Sex workers
Sex workers have been associated with the HIV/AIDS epidemic since its onset, due to the nature of their work. Governments have long debated the advantages and disadvantages of regulation, prohibition, or tolerance of prostitution. The majority of today�s societies present �moral� and contradictory objections to prostitution: e.g., on the one hand, some countries recognize the sex industry as an important source of commerce; yet, they condemn earning money through sex.
Some governments, donors, and NGOs place trafficking of women and children in the same category as prostitution. Not only is this not the case, but it makes working with sex workers very difficult, because it leads directly to the call for elimination of both, which threatens the livelihood and even survival of many women who have chosen to do sex work. It also compounds the stigma by putting children into the picture.
In many countries, like Canada, Thailand, England, and Brazil, everything related to the management of sex work (such as owning a brothel) is illegal, while being a prostitute is not illegal. These �tolerant� systems are hypocritical, as they exploit prostitution but make their class organization and the possibility of fighting for labor protection and health and political rights extremely difficult. An important step forward in this respect has been recently achieved in Brazil. Following the recommendations of the regional Latin American and Caribbean Consultation on Prostitution, held in Lima, Peru, in February 2007, the Brazilian National AIDS Program, in collaboration with the National Network of Prostitutes, the National Articulation of Transgenders, and the National Network of Transsexuals, has implemented the National Consultation on STI/HIV/AIDS, Human Rights and Prostitution. Given its past experience and commitment to the issue, Pathfinder representatives in Brazil were invited to be participants in this important and historic meeting. Main recommendations emanating from the consultation include creation of a multi-ministerial committee to initiate discussion on the issue, as well as commitment from the Special Secretariat for Women�s Policies, linked to the President�s Cabinet, to encompass the needs and interests of prostitutes (women, transvestites and transsexuals alike) into its strategic planning.
On the other hand, some governments, like Germany, Switzerland, Chile, and Austria, although regulating prostitution, place the industry under the control of the police rather than the mercantile codes. In Switzerland, a woman deciding to leave sex work needs to file a form in a police station and wait three years for a �good conduct� certificate.
In Greece and Austria, obligatory periodic medical certifications and compulsory HIV testing are barriers to female sex workers preserving their privacy and choosing their own preferred physicians. These medical certifications not only violate medical confidentiality, but also create a false sense of health protection from the State. In fact, they serve more to detect diseases rather than to prevent them. In other countries, where prostitution per se is illegal, like the USA (with the exception of the State of Nevada, where brothels and prostitution are legal, but regulated), even communication between two people with the intent of prostitution is considered a crime and can lead to long prison sentences. This creates hiding and isolation, compounded by an atmosphere of police bribery and coercion, which increases vulnerability to and spread of HIV.
The global movement for the promotion and protection of the rights of sex workers is initiating a new prostitution policy allowing sex workers to organize and represent themselves. In seeking the recognition of prostitution as a legal occupation, and defining their own professional activity and identity, prostitutes are stepping towards what is being called �self-determination of sex workers.�
Increased HIV vulnerability for sex workers
There are many factors contributing to HIV vulnerability for SW, which, if understood, can lead programmers to devise solutions that reduce risk and acknowledge the sex workers� basic human rights.
As with MSM and IDU, health service personnel are rarely trained to provide services relevant to sex workers, including integrated services and responsiveness to their specific needs (e.g., where STI services for SW are provided apart from the general population, they reinforce stigmatization and do not meet the overall health needs of sex workers and their children and families. Difficulties in accessing public health facilities force sex workers to seek alternative healthcare treatment, mostly following traditional beliefs with no scientific basis and of minimal efficacy;
Social marginalization associated with the life style of sex workers maximizes their exposure to violence;
The clandestine nature of sex work makes the adoption of safer sex practices more difficult;
Gender inequality promotes submission to client pressure to engage in unsafe sex for more money, which makes safer sex difficult to negotiate;
Lack of personal security in the working environment, and;
High geographic mobility helps to interrupt accessing already established prevention and health interventions for sex workers.
