conﬂicts with the law, however, and many observers believe it represents a questionable practice from a human rights point of view—regardless of the merits of the legal, regulated policies governing sex work.

In Balakovo, Russia, there is a crisis center for vulnerable groups that provides a wide range of health services. At this program, which is part of the city’s Comprehensive Plan on the Fight Against HIV/AIDS, sex workers and others can get free testing, counseling, and treatment referrals.

In Georgia, the NGO “Tanadgoma” cooperates with another organization, “Health Cabinet”, to provide free, anonymous, and conﬁdential testing services for HIV and STIs. Meanwhile, at the AIDS Centre in Nizhny Novgorod, Russia, sex workers can get the following free of charge: anonymous testing for HIV, syphilis, and hepatitis as well as counseling from diﬀerent specialists (including those focusing on infectious diseases,skin and venereal diseases, gynecological concerns, oral care, and neuropathology). Additional counseling and treatment of STIs are provided in cooperation with the city’s Institute for Skin and Venereal Diseases.

In Vilnius, Lithuania, the Social Disease Center “Demetra” (which operates through the AIDS Center) oﬀers various services for sex workers, especially those working in the streets, including access to free condoms, sterile injecting equipment, and counseling and testing for HIV and STIs. It is, however, the only facility of its kind in the entire country.

HIV/STI AND HARM REDUCTION INTERVENTIONS AMONG SEX WORKERS 61

Projects from Macedonia, Romania, Slovakia, and Ukraine stressed the need for more specialized services for sex workers in their countries. They pointed to a poor-quality and inadequate services in the public sector and a lack of professional health care providers who understand sex workers’ needs and lifestyles.

The NGO ARAS reported that in Romania, its “Night by Night” initiative oﬀered the only specialized medical services for sex workers. In partnership with other institutions, the initiative oﬀers diagnostics and STI treatment to its sex worker clients. Also, in May 2004, ARAS helped create a partnership to provide comprehensive medical care for sex workers.

Many other projects in the region have also succeeded in developing similar partnerships with existing public health services and clinics. By providing specialized STI services for sex workers in existing public health institutions, they are able to utilize the facilities’ full range of expertise and equipment. Such partnerships are a welcome development for the most part, but signiﬁcant challenges must be overcome regarding procedures, staﬃng, client privacy, and strict guidelines concerning potential coercion.Access to treatment is even more limited among members of high-risk, marginalized groups including sex workers, IDUs, men who have sex with men, prisoners and, in some settings, migrants or ethnic minority groups (WHO, 2004b). Discrimination is the major reason that, of those on ART now, the percentage of high-risk individuals is far lower than their proportion of individuals in need.In Russia,for example,recent data indicate that just 5% of HIV-positive Russians receiving ART are former or current drug users, even though they represent a signiﬁcant majority of all infected.

I arrived in a city to ﬁnd a job. Living in the countryside was impossible. Three kids looked at me with hope. Here I can do nothing. Three months I worked in a store and…what can I do with a daily salary?

— a sex worker from Tbilisi, Georgia, cited by the NGO“Tanadgoma”

According to the results of an HIV/AIDS/STI behavioral surveillance survey for sex workers, conducted in Latvia in 2002, only 41% of 92 sex workers surveyed had completed primary education.The NGO RAN in Tajikistan reported that 26% of 493 sex workers surveyed did not have any formal education, and that 49% had completed primary school only.

Such data indicate that helping sex workers develop new or additional skills, as part of an eﬀort to broaden income-generating possibilities, could be an important priority for projects UNAIDS,“AIDS Epidemic Update, December 2004.”Additional information available online at www.unaids.org.

HIV/STI AND HARM REDUCTION INTERVENTIONS AMONG SEX WORKERS 63

throughout the region. These eﬀorts would likely improve sex workers’ economic and social situation and help to reduce their risk behaviors and vulnerability. This is especially important since sex workers who do not rely on sex work as their only source of income are less likely to acquire HIV than those who do (Longo et al., 1997).

Despite the obvious importance of socio-economic factors, there are virtually no services in the region providing sex workers with alternative employment opportunities or professional training. Of the respondents to this report, only one (the AIDS Information and Support Center in Tallinn, Estonia), said it had plans to oﬀer skills such as foreign-language training and computer use in the near future.Another key problem is that even if a sex worker has marketable skills, she may not be able to get a job because of legal constraints. In some countries, oﬃcially recognized employment—not to mention access to various health and social services—is possible only with proper identiﬁcation documents and residency permits. Many if not most sex workers do not have the required documentation, thus further limiting their ability to seek and retain another income-generation source. Obtaining the documents can take a long time, even if the individual is eligible for them. According to report data, securing an oﬃcial identiﬁcation passport in Bishkek, Kyrgyzstan, can take as long as 1-2 years.

