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Revista Brasileira de Epidemiologia

Print version ISSN 1415-790XOn-line version ISSN 1980-5497

Rev. bras. epidemiol. vol.18  supl.1 São Paulo Sept. 2015

https://doi.org/10.1590/1809-4503201500050003 

SPECIAL ARTICLE

The Peer and Non-peer: the potential of risk management for HIV prevention in contexts of prostitution

Gabriela Silva LeiteI 

Laura MurrayII 

Flavio LenzIII 

IFounder of the Brazilian Network of Prostitutes; Davida - Prostitution, Civil Rights and Health - Rio de Janeiro (RJ), Brasil.

IIDepartment of Sociomedical Sciences, Mailman School of Public Health, Columbia University - New York, United States.

IIIDavida - Prostitution, Civil Rights and Health; Graduate Program in Communication at the Universidade do Estado do Rio de Janeiro - Rio de Janeiro (RJ), Brazil.


ABSTRACT

Sex workers have been the protagonists and focus of HIV prevention campaigns and research since the late 1980s in Brazil. Through a review of national and international literature, combined with a history of sex workers' involvement in the construction of the Brazilian response, this article explores the overlaps and disconnects between research and practice in contexts of prostitution over the past three decades. We review the scientific literature on the epidemiology of HIV among sex workers and prevention methodologies. We conclude that although research focus and designs often reinforce the idea that sex workers' vulnerability is due to their sexual relationships with clients, their greatest vulnerability has been found to be with their nonpaying intimate partners. Few studies explore their work contexts and structural factors that influence safe sex practices with both types of partners. The negative effects of criminalization, stigma, and exclusively biomedical and peer education-based approaches are well documented in the scientific literature and experiences of sex worker activists, as is the importance of prevention programs that combine empowerment and human rightsbased approach to reduce HIV infection rates. We conclude that there is a need for actions, policies, and research that encompass the environment and context of sex workers' lives and reincorporate the human rights and citizenship frame that dominated the Brazilian response until the end of the 2000s. As part of HIV prevention efforts, female sex workers need to be considered above all as women, equal to all others.

Keywords: HIV; Risk management; Prostitution; Human rights; Sex work; Sex workers; Public policies

RESUMO

Prostitutas têm sido protagonistas e foco de campanhas de prevenção de HIV desde o final da década de 1980 no Brasil. Com base em um levantamento da literatura nacional e internacional, combinada com a trajetória do movimento de prostitutas na construção da resposta brasileira à epidemia, este artigo explora as sobreposições e incoerências entre pesquisa e prática em contextos de prostituição nas últimas três décadas. Na revisão da literatura científica, verificamos que a maior vulnerabilidade desse grupo social ocorre com os parceiros íntimos, não-comerciais; entretanto, o foco das pesquisas e a forma que são feitas geralmente reforçam a ideia de que a vulnerabilidade decorre de seus clientes. Ao mesmo tempo, há poucos estudos sobre seus contextos de trabalho e fatores estruturais que influenciam práticas sexuais mais seguras com ambos os tipos de parceiros. Os efeitos negativos da criminalização, do estigma, e de abordagens exclusivamente biomédicas e baseadas de uma forma isolada na metodologia de educação pelos pares estão bem documentados na literatura científica e nas experiências de ativistas, assim como a importância de programas de prevenção baseados em direitos humanos e sexuais. Concluímos que há necessidade de ações, políticas e pesquisas que incluam o ambiente e contexto nos quais profissionais do sexo trabalham, que reincorporem o arcabouço de direitos humanos e cidadania que dominou a resposta brasileira até o final da década de 2000, e que prostitutas devem ser consideradas e tratadas como mulheres, iguais a todas as outras.

Palavras-chave: HIV; Gestão de riscos; Prostituição; Direitos humanos; Profissionais do sexo; Políticas públicas

INTRODUCTION

The concept of risk management assumes that people are autonomous and able to make decisions in their best interest if they have enough information to reduce their information on how to reduce their risk of getting HIV. Risk management strategies, such as those promoted by the social movement of sex workers in Brazil, prioritize autonomy and leadership while also recognizing that the context in which decisions are made have as much to do with the information available as to their interest in protecting themselves.

HIV prevention in prostitution contexts in Brazil remains an important subject for analysis and the development of new prevention strategies. Even after three decades as the focus of campaigns, sex workers continue to have a HIV prevalence of 4.9%1, estimated to be more than 15 times higher than the prevalence in the general population of women aged 15-49 2.

By definition, prostitution involves sexual, affective and material exchange. Thus, risk management strategies must move beyond simply looking at decision making related to disease risk towards considering how sex workers manage financial and work related issues (for example, clients offering more money to have sex without condoms, or sex workers having to accept, or refuse, certain prevention methods to keep their jobs).