Effective HIV prevention strategies for sex workers
HIV prevention programs for sex workers that focus solely on individual risk behavior won�t work unless the social context in which sex workers negotiate health behaviors is also addressed. While an individual sex worker may know about safer sex and have safer sex skills, she may also be plagued by perceived and real stigma, discrimination, and marginalization from community life and civil society. This social experience may undermine her self-confidence and ability to practice safer sex, particularly when confronted with ongoing resistance from sex partners (both commercial and regular partners) and economic pressures.
Conversely, HIV prevention interventions with sex workers can be highly effective, especially when strategies recognize their human rights, and the sex workers themselves play proactive roles in all program design, from strategy, to monitoring activities, to evaluating outcomes, to disseminating results. Sex workers should have a place on National AIDS Councils to provide their unique perspective and bring focus and action to their specific issues and needs, as well as to confront stigma among others responsible for AIDS policy and programs.
HIV/AIDS prevention among sex workers is greatly enhanced by strengthening their professional identity and by combating the male dominance (by brothel owners, pimps, clients, and partners) that overpowers this group almost everywhere. (In India, most brothel owners are women - generally former sex workers - but they tend to perpetuate the power structures they experienced during their own working years.) To achieve pride in their work, sex workers should be empowered to promote their own care and safety. In this regard, sex worker organizations are important tools for prevention, rights recognition, and addressing the occupational hazards of sex work.
The promotion of the female condom emerges as an important prevention strategy that recognizes the women as citizens and bearers of rights and obligations. The female condom increases autonomy in women�s professional activities, especially given the difficulties negotiating with clients reluctant to use the male condom.
The role of peer educators
Peer educators are generally accepted by their communities, are well-positioned to disseminate basic correct information regarding HIV/AIDS using a face-to-face approach, and can increase awareness about the epidemic and its effects on their lives. Peer educators can speak to the situation people live and work in, giving meaning to information and knowledge specific to group, sub-group or individual. Their presence favors real change in behaviors, beliefs, and attitudes.
Peer programs face real difficulties. Sex workers trained as peer educators may no longer consider themselves prostitutes, but want to view themselves as �healthagents;� here is where self-stigma is revealed at its fullest. Is it surprising that sex workers tend to take on the views of society, even when it includes self-condemnation? As a consequence, other sex workers then feel stigmatized and may stop being companions of the peer educators, losing the benefits of that relationship and becoming simply the target group of the project interventions. This is a dangerous development, as the peer educator gradually looses the social links that legitimate her interaction with her peers. Identification and training of peer educators, therefore, should take into consideration the existing intricate social networking of the community. Someone chosen as a peer educator must be able to withstand stigma and continue to stand with her peers and be given ongoing project support for that role. Peer educator and clinic provider training agendas should not only include technical aspects of the epidemic (medical, epidemiological, psycho-social), but must also discuss topics directly touching prostitution or MSM and IDU, as well as explore all the elements that make their lives so complex and challenging and make them targets for stigma and discrimination.
For peer strategies to succeed, peer educators must accept their responsibilities as role models, adhering to skills and knowledge they have acquired regarding condom use with regular sexual partners and health seeking behavior.
Supplemental skill building vs. �rehabilitation� of sex workers
Experience has shown clearly that strategies that promote sex worker �rehabilitation� or �reintegration into society� offer a clear path to failure, since they reinforce nothing but self-stigma and prejudice. These strategies usually backfire and simply drive sex workers away and further underground, which enhances their vulnerability.
Unfortunately, this approach has been used too often in HIV prevention strategies targeting sex workers implemented either by government or civil society organizations and not run by sex workers themselves. It reveals an ingrained prejudice against sex work, while little or nothing is offered in terms of effective and sustained financial alternatives to sex workers� life needs. Often, when sex workers return to their original families, they fall victim to even stronger discrimination and physical violence for the rest of their lives. On the other hand, offering trade and skills training to sex workers without strings, as a path to supplementary income and more economic independence (increasing her ability to reject unsafe safe), is not the same as offering these trainings as a way to �leave the trade.�
In some countries like Vietnam, rehabilitation camps are set up for sex workers and MSM who have been arrested. They receive some education and job skills training, but projects are generally under-funded, the job skills training obsolete, and there are few real alternatives to sex work offered. Overall, the experience reinforces stigma and isolation. Once discharged, most people return to sex work because they can�t make a living otherwise.