Fifty-one percent of the projects surveyed said they oﬀered various social services for sex workers, including health counseling and referral; assistance in obtaining personal documentation, social and humanitarian assistance, and psycho-social counselling. The AIDS Information and Support Center in Tallinn, Estonia said it provided an area in its drop-in center where sex workers are oﬀered coﬀee,tea,or a hot meal as well as a place to take a shower and do laundry.

Migrants. Several projects reported that they served a large number of sex workers who are migrants (seasonal or residential). Data regarding migrants are partly reﬂected in Table 9 in the Appendices; however, no data were provided by the projects on speciﬁc services provided to this sub-group of sex workers. This elision clearly indicates the need for greater awareness about migrant issues among projects and other service providers, especially since sex workers who migrate or are mobile are often at higher risk for contracting HIV and other negative health eﬀects than local sex workers (Mann et al., 1996). Migrants often work in the least-protected parts of the sex industry, such as on the streets. Their access to services and information is often limited by lack of civil and legal status; restricted freedom because they are bonded or traﬃcked; language limitations; cultural barriers; and heightened mistrust and fear of authorities.

Sex Work, HIV/AIDS, and Human Rights in Central and Eastern Europe and Central Asia

Children of sex workers. Survey data indicated that a signiﬁcant number of sex workers in the region have children. A project in Uzbekistan reported that that 61% of 250 sex workers covered by the project had children. Nearly the same percentage, 64% of 832 sex workers covered, was reported by respondents in Kyrgyzstan. Furthermore, more than one-third of them had more than one child. In Lithuania, 58% of 154 sex workers said they had children, with 26% reporting 2-3 children. In Macedonia, 56% of 53 sex workers surveyed said they had children.

Inmostcases,childrenof sexworkersliveinpoverty;facestigmaandsocialdiscrimination if their mothers’ behavior is known; and have a greater-than-average likelihood of being exposed to potentially destructive behavior such as drug use. For all of these reasons, there is a great need for social services targeting them speciﬁcally. Little information was provided by the projects on this issue. Projects in Zenica, Bosnia and Herzegovina; Vilnius, Lithuania; and Tashkent, Uzbekistan were the only three out of the 39 total projects that reported oﬀering speciﬁc social services to sex workers’ children. The NGO “Margina” from Zenica, Bosnia and Herzegovina provided social assistance related to school activities and helped organize therapeutic activities, often in cooperation with other NGOs. The AIDS Center in Vilnius, Lithuania oﬀered educational trainings covering topics on prevention of drug use,alcohol,STIs, and HIV/AIDS; at the time of the research, 36 women had passed these trainings. The center also helped sex workers with children to complete the documents necessary to obtain social welfare and to send their children to boarding school, if requested. Staﬀ also provided supplies such as food, clothes, and hygienic products, and organized festive dinners for children.

HIV/STI AND HARM REDUCTION INTERVENTIONS AMONG SEX WORKERS

Several surveyed organizations mentioned that they had diﬃculties involving sex workers as peer educators in their activities. The reasons given included lack of trust and respect from other sex workers,too much control from and dependency on pimps,and the inherent mobility of the sex work scene. Nevertheless, the projects all said they would continue their eﬀorts to integrate peer education into their work and strengthen relationships with the sex work community by providing continuous trainings for sex workers and implementing activities that go beyond HIV and STI prevention needs.

Sex Work, HIV/AIDS, and Human Rights in Central and Eastern Europe and Central Asia

Advocacy and policy eﬀorts

In addition to responses and interventions such as those described above in Section 4.6, additional emphasis should be placed on improving the policy environment and practices aﬀecting sex workers. In many places, stigma and conservative social and cultural traditions severely limit the ease and apparent practicality of program and policy development.Therefore, it is important to raise awareness among governments, law-enforcement agencies, religious institutions,other civil society groups as well as the general public about the value and necessity of investing in locally appropriate ways of preventing HIV and STIs among sex workers. The majority of projects covered by this survey reported emphasizing the development of advocacy eﬀorts aimed at creating a more favorable environment for their activities—eﬀorts that include approaching local government oﬃcials, law enforcement agencies, and the media.