The international literature has increasingly focused on the political, social, and economic contexts where sex workers live and work in order to understand their vulnerability and improve interventions 3. As an occupation recognized by the Ministry of Labor since 2002, prostitution has aspects that remain in Brazil's Penal Code. Although the inclusion of "sex workers" in the Brazilian Classification of Occupations by the Ministry of Labor ensures the right to social security and other labor benefits, commercial activities related to prostitution (such as brothels) are illegal, which creates an extremely difficult context for sex workers to work safely. Structural issues thus must also be the focus of analyses in terms of the population's vulnerability to HIV in Brazil.

In their extensive literature review regarding the influence of structural determinants on the global epidemiology of HIV among female sex workers, Shannon et al. 3found that the decriminalization of prostitution would have the greatest effect on reducing HIV incidence globally among sex workers, avoiding 33%-46% of new infections over a decade, even more than antiretroviral therapy for sex workers and their clients (who have CD4 <500 cells/mm3) (34%). The study by Shannon et al. indicates that the context in which sex workers make decisions about HIV prevention is as important as the methods they have available. The editors of Lancetspecial issue on female sex workers, where the Shannon et al. article was published, emphasize the importance of implementing actions in solidarity with sex workers in order to "protect their health, integrity, and autonomy." 4

This article systematizes current research and successful intervention experiences in contexts of prostitution globally to contribute to increasing sex workers' autonomy to make informed decisions regarding their health, rights and HIV prevention. First, we conduct a literature review of structural and behavioral strategies used to reduce sex workers' vulnerability to HIV. Then, we discuss promising interventions published in national and international literature to identify possible risk management strategies. Next, we present a detailed historical background of the development of HIV public policies, interventions and activism among sex workers in Brazil. This backdrop provides the broader scope within which research and interventions have been developed in addition to locating our recommendations within the current political context regarding prostitution, HIV and AIDS.

METHODS

This article brings together historical, scientific, institutional and journalistic research and texts on prostitution and HIV. We also bring experiences and reflections from over thirty years of Gabriela Leite's activism seeking social, political, cultural, and economic changes in prostitution contexts; 2 decades of activism in communication and human rights of Flavio Lenz; and the trajectory of Laura Murray in research and activism in the field of AIDS and sex workers' rights. It is important to note that the main body and central ideas of this article were maintained in the final revision, conducted after Gabriela Leite's death in October 2013.

Historical research sought to reconstruct and critically contextualize the dialogs and partnerships between the social movement of prostitutes and the federal health sector. The analysis was based on government, non-profit, commercial and citizen media documents from the archival collections of Davida - Prostitution, Civil Rights and Health and the Brazilian Interdisciplinary AIDS Association (ABIA). It also included reports and studies promoted, funded and led by the Department of STDs, AIDS and Viral Hepatitis and Brazilian Network of Prostitutes (in Portuguese "Rede Brasileira de Prostitutas," RBP) Other types of documents produced by these institutions were also consulted, including prevention manuals, publications, letters, and notes. In addition to these sources, a search was conducted in the Brazilian AIDS News Agency, commercial media and news content run on the AIDS Department's website (Tag Notícias Department of STD, AIDS, and Viral Hepatitis), and in the newspaper Beijo da rua (print and electronic version), which has accompanied the prostitute movement since 1988.

The literature review of scientific and programmatic literature on HIV and prostitution was conducted in August, 2013, using the search engines SciELO and PubMed, from the National Institute of Health in the United States (www.pubmed.gov) and the websites of the World Health Organization (WHO), UNAIDS, World Bank, and the Department of STD, AIDS, and Viral Hepatitis in Brazil's Ministry of Health. In SciELO, the search was conducted with the keywords "prostituição," "profissionais do sexo," "prostituição e HIV/AIDS," "trabalho sexual e HIV/AIDS," and "profissionais do sexo e HIV/AIDS" in abstracts. In PubMed, we prioritized publications in the category of "review" and searched for the terms "sex work," "sex work and HIV prevention," "sex work and STI prevention," "structural interventions," and "community empowerment" in the titles and abstracts of the articles. In addition, two more searches were conducted, in titles and abstracts, with "structural factors and sex work" and "structural interventions and sex work."

The search resulted in a total of 252 articles, including 117 scientific articles in SciELO, 135 on PubMed, and 10 books and 15 reports from international agencies sites and Davida and ABIA archives. First, duplicates were excluded. Then, abstracts were analyzed, and the articles not exclusively focused on adult prostitution and vulnerability to HIV and/ or STDs were eliminated. We added relevant publications of references from the bibliographies of the articles identified in the initial search. Finally, four specific criteria were established to organize the material according to the study objectives: 1) texts focusing on prevention methods and behavioral strategies to reduce HIV transmission; 2) articles on structural determinants of HIV in prostitution contexts; 3) evaluations of STD and HIV prevention interventions with sex workers; and 4) articles about sex work and the contexts where it takes place. Articles not encompassed in one of these categories were discarded. The analysis presented included a total of 82 articles.

