THE LANCET SERIES ON HIV IN SEX WORKERS; PAPER 4 BURDEN AND HIV IMPACT OF HUMAN RIGHTS VIOLATIONS AGAINST SEX WORKERS

Abstract

We reviewed evidence from over 800 studies and reports on the burden and HIV impact of human rights abuses against sex workers across policy climates. Published research documents widespread abuses of human rights perpetrated by both state and non-state actors. Such violations facilitate HIV vulnerability, both directly and indirectly, and undermine effective HIV prevention and intervention efforts. Violations include homicide, physical and sexual violence from law enforcement, clients and intimate partners, unlawful arrest and detention, discrimination in accessing health services, and forced HIV testing. Abuses occur across all policy regimes, though most profoundly so where sex work is criminalized through punitive law. Protection of sex workers’ human rights is critical to respect, protect and fulfill human rights, and to improve their health and wellbeing. Findings affirm the value of rights-based HIV responses for sex workers, and underscore the obligation of states to uphold the rights of this marginalized population.

INTRODUCTION

Sex workers are an established key population for HIV, with a high burden documented amongfemale,¹ male,² and transgender,³ sex workers. HIV prevention and treatment interventions for sex workers are cost-effective, and can reduce this burden.⁴ Yet sex workers face significant barriers in accessing prevention and treatment. Though not always described as human rights violations, social injustices including poor working conditions, violence, police harassment, and discriminationhave long been considered barriers to HIV prevention and successful treatment for sex workers.^4,5 These experiences constitute violations of human rights, or the freedoms and dignities derived inherently on account of being human.⁶ The health and human rights framework has guided the global HIV response to an unprecedented degree in public health,⁷ in part because the epidemic demonstrates the cost ofrestrictions on human freedom and dignity.⁶

Sex workers’ human rights are rarely addressed within human rights conventions or declarations. All persons are entitled to the fundamental rights and protectionsarticulated by the Universal Declaration of Human Rights (1948), the International Convenant on Economic, Social and Cultural Rights (ICESCR; 1966), and the International Covenant on Civil and Political Rights (ICCPR; 1967). These rightsare not abrogated by status as a sex worker. One of the only conventions to specifically address sex workersis the Convention on the Elimination of Discrimination Against Women (CEDAW; 1979), through a Committee recommendation which emphasized sex workers’ vulnerability to violence owing to marginalization and criminalization of sex work, and affirms their need for equal protection of laws against abuse.⁸ Historically, human rights bodies have been reluctant to address human rights violations against sex workers due toperceived morality concerns. More recently, UN guidelines and reports increasingly address human rights violations against sex workers.^5,9-12 Sex worker and advocates use the human rights framework to evaluate their experiences and document rights violations,^13-17 inspiring others, including the CEDAW Committee¹⁸ and UN Special Rapporteurs,^19,20 to do the same.

To improve our understanding of the range, epidemiology, and HIV impact of human rights violations against sex workers, we comprehensively reviewed the literature, and describe human rights profiles across four dominant policy responses to sex work. In doing so, we recognize the right to health as a basic human right, and describe how health is influenced by other human rights violations against sex workers.

Human Rights Violations Among Sex Workers: HIV Impact

Many human rights abuses experienced by sex workers go unreported to police or other officials based on a sense of futility and fears of further violence. Table 1 details violations and HIV impacts.

Table 1.

