A study published in the medical journal The Lancet found that about 60 percent of sex workers surveyed were living with HIV.

Towards the end of last year, I was in Port Elizabeth presenting on the national Red Umbrella Programme sex worker project at the Nelson Mandela Municipality Summit on TB and HIV.

While I was listening to presentations, I noted that participants gasped and tut-tutted with shock and disapproval when speakers spoke about “girls selling their bodies at the back of shebeens”, and “prostitutes having sex with 25 or more men per week”.

I looked forward to my presentation with relish, thinking: “Great, a virgin audience.” I started by asking the audience to call out words they associated with the words “sex worker”.

The words that came up were, “money”, “young girls”, “police”, “HIV and STIs”, “poverty” and “low morals”… a useful informal barometer of attitudes in the room.

I focused my presentation on a simple message: “Sex workers are human beings, and enjoy the same constitutional rights as any other citizen.”

I advocated for sex work to be recognised as work, and argued why decriminalisation of adult, consensual sex work was the legal model with the best possible outcome to combat HIV and protect sex workers’ rights.

As an aside, I noted that sex workers say: “We are not selling our bodies. Our bodies belong to us. We are selling sex.”

As usual, questions after the presentation were lively.

People asked about types of sex work, transactional sex, promiscuity and morality, culture, child sexual exploitation, pimps, the number of sex workers in South Africa, and about care for HIV-positive sex workers.

I knew there had been some shifts in attitude when a later speaker again spoke about sex workers “selling their bodies”, and the group corrected him in unison: “Not selling bodies, selling sex.”

SA rapidly scaling up HIV services for sex workers

That I was at that meeting at all, and that sex work was on the agenda, was the confluence of a cascade of factors, and a vindication of a long, often unpopular struggle in the margins of HIV.[quote float= right]“We are not selling our bodies. Our bodies belong to us. We are selling sex”

In 2010 it was reported that, while almost one in five new HIV infections could be attributed to the sex work industry, less than 5 percent of the estimated 153 000 sex workers in South Africa were reached with HIV prevention services (aids2031; 2010).

Thankfully, four years later, we can say that this is no longer the case. Things have moved rapidly in the sex work sector.

In the past year, the Global Fund-supported national sex work programme, now branded the Red Umbrella Programme, has scaled up rapidly and dramatically.

We have gone from eight sites around South Africa to 70 sites in all nine provinces, and from 50 peer educators to 560.

Before last year there were eight implementing partners; now there are 19.

The 70 sites in all nine provinces, covering a diverse range of South African cities and towns, were selected to take services to sex workers where they were most needed, and were informed by the Sex Worker Population Size Estimation study, commissioned by the South African National AIDS Council (SANAC), and conducted by Sweat.

At the sites, sex worker peer educators, led by a site co-ordinator (most of whom are also sex workers) implement combination prevention programmes for sex workers.

They engage with sex workers wherever they work: streets, brothels, truck stops, bars, hotels, shebeens and sex workers’ homes.

They distribute condoms and lubricant, provide health and human rights support, and refer for HIV testing and other health, social and legal services.

Local service providers are also offered sensitisation training to increase their “sex work friendliness”.

Peer educators and site co-ordinators have been trained, with some receiving additional training as paralegals and HIV counselling and testing counsellors.

For many, it is their first experience of formal employment.

Sweat provincial managers have taken the work into provinces and districts, engaging with provincial strategic plans, and working towards strengthening sex worker inclusion in provincial, district and local AIDS Councils.

They also provide support and capacity-building for the 19 implementing partners to ensure programme quality and consistency.

Criminalisation, not ignorance fuelling HIV

The best research we have  from The Lancet medical journal tells us that South African female sex workers have an estimated HIV prevalence rate of 59.8 percent, one of the highest prevalence rates in the world. When this figure hit the media recently, some newspapers jumped to the conclusion that sex workers are either ignorant about HIV or reckless about their health.

In fact, this is a shocking legacy of decades of criminalisation, marginalisation, stigma, discrimination and human rights violations.

While most sex workers are knowledgeable about safe sex and support the idea of 100 percent condom use, the environment in which sex workers operate creates obstacles to practising safe sex.

Sex workers are subject to high rates of violence, including rape, from police and clients.

Police are known to confiscate condoms, or use condoms as evidence of sex work, which makes carrying condoms risky. Police harassment and the threat of arrest are ever present realities in sex workers’ lives.