Among the selected articles, the majority was focused on female sex workers. The few studies carried out with men and transgender sex workers present contexts distinct from female prostitution in a variety of ways, including where and how they work, and social and cultural factors influencing condom use with clients and steady partners. Given this context, and considering the limited space available to expand on these differences, we decided to focus on female prostitution.

RESULTS

PREVENTION METHODS

In national and international literature, male condoms are the primary and most effective method of prevention studied and highly recommended as an intervention. In Brazil, a high rate of condom use with clients has been documented. In a study conducted between 2008 and 2009 by Szwarcwald et al.5, 90.1% of the sex workers interviewed said they used a condom in their last vaginal sexual relationship with a client, compared to 36.6% with steady partners. 5

In a systematic review of the literature on HIV prevalence among vulnerable populations in Brazil, Malta et al. 6found that sex workers were three times more likely to use condoms with clients than with steady partners (67.3 versus 19.2%)6. This difference between condom use with clients and partners is consistent with the results of other studies conducted in Brazil 7 9, and is a major trend in international research 10 12. Only one survey specifically about the use of female condoms was found. Oliveira et al. 13applied a semi-structured questionnaire with a convenience sample of 19 sex workers who reported having used female condoms13with partners (7) or steady customers (8). However, 14 people from the group interviewed reported not having used female condoms the last five times they had sexual intercourse.

Both this study and the evaluation conducted by the National STD/AIDS program in partnership with the University of Brasília (UNB), with 2,712 sex workers 9, found that in the sex work context, female condoms are used less than male condoms.

Although testing for STDs and HIV has been encouraged and included in prevention actions with sex workers, we did not find periodic presumptive treatment for STIs intervention models for STD and/or HIV testing (without being linked to other interventions), vaginal microbicides, preexposure prophylaxis (PrEP), or postexposure prophylaxis (PEP) in the Brazilian literature. In the international literature, a systematic review conducted by Shamanesh et al. 10on HIV prevention interventions with sex workers from low- and middle-income countries presents an overview of interventions in 15 countries 10. Among the 26 studies included in the analysis, four evaluated the microbicides and fourteen STD treatment 14. The authors found no evidence supporting the effectiveness of PPT or microbicides in reducing HIV incidence in sex work contexts. In turn, in their meta-analysis of PPT, Steen et al. 14concluded that treatment can reduce the prevalence of STDs in some areas where prevalence is high if implemented in conjunction with peer-education interventions and condom distribution.

PROSTITUTION CONTEXTS AND THEIR RELATION TO HIV

Ethnographies written about prostitution in Brazil highlight how areas where it occurs are fields of production of affection, culture, knowledge, and politics. They are transversed and constructed by people whose subjectivities do not fit neatly into cohesive categories or groups, and much less, the category of "risk group". 15 19. Prostitution occurs in streets, plazas, hotels, bars, and closed establishments such as brothels, saunas, and private clubs, and through print advertisements or the Internet. In each of these areas, the types of relationships that sex workers have with owners or agents range from no relationship to agreements with strict rules and time/motion regulations. Where some kind of agreement exists, sex workers typically earn money through dates with clients, and the owners profit mainly by selling drinks, entrance fees for clients and renting rooms, in part, to avoid being prosecuted under Brazil's law against maintaining "houses of prostitution." Establishments vary in price and exclusivity and usually are more difficult to access (mainly owing to their illegal status) for prevention and mobilization activities compared with street contexts or bars 15 20.

National and international studies have evaluated the relationship between the socio-political contexts where women work and vulnerability to HIV. In the international literature, a number of studies have concluded that criminalization and lack of safe places to work are significantly related to unprotected sex 21 23. In a study conducted with street sex workers in Canada, Shannon et al. 21found that unprotected sex was associated with working on dark streets to avoid the police (OR = 2.08, 95%CI 1.06 to 4.49) and having sex in public spaces or the client's car (OR = 2.00, 95%CI 1.65 to 5.73). In Moscow, having suffered threats from establishments' owners or being forced to have sex with police officers were associated with a higher prevalence of STD/HIV (OR = 3.65; 95%CI 1.34 to 6.78 and OR = 2.50, 95%CI 1.17 to 5.25, respectively) 22. In India, a cross-sectional study with 835 sex workers found that being arrested and having their workplace raided by the police were significantly linked with the presence of STI symptoms (OR = 3.77, 95%CI 2.28 to 6.23 and OR = 3.72, 95%CI 2.61 to 5.31) 23.