Human Rights Violations & Impact on HIV and Safety

Human Rights Violations	% affected	Impact on HIV and safety	Human Rights Infringed
Homicide	• Rate among sex workers is seventeen times that of the general population.22	n/a	• Right to life (ICCPR, Article 6; ECHR, Article 2; ACHR, Article 4; ACHPR, Article 4) • Right to Equality and non-discrimination (ICCPR, Articles 3 and 26; CEDAW, Article 2; ECHR, Article 14; ACHR, Article 24; ACHPR, Article 3) • Right to the highest attainable standard of health (ICESCR, Article 12; CEDAW, Article 12; ACHPR, Article 16)
Physical or Sexual Violence by Police	• Sexual violence 7-89%32,34,40,45-48 • Physical violence 5-100%32,40	• Police-perpetrated sexual violence is often unprotected • Police sexual violence significantly associated withaccepting more money for unprotected sex, inconsistent condom use, STI symptoms,46and STI/HIV infection45 • Undermines sex workers' ability to obtain protection from police	• Right to equality and non-discrimination (ICCPR, Articles 3 and 26; CEDAW, Article 2; ECHR, Article 14; ACHR, Article 24; ACHPR, Article 3) • Right to security of person (ICCPR, Article 9; ECHR, Article 5; ACHR, Article 7; ACHPR, Article 6) • Right to freedom from torture and cruel, inhumane and degrading treatment (ICCPR, Article 7; CAT; ECHR, Art. 3; ACHR, Article 5; ACHPR, Article 5) • Right to the highest attainable standard of health (ICESCR, Article 12; CEDAW, Article 12; ACHPR, Article 16) • Right to life (ICCPR, Article 6; ECHR, Article 2; ACHR, Article 4; ACHPR, Article 3) • Right to Privacy (ICCPR, Article 17; ECHR, Article 8; ACHR, Article 11)
Arbitrary Arrest and Detention	• 4-75% report arrest; lawfulness unclear34,42,46,52-54,70 • 21-29% experienced police raid46,123	• Arrest and detention a context for police harassment, mistreatment, and physical and sexual violence17,32 • Sexual abuse in detention and at the time of arrest can confer immediate HIV risk • Fear of arrest is a barrier to HIV testing62 • Where sex workers move underground to avoid police detection, greater risk for pressured into unprotected sex59 • Arrest, raids and imprisonment associated with unprotected sex,46,60 STI/HIV symptoms and infection46,52,61,54 and client-perpetrated violence46 • Limited access to HIV prevention materials (e.g. safer sex and harm reduction supplies) in places of detention	• Right to Equality and Non-discrimination (ICCPR, Articles 3 and 26; CEDAW, Article 2; ECHR, Article 14; ACHR, Article 24; ACHPR, Article 3) • Right to Liberty and Security of Person (ICCPR, Article 9; ECHR, Art. 5; ACHR, Article 7; ACHPR, Article 6) • Right to Freedom from Torture and Cruel, Inhuman, and Degrading Treatment (ICCPR, Article 7; CAT; ECHR, Article 3; ACHR, Article 5; ACHPR, Article 5) • Right to a fair trial (ECHR, Article 6; ACHR, Article 8; ACHPR, Article 7) • Right to the highest attainable standard of health (ICESCR, Article 12; CEDAW, Article 12; ACHPR, Article 16)
Police Seizure of Condoms or Syringes	• 7% -80% report condom confiscation38,46 • 29%-48% report syringe confiscation47,56	• Can prompt unprotected sex27,38,46 and unsafe injection practices • Sex workers and their managers stop carrying or providing condoms58,64 • Syringe confiscation associated with HIV56	• Right to the highest attainable standard of health (ICESCR, Article 12; CEDAW, Article 12; ACHPR, Article 16) • Right to Freedom from Unlawful Interference (ICCPR, Article 17) • Right to Equality and non-discrimination (ICCPR, Articles 3 and 26; CEDAW, Article 2; ECHR, Article 14; ACHR, Article 24; ACHPR, Article 3) • Right to work (ICESCR, Article 6; ACHPR, Article 15) and to enjoy just and favourable conditions of work (ICESCR, Article 7; CEDAW, Article 11)
Police Extortion	• Some form of extortion 12% -100%32,34,44,46-48,56	• Can prompt sex workers to take on riskier clients or forms of sex44 • Associated with inconsistent condom use and STI symptoms.46 • Undermines sex workers' ability to obtain protection from police	• Right to equality and nondiscrimination(ICCPR, Articles 3 and 26; CEDAW, Article 2; ECHR, Article 14; ACHR, Article 24; ACHPR, Article 3) • Right to Freedom from Unlawful Interference (ICCPR, Article 17) • Right to the highest attainable standard of health (ICESCR, Article 12; CEDAW, Article 12; ACHPR, Article 16)
Impunity: Failure to investigate, police threats, violence and other impunity when sex workers report violence	• 39-100% feel they cannot report violence to police32	• Enables police, clients to perpetrate physical and sexual violence against sex workers with impunity	• Right to equality and nondiscrimination (ICCPR, Articles 3 and 26; CEDAW, Article 2; ECHR, Article 14; ACHR, Article 24; ACHPR, Article 3) • Right to Liberty and Security of Person (ICCPR, Article 9; ECHR, Art. 5; ACHR, Article 7; ACHPR, Article 6)Right to Freedom from Unlawful Interference (ICCPR, Article 17)
Forced Rehabilitation and Detention	No quantitative estimates identified	• Unhygienic conditions, lapses in medication and health services • Context for rape and physical violence	• Right to liberty and security of person (ICCPR, Article 9; ECHR, Art. 5; ACHR, Article 7; ACHPR, Article 6) • Right to the highest attainable standard of health(ICESCR, Article 12; CEDAW, Article 12; ACHPR, Article 16) • Right to Equality and non-discrimination (ICCPR, Articles 3 and 26; CEDAW, Article 2; ECHR, Article 14; ACHR, Article 24; ACHPR, Article 3) • Right to Freedom from Torture and Cruel, Inhuman, and Degrading Treatment (ICCPR, Article 7; CAT; ECHR, Article 3; ACHR, Article 5; ACHPR, Article 5) • Right to Privacy (ICCPR, Article 17; ECHR, Article 8; ACHR, Article 11)
Physical and sexual violence by non-state actors	• 8- 76% report physical or sexual abuse by clients25,34,40,45,46,48,68,70,72-74 • 4-64% report physical or sexual violence from non-paying intimate partners34,70	• Client violence is associated with STI/HIV45,73,74 • Client violence is often perpetrated when sex workers refuse unprotected sex or certain types of sex • Barrier to accessing health services82	• Right to equality and non-discrimination (ICCPR, Articles 3 and 26; CEDAW, Article 2; ECHR, Article 14; ACHR, Article 24; ACHPR, Article 3) • Right to security of person (ICCPR, Article 9; ECHR, Article 5; ACHR, Article 7; ACHPR, Article 6) • Right to freedom from torture and cruel, inhumane and degrading treatment (ICCPR, Article 7; ECHR, Art. 3; ACHR, Article 5; ACHPR, Article 5) • Right to the highest attainable standard of health (ICESCR, Article 12; CEDAW, Article 12; ACHPR, Article 16) • Right to life (ICCPR, Article 6; ECHR, Article 2; ACHR, Article 4; ACHPR, Article 3) • Right to work (ICESCR, Article 6; ACHPR, Article 15) and to enjoy just and favourable conditions of work (ICESCR, Article 7; CEDAW, Article 11)
Institutionalized discrimination: Discrimination in Access to Health Services and Social Services		• Discrimination in access to health services, HIV prevention and care, and social services undermines access to the cascade of testing, treatment, adherence and viral suppression34,26,62,81,82,44,79 • Discriminatory or inaccessible shelter services renders sex workers vulnerable to violence as well as resulting HIV risk84,85	• Right to Equality and non-discrimination (ICCPR, Articles 3 and 26; CEDAW, Article 2; ECHR, Article 14; ACHR, Article 24; ACHPR, Article 3) • Right to the Highest Attainable Standard of Health (ICESCR, Article 12; CEDAW, Article 12; ACHPR, Article 16) • Right to Life (ICCPR, Article 6; ECHR, Article 2; ACHR, Article 4; ACHPR, Article 3) • Right to adequate standard of living, including adequate food, clothing and housing (ICESCR, Article11)
Forced HIV testing	No quantitative estimates identified	• Can worsen discrimination and stigma • Drive sex workers away from health services • Can subject sex workers to criminalization if they test positive and to violence	• Right to Equality and non-discrimination (ICCPR, Articles 3 and 26; CEDAW, Article 2; ECHR, Article 14; ACHR, Article 24; ACHPR, Article 3) • Right to Security of person (ICCPR, Article 9; ECHR, Article 5; ACHR, Article 7; ACHPR, Article 6) • Right to Freedom from Torture and Cruel, • Inhuman, and Degrading Treatment (ICCPR, Article 7; CAT; ECHR, Article 3; ACHR, Article 5; ACHPR, Article 5) • Right to Privacy (ICCPR, Article 17; ECHR, Article 8; ACHR, Article 11) • Right to the Highest Attainable Standard • of Health (ICESCR, Article 12; CEDAW, Article 12; ACHPR, Article 16)