In India and Brazil, the operational experience of Pathfinder International has demonstrated that when sex workers feel free to talk with staff of prevention programs, many express excitement and satisfaction in doing sex work, because they are able to make a decent living and help themselves and their families.
Other actions that strengthen HIV prevention among sex workers include:
� Community meetings: Regular sex worker community meetings facilitate discussions about work, safety, and life issues affecting members of the group (police violence, inaccessibility of health services, safety with clients, care for children) and the development of action plans to confront these issues collectively. This activity is the most likely to guarantee the spontaneous formation of self-help groups. Health expert participation can be important initially to link social-survival issues and vulnerability to HIV infection. Also, health expert participation can support peer educators and counter the stigma that can make sex workers react negatively to peer comments and suggestions (e.g., self-stigmatizing feelings like �if you are one of us, we can get nothing useful from you�). Once sex worker groups realize their autonomy in their discussions and activities, there should be �a transfer of power� from the health or program expert to emerging leadership within the group.
To secure continued participation of sex workers in these community meetings, experts from related areas of interest (lawyers, social workers, beauticians, policy makers, journalists) should be invited, as they will broaden meeting discussions beyond medical issues and expose members to valuable information.
The frequency and timing of such meetings should be decided by the sex workers themselves, and amenities should be offered to participants (tea, soda, biscuits, etc.) Members should be encouraged to suggest themes for each discussion, so that all collective interests are addressed in the long run. Experience has shown that a balance of light issues (like beauty and fashion tips, and healthy cooking) with more substantial ones (safer sex practices, partner negotiation for condom use, legal assistance, gender-based violence) can keep the meetings from becoming too serious and potentially boring exercises. There should also be room for flexibility: if one participant wishes to discuss an urgent issue (e.g., domestic violence, internal community conflicts, drug abuse ), it should receive priority - boosting group social integration - before moving into the scheduled topic of the day. Condom distribution should always happen at the end of the meetings, with the provision of individual quantities as requested.
Ideally, community meetings should take place in a neutral �safe-haven,� but most often are held within health facilities, NGO offices, or the house of a sex worker. Whatever the venue, total confidentiality on what is discussed during these meetings must be ensured. Audio-visual equipment, including CD and DVD players, can play an important role in enticing sex workers to participate in the meetings, especially when they are also used for entertainment activities.
� Encouraging artistic expression: Videos and films can promote social integration with the external community, as well as strengthening sex worker organization. There is a long list of commercial films with sex workers as main characters that can be used to generate interesting discussion. Plays involving sex workers as actors to reinforce plot credibility are important to show sex work as work, to build self-esteem and self-acceptance, and to dialogue with the external community. They can also mobilize clients for safer sex if presented in public spaces. The humor derived from well-known, shared, recognizable daily situations can contribute to the assimilation of the information and reduction of self-stigma.
� Skill-building workshops: If responding to the interests of the community, these workshops (like literacy, beauty, fashion design and sewing, candle and soap-making workshops, making crafts, as well as opening of small businesses like market stalls or convenience stores) are very important in boosting self-esteem, promoting social integration and inclusion, and encouraging creativity. Additionally, the sale of products generated in these workshops is a potential source of income for sex workers, for sustainability of sex worker groups and associations, and for access to microcredit. Tutors or even �income-generating activity� enterprises can be hired or volunteer to conduct training sessions, including business skills.10
As in community meetings, skill-building workshops can stimulate group discussion and exchanges about gender issues, sexuality, and other vital topics of interest. Workshop tutors can be trained to facilitate this type of informal exchange. Condoms should always be distributed at the end of each session.