These international studies focused on the political and social characteristics of the places where women work are exceptions; the majority of studies do not probe into the characteristics of the contexts where women work, focusing instead on individual risk factors related to their professional environment. For example, Damacena et al. 1investigated the association between HIV infection and the type of workplace (street, bar, motel, etc.), time working in sex work, price charged, and average number of sexual encounters per day 1. The data analysis suggests that structural factors such as economic vulnerability (the lower the price, the higher the prevalence: OR = 0.713, 95%CI 0.522 to 0.970) and working conditions (the longer, the higher the prevalence: OR = 1.020; 95%CI 1.013 to 1.067) were significantly associated with HIV infection 1. Studies, however, are not designed to identify the structural and environmental context of the workplace that contribute to increasing sex workers' vulnerability to HIV. Instead, they tend to focus on the sex workers' individual behaviors and history in the profession.

Studies conducted in Brazil indicate that sociocultural factors external to the work environment particularly, as they relate to autonomy and integration into social networks, also have significant associations with condom use. In a survey of 434 sex workers in Rio de Janeiro, Kerrigan et al. 25found that that social cohesion and mutual aid (measured through eight factors, including: level of group connectedness, caring, and potential for instrumental, emotion and material support) (OR = 1.30; 95%CI 1.02 to 1.66), possession of official documents and access to resources (OR = 1.36, 95%CI 1.11 to 1.65), and participation in community organizations (OR = 1, 56; 95%CI 1.04 to 2.34) were significantly associated with condom use with clients in the last four months. According to Lippman et al. 26, high social cohesion was inversely associated with the number of unprotected sex acts in the week prior to interview (IRR = 0.80; p<0.01), and the women's participation in social networks was associated with a reduced frequency of unprotected sex (IRR = 0.83; p = 0.04).

EVALUATIONS OF INTERVENTIONS

We found four types of interventions in our literature review: peer education, structural interventions, community empowerment interventions, and biomedical interventions. It is important to note that condom distribution is included in all of the interventions, as is peer education as a strategy. The term "structural intervention" has been used to describe a variety of interventions in different contexts, including prostitution 27, but it is used here to refer to strategies aimed at changing social, political, and cultural contexts where sex workers live and work. Structural interventions thus might include changing laws that criminalize the profession, reducing stigma and gender inequality, respecting prostitution as a profession, and effective participation of sex workers in social and political spaces of decision-making.

The term "community empowerment" in the context of interventions is defined in the literature as sex worker-led responses, which aim to change the social and political contexts in which they work and live 28. Although they include peer education components, condom distribution, and access to STD testing and treatment, interventions are not exclusively focused on health issues or STDs. Structural measures such as community empowerment are based on the idea that peer education itself is not enough to prevent STDs and HIV transmission, which has been proven by a recent systematic review of peer education programs in developing countries 29. Although some effects on behavior change have been observed, the analysis of thirty studies with different populations concluded that there is no evidence that the methodology reduces STIs and HIV prevalence when implemented apart from other behavioral and structural interventions 29. Medley et al. 29argue that the lack of more descriptive information about how these programs are implemented and evaluated makes it difficult to identify what aspects of programs contribute or not to their effectiveness. The authors also highlight some issues related to implementation that need further attention and analysis: recruitment, training and supervising peer educations, renumeration, and retention.

In her "travesti ethnography" of a prevention program with travesti sex workers in Sao Paulo, Pelúcio 30highlights other considerations and criticisms of peer education methodology 30. She addresses how these programs focus exclusively on sex workers instead of their clients. Thus, Pelúcio argues that the methodology ends up reinforcing the stigma surrounding prostitution in two ways: creating inequalities between sex workers and categorizing them as the "risk group," while protecting clients from this stigmatized category- making protection the responsibility. Pelúcio's ethnography shows how the methodology creates differentiation rather than closeness and solidarity among sex workers. Although the intention is a dialogue between equals, the methodology creates a hierarchy between peers as it is structured around an idea that one peer has information that the other needs, yet does not have.

Peer education strategies have been assessed as a part of broader interventions in Brazil. The first and largest evaluation of prevention actions for sex workers was the survey Avaliação da Efetividade de Ações de Prevenção Dirigidas às Profissionais do Sexo em Três Regiões Brasileiras 9(Effectiveness of Prevention Actions For Sex Workers in Three Brazilian Regions). The survey was conducted during 2000 and 2001, with 2,712 sex workers of whom half had participated in a project supported by the National STD/AIDS Program and the other half had not. Results show significant differences in condom use with clients among women who participated in the intervention and those in the control group; women who participated in the intervention were more likely to report consistent condom use with clients (defined as the use of condoms in all sexual relations in the past six months) (OR = 1.86, 95%CI 1.57 to 2.20). Differences were also found in the number of sex workers reporting condom use with steady partners (OR = 1.67, 95%CI 1.37 to 2.03), being tested for HIV (OR = 1.69, 95%CI 1.44 to 1.98) and having undergone a gynecological examination in the previous year (OR = 1.55; 95%CI 1.32 to 1.82) 9. As the elements of the interventions were not evaluated separately, the effect of peer education cannot be evaluated in isolation.