International Covenant on Civil and Political Rights (ICCPR)

International Covenant on Economic, Social, and Cultural Rights (ICESCR)

Convention on the Elimination of All Forms of Discrimination against Women (CEDAW)

Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (CAT)

[European] Convention for the Protection of Human Rights and Fundamental Freedoms (ECHR)

American Convention on Human Rights (ACHR)

African (Banjul) Charter on Human and Peoples’ Rights (ACHPR)

Homicide

Sex workers are highly vulnerable to homicide, andhave been explicitly targeted by serial killers in Canada, the United States, Iran, Namibia and the United Kingdom.²¹ In the US, sex workers’ homicide rate is seventeen times that of the general population.²² Canada saw an estimated 300 sex worker murders between 1985 and 2011.²³ This grave rights violation reflects a culmination of social marginalization, lack of equal access to police protection and a climate of impunity towards violence against sex workers.²¹

Police Repression, Extortion, and Physical and Sexual Abuse

Street-level policing is a primary means of addressing sex work. It is often intensified with crackdowns on sex work, often timed with political motivations.²⁴ Police frequently harass sex workers;^25-27 including name calling,²⁸ and humiliating treatment, such as transgender sex workers being “defaced”, or stripped of their clothing.^27,29 Severe physical violence such as beatings, public whippings and shocking with electrical rods can occur in police detention.^30-32

Male, female, and transgendered sex workers alike report severe sexual violence, including gang rape and forced unprotected sex by police officers; including that at the time of arrest and while detained.^{26,32-41,29,30,42,43} Arrest can be a context for rape;^17,32 with sex workers being driven far away for sexual assault, rather than the police station, on the pretext of arrest.^17,44 Quantitative estimates vary widely, with police-perpetrated sexual violence reported by 7-89% of sex workers.^{45,46,32,34,40,47,48} Such abuse is significantly associated with prevalent STI/HIV.⁴⁵ Police have been found to coerce sex under threat of arrest, prolonged detention or further violence.^{17,24,33,35,37,38,48} Such acts are often described as “free services” or in “exchange for release”,^{32,34,38,48,49} a characterization that minimizes the inherent power imbalances between police and sex workers. Where police wield the power of arrest, and where sexual acts occur under the threat of harm, they constitute sexual violence. Given the power disparity between police and sex workers, sex workers also have little control over condom use.^30,43

Police wield tremendous power over sex workers, particularly where sex work is criminalized. They leverage power through arrest and forced detainment of sex workers. Police often disregard due process, with arrest occurring without explanation^24,50,51 and often on no legal grounds.³³ Where quantified, between 4-75% of sex workers report arrest.^{34,42,46,47,52-54} Widespread arrest can occur during organized raids,^33,46 often under the guiseof anti-trafficking,³³ and accompanied by severe physical and sexual violence.⁵⁵ Conditions of detention are often poor and include forced labor such as forced cleaning or grounds-keeping work.^{17,30,32,33,44} Humiliation and public shamingare also tools of abuse against sex workers.^17,33,44,28 Some have been forced to forgoART, other medication, condoms, and harm-reduction materials while in detention.^30,44

Police also abuse their power by extorting fines and information from sex workers, often under threat of arrest, physical violence, and gang rape.^17,32,37 Where quantified, extortion affects an estimated 12% -100% of sex workers.^{32,34,44,46,48,56,47,57} Financial extortion prompts sex workers to take on riskier clients or forms of sex to compensate,⁴⁴ and has been shown to increase risk for inconsistent condom use and STI symptoms.⁴⁶

Police repression is a complex system wherein police exploit their power where sex work is criminalized by policy and practice. The resulting climate of fear⁵⁸ impartsdirect HIV risk, e.g., police-perpetrated sexual violence is associated with STI/HIV.⁴⁵ Indirect HIV risk can also result, with sex workers being displaced towards isolated and dangerous settings to avoid police detection, effectively forcing them to trade their safety and well-being for relief from police interference.^33,44,50 Police repression forces sex workers to move their work off main streets,⁵⁹ into lesser known areas, prompting risk for being pressured into unprotected sex by clients, and violence and other hazards. Other evidence links police arrest, raid, extortion and sexual violence with client violence.⁴⁶ Arrest and imprisonment are associated with unprotected sex^46,60 including that for which clients offer higher payment,⁴⁶ as wellas STI/HIV symptoms and infection.^46,52,61,54 Fear of arrest canconstitute a barrier to HIV testing,⁶² where sex workers fear contact with any type of services for the possibility of police involvement.

