Presentation by Matthew Chersich, at the National Sex Work Symposium, in the second session of Day1 on 'Recommendations for South Africa' (Boksburg, 22 August 2012).

1. WHO recommendations for
prevention and treatment of
HIV and other STIs for sex
workers in low- and middle-
income countries (draft)
Matthew Chersich

2. Presentation outline
• Recommendations (draft)
▫ PPT evidence summary
• Alcohol and sexual behaviour
• Guidelines process

3. Decriminalisation and proactive responses
• As recommended in International Guidelines on
HIV/AIDS and Human Rights, the report of UNAIDS
Advisory Group on HIV and Sex Work and report
presented to Human Rights Council by UN Special
Rapporteur on Right to Health, all countries should
work toward decriminalization of sex work and
elimination of unjust application of non-criminal
laws and regulations against sex workers.
• Governments should establish antidiscrimination and
other rights-respecting laws to protect against
discrimination and violence faced by sex workers
in order to realize their human rights and reduce their
vulnerability to HIV infection and the impact of AIDS.
(Good practice recommendations)

4. 1. “We are despised in the hospitals”: Sex workers’
experiences of accessing health care in four African
countries (submitted CHS) F Scorgie, D Nakato, E Harper,
M Richter, S Maseko, P Nare, J Smit, MF Chersich
2. Human rights abuses and collective resilience among
sex workers in four African countries
F Scorgie, D Nakato, E Harper, M Richter, S Maseko, P Nare, J
Smit, MF Chersich

5. Types of health services
• Health services should be made available, accessible
and acceptable to sex workers based on the principles of
non-discrimination and right to health (Good practice
recommendation)
1.Health services for sex workers: a comparison of
service package and delivery models in Africa and
India
• WHO recommend interventions to enhance community
empowerment among sex workers. (strong
recommendation, very low quality of evidence)
1.Socio-Demographic Characteristics and
Behavioral Risk Factors of Female Sex Workers in
Sub-Saharan Africa: A Systematic Review AIDS &
Behaviour 2012 F Scorgie, MF Chersich, I Ntaganira, A
Gerbase, F Lule, YR Lo

6. General HIV prevention and treatment
• WHO recommends consistent condom use among
sex workers and their clients. (strong
recommendation, moderate quality of evidence)
• WHO recommend offering voluntary HIV
counselling and testing to sex workers. (in line
with existing WHO guidance)
• WHO recommend using the current WHO
recommendations on ART use for HIV-positive
general populations for sex workers.

7. STI services: care for symptomatic and
asymptomatic sex workers
• We recommend using the current WHO STI syndromic
management guidelines for symptomatic STIs among
sex workers and their clients. (in line with existing WHO
guidance)
• WHO suggest offering periodic screening for
asymptomatic STI in female sex workers
(conditional recommendation, low quality of evidence)
• WHO suggest offering female sex workers periodic
presumptive treatment, where prevalence high, as
a temporary measure (conditional recommendation,
moderate‐to‐high quality of evidence)

8. Lesedi: Condom use and STI prevalence
among women using the services
Rapid reduction of curable STIs
Condom use rises with
programme
20 35
18
30
16
14 25
12 20
10
8 15
6 10
4
5
2
0 0
1¡ visit 2¡ visit 3¡ visit 4¡ visit
Gonorrhea Chlamydia Genital ulcer Condom use with clients

9. Lesedi
Miner STI
prevalence
NG &/or CT Genital ulcer
STI declines
15%
measured in
10.9% miners as well
10% (intervention
targeted only
6.2% 5.8%
women)
5%
1.3%
0%

10. Angeles
City,
Bringing STI Philippines
services to sex
workers
One-time
PT with and
without
improved
services

11. Neisseria
gonorrhoea
Chlamydia trachomatis
RCT results: 1. R Steen, M Chersich, A Gerbase, G Neilsen, A Wendland, F Ndowa, EA Akl, YR
Lo, SJ de Vlas. Periodic presumptive treatment of curable STIs among sex workers: a systematic
review. AIDS. 2012
2. R Steen, M Chersich, SJ. de Vlas Periodic presumptive treatment of curable sexually transmitted
infections among sex workers: recent experience with implementation. Current Opinion in Infectious
Diseases 2012

12. PPT implementation
Feasibility: Feasible to introduce PPT for sex workers in range of
settings
Frequency and duration of PPT may vary depending on STI
prevalence (existing burden) and incidence (rate of reinjection).
 Screening for syphilis, using accurate and affordable tests,
should be available to sex workers whether or not PPT is
provided.
 In settings where interventions have reduced sex worker STI
prevalence and increased condom use, PPT can be phased out
or withdrawn.
 Azithromycin!

13. Substance use
• WHO recommend using current WHO
recommendations on harm reduction for sex
workers who inject drugs.
• WHO recommend including unvaccinated sex
workers at higher risk for acquiring hepatitis B
virus (HBV) infection as targets of catch‐up
HBV immunization strategies in settings
where immunization has not reached full
coverage.

14. Alcohol and sex work
• Hazardous and harmful drinking changes sexual
behaviour (?)
• Pathways include: condom use & accidents,
choice and number of partners, vulnerability to
sexual violence, type of sex act
• Intervention evidence lacking
• Neuman M, Schneider M, Nanau RM, Parry C, Chersich M.
The Relationship Between Alcohol Consumption and HIV
Infection and Risk Behaviour: A Systematic Literature
Review of High-Risk Groups, with a Focus on South Africa.
Book title: Public Health - Social and Behavioral Health.
2012

15. What’s new in WHO guidelines
• Access means more than being available
(coverage, integrated, stand-alone, diagonal
services)
• Considerable focus on structural changes: laws
and empowerment (aims to reduce social
vulnerability and raise service utilization)
• Missing is emotional partners and alcohol use in
sex work settings
• New processes...

16. Process Process
• Began in mid 2010....
• Leadership of community representatives in
guidelines, “extensive consultation”
• Emotional partners excluded
• Systematic review of low-quality evidence