A common practice is to round up sex workers before the weekend, and release them without charge on Monday. Almost all sex workers have experienced demands for bribes and free sexual services in exchange for not being arrested.

Police harassment creates a climate in which sex workers have to negotiate speedily with prospective clients, sometimes ending up in dangerous situations.

Sex workers who are sexually assaulted are often turned away from police stations, being told “sex workers can’t be raped”, and we have also documented cases of sex workers being refused health care, including post-exposure prophylaxis to prevent HIV after being raped.[quote float= left]”Your kids are at home alone. You need money to feed them… A client comes along and is prepared to pay you double for ‘skin-to-skin’ sex. That is a very tough decision”

Brothels, being illegal, do not have to adhere to any occupational health standards, unlike in New Zealand, where sex work is decriminalised, and sex workers have the right to turn down clients who refuse to use condoms.

In some parts of South Africa, condoms are scarce or don’t reach sex workers, and in many places, sex workers avoid going to clinics to ask for condoms or health care out of fear of stigma, exposure and ridicule.

Finally, it is clients, and not sex workers, who request unprotected sex, with clients regularly offering financial incentives.

One sex worker told me: “Imagine it is late at night. It is raining. You are standing on the street waiting for clients. Your kids are at home alone. You need money to feed them and send them to school. A client comes along, and is prepared to pay you double for ‘skin-to-skin’ sex. That is a very tough decision.” If these and other structural impediments to HIV prevention are not addressed, the goal of reducing sex workers’ HIV burden will have limited success.

The time for the decriminalisation of sex work has come

While the foundation of the Red Umbrella Programme is bio-behavioural interventions – HIV counselling and testing, distribution of condoms and lubricants, referrals to services, and safe sex education – the game-changer is its attempt to tackle structural interventions.[quote float= right]”Decriminalisation is the single, simplest thing governments can do to reduce HIV … Unfortunately, our campaign for this evidence-based intervention is held hostage by the infamous US government ‘Anti-Prostitution Pledge’”

The concept of structural interventions is one that the South African HIV community has struggled with in the past, but fortunately there is growing evidence for the impact of structural interventions on HIV infection in sex workers.

These interventions include policy reform, addressing gender-based violence, addressing workplace safety, mobilisation of sex workers to speak out for their rights, skills development, training and sensitisation of health care workers and police, gender empowerment, and interventions to address stigma and discrimination.

The idea that sex work should be recognised as work, in order to protect sex workers’ human rights and labour rights, and in order to reduce sex workers’ HIV risk, is no longer as controversial as it was a decade ago.

A recent World Values Survey showed that South Africa is in the top 10 countries in the world in terms of tolerance of sex work, yet the only country in the top 10 where sex work and all associated activities are fully criminalised.

Decriminalisation of sex work is recommended by international bodies such as the World Health Organisation (WHO), the UN, the Commonwealth Heads of Government, and here in South Africa by the Commission for Gender Equality and SANAC.

Recently, in a special edition on HIV and sex work published to coincide with the Melbourne International Aids Conference last year, an article in The Lancet concluded that: “Decriminalisation of sex work could have the largest effect on the course of the HIV epidemic, averting between 33 and 46 percent of (new) infections over the next decade through combined effects on violence, police harassment, safer work environments, and HIV transmission pathways.”

This means that decriminalisation is the single, simplest thing that governments can do to reduce HIV among this population.

Unfortunately, our campaign for this evidence-based intervention is still held hostage by the infamous US government “Anti-Prostitution Pledge”.

Despite the fact that the pledge – which requires recipients of US funds to acknowledge that they are “opposed to the practices of prostitution and sex trafficking, because of the psychological and physical risks they pose for women, men and children” – has been overturned in the US, it still applies to international recipients of US funding, and is in fact being applied with greater vigour, as now not only recipients, but also sub-recipients are required to sign the pledge.

This puts many of our partner organisations, who receive funds both from Global Fund, which follows the WHO recommendations on decriminalisation, and the US government, in a moral dilemma. It also places the Red Umbrella Programme at risk of not being able to fulfil its mandate.

We have to push back against recommendations that are based on morality and political opportunism, as opposed to those which are based on evidence and a respect for human rights.

As Victor Hugo said: “Nothing can stop an idea whose time has come”.

Decriminalisation of adult consensual sex work is an idea whose time has come.

Maria Stacey is acting director of the Sex Workers Education and Advocacy Taskforce (SWEAT). This opinion piece was first published in the 9 February edition of the Cape Times newspaper.