Police confiscation of condoms and syringes, and use of condoms as evidence of sex work

Condoms are an evidence-based HIV prevention tool and a central component of global prevention strategies.Yet many sex workers fear carrying condoms,⁶³ which can be used by police as evidence of sex work and even confiscated.^{24,32,27,48,58,60,64} Where quantified, between 7-80% of sex workers describe police confiscating, destroying or using condoms as evidence against them,^38,46 and over one third describe not carrying condoms for fear of law enforcement.³⁸ Being caught with condoms can prompt police extortion.^27,38 Sex workers have few alternatives to unprotected sex when condoms are confiscated or forgone for fear of harassment.^27,38 When quantified, condom confiscation is associated with unprotected sex.⁴⁶ Police condom confiscation can also make venue managers reluctant to provide condoms.⁶⁴ Similarly, sex workers involved in injection drug use can suffer syringe confiscation, even where syringe purchase is legalover the counter.⁵⁷ In turn, syringe confiscation is associated with prevalent HIV.⁵⁶ Syringe confiscation is also associated with police-perpetrated sexual violence, illustrating the potential for multiple, interactivepolice threats to sex workers’ health and safety.⁵⁷

Impunity and Discrimination in Access to Justice

Police abuse clearly conveys discrimination in accessing the criminal justice system. Fear of stigma and discrimination are powerful barriers to reporting crimes to the police.²⁹ Sex workers who do seek justice can experience police inaction and resistance to taking reports of abuse.^32,21,65 Police often uphold a harmful and discriminatory notion that sex workers cannot be raped,^29,66 further undermining sex worker protection under laws against sexual violence. Even where sex work is legal, police have been found unwilling to protect sex workers.⁶⁷ Fear of being implicated in criminal activity can also impede sex workers comfort in reporting abuse to police.^28,32,65 Based on the totality of these injustices, sex workers describe a profoundsense of futility and lack of protection of the criminal justice system.⁶⁸

Forced“Rehabilitation”and Detention

Forced or mandatoryrehabilitation, and other detention,often under the guise of anti-trafficking, has been documented,particularly following “raid and rescue” operations.^26,33,55 Forced rehabilitation is often implemented by the state or by NGOs including religious groups in collaboration with states. Sex workers have faced forced confinement, forced labor, forced STI and HIV testing, and poor treatment, including unhygienic conditions. ^31,33,55 They have been denied medication and medical services including that for HIV,^33,55 as well as antenatal visits and vitamin supplements during pregnancy.⁶⁹ In some cases, rape and other physical violence occur during forced rehabilitation.^33,64 In China, suspected sex workers have beendetained for up to two years without trial in “re-education through labour” centers.³¹

Violence from non-state actors

Non-state actors also feature prominently in human rights violations against sex workers. Physical and sexual abuse perpetrated by clients,and those posing as clients, is common, and often occurs during condom negotiation.^{25,34-36,40,45,48,50,53,70-72} Client-perpetrated physical and sexual violence, including forced anal sex,⁷³ is associated with STI/HIV risk behavior^39,45,70,72 and infection.^39,45,73,74 Abuse is fueled in part by recognition of sex workers’ barriers to seeking justice, which enables perpetration of physical and sexual violence with impunity.⁶⁵

Sex workers also suffer intimate partner violence,^{34,70 ,75} yet fear of police mistreatment can be a significant barrier to reporting.⁷⁶ Abusive intimate partners exploit the illegality of sex work, and may threaten to expose them to police, as tactics of control.²⁹ Sex workers also suffer abuse through vigilante raids and violence by NGOs, religious groups and private militias.

Unsafe Working Conditions and Lack of Labor Protection

The International Labour Organization's guidance on HIV and the workplace is inclusive of sex workers, and emphasizes workplace safety.⁷⁷ Yet lack of labor protections can expose sex workers to abusive and unsafe conditions with few options for redress.⁷⁸ Fear of abuse from managers leaves sex workers with little control over their working conditions, including inability to decline specific clients or sex acts, as well as inability to enforce condom use with clients. Criminalization of third parties, i.e., individuals other than sex workers and their clients, such as managers, can make it difficult to report labor abuses without losing employment.⁷⁸ In most places, particularly where sex work occurs in the informal economy, sex workers lack basic labor rights such ascompensation for workplace injury, health insurance, and unionization.