Other organizations reported having developed decent if not good models of cooperation with law-enforcement agencies.In Burgas,Bulgaria,the NGO Dose of Love said it sends regular information about its activities to the local municipality and police every six months,steps that help it maintain a good relationship with these institutions. LET, an organization in Zagreb, Croatia, formed a joint project with the police to clean up neighborhoods where syringes are often discarded.

Harm reduction projects in Poltava, Ukraine, reported having successfully obtained permission to monitor police actions/raids to document possible human rights violations of sex workers. Police oﬃcers usually inform them of the place and time of the raids in advance. They also collect statistics and cooperate in providing access to health services for sex workers by providing transportation and similar assistance.In return,the projects provide trainings for police representatives on tolerance, characteristics of social work with vulnerable populations; and psychological issues often aﬀecting IDUs and sex workers.In St. Petersburg, Russia, the NGO Humanitarian Action initiated a training program on issues of harm reduction, HIV/AIDS, hepatitis, and STIs comprising a team of professional educators formed from psychologists working in the City Department of Internal Aﬀairs. The main objective of the program was to change the attitude of law-enforcement entities and policies towards harm reduction programs.

In their advocacy eﬀorts,some projects reported involving a wider spectrum of specialists into their harm reduction activities. For example, the NGO “Marija” (Volgograd, Russia) organizes seminars at which various specialists (social workers, psychologists, and educational workers) discuss key issue with government representatives. A Russian–German conference in Volgograd, titled “Improvement of public cooperation in protecting rights and interests of vulnerable groups”, discussed the rights and interests of sex workers.

HOPS (Skopje, Macedonia) reported having established an excellent cooperative relationship with the Institute for Social Work and Politics at the University of Sts. Cyril and Methodius, through which harm reduction principles and issues related to working with marginalized groups are introduced to students.

Self-organizing

Helping enhance the ability and willingness of sex workers to organize among themselves should be a major priority of harm reduction projects and other organizations that work with sex workers. The support and assistance of projects, government agencies, and other entities and committed individuals are vital. However, only sex workers themselves are able to fully articulate what they want and need—and forcefully protect the human rights,health,and well- being of themselves and their peers.As noted by the authors of a study of such eﬀorts:

Self-organization can help to overcome the problems of isolation and lack of self-esteem caused by marginalization and stigmatization. It can also help to promote and sustain safe sex and safer working conditions by increasing sex workers’ control of their working environment. Some sex worker organizations have evolved into powerful self-advocacy
forces which actively challenge human rights violations and causes of sex workers’ vulnerability. Many strategies for improving conditions for sex workers have been developed and implemented by sex worker
organizations, in many cases before HIV was identiﬁed and programs were funded — (Longo et al., 1997)

Sex Work, HIV/AIDS, and Human Rights in Central and Eastern Europe and Central Asia

In April 2004, for example, the NGO Odysseus from Bratislava, Slovakia started to facilitate a bimonthly self-support group for female sex workers. Over the ﬁrst few months, however, it had only been attended by 2-4 sex workers at a time. The AIDS Center in Vilnius, Lithuania reported that in 2002, an organization comprising sex workers among its members was founded.Among its activities was the establishment of a self-support group that organized diﬀerent activities such as group therapy and relaxation. The AIDS Center reported that 6-15 women attended but that the activities were not always well-developed, at least in part due to a lack of leadership among sex workers.

In Nikolaev, Ukraine, a public organization called Orchid was created with the support of a local charitable foundation, Blagodinist, to focus on issues related to protecting the rights of sex workers was created. Several members of Orchid reportedly had experience with sex work.

Because of the need for mutual help and better self-organization, some sex workers have created small informal groups within which they manage basic personal needs. In Poltava, Ukraine, for example, a small group of sex workers have organized themselves in such a way that they share their income,take care of each other when ill,and look after one of the women’s child.