Two Brazilian experiences of structural interventions have been positively evaluated in the scientific literature. In Projeto Encontros, a structural intervention implemented in Corumbá (MS) in 2003, with female, male, and transgender sex workers that included mobilization and social inclusion, Lippman et al. 31found that sex workers actively participating in the intervention had a higher probability of reporting condom use with steady clients (OR = 1.9; 95%CI 1.1 to 3.3) and lower probability of STD occurrence (OR = 0.46, 95%CI 0.2 to 1.3). In an intervention with behavioral, sociocultural, and programmatic elements implemented in Amazonas, Benzaken et al. 32found an increase in the purchase of condoms, the approval of a law to continue prevention actions developed as part of the project, and an increase in condom use with clients 32.

Recent international research has also pointed to the need for structural interventions 10 28 33 35, showing significant results in their ability to reduce STD and HIV incidence and increase condom use with new and steady clients 10 36. Shamanesh et al. 10focused on HIV prevention-driven interventions with sex workers in low- and middle-income countries 10. Four types of interventions were identified: 1) behavior change and condom promotion; 2) microbicides and condoms; 3) regular testing and early treatment for STDs combined with condom use; and 4) structural interventions. It is notable how biomedical approaches dominate the literature reviewed in the article, in particular, in the African context and studies evaluating vaginal microbicides and STD treatment. The authors point out the limitations of the studies selected and methodological challenges inherent in conducting research to evaluate interventions in prostitution contexts. Even with this caveat, they conclude that there is evidence that structural interventions, policy changes, and/or sex workers' empowerment reduce sex workers' vulnerability to STDs and HIV.

Kerrigan et al. 28analyzed the effectiveness of community empowerment interventions 28. The systematic review was conducted as part of a World Health Organization (WHO) project to develop technical recommendations for STD and HIV prevention with sex workers based on evidence from research that fit the study's eligibility requirements. 36. Ten studies were eligible for analysis, in accordance with the criteria established (being published in an academic journal between 1990 and 2010, addressing community empowerment interventions, using a pre/post study design, measuring HIV, STD prevalence or condom use, being conducted in a low or middle-income country). They found that all interventions contemplated political mobilization, the recognition of prostitution as a profession, and three elements of prevention: peer education, condom distribution, and provision or expansion of testing services. A meta-analysis found significant associations between community empowerment interventions and decreases in HIV prevalence 26. The authors concluded that, although most studies were observational and had low accuracy, the findings "have sufficient strength and importance to strongly encourage" the implementation of community empowerment interventions with sex workers 26.

In addition to the literature from academic journals, in 2012, three important documents on sex work and AIDS were published by international institutions, including WHO 36, the World Bank 2, and the Global Commission on HIV and the Law 37. All documents recommend structural interventions and emphasize the importance of partnerships with sex worker organizations. in addition, both the global commission and who explicitly recommend the decriminalization of prostitution. In 2011, UNAIDS also published four annexes to their 2009 Guidance Note on HIV and Sex Work. UNAIDS published the annexes after an extensive discussion and revision of the original document made in conjunction with sex workers 38, and strongly recommends structural prevention programs and decriminalization.

HISTORY OF PREVENTION ACTIONS

Previna (1988-1990) was the first national project for HIV prevention among sex workers including travesti and male prostitutes, in addition to gays and men who have sex with men, prisoners, and injecting drug users. Formal partnerships between the National STD/AIDS (PN-DST/AIDS) and leaders/organizations involving these populations were established, along with the introduction of the peer education methodology in STD/HIV prevention interventions for specific populations 39.

In 1989, the Brazilian Network of Prostitutes (RBP), founded two years earlier, held its second national meeting in Rio de Janeiro. The issue of prostitution and AIDS was addressed, focusing on sex worker engagement in in prevention actions supported by the government. Previna project staff presented three prevention manuals aimed at female, transgender, and male sex workers for validation by meeting participants. A program run by prostitute and activist Gabriela Leite at the Institute for Religious Studies (ISER) developed the manuals with assistance from the Group of AIDS Support and Prevention of Minas Gerais (GAPA-MG) 40 42.

The event represented the consolidation of a partnership where "sustainability and decentralization of actions, a protagonist role of the target populations [...] and, most importantly, the notion of stigma were discussed and understood as essential components of serious work" 43. The civil society and government partnership expanded to include human rights, citizenship, prejudice, labor rights and regulation, and access to health services. This moved beyond a hygienist vision of prostitution as being associated with disease towards the concept of vulnerability as a more productive framework for prevention.

Previna II, made possible as part of loan agreements with the World Bank, ensured the continuation of prevention actions by supporting sex worker organizations and AIDS NGOs that worked with the population. The process of decentralization of the Brazilian Public Health System (SUS), along with the proliferation of prostitute organizations and their growing access to public funds for the prevention contributed to the strengthening the RBP. In 1994, the RBP held its third national meeting and in 1995, Davida-Prostitution, Civil Rights, Health, an organization founded in 1992 under the leadership of Gabriela Leite, reissued the prevention manual developed by the Previna project, also with funds the Ministry of Health, and distributed it to the RBP's network of sex worker organizations.