Institutional Discrimination: Discrimination in Access to Health or Welfare Services

Sex workers suffer discrimination and denial of health services, including HIV testing and treatment.^36,44,79,80 Confidentiality is not always assured,⁴¹ andmany sex workers are reluctant to disclose their work,²⁸ or face backlash when it is discovered.⁸⁰ Stigma and fear of discrimination are formidable barriers to accessing VCT and othercare,^{34,26,62,81,82} as well as ART treatment and adherence.^44,79 Sex workers are also subject to HIV-related discrimination, where seeking services, initiating ART, or otherwise being identified as positive could expose them as diseased with resultant loss to clients and thus income,^79,81 and sex workers have been criminalized for being HIV positive. Sex workers who cannot present male partners have been denied STI treatment on the basis of not presenting a male partner, ⁸³ as has been observed in denial of prevention of mother to child transmission (PMTCT) services.The presumption of sex work, or even extramarital/pre-marital sex, can be enough to reduce women's access to health care.Institutional discrimination extends beyond health sector. In some settings, sex workers have been unable to obtain basic social services, including bank accounts and microfinancing support programs.^29,44 These discriminatory practices, particularly inaccessible shelter services, prompt risk for violence and other HIV risk. ^84,85

Mandatory and Forced HIV Testing and Health Exams

Sex workers are targeted for forcible and coercive HIV testing,⁸⁶ including that in detention centers and affiliated health clinics.²⁴ Mandatory HIV and STI screening is a common component of sex worker registration systems.^87,88 Yet this approach fails on public health and human rights grounds where sex workers have little control over testing conditions, and are not always assured access to ART. Violations of patient confidentiality and criminalization of HIV+ sex workers are also found in regimes of mandatory testing.^32,89 Mandatory testing can become a tool of discrimination against sex workers.⁹⁰ Police can also use testing as a tool of exploitation and harassment. Sex workers report forced STI testing in detention and the aftermath of police raids.^51,32 Police can abuse the threat of forced testing as a means of extortion and a pretext for detaining or abusing them.³²

Policy Approaches to Sex Work:Human Rights Profiles

Policy approaches to sex work are inclusive of both codified laws as well as their implementation via policies and practices.Enforcement can occur through valid means as well as abusive and illegal practices. Table 2 describes the dominant policy approaches to sex work and their influence on human rights for sex workers. We do not cover all of the possible intersecting laws, policies and practices that affect sex workers but rather portray the dominant responses. Some are discussed in greater detail elsewhere.^2,3

Table 2.

Health and Human Rights Profiles Across Policy Climates

	Criminalization	Partial Criminalization	Legalization	Decriminalizatior
Description	Full Criminalization Criminal or punitive laws prohibit all of the following: the selling of sex, the purchasing of sex or earning money from someone's sex work (i.e. as a manager, as sex workers' working together cooperatively, as support staff, or as a landlord renting a home to a sex worker), and may be included within broader laws on trafficking, such as in South Korea Indirect forms of criminalization include prohibitions on “solicitation for the purposes of prostitution” or “being found in a brothel”.	Criminal or punitive laws prohibit eitherone or two of the following: selling sex, buying sex or earning money from someone's sex work (i.e. as a manager, as sex workers' working together cooperatively, as support staff, or as a landlord renting a home to a sex worker). Given the rise in prominence of the Swedish approach of criminalizing buying sex and earning money from someone's sex work, and the unique issues this model raises, we focus on it here.	Sex work is legal under specified conditions. Legalization is most often accompanied by mandatory registration, health exams, testing and occasionally STI treatment. Regulation is often discriminatory and enforced through criminal law, e.g., sometimes only targeting female sex workers. Earning money off of someone's sex work may or may not be criminalized (by extension brothels or renting lodging to sex workers may or may not be criminalized). Regulations may favor sex workers working independently from indoor locations or may make it difficult to do so legally and favour large-scale brothels.	Sex work is legal occupational healthand specific to sex work other work environments health and safety Municipalities may regulationsunder by
Guiding Purpose	Eradication of sex work on grounds of public health, morality and/or public order.	Eradication of sex work on grounds of public health, morality and/or public order.	Regulation of sex work for public health and/or public order, through containment, control and/or taxation of sex work.	Protection of sex promotion of sex and safety.
Examples	South Africa, Kenya, Uganda, Zimbabwe, South Korea, Bosnia-Herzegovina, India, Russia, United States	Sweden, Norway	Hungary, Austria, Nevada (USA), Senegal, Tijuana (Mexico)	New Zealand, New
Human Rights and Health Profile and Implications	The most severe and systematic rights violations occur within contexts of punitive laws (full or partial criminalization). Punitive laws, even when lawfully applied, impede sex workers' ability to protect their health and safety and create an antagonistic relationship with law enforcement. The resulting climate of impunity emboldens police, health sector, and non-state actors to abuse sex workers rights. In turn, sex workers are vulnerable to exploitation, and inhibited from seeking redress for abuses. Particularly where rule of law is weak, punitive laws often give cover to widespread abuses. Where sex work is criminalized rather than protected by law, discrimination against sex workers can be institutionalized not only by police but additionally by actors in health and other sectors. Together criminalization and its concomitant impunity, institutional discrimination and social marginalization contribute to abuse, pose direct and indirect HIV risk, and impede access to prevention, services, care, treatment and support.	The most severe and systematic rights violations documented within the literature occur within contexts of punitive laws (full or partial criminalization). Notably, partial criminalization creates harms similar to those of full criminalization by impeding sex workers' ability to protect their health and safety and creating an antagonistic relationship with law enforcement with a resulting climate of impunity. Client criminalization is considered to have undermined sex worker safety and health, with rushed negotiations undermining condom use, displacement of sex workers to isolated locations to evade police detection, police harassment, and fear of police reporting66,94 Discrimination can be institutionalized, for example making receipt of medical care contingent on stopping sex work.66 As in other criminalized climates, the legal framework conceptualizing the purchase of sex as an act of violence can undermine HIV-prevention services as it is perceived as enabling a crime.66	Rights violations are documented in legalized environments. Poorly specified tolerance zones, can enable arbitrary arrest49 and extortion, particularly where rule of law is weak. Mandatory HIV/STD testing is often a component of regulatory systems, though it is sometimes costly and does not always enable ART access. Physical and sexual violence by clients and police has been documented in regulatory environments, including in specified “legal” settings. Regulation can create a two-tiered system leaving some sex workers unprotected by the law.108Police failure to investigate abuse has been documented. Discrimination in the health sector is documented, and sex workers living with HIV can be criminalized.89 The lack of legal protection against discrimination or abuse, and the costs and requirements of registration, often make it unappealing for sex workers. That sex workers evade regulation raises questions about the utility of this approach in meeting public health and rights objectives.	Decriminalization evidenced by decreased impunity where sex decriminalization, Zealand. In New Zealand, most decriminalization violence and increased safer sex. Access increased, though against sex workers workers are still reluctant In New Zealand, only than 4 sex workers an increase in sex independently or for management. In New South Wales, in decriminalized to safe sex skills at suggesting greater decriminalized settings. We also note New assessing their legal large-scale independent hundreds of sex workers
Legal Approach to Trafficking or Coerced Sex Work	Criminalizes trafficking, coerced sex work andsexual exploitation of minors.	Criminalizes trafficking, coerced sex work and sexual exploitation of minors.	Criminalizes trafficking, coerced sex work, andsexual exploitation of minors.	Criminalizes trafficking, andsexual exploitation