Sex Work, HIV/AIDS, and Human Rights in Central and Eastern Europe and Central Asia

Conclusions and Recommendations

As the HIV/AIDS epidemic gathers steam throughout much of CEE/CA, improving the health, well-being, and human rights conditions of sex workers becomes even more critical than ever. They may be marginalized, discriminated against, and subjected to violence on a regular basis,but ignoring or even condoning such behavior could have ramiﬁcations far more devastating and immoral than just shocking disregard for the dignity and human rights of an isolated group of individuals.HIV has arrived in the region,and all are ultimately vulnerable.It is unclear whether sex workers represent a“bridge” between IDUs and the general population in terms of HIV transmission, but clearly the threat remains. The health and safety of all citizens thus depends on working with and for sex workers to help them protect themselves from harm. This will require a greater commitment among all members of society to accept and support the provision of comprehensive, pragmatic services for those most in need. It also depends on the recognition that enforcing international human rights standards is a cornerstone of eﬀorts to remove stigma and discrimination.

More broadly, sex workers are and must viewed as members of society in general—and thus deserving of the same rights and services available to all. This belief is at the heart of all recommendationsbelow,whicharederivedfromtheﬁndingsofthisreport.Theyaredividedinto interrelated yet distinct categories:for policymakers,for health authorities,for law-enforcement authorities,for service providers,and for researchers.Many of the recommendations are aimed athigh-leveldecision-makers,projectmanagers,ornon-sexworkingindividualswhootherwise can have a direct eﬀect on sex workers’ lives.Yet at the same time, it is important to recognize that all of the recommendations’ success also relies to some extent on removing obstacles that prevent sex workers from organizing among themselves or being able to trust each other, let alone law enforcement or other authority ﬁgures. As sex workers feel more comfortable and less fearful in general, they are able to work together more closely and consistently to advocate for their rights. As much as anything else, this development could have a particularly positive eﬀect on their own health and the health of those in their lives.

Recommendations for policymakers

• Government oﬃcials from across the spectrum should summon greater levels of political will and commitment to address social marginalization, economic exclusion, and violence within broader governance.

The ﬁndings of this report highlight the important role played by external factors in limiting the scope and eﬀectiveness of HIV and STI prevention among sex workers in CEE/ CA. Among these factors are economical instability, poverty, high levels of unemployment, repressive policies and laws, social inequality, poor enforcement of human rights guarantees, widespread and widely tolerated violence against women, discrimination of migrants, and lack of adequate public health services. Governments must seek to address all of these issues in order reduce the impact of HIV/AIDS in their countries, especially among their most marginalized citizens.

• Mechanisms should be initiated, preferably in cooperation with human rights groups and civil society, to enhance the independent monitoring of human rights agreements; protect the rights of vulnerable populations; and punish violators.

The human rights of sex workers, especially those working on the streets and injecting drugs, are easily breached on a daily basis, especially by the police, pimps, clients, the mass media, and public health providers. Apart from being important in itself, guaranteeing the human rights of sex workers should be seen as an essential element of a country’s overall HIV response. Sex workers’ ability and willingness to access crucial harm reduction services are greatly limited when their rights are violated regularly. They deserve equal rights and justice— and the availability of appropriate legal assistance to obtain it.

• Repressive national legislation regarding drug use and the provision of eﬀective interventions, such as harm reduction services, should be revised to reﬂect pragmatic, compassionate policies. Most importantly, harsh penalties for drug use should be eliminated because they restrict the ability and willingness of those at risk to obtain information and services to protect their own health and the health of those around them.

Epidemiological data conﬁrm that injecting drug use remains the main mode of transmission of HIV in most countries of CEE/CA. As suggested by the UN Guidelines on HIV/AIDS and Human Rights, national legislation and policies should be adopted to create an enabling environment for an eﬀective HIV response. Governments should reinforce their commitments to eﬀective HIV prevention and care in general and particularly to harm reduction measures, as outlined in the UN Declaration of Commitment on HIV/AIDS.

Sex workers’ involvement in all government-organized HIV/AIDS and human rights initiatives should be made a priority and guaranteed.

Sex workers should be represented on human rights commissions; local and national HIV/AIDS planning organizations, including those dealing with prevention and treatment; and country coordinating mechanisms (CCMs) in countries where the GFATM operates. Furthermore, any and all policies that aﬀect sex workers should be considered and introduced only with the participation and acceptance of sex worker representatives.

Recommendations for health authorities

HIV testing must be voluntary and conﬁdential for all individuals, including sex workers, IDUs, and others at high risk for contracting the virus.

Forced or compulsory testing,whether initiated by health or law-enforcement authorities, breeds distrust and fear among sex workers and members of other marginalized groups. They may therefore shun or avoid health facilities and treatment centers; as a consequence, they are less likely to be integrated into public health systems. This limits health authorities’ ability to establish a comprehensive HIV/AIDS response.