In 1997, the movement stopped a USAID funded research project that intended to carry out HIV testing in prostitution areas in Rio and other cities 44. The sex workers' argued that there had been no dialogue with them regarding the initiative (research did not follow the National Health Council Resolution 196/96 - today 466/2012 - regarding research with human beings nor pass through an ethic's committee). The movement further argued that the collection of blood samples in prostitution areas would reinforce stigma, and emphasized that anonymous testing centers were the appropriate reference centers for such procedures. 44 45.

Later, in 2002, the national project Esquina da Noitemobilized over 50 associations of sex workers across the five regions of Brazil as part of its goals to identify and train sex workers 39. Implemented by RBP and PN DST/AIDS, the project had one general coordinating body per region (an association of sex workers linked to the RBP) these same organizations, alongside other NGOs and informal groups, developed activities. All projects continued the peer education and free condoms approach in addition to emphasizing human rights, increased self-esteem, labor rights, and the fight against stigma. The Esquina da Noite also gave rise to the project Tulipa, a project coordinated by the National Articulation of Travestis and Transgendered People ( Associação Nacional de Travestis e Transgêneros- ANTRA) that had a similar format and goals as Esquina da Noite. The expansion also meant increased focus on investment and on the importance of strengthening the organizational capacity of NGOs for sex workers, both to implement HIV prevention projects and to defend human and labor rights.

The national campaign entitled "Sem vergonha, Garota. Você tem Profissão" (Don't be ashamed, girl. You have a profession), launched by the Ministry of Health in 2002, is emblematic of this approach. The campaign was developed in partnership with the RBP and included adhesives, brochures, manuals for health professionals, and a radio spot, reflected the increased recognition of prostitution as a profession, as it had been included in the Brazilian Classification of Occupations (CBO) in the Ministry of Labor and Employment that year 46. In 2005, the Brazilian Government sided with the RBP and refused to sign a cooperative agreement issued through USAID as part of the President's Emergency Plan for AIDS Relief (PEPFAR) that included what came to be known as the "anti-prostitution pledge". The pledge condemned prostitution and impeded the disbursement of funds to organizations that defended legalizing prostitution and that did not have an organizational statute explicitly opposing it. 47 48.

In response, the sex worker movement and the federal government implemented the project Sem Vergonha (2006-2008), with federal funding. Davida coordinated the national project and implemented the actions around the main topics of political leadership, human rights, sustainability, and advocacy along with regional coordinators of other sex work associations 39.

In 2007, sex workers were included in National Integrated Plan to Confront the Feminization of the AIDS Epidemic and other STDs. It was revised in 2009, and affirmative agendas for specific populations were added, including one for sex workers 49. The plan was well-received by the organized movement, as it would insert prostitutes into policies for women in general, a long-standing demand of activists; however, the evaluation of its implementation pointed out "a smaller volume of actions for groups of women included in affirmative agendas" compared with women in general 50.

Early the following year, Brazil promoted the First National Consultation on STD/AIDS, Human Rights and Prostitution, and a few months later, RBP representatives were received by the Health Minister (at the time, Jose Gomes Temporão). The RBP presented the Minister with a document that included 17 recommendations selected from the dozens developed at the Consultation (and incorporated into the affirmative agenda in the Feminization Plan), such as: survey of human rights violations against sex workers and the legal response given to them; separating prostitution from topics such as the sexual exploitation of minors, trafficking and sex tourism; and adjusting the hours of public services to the needs of sex workers 51. The Minister said that he would share the recommendations with colleagues from the government offices of Law, Labor, Welfare, Culture and Women's Rights, in addition to forming an interministerial commission on prostitution, but this committee was never created 52.

As an outcome of this process, in August 2011 the RBP announced that they would no longer "participate nationally in requests for proposals related to AIDS" that "undermine the Network Principles [...]; reinforce an idea of prostitutes as distributors of disease and condoms; do not guarantee sustainable actions, thereby compromising full implementation". They also pointed out the need for "support from other areas, especially the recognition and regulation of the profession" 53. Moreover, according to the 2011 report from the meeting in Belém, where this decision was made, debates considered that "prostitutes should think about accessing the SUS rather than expecting organizations to bring them supplies; they should go to health posts and demand condoms, appointments and access." An experience in the south region, where sex work activists stopped providing condoms in their outreach and instead started talking about "self-organization, labor and human rights," was reported as "very difficult at first", but "rewarding, with many women enrolling in the National Social Security Institute (INSS) and ensuring rights based on the Brazilian Classification of Occupations (CBO)" 53.

The decision announced by RBP was maintained until March 2013. At this time, in Joao Pessoa (PB), associations from the north and northeast regions, Minas Gerais and Rio Grande do Sul took part in a communication workshop, sponsored by the STD, AIDS and Viral Hepatitis Department, with the goal of developing an online prevention campaign to be launched on June 2: the International Sex Worker Rights Day.