Criminalization of sex work through punitive law

The dominant global response to sex work is criminalization through punitive law, both criminal and administrative.⁹¹ Countries vary both in the extent of criminalization and the specific aspects of sex work that are prohibited. Many laws directly criminalize the selling of sex. Others criminalize through prohibiting the purchase of sex or earning money from someone's sex work. Many settings also criminalize sex work indirectly, through prohibitions on aspects of sex work such as communicating for the purposes of prostitution or being found in a brothel. Some countries like the United States, with the exception of some parts of Nevada, have full criminalization of virtually all aspects of sex work, e.g., selling sex, buying sex, earning money from someone’ sex work, running a brothel. This approach criminalizes not only sex workers, but additionally clients and third parties such as managers, or security.⁴⁴ Sex work can also be criminalized under religious law, traditional law or executive orders, and criminalized or repressed via discriminatory targeting of other laws, e.g., pertaining to vagrancy, sodomy, drugs or immigration.²⁰ For example in Iran, sex work was punishable by execution under Shari’a law; under the new penal code sex workers can face punishment by death under adultery charges.⁹²

Some countries criminalize only some aspects of sex work, i.e., partial criminalization. In Brazil for example, brothel-keeping is criminalized while individual sex work is not. Many countries combine prohibitions, e.g., criminalizing brothel-keeping and selling sex, as in Russia and most countries in Eastern Europe and Central Asia.^32,93

The Swedish “end demand”criminalization approachprohibits buying sex andearning money from someone's sex work, and is increasingly popular based on its client orientation. Yet despite the focus on clients, sex workers’ health and safety can suffer.⁶⁶ Sex workers continue to face police harassment as “party to a crime”, and fear reporting crimes.^66,94 Safety dynamics are similar to those seen where selling sex is criminalized in that fears of arrest can rush negotiations with clients, and sex workers can be displaced into isolated and dangerous areas to evade client detection by police. While adopting legal sanctions against buying sex, nations such as South Africa, South Korea and Lithuania have also maintained the criminalization of selling sex, and South Korea increased raids against sex workers following the passage of the law. ⁹⁵

Human rights abuses are most profoundly felt under regimes of criminalization, with both state and non-state actors perpetrating physical and sexual violence, harassment and discriminatory practices.^{29,30,32,45,46,50,72 ,73,83} Sex workers who also use drugs often face escalating or exacerbated sentencing for one or both offenses. Criminalization enables and institutionalizes discrimination against sex workers, undermines their access to justice, and gives cover and license to police and non-state-actors to abuse their rights.It undermines sex workers ability to work safely and protect their health. Even when lawfully implemented,criminalization can impede client screening and condom negotiation, prevent sex workers from working together or in known locations with safety features, pose an obstacle to hiring security personnel, and make it more difficult to gather evidence against those who coerce or exploit sex workers.³² Criminalization, including regimes that do not criminalize selling sex directly, can prohibit state-support for sexual risk reduction programs, condom distribution, and violence prevention with active sex workers.⁶⁶

Legalization of Sex Work

Generally, where sex work is legalized, it isallowed under specified conditions and otherwise punishable by law. It is predicated on sex work regulation, often for infectious disease control or sex workcontainment, control and taxation. Where sex work is legalized, as in Switzerland, Turkey, Hungary, and Tijuana Mexico, it is often regulated through mandatory registration and mandatory health exams and testing, and criminalized if not conducted within specific areas.^49,75,88 Regulation is often discriminatory in policy and/or practice, and many sex workers attempt to evade it. Sex workers often forgo mandatory registration, yet operating outside the system limits their access to necessary HIV and STI services, as in Tijuana, Mexico.⁸⁸ This resulting two-tier system illustrates unintended public health consequences of legalization. Registered and unregistered sex workers also differ significantly in their earnings, work locations, and drug use patterns⁸⁸ suggesting underlying differences in HIV risk. Legalization does not assure rights-based law enforcement practices. In Hungary, where sex work is legal within tolerance zones, reluctance to clearly designate and enforce those tolerance zones actually enabled police abuse of sex workers, including arbitrary arrest.⁴⁹ Counter to goals of sex worker safety, legalization also does not eliminate physical violence against sex workers, as illustrated in Switzerland.⁹⁶ Similar evidence from Turkey is even more egregious given police presence in brothels to ensure safety.⁷⁵