Harm reduction services, including needle/syringe exchange, should be available at all public health facilities.

The number and scope of existing harm reduction programs is far too limited in most of CEE/CA, especially in countries of the former Soviet Union. Public health facilities should oﬀer such services as a matter of course as part of an overall eﬀort to prevent the spread of HIV. The services available should include voluntary counseling and testing for HIV and STIs; condom promotion and availability; safer sex education; needle and syringe exchange; substitution treatment for drug dependence; and HIV and STI treatment. In particular, sex workers who inject drugs should be made aware of the availability of these services and how they can access them.

CONCLUSIONS AND RECOMMENDATIONS

Migrants should have improved access to public health services.

Internal or external migrants,who constitute a majority of sex workers in many parts of the region,areespeciallyvulnerabletoHIVandSTIs,andtheiraccesstohealthservicesisverylimited. Most often they have no health insurance due to lack of residence or identiﬁcation documents, and are forced to contact private clinics and pay for services, which most of them cannot aﬀord. Public health facilities should oﬀer special low-threshold services for migrants regardless of their legal status; these should include free and anonymous HIV testing and counselling,treatment for medical conditions, and referrals to other appropriate social services.

Policies and procedures in health care delivery that discriminate against IDUs and sex workers should be identiﬁed and removed.

The surveys for this report highlighted regular instances in which health care workers and medical professionals denied care to IDUs and sex workers. Such discriminatory actions represent a clear violation of individuals’ right to health and should never be tolerated or countenanced for any reason whatsoever. Health authorities should implement training programs for all staﬀ as well as monitoring mechanisms in which complaints are investigated thoroughly and conﬁdentially.

Evidence also indicates that IDUs are routinely denied access to antiretroviral treatment (ART) or placed last on the list of priority patients. These practices are immoral and based on stigma, discrimination, and a lack of understanding as to the ability and willingness of most IDUs to comply with often-complicated treatment regimens. IDUs and sex workers must have equal access to ART and treatment for STIs and other conditions.

Recommendations for law-enforcement authorities

Zero-tolerance policies should be implemented to help stem harassment and abuse of sex workers by the police.

Inallcountriessurveyed,violationsof sexworkers’rightsbypolicewerecitedasapersistent problem.Harassment and abuse often consist of physical violence,including beatings; illegal or unjustiﬁed detentions and arrests; coercion to sex; bribery and extortion; displacement of sex workers; enforcement of compulsory HIV/STI testing; and refusal to enforce laws that protect sex workers and others involved in sex work. Such a situation calls for immediate action by law-enforcement authorities across the region. Police oﬃcers found violating the rights of sex workers and all other people should be punished. Procedures should be established to monitor and guarantee complainants’ safety and conﬁdentiality, and public campaigns should be implemented to encourage citizens to report police abuse and harassment.

All members of the police and other law-enforcement entities should receive regular training on issues related to HIV, drug use, and the legal and human rights of all individuals, especially sex workers and other vulnerable groups. Police should also be expected to refer—but never in a coercive or threatening manner—sex workers and IDUs to programs, projects, and shelters where they can receive appropriate assistance

Sex Work, HIV/AIDS, and Human Rights in Central and Eastern Europe and Central Asia

Education eﬀorts aimed at law enforcement would be particularly helpful because police oﬃcers have regular contact with sex workers and IDUs. With appropriate training and motivation, they could play very positive roles in HIV prevention eﬀorts by providing health information as well as non-violent referral to health services. Already, there are examples in the region of close cooperation between the police and health entities, in particular harm reduction organizations. Top police department oﬃcials could speed up this process by facilitating regular meetings between police and public health services.

Recommendations for service providers

Programs targeting sex workers in general and speciﬁc groups within sex worker populations need to be expanded and diversiﬁed.

Coverage of sex workers by service providers was estimated by this survey to be a little higher than coverage of IDUs by most harm reduction organizations. However, in most cases coverage still remains below the level—which some experts have stated is about 60% within a given community—to eﬀectively control and reduce epidemics of HIV and STIs among sex workers. Service providers thus need to expand their outreach eﬀorts as well as the range of services they oﬀer, including access to condoms and needles/syringes and social services such as housing, child care, assistance with documentation, professional training, and legal education and assistance.

Service providers should seek to establish better links with human rights organizations/activists and other stakeholders in the region as part of an enhanced eﬀort to monitor violations.