� Community radio: Although not commonly included in HIV prevention strategies with sex workers, the establishment of sex worker community radio is an easy, agile, dynamic and efficient channel for the dissemination of information to the community. What differentiates community radio from other commercial stations is the priority given to the interests and culture of a given group. In this case, sex workers and their organizations can adopt an ethical and political vision that supports the right of citizenship and the exercise of democracy for the group.
Programs broadcast by community radio are mainly educational, with a strong participatory approach, and with everyone in the entire community having the possibility of voicing his/her ideas and opinions. In most places in the developing world, low income populations, women and men of all ages, listen to the radio daily, so it is easy to understand the educational potential of community radio for disseminating quality, effective information on sexuality, reproductive health, HIV/AIDS prevention, and social integration of vulnerable and marginalized groups by reaching the broader community with the same messages.
� Working with brothel owners: In countries where sex work is often based out of brothels, it may be important to work with brothel owners, who can be appealed to at least around the profit motive, (if women stay healthy they can work longer and clients will stay healthy), and who may possibly hold independent concern for the health of the women. Without their participation, it is often difficult to reach the women initially, or for them to get permission to come out for health services or for gatherings. In the Mukta project in India, several brothel owners and Tamasha Dancer11 managers were recruited as peer educators. Winning their confidence, proving that the project has no ties with the police, and engaging them in the work of the project when possible is important. Of course there are brothel situations in many countries where no common ground can be fond with the owners and other strategies for reaching the women are needed. Each situation must be looked at individually to find the best way to uphold the interests of the sex workers.
� Working with clients and regular sexual partners: HIV prevention strategies with sex workers usually pay little attention to the specific informational needs of clients. A 2002 study by Guanira and collaborators in Peru12 found that 44 percent of men aged 18-29 years had paid for sex in the previous year. Of these, 45 percent said they did not consistently use condoms with sex workers. A 2003 Brazilian study of 3,000 sex workers13 found that, despite the overall high rates of condom use with clients (65 percent and more), sex workers reached by HIV prevention interventions did not show any significant difference from the general female population in terms of constant condom use with regular sexual partners (around 20 percent).
Negotiating condom use with clients, and in particular with regular sexual partners, can be a difficult skill to exercise. Gender inequity, poverty, domestic violence, illiteracy, young age, and society�s expectations of �married� or partnered couples, all play significant roles in perpetuating vulnerability of sex workers to HIV infection, no matter how aware they are of the benefits of condom use and genuinely willing to use them.
Regular sexual partners are probably the most difficult group to reach with condom promotion and HIV prevention messages. They can be unaware of their partner�s work, or are aware and avoid any contact with it. Or, like many women, they can fall into the social norm that there is no place for condoms in marital or committed (�love�) relationships. In these cases, protection depends on the empowerment of SW to influence promoting condom use with their sexual partners, and on the impact of HIV prevention messages on the general male population. In other cases, husbands actively promote their wives� activities and protection. For example, in India, some husbands take care of the children at night when the wives are working; in other places, the husbands solicit business for their wives. The direct involvement of these men makes it easier to approach them about safer sex and condom use along with their partners.
� Reaching street-based SW with information and services: Street-based SW are generally much more difficult to reach than those who are brothel-based, although this is less true where SW are more organized and are less self-stigmatizing. By definition, they work more alone, are more isolated and hidden, and they may come from another community and be invested in their anonymity. They may be more vulnerable to violence and less able to negotiate condom use. In fact, in India a street- based SW can be arrested just for carrying a condom, as this is seen as evidence of �immoral behavior.�
Special assistance can involve peer educators aware of their circumstances, who connect with them on the street. Drop-in centers allow them to find others to network with for information, emotional and social support, and referral to health services when needed, e.g., mobile clinic services near where they work.
Just as with SW themselves, clients of brothel-based SW are easier to reach than those who are street-based. In both cases, it is preferable to use SW peer educators to interact individually with clients, rather than involving men in group discussions, where the lack of privacy can hinder their participation. They should receive leaflets promoting condom use and STI/HIV prevention messages. Male group discussions can be effective when conducted in their work environment, with members of community organizations, or within associations or unions (e.g., construction workers; miners; police; soldiers and sailors; taxi, rickshaw, and truck drivers).