Decriminalization of Sex Work

New Zealand and New South Wales Australia are the only jurisdictions that operate under full decriminalization, i.e., where sex work is not penalized through punitive laws, and regulation is premised on worker health and safety and comparable to that for similar forms of labor. While New South Wales retains minor offenses, e.g., prohibition of street solicitation in proximity to certain building such as churches or schools, they are rarely used, thus the climate in practice remains one of decriminalization. In New Zealand, the Prostitution Reform Act of 2003 decriminalized sex work through national law and redirected funds from police enforcement towards to provide health and social services for sex workers.⁹⁷ The reform is considered to have reduced violence to sex workers, and increased sex worker comfort in reporting abuse to police,though some safety issues persist.⁹⁷ Decriminalization also improved police attitudes towards sex workers, and prompted them to notify sex workers of potential attackers.⁹⁷ Police liaisons designated to work with sex workers on abuse issues also improved safety.

Gaps in the rights-based response to HIV for sex workers

There are significant gaps in realizing the rights-based global HIV response recommended by UNAIDS.⁵ Rights abuses merit swift response and prevention in their own right. Moreover, they threaten our success in responding to the HIV epidemic. International guidance asserts that criminalization of sex work not impede HIV prevention.^5,9 Yet in practice, police abuse and punishment undermine sex workers’ access to and use of HIV prevention, testing and treatment, and heighten risk for physical and sexual violence. Many of the human rights violations identified represent gross misinterpretations of policy. Even where sex work is illegal, abusive policing practices including physical and sexual violence are unlawful- yet pervasive. Sex workers who experience sexual violence face cascading human rights violations when their access to justice is stymied by police tolerance for abuse, and the pervasive notion that sex workers cannot be raped.

Optimizing the HIV prevention and treatment continuum through enhancing human rights

Sex workers’ safe and equal access to HIV testing and treatment are challenged both by discrimination and denial of services, as well as humiliation and abuse where such services are mandated, too frequent, too invasive, and not supported by public health evidence.Policies and practices alike mustenable sex workers to exercise their rights to nondiscrimination in accessing testing and the life saving treatment that now exists.Treatment is particularly critical in settings where large populations of untreated individuals exist and health access is not assured. Investing in policies and programs, including community engagement strategies, which empower sex workers to enjoy their rights, contributes to improving HIV prevention outcomes,⁹⁸ and likely intervention outcomes as well. Reform of legal frameworks to promote human rights for sex workers may also generate improvements in HIV outcomes. The psychosocial impact of human rights violations may also undermine treatment success. While no quantitative estimates exist specific to sex workers, abuse and other stressful events compromise ART uptake, adherence and viral response.^99,100 Human rights violations could similarly undermine the success of other HIV status dependent interventions, such as pre-exposure oral or topical chemoprophylaxis. To date 3 trials have shown efficacy for men, and two for women^101-103 [mrd1] and evidence from injection drug users affirms adherence and efficacy for women¹⁰⁴ [mrd2] despite women's low adherence in past trials.

Without addressing human rights violations among sex workers, simply providing HIV prevention and treatment services will remain an insufficient and misguided response. Rather, optimizing the impact of evidence-based HIVinterventions requires assuring sex workers of their human rights. This can be achieved through reform to policy and practice to assure safe working conditions, access to police protection instead of abusive and discriminatory treatment, and equality and nondiscrimination in accessing health services.

Evidence-Based Reform: THE HUMAN RIGHTS FRAMEWORK FOR CHANGE

There is arguably an urgent need to address the health and human rights of sex workers both to achieve human rights goals and to achieve public health objectives. Two mutually reinforcing strategies can harness the human rights framework for change: policy reform, and changes to practice through sex worker empowerment and partnerships for change.

Policy reform for human rights promotion: Decriminalization

Human rights violations against sex workers occur across all policy regimes, particularly where there is poor rule of law. They are most egregious in climates ofcriminalization.The United Nations High Commissioner on Human Rights and UNAIDS hasrecommended decriminalization to uphold sex workers’ human rights and health,⁹ as have the United Nations Special Rapporteur on Health and Human Rights,²⁰ the UNAIDS Guidance Note on HIV and Sex Work,⁵ the Global Commission on HIV and the Law,¹¹ and the United Nations Development Program.¹⁰ Sex workers, national and international advocates, ^{13,15,105,106} also call for decriminalization premised on the importance of sex workers’ health and safety as a means of promoting health and human rights.The Supreme Court of Canada recently struck down key provisions of the law governing sex work to improve sex workers’ rights to life, liberty and security.

Aligning practice with human rights promotion: Supporting health and human rights of sex workersfrom the ground up

Policy reform through decriminalization will be insufficient in ensuring human rights for sex workers where they are ostracized or lack protection and dignity based on other social vulnerabilities. Sex worker mistreatment often reflects not only sex work-related marginalization, but a host of additional social vulnerabilities, such as poverty, ethnicity, migrant status, gender,gender identity, and sexual orientation, and substance use.^{29,32,34,37,44,50} Abuse is often described as moral punishment.Social transformation is required to ensure equitable treatment and transform the widespread tolerance of abuse of sex workers.