The week the online campaign was launched, however, three of the pieces were removed from the website by direct order of the then Health Minister Alexandre Padilha. Each piece was composed of a text with an image of one of the sex workers who participated in the workshop. The campaign pieces taken down from the site read: "I am happy being a prostitute"; "Our biggest dream is that society see us as citizens"; and "Not accepting people the way they are is violence", Those related exclusively to prevention remained on the website. In response, the RBP issued a statement denouncing the Ministry's decision as part of a broader process of "the sanitization of life" and as a violation of the SUS principles regarding community participation, equality and integrity 54.

The Ministry of Health invited the RBP to a meeting to discuss what had happened. The Ministry claimed that the messages removed were human rights, rather than health, issues. They also apologized for their "technical error" in not going through the Ministry's formal approval mechanisms prior to releasing the campaign online. The activists requested a public apology for the censorship and alteration of the campaign, immediate withdrawal of altered pieces still online, and an invitation to another meeting "within the historical principles of partnership and of the SUS" 55. The dialogue about the issue was never continued, and the (edited) campaign remains on the Ministry Of Health's website 56.

However, in November 2013, representatives from ten organizations affiliated with the RBP agreed to be trained to apply oral rapid HIV tests with their colleagues, both in the physical spaces of the organizations and what the project refers to as "socialization areas", an euphemism for prostitution zones and brothels 57.

This intervention model goes against the principles, strategies, and actions developed and practiced throughout 30 years of sex worker activism in Brazil and documented in the 2008 Consultation and affirmative agenda in 2009. In particular, positions expressed in 1997 regarding how such interventions contribute to increasing stigma, and then once again reaffirmed in the Brazilian Network of Prostitute's Letter of Principles written in 2008, which states, "the offering of exams and other medical procedures in places where prostitution is practiced is repudiated, except in cases involving the general population" 58.

The exclusively biomedical model marks the abandonment of prevention policies based on human rights, in social and political changes in contexts of prostitution, and public initiatives and policies articulated with various state sectors, including, but not limited to, the health sector. Renouncing this common heritage rather than preserving and developing it risks losing a historical foundation of extreme relevance.

DISCUSSION

Both the Brazilian experience and national and international research suggest that prevention policies and actions focused on improving the quality of life and work environment of sex workers (and thus, their happiness) should be promoted in prostitution contexts. The objectives and focus of interventions must go beyond condom use with clients and testing for diseases. Actions, policies and research must broaden to the political context of sex work and women's intimate relationships outside of it. It is equally important that sex workers be seen as independent women who are able to make decisions to take care of their health.

We call attention to four results of this analysis that we will discuss in detail before making recommendations for interventions. First, in terms of prevention methods, the focus is on condom use with clients in research and interventions. Data on the effectiveness of certain biomedical approaches are either inexistent (in the case of brazil) or inconclusive (in international revisions). In a systematic review of about combined prevention for sex workers published after the review conducted for this article, Bekker et al. 59confirmed the low number of studies on biomedical methodologies in prostitution contexts and that specific research evaluating PrEP or "test and treat" with female sex workers has not yet been conducted 59. While recognizing the potential benefits of such biomedical approaches, the authors advise that interventions must always include "combinations of biomedical, behavioral, and structural interventions specific to local contexts that are led and implemented by sex workers" 59.

Second, sex workers' lives outside of their professions, where their vulnerability with steady partners is much higher, have been virtually ignored by research and interventions. Sex workers are aware of the importance of condom use; in a survey conducted with women arrested in Fortaleza (CE), having a history of prostitution was one of the factors associated with the proper use of condoms (p <0.049) 60, but the rate of use with intimate partners was low in all studies found. There is a lack of qualitative studies exploring sex workers' relationships with steady partners to better understand the low rate of condom use in these contexts. Surveys conducted in Brazil 25 26 also found that sociocultural factors related to autonomy and inclusion in social networks are significantly associated with condom use. Thus, risk management strategies must be directed at the environment outside of work to promote autonomy in intimate and social relationships. This is a long-time demand of the prostitute movement, which even raised the possibility of a campaign aimed at couples in 2002 61.

Third, in most studies, prostitution is not treated as a profession, often being researched within a "risk group" framework. This is a stark contrast to the recommendations developed by prostitutes in the National Consultation of 2008 and guidelines that guided government prevention actions until the mid to late 2000s. Apart from several etnographies, there is also limited information about the organization of the sex industry in the country and even less on how structural factors of work contexts (such as the role of the police, relationship with owners, and criminalization of some aspects of the profession) are related to the sex workers' vulnerability to violence and illness.

