As HIV scientists, advocates and patients gather at the International AIDS Conference in Melbourne this week, there is an increasing focus on the role that the criminalization of sex work is playing in the worldwide epidemic.
Experts say laws that prohibit prostitution are hampering efforts to control the global HIV epidemic.
During the opening session of the conference, the executive director of the joint United Nations program on HIV/AIDS, Michel Sidibé, chided governments for criminalizing sex work.
"We cannot run away from the harm caused by criminalizing populations," Sidibé said. "We must implement the recommendations of the Global Commission on HIV and the Law."
'Where criminal laws have actually been removed, rates of HIV and sexually transmitted infection are very, very low' - Sandra Ka Hon Chu, Canadian HIV/AIDS Legal Network
That UN-convened commission found that making any part of prostitution illegal, whether it be the buying or selling of sex, makes workers less able to protect themselves from infections or seek treatment if they become infected.
It's a conclusion supported by a large body of research evidence, including now a series of seven papers on HIV and sex workers published this week by the medical journal Lancet.
One of the articles analyzed published studies on HIV rates among sex workers, condom use and other data from three cities — in India, Kenya and Vancouver.
Author Steffanie Strathdee of the University of California, San Diego said it's clear sexual violence against female prostitutes and the criminalization of their work make them less likely to use condoms.
Eliminating sexual violence would avert an estimated 17 per cent of infections in Kenya and 20 per cent in Canada by creating safer working conditions in which sex workers could demand clients use condoms, she said.
But her team showed that decriminalizing sex work would have a far bigger impact in reducing transmission.
"We've shown that up to 46 per cent of incident HIV infections could be averted in any of the three cities we examined by just fully decriminalizing prostitution," she said.
Sandra Ka Hon Chu is co-director of research and advocacy with the Canadian HIV/AIDS Legal Network in Toronto, which opposes Canada's proposed new prostitution legislation. The bill before Parliament would make it illegal to buy sex, and is expected to receive third reading in the Commons this fall.
Chu is among more than 220 legal specialists and advocates who've written an open letter to the prime minister to reconsider the bill. She said its effect will be to create the conditions that lead to riskier sex and more HIV infections.
"When you're driven to isolated areas because of policing, because your clients are being arrested, it's harder for you to negotiate condom use, harder for you to insist on safer sex or even discuss what you want to do in advance."
She said in countries that criminalize prostitution, including Canada, sex workers report having their condoms confiscated by police as evidence of criminal behaviour, so many choose not to carry them.
Criminalization means sex workers are less likely to seek out treatment if they become infected, according to The Lancet series. Chu said in Canada, if they're incarcerated they may also experience interruptions or difficulty accessing treatment.
Chu and Strathdee, and others at the AIDS conference, point to New Zealand and New South Wales in Australia. Both jurisdictions have repealed laws that made sex work illegal. The results have been dramatic, Chu said.
"Where criminal laws have actually been removed, rates of HIV and sexually transmitted infection are very, very low, rates of condom use are very, very high, and sex workers as a whole feel very empowered to insist on safer sex with their clients."
About .01 per cent of people age 15 to 49 are infected with HIV in New Zealand. In Canada the prevalence is more than double that, according to UNAIDS.