� Addressing police harassment: Sensitization workshops conducted regularly with police management and members can prove highly beneficial in the long run, even in contexts where prostitution is considered illegal. It may help to involve local MOH leadership in approaching the police for collaboration.
The police are key to preventing violence and other SW rights violations. Some may be personally engaged in bribery, coercion, and violence against sex workers. But, wherever possible, the role of police as protectors of citizens from abuse and injury should be the context in which to enlist their protection and cooperation, as well as engaging their support in slowing the spread of AIDS by ensuring a safer environment. Finding common ground and avoiding confrontational exchange is important for the success of this intervention. Topics for discussion may include HIV prevention, sexuality, gender issues, stigma, and discrimination.
Police must be sensitized to the importance of not harassing sex workers who distribute condoms for prostitutes and their clients - a frequent event that generally breaks down the motivation of well-intentioned peer educators.
� Advocacy for the rights of sex workers as citizens: To halt their disenfranchisement, projects should work to guarantee that sex workers are able to claim the benefits to which all citizens are entitled, such as identification or voter cards, national health insurance, the ability to get their children into state-run schools, the right to housing, to clean water, and to police protection for their safety. In some countries, sex worker organizations have been recognized by the state and are able to receive benefits to develop their activities.
� Promoting social integration and interaction with the society in general: Actively fighting stigma and discrimination in the society can have an enormous impact on the empowerment of sex workers. To improve the social environment around marginalized populations, collective spaces can be established for interaction and integration and partnerships built with one another and with other groups also wrestling with female discrimination (e.g., women�s and human rights groups).
The implementation of community-wide cultural and social events should initially focus on including those more �open� segments, such as university teachers and students, local artists, and members of other social movements. In the implementation of Project Encounters in the city of Corumb�, Brazil, monthly parties (�Hot Pink Parties�) were jointly organized by the local sex work association and the university community to break down social barriers. These social gatherings received much attention from the local media, and after some time, they became a hit among the city�s university students.
Large manifestations, parades, fairs, celebrations where possible, support sex workers� assertion that sex work is work, and that they deserve occupational safety and dignity. The participation of government leaders, celebrities, and prominent women helps raise the self-esteem and protection and safety of the sex workers, and helps the broader community be more open to information about sex workers, and about their similarities with the community, rather than their differences. In India, participation of sex workers in �International Women�s Day� and other national holidays (e.g., Republic Day) has garnered the support and participation of civil authorities, police and �Bollywood� celebrities.
� Establishment of sex worker associations: It is crucial to encourage the establishment of sex worker organizations that can give voice to the sex worker community and develop a network of partnerships with other community-based and governmental entities. This may be the most ambitious intervention and, in the long run, offer the greatest potential for impact on community-led structural changes. It promotes social integration, social capital and social inclusion, all pivotal components of collective empowerment of sex workers. In many situations though, a country�s legal framework or donor interests do not allow prevention interventions on that organizational level. Therefore, each environment will require specific strategies and tactics for collective empowerment. Project Encounters (Pathfinder do Brasil in collaboration with the Population Council) supported the establishment of a sex work association in the city of Corumb�, which was recognized as a �best practice� by the National AIDS Program. Three years after the end of the project, the association is still actively engaged in designing and implementing their own HIV prevention and human rights projects, supported through municipal, state and federal funds.
Men who have sex with other men
According to UNAIDS, 5-10% of HIV infections worldwide are estimated to occur through sex between men.14 Men who have sex with other men (MSM), like female sex workers, have always been associated with the spread of HIV/AIDS. This has led to even greater social stigma and prejudice towards homosexual practices than already existed before the epidemic.15
After 25 years, the social representations that initially identified American homosexuals as HIV �core transmitters of the gay plague� or �victims of sin� still exist today and cause intense individual suffering and low self-esteem all over the world. The Vatican has often criticized the rise of gay rights as a potential threat to the traditional model of the family. In June 2006 the Holy See said that homosexual partnerships, along with a host of other practices, are to be seen as a sign of the �eclipse [the absence] of God,� maybe one of the strongest images ever used to scorn a community so completely.16 In some Muslim countries, homosexual acts are illegal and punishable with death, as in the hideous public hanging of two gay teenagers in Iran not long ago. The outcry of international civil society has not been able to reach deafened political and conservative religious ears.