Persistent human rights violations negatively aﬀect sex workers in all countries, including violence, intimidation, arbitrary detention, and denial of services. Human rights organizations have often been reluctant to closely consider and monitor violations against sex workers, but there are signs that they are beginning to respond more appropriately.Service providers should actively seek the assistance of these organizations and work closely with them to publicize abuses and eﬀect policy reform. They should also consider increasing their advocacy eﬀorts among a wide range of other stakeholders—for example,from the education sector and among oﬃcials at local and national governments—as part of an eﬀort to improve sex workers’health and safety.

Better program monitoring and evaluation would be a useful step toward improving planning and service delivery in general.

Many projects are unable to gather reliable data about their programs on a regular basis. This can greatly limit their eﬀectiveness and hinder local and national responses to HIV/AIDS. Lagging projects should seek ﬁnancial and technical assistance to improve their monitoring and evaluation procedures; others, meanwhile, should remain vigilant that their procedures remain eﬀective and thorough.

CONCLUSIONS AND RECOMMENDATIONS

Recommendations for external donors

Donors, especially foreign development agencies, need to base their response and funding on the real situation on the ground and on scientiﬁc evidence—and not on domestic ideological considerations in their own countries.

Donor policies can and do greatly inﬂuence the eﬀectiveness of nations’ HIV/AIDS response, especially in lower-income countries of the region. Donors should be encouraged to recognize and understand the nature of the epidemic and what type of interventions are the most appropriate and eﬀective in preventing the spread of HIV and treating those living with HIV/AIDS. In CEE/CA this means they should support harm reduction services, including needle/syringe exchange, for IDUs—many of whom are sex workers. Withholding funds to address the main risk factors may be worse than providing no funds at all since such policies can have a direct eﬀect on the overall national response

Staﬀ at multilateral and bilateral aid entities—as well as public health system employees at all levels—should be encouraged to speak up in response to perceived mismanagement, misallocation of priorities, and discrimination. They should be able to note their objections conﬁdentially and without risk of reprisals such as dismissal.

Personnel involved with the GFATM, World Bank, UN agencies, and bilateral funders are often in the position to positively inﬂuence aid disbursal by national, regional, and local authorities. Their ability and willingness to help monitor aid and program development can ensure that funds and services reach the intended recipients. At the same time, though, international aid entities should not exercise undue control over national public health policies and priorities. Local oﬃcials should also feel as though they can criticize international funders without risk of losing their jobs or engagement in future activities.

The policies and programs of various donors should be better organized and coordinated to ensure continuity of service, especially in countries where service provision depends mostly on donor assistance.

Often, donors base their support strategies on the assumption that responsibility for funding implementing interventions will be handed over to national governments after several years of donor operations. Unfortunately, however, this has not always been the case over the past decade in the region. In many cases, national governments are unprepared to take on projects because of ﬁnancial or capacity restraints—especially a dearth of qualiﬁed staﬀ at all levels—or because they did not receive expected support from other sources. Donors should strive to ensure ﬂexibility so that vital service provision to vulnerable groups is not disrupted due to gaps in funding.

Sex Work, HIV/AIDS, and Human Rights in Central and Eastern Europe and Central Asia

Recommendations for researchers

Researchers, scientists, national governments, and multilateral organizations should collaborate on the establishment of professional, sustainable research teams that publish more speciﬁc and accurate data on the HIV/AIDS epidemic and vulnerable populations, including sex workers, in CEE/CA.

As evidenced by the responses to this report’s questionnaire, data are often imprecise or diﬃcult to obtain for a number of key HIV-related ﬁgures. These include, but are certainly not limited to, the following: total number of individuals infected with the virus; total number of IDUs across a country or region; transmission vectors and trends, especially regarding injecting drug use and sex; total number of sex workers, broken down by nation, region, and municipality; number of sex workers with HIV and/or STIs, HIV prevalence among sex workers,andinfectiontrends;totalnumberinneedof antiretroviraltherapy(includingnumber of sex workers) and how many individuals are actually receiving the medicines; percentage of sex workers who have health insurance; and rates of police abuse and harassment against sex workers.