For example, what are the work environment factors that cause HIV infection rate to increase alongside time in the profession? Is there a relationship between sex workers' earnings and receiving money directly from clients, or through a brothel manager? Have the police arrested women while they are working? Are condoms used by the police as proof of managing a sex establishment? Our review raised these questions and their answers will contribute to designing structural interventions that promote sex workers' autonomy and ability to make informed decisions. They will also assist in integrating stigma reduction and respect towards sex work as a profession into sexual and reproductive health programs.

Finally, one must rethink interventions in which the legitimacy and citizenship of sex workers is linked to their role as peer educators. In the early 2000s, a reference document published by the then National Program for STD/AIDS suggests that peer education might reinforce the stigma surrounding prostitution 43. The authors state that "the stigma - from which everybody wants to escape - appears in its plenitude: prostitutes are no longer partners and become the target audience of the project; the monitors or health workers fail to belong to a professional category and become part of another"43. This transition to another social identity demonstrates precisely what Lenz describes as a "desire contrary to being a peer, of being a non-peer" 62. As Lenz argues, the desire to be a non-peer presents a challenge to peer education programs because "being a prostitute gives them legitimacy and credibility to act as prevention agents" 62.

In designing and implementing new prevention technologies currently promoted by "peers" in prostitution areas, it is useless to assume that "peer" is synonymous with understanding, equality and symmetry, and not consider how the practice can create hierarchies. We do not believe it occurs consciously or purposely, but peer educators seem to follow this path from peer to non-peer when involved in peer education interventions. The peer educator takes on a posture of "knowing more" as opposed to peer who "works together". In the prostitution context, this methodology has an unintended and dangerous result: reinforcing stigma as the relationship between equals ceases to exist. Is it thus possible that this methodology, in which peer educators are nearly transformed into representatives or mediators of the State, a hidden form of State tutelage? And perhaps a way of enforcing State power and knowledge, without requiring its direct participation?

The insistence and persistence of prevention methods that compromise both sex workers' autonomy and solidarity among peers suggests that, even 27 years after the 1988 Constitution, the issue of tutelage has not been resolved. Why not treat prostitutes as subjects with rights, including the right to be happy, and to be respected as an intelligent being who knows how to make their own decisions? Why do we keep insisting on implementing prevention programs that focus only on condom use with clients when research and activism have made it clear that their greatest vulnerability is with steady partners? Why do the federal government and various state and local governments continue to invest in peer education, even though international surveys show that this methodology alone is not effective in reducing the prevalence of HIV? These are urgent questions that need answers so that we can stop going around in circles and move forward with prevention actions without state tutelage.

CONCLUSION

To promote greater autonomy of individuals within risk management strategies and to avoid current trends of tutelage, sex workers must be considered, treated, and respected as subjects of rights, whether they are having sex for love and/or money. Specifically, we recommend:

  1. The development of campaigns for the general public, segmented only by gender and sexual orientation, age (young and older groups), and other major sociodemographic characteristics. we reaffirm that prostitutes are, above all, women; so, they should be seen and cared for by the public health system. Such a campaign must also include sex workers' clients, a group that is a key to prevention and that has been nearly invisible in campaigns;

  2. Conduct and promote critical evaluations of peer education programs, including how they are implemented (educator recruitment, supervision, and training), and issues that affect the efficacy and impact of the programs. Understanding implementation is a key to understanding methodology;

  3. Conduct a comprehensive review of what the sex industry is. Prostitution includes a vast range of individuals that structure the industry itself and, like any other business, involves a large group of people with a wide variety of professions. In order

  4. to develop prevention strategies, we need to understand what this space is and what happens in it. Therefore, qualitative studies must be conducted in various disciplines (anthropology, sociology, economics, communication, social psychology, law, among others);

  5. The implementation of interventions in line with workplace health and safety programs, based on more accurate information about the sex industry. To develop strategies in workplaces, it is of no use to assume "peer" as synonymous with understanding, equality, and symmetry while ignoring how the practice might create hierarchies (both among professionals and between professionals and their clients);

  6. More research, debates and dialogs about male and transgender sex workers, from a research and intervention perspective. Although important ethnographic studies have been carried out with both populations, there is a lack of studies recognizing the diversity and complexities of implementing prevention projects with these populations and their vulnerabilities;

  7. Qualitative research and pilot projects to develop campaigns and risk management strategies related to prevention among couples. Condom use with steady sexual partners is a difficult for all, not only sex workers, and this subject has not been given the attention it deserves;

  8. Political support from public health officials to promote dialogs between the organized prostitute movement and other government sectors, in addition to supporting the decriminalization and regulation of prostitution to guarantee sex workers' health and rights.

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Financial support: Gabriela Leite was supported by Fundo Elas para Investimento Social as to the development of text.

Received: January 19, 2014; Revised: November 02, 2014; Accepted: December 18, 2014

Corresponding author: Laura Rebecca Murray. Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University. 722 West 168th Street, 10032, New York, NY, EUA. E-mail:laurinhamurray@gmail.com

Conflict of interests: nothing to declare

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