Yet, it should be remembered that the homosexual community was the catalyst of the very first and urgent public response to the epidemic, beyond the scope of health services, reversing the social ideas that have erroneously associated men that have sex with men with promiscuity and disease. The actions of the homosexual movement focusing on HIV/AIDS prevention and care have been characterized by quick and broad mobilization of activists and sympathizers, for the creation of innovative and efficient strategies like safer sex workshops. They also raise issues related to diversity, free expression of sexual orientation, sexuality, solidarity, citizenship and defense of human rights.
The strength of the homosexual organized movement in pushing for human rights policies is best exemplified by the recent stance of the Brazilian government, which is currently implementing a multi-ministerial program entitled �Brazil without Homophobia,� coordinated by the Special Secretary of Human Rights, linked directly to the President�s Cabinet. The program, thoroughly designed with the active participation of the Brazilian homosexual movement, delineates a series of actions that different sectors (Culture, Justice, Health, Education, etc.) are expected to put in place to counter the effects of the homophobia that exists within society. It is important to remember that Brazil, despite the openness of its population to sexual issues, is one of the leading countries in the number of homophobic crimes perpetrated against gays, transvestites, and transsexuals.
MSM � not all the same
The term MSM has been coined as a way to describe a wide range of practices and identities. Very often, this concept does not contemplate the variety of manifestations of sexuality among men in a single country or context. In some countries, the gay, bisexual, and transgender social movements argue that the concept of MSM is discriminatory, since it does not recognize this diversity and the different specific needs in terms of health and human rights. It is therefore fundamental to differentiate the homosexual practices (when two men have sexual relations) with the homosexual identities (the way some groups express their culture and lifestyles and that fulfill the specific sexuality of these people). The idea that some men that have sex with men still consider themselves heterosexuals (or simply men) must be taken into consideration when designing messages for prevention interventions.
The linkage between these sexual identities and the values and meanings of masculinities must be considered to build a gendered understanding of these phenomena. Frequently, the concept of sexual orientation is related to a specific kind of social identity, that is known as the Western gay identity and lifestyle that may not have an equivalent in some countries. Very often, programs and projects focused on this population are based on the Western gay identity, and they fail to reach those people at risk who do not identify themselves with this specific way of living or expression. Even worse, some programs can spread widely the notion that people who are not openly gay (that is, do not have a Western gay identity) are a major source of HIV transmission, since they live �double lives.� It is only with the proper understanding of these key issues that we will be able to design and implement prevention programs in tune with the social and cultural meanings of the sexuality and gender of the specific groups. Creativity is needed to build programs that contemplate all the needs and interests of the variety of people represented under the MSM concept, without any kind of prejudice and with a socially/culturally sensitive approach.
�In Brazil, the transvestite and transsexual organizations definitively differentiate themselves from the gay community on the one hand, and from the MSM concept on other hand. Their main argument is that sexual orientation does not apply to them, since they have a �feminine� gender identity. Many, actually, consider themselves female heterosexuals, having specific ways of socialization and networking. It is known that they have distinct health and human rights needs, since they usually are the more discriminated against group. In other countries, this issue probably appears with other meanings, but it is important that HIV prevention programs respect this assumption, and promote better visibility and access for the transgender community. A recent policy related to the Brazilian health system guarantees that individuals be registered at health facilities using their social name (Mary, for example) instead of the name appearing in their national identity card (John, for example).