This list is by no means complete. Even by itself, though, it oﬀers clear proof that current data-collection eﬀorts are inadequate.All stakeholders involved have a vested interest in better information as to the scope and extent of the epidemic as well as those aﬀected by it.A research institution or UN agency should perhaps take the lead in building up epidemiological and social research capacity on HIV/AIDS throughout CEE/CA. This eﬀort may prove tricky and complicated given the wide-ranging political, economic, and social diﬀerences in the region— including, for example, the isolationist government in Turkmenistan and concerns elsewhere related to forced testing, conﬁdentiality, and coercion. In the long run, though, comprehensive and appropriately targeted service delivery can only be achieved based on reasonably accurate data. Also, better data would help governments and donors plan for the future in terms of ﬁnancial allocation, medicine procurement, and prevention messages.

The eﬀects of decriminalization of sex work should be carefully analyzed, and the results made widely available. Special attention should be paid to experiences in other countries of the region (notably Hungary and Latvia).

Many governments in CEE/CA are particularly reluctant to decriminalize sex work out of concern that sex worker populations and/or HIV and STI rates will skyrocket. Most studies elsewhere in the world indicate that neither eﬀect occurs; in fact,it generally appears as though decriminalization improves sex workers’ health and reduces HIV transmission among them. Other countries in the region may need additional convincing, however, and may also require blueprints based on decriminalization policies elsewhere and subsequent regulation of sex work.

The research should of course be conducted in a thoroughly objective manner and even suggest reforms to existing regulations in Hungary and Latvia. For example, there are concerns that in those two countries, mandatory HIV/STI testing of sex workers and lack of conﬁdentiality of diagnosis may further marginalize sex workers and worsen their access to HIV and STI treatment. These are important human rights issues that must be addressed appropriately for decriminalization to achieve its most important goals: better health care for sex workers and reduction in abuse, harassment, and discrimination.

CONCLUSIONS AND RECOMMENDATIONS

Sex Work, HIV/AIDS, and Human Rights in Central and Eastern Europe and Central Asia

References

AIDS Infoshare (2001).“Basic characteristics of the commercial sex industry in four regions in Russia where HIV/STI prevention activities have been established under AIDS Infoshare project activities”.

AIDS Infoshare (2003). Expert survey:“Needs of regions in legislative and normative regulation of commercial sex work (prostitution)”. Report available from CEEHRN.

AFEW (2003). Summary report of baseline characteristics of NGO counterparts in Uzbekistan, Tajikistan and Kyrgyzstan. Prepared under the Drug Demand Reduction Programme in Central Asia.

AFEW (2003a).“Report on the rapid assessment and response to sex work, drug use, and HIV in the Central Asian Republic of Tajikistan”. Prepared under the Drug Demand Reduction Programme in Central Asia.

Andrushchak, LI and Khodakhevich, LN (2000).“The reduction of the HIV vulnerability of women involved in the sex business in Ukraine through social mobilization and the creation of self support networks”. Zhurnal Mikrobiologii, Epidemiologii i Immunobiologii; 4: 118-119.

Arsova T. (2000).“Prostitution and sex workers in Bulgaria: Analysis of the situation and the risk with regards to HIV/AIDS/STDs”. Health and Social Development Foundation, UNDP; PROJECT No BUL/98/

005; National HIV/AIDS Strategy Planning.

Asia Paciﬁc Women’s Consultation on Prostitution press release (1997). Online: www.hartford-hwp.com/archives/50/008.html (accessed January 16, 2005).

Benotsch, E, Somlai,AM, Pinkerton, SD, Kelly, JA, Ostrovski, D, Gore-Felton, C and Kozlov,AP (2004). “Drug Use and sexual risk behaviors among female Russian IDUs who exchange sex for money or drugs”. International Journal of STD & AIDS; 15: 343-347.

Borisenko, K, Safarova, E, Shegay, M, Filatova, E and Sheilihov, N (1999).“Socio-demographic characteristics of female sex workers attending the clinical centre ‛Sanam’in Moscow for STI care”. International Conference on HIV/STIs, Denver, USA.

Burris S,Villena D (2002). “Adapting to the reality of diﬃcult HIV policy choices in Russia, China, and India”. Human Rights magazine,Winter 2002.

CEEHRN (2004) Maps project. Online: www.ceehrn.org/index.php?I=12227.

CEEHRN (2002).“Injecting drug users, HIV/AIDS treatment and primary care in Central and Eastern Europe and former Soviet Union”, July 2002.

Council of Europe, Legal Aﬀairs.“Croatia: Relevant provisions of the Criminal Code”. Online: www.coe.int.

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