Situations that increase the vulnerability of MSM to HIV
� Homophobia (be it within the family or community circles, such as school, work, church, sports, and many other environments) is undoubtedly the most important factor contributing to the high vulnerability of MSM to HIV infection, and it is one of the primary obstacles to effective HIV prevention among this group;
� The low self-esteem, due to the negative values imposed by society on homosexuals, increases the likelihood of risky sexual behaviors, like cruising in isolated and dangerous places for casual sex, and being prey to police violence, theft, and even murder;
� Often, men who practice occasional homosexual sex do not, because of stigma, recognize themselves as homosexuals or bisexuals. This increases their vulnerability to HIV/AIDS, since they do not feel susceptible to the infection and, being outside of the MSM community, don�t have access to relevant preventative information;
� The gender role assignments that classify people�s sexuality as �active� and �passive� also interferes with the negotiation between male partners regarding condom use. Often �active� sexual partners refuse to use a condom, since they consider themselves heterosexuals;
� As discussed above, health services are organized without any input from the MSM community, and negative and punitive provider attitudes are not challenged or changed. Therefore services cannot address the particular needs, interests, and vulnerabilities of gays, transvestites, and transsexuals;
� Social and political organizing of MSM is very difficult in strongly homophobic or culturally conservative societies. Even establishing their own organizations to provide information that they can�t get from health services, or organizing forums for discussion and designing structural actions are all extremely difficult;
� Most MSM are also married and must live a hidden double life, which increases their own vulnerability as well as that of their wives and children. Recent studies in districts of Maharashtra, India show a range of 63-81% of the MSM as married;
� Adolescent homosexuals are much more prone to physical abuse, discrimination at school, and domestic violence. Also, the recent improvements in AIDS-related morbidity and mortality due to more accessible treatment have caused a dangerous trend in reduced condom use among young gay men;
� Educational materials for HIV prevention, as well as mass campaign messages, are mainly directed at the heterosexual population, creating the false impression that homosexual intercourse is risk-free. A recent study conducted with truckers in India has shown that the message about female sex workers transmitting AIDS has been so effective that even �heterosexual� men prefer to have sexual relations with a man so they won�t be exposed to AIDS;
� Very low visibility of homosexual behavior in all male environments, like prisons, factories, mines, and military settings, which adds to the lack of political commitment in addressing MSM;
� The return in some countries, of the �bare-backing� (unprotected sex) practice between MSM, who knowingly expose themselves and their sexual partners to a higher risk of HIV infection;
� In the specific case of transvestites and transsexuals, deep social stigma excludes them and limits their job opportunities and acceptance in society, further increasing their vulnerability to HIV infection;
� Additionally, the use of silicon for body modeling may place transgender individuals under increased vulnerability due to the conditions under which such procedures take place. Usually, industrial silicon is injected at home, where sterilization of syringes and needles is not always done adequately, causing possible infection with HIV and other pathogenic organisms.
Effective HIV prevention strategies for MSM
Just as for sex workers, HIV prevention interventions for men that have sex with men should focus on:
� Behavioral interventions to promote safer sexual practices, especially those related to constant and correct condom use with all sexual partners (fixed, occasional, clients, women, wives, etc.);
� Guaranteeing equal access to comprehensive, quality, appropriate, health services, e.g., VCT, care for both HIV-positive and negative persons, prevention services for both HIV negatives and positives, potentially together, integration of prevention and treatment, and referral to other specialized services (psychological, physiotherapy, laboratory, STI services, etc.);
� Improvement of community development indicators, principally those related to social integration (e.g., counting on friends when medical services, money, shelter, or discussing police violence, etc., are needed);18
� Development of educational and informational materials, addressing human rights alongside health issues. However, given the diversity of the various expressions of homosexuality (openly gay men, �closeted� gay men, bisexuals,transgender or transsexual individuals, adolescents and older men, etc.), messages, and approaches may differ substantially for each specific group;
� Promotion of safe sex workshops. These were first initiated by the American gay community at the onset of the epidemic to disseminate a set of sexual practices and care components that would diminish or eliminate the risk of HIV infection. Such workshops are still one of the most effective ways to reduce vulnerability of MSM. The implementation of such meetings should be broadened in scope, and also cover structural issues that may be of interest to participants, like domestic and police violence, discrimination at school and in the work environment, relationships, bisexuality, marriage and fatherhood, living with HIV/AIDS - all examples of topics that can generate lively and critically important discussions.
The ultimate goal of these safer sex workshops is to move gradually from a gathering of individuals discussing safer sex practices and coping mechanisms into a more cohesive and empowered group that can jointly elaborate action plans to confront complex collective issues. Of particular importance is the implementation of meetings with adolescent gay men, where they will find a safe haven to openly share their inner feelings of discovering sexuality in a social and religious environment that constantly bombards them with guilt and shame. Effective strategies for emphasizing constant and correct condom use and water-based lubricants among adolescent gay men are particularly important.
In the beginning it is very likely that such community meetings will be only attended by openly gay men (the minority), while those still not comfortable with their sexuality (the majority) will feel more reluctant to participate. In this respect, peer face-to-face interventions in cruising areas (bars, bathhouses, parks) can play an important role in the accessibility to condoms and educational materials by a greater percent of the homosexual community. Selection and training of peer educators should be tackled with the same care as described above for sex worker peer educators.
� Training and sensitization of teachers on issues related to sexual diversity can help them review their vision and opinions on homosexuality and provide counseling and support to MSM adolescents to decrease their vulnerability. They can also collaborate through their work - in and out of school - in the eradication of social prejudice against MSM and promotion of tolerance. Likewise, they can work with parents to accept and support their children and their sexual orientation to keep them safe. Teachers are in a good position to be effective in this effort. They are invaluable in the design of educational material specifically addressing issues of interest to the MSM community (condom use, HIV voluntary counseling and testing, human rights, self-esteem, etc.) In Brazil, Pathfinder is embarking in an important partnership with the Ministry of Education, the National Association of Gays, Lesbians, and Transgenders, and two other local partners to implement a project addressing homophobia in the public school system. Planned activities include the implementation of nationwide qualitative research to assess levels of homophobia among students, teachers, and educational material currently in use, as well as the design and distribution of informational kits addressing topics of homophobia to 6,000 schools in the country;
� Just as for SW, police harassment against MSM can be reduced through sensitization workshops conducted with police members, even where homosexuality is illegal. Here as well, topics for discussion may include HIV prevention, sexuality, gender issues, and stigma and discrimination. The role of the police in protecting citizens from all sorts of abuse should be acknowledged, avoiding any type of confrontational exchange. However, as with SW, some police in some countries rob MSM and have forced sex with them on threat of violence, and this needs to be urgently addressed;
� Support to political manifestations of the homosexual community, like Gay Pride parades and rallies - in countries where homosexuality is not considered a crime - can greatly increase visibility of gay men and foster discussions on public policies to curb social homophobia.19 These events are also important spaces for the promotion of self-care, citizenship, and self-esteem. In Brazil, for example, the National HIV/AIDS Program annually allocates significant funding to support dozens of Gay Pride parades all over the country, as part of its rights-based policy.
Male Sex Workers
Addressing the specific needs and interests of male sex workers can further reduce the vulnerabilities of the general MSM population. In general, male sex workers tend to be either bisexual men or transgender individuals, and different approaches should be designed, depending on the target group being reached.
For both male and female sex workers, focus should be put on negotiation skills for condom use, avoiding or organizing against police harassment, and establishment of self-help groups. On the other hand, social stigma and prejudice make clients of male sex workers much more difficult to reach than those of SW. Male sex workers can be trained to be the main providers of HIV prevention messages to their clients.
Finally, it is effective to establish organizations of MSM, encouraging them to have a key place in HIV prevention and care programs. More importantly, these MSM community-based organizations should be encouraged to help define advocacy interventions leading to the de-criminalization of same-sex acts between consenting adults, as well as the passing of antidiscrimination policies against human rights violations based on sexual orientation.20 Networking is not only the right thing, but is the only way to empower them to decrease HIV transmission among MSM. These organizations should also be assisted in their efforts to lobby governments, National AIDS Programs and donors to include MSM in their HIV programming and funding priorities.