Sex workers themselves are a powerful force in health and human rights promotion, even where sex work is criminalized. Community empowerment, grounded in sex worker insight and leadership,entails sex workers organizing, sharing experiences in a safe space, and prioritizing their own needs for human rights and health.¹⁰⁷ Empowerment-based HIV prevention demonstrates impact and cost-effectiveness in sexual risk reduction and HIV prevention for sex workers.^4,107 Yet the impact ofsex worker empowerment extends far beyond these endpoints.It is central in reforming harmful practices and shaping the broader social structure in which sex workers live and work. In addition to policy reform, gains achieved through community empowerment include rights promotion across health, social and criminal justice sectors, including enabling sex workers’ access to bank accounts, microfinance programs and health insurance, as well as reductions in violence, and meaningful challenges of the social exclusion of sex workers and threats to their dignity.^29,33,39,93 Strategies span strategic litigation, civil disobedience, public education, training of police, judges and health workers, and formal partnership with government bodies.^44,93,108 Sex worker organizing fosters resilience for sex workers, and transforms the social climate to one that recognizes -rather than marginalizes- this group.²⁹ Community empowerment is threatened by criminalization and abusive practices that prevent sex workers from gathering and organizing safely. Governments at a minimum must allow sex work organizations to exist and thrive without interference. They should be encouraged to engage with sex worker organizations to develop, implement and evaluate policy.

Dismantling the Climate of Impunity

Advancing human rights for sex workers requires reforming the culture of impunity. Both abuse by state-actors,and systemic lack of response to sex workers’ reports of violence foster impunity that perpetuates violence, and conveysan acceptability of violence towards sex workers.Failure to hold perpetrators accountable isa policy of tolerance for abuse.³² Even in criminalized regimes, sex worker partnerships with legal and criminal justice sectors can have a significant impact on impunity.In Poland³² and Andhra Pradesh, India,¹⁰⁹ sex workers have led change in partnership with police through training on sex worker rights and establishing safe reporting of abuse. These partnerships exemplify meaningful steps towards dismantling impunity. Training for police and judges, and court accompaniment for sex workers charged with crimescan also provide access to justice for sex workers.¹¹⁰ In South Africa, sex workers can receive paralegal training on due process and sex worker rights, to ensure sex workers’ rights are upheld throughout the legal process.¹¹¹ These examples again illustrate the value of investing in sex worker organizing and partnership with legal and criminal justice sectors to support health and human rights.

Improvement of the evidence base

While recent advances are heartening, the epidemiological evidence base documenting human rights violations against sex workers, and the HIV-related impact,remains weak. Small sample sizes limit the precision of estimates. Inconsistencies in definitions of human rights violations limit cross-setting comparisons.Most studies reviewed were cross-sectional, leaving temporality and causality unclear.Perpetrators of physical and sexual violence are not always specified, masking the primary perpetrators of human rights abuses and providing little direction for intervention targets. The findings and limitations identified emphasize the need for rigorous, and broadly generalizable research across settings to clarify the burden, determinants, and HIV impact of human rights violations against sex workers. The global ongoing surveillance with sex workers as a key HIV risk population is an opportunity for human rights assessment.Community-based and biomedical HIV intervention evaluations should integrate human rights outcomes and consider rights-related barriers to success.Sex workers must have meaningful roles in such efforts.Research with transgender and male sex workers is scarce.The impact of human rights violations on sex workers’ treatment-related outcomes, including access, adherence, and viral suppression, is unclear. The extent of human rights violations identifiedraises the issue of ethical obligations in sex work-related research. Internationally agreed upon ethical guidelines for research with sex workers are lacking. Current findings recommend the provision of violence support and sex worker support resources to sex worker participants in any type of research.

Conclusion and future directions

Fundamental non-derogable rights, those that no government has the power to suspend under ICCPR, include the right to freedom from torture, cruel, inhuman and degrading treatment or punishment; and the right to recognition before the law, are not lost by virtue of being a sex worker or being alleged to be selling sex. Too many countries and governments, legal systems and police practices, remain where these rights have indeed been violated. Impunity for sexual violence and other human rights violations, and the failure to investigate and prosecute these violations, is a state failure. Where police themselves not only fail to investigate human rights violations, but commit them through physical and sexual violence and degrading treatment, a further state failure has also occurred. In all such cases, perpetrators and governments must be held accountable.

Evidence-based, rights-based policy reform must be synergized with sex worker input to respond to, protect, and promote their rights. Ongoing human rights surveillance is critical. The Global Fund's Technical Review Panel's recent request for a human rights analysis as part of the proposal process is concrete advancement. Human rights organizations and bodies have a duty to move beyond debates on the morality of sex work to work directly with sex workers on documenting, denouncing and redressing the violations they experience. At the State level, governments must address the fact that many of their laws and practices as implemented contradict not only human rights and health goals, but also human rights covenants and treaties to which they are signatories.

The impact of public health investments in evidence-based HIV prevention, care and treatment is severely constrained where sex workers’ human rights are violated. International funders such as the Global Fund, PEPFAR, DFID, the European Union and others must partner with and fundsex workers’ organizationsto ensure that rights and health are at the core of their investments in HIV prevention and care programs. Sex worker organizing generates some of the most crucial and effective work on health and human rights and yet is severelyunderfunded. Less than 1% of funding on HIV-prevention is being spent on HIV and sex work, and even less is being directed towards sex workers’ organizations.⁵ It is inconsistent with human rights principles to deny basic rights, based on status, or assumed status, as a sex worker. Moreover, protection of the human rights of sex workers isnot merely good public health practice or good governance, it is a state obligation under international human rights law. Theextent, severity, and impact of human rights violations against sex workersidentified through this review and by the UN Special Rapporteurs and the UN High Commissioner for Human Rights ^9,19,20 should provide the mandate and courage necessary for meaningful reform.

Panel 1: Search strategy and selection criteria

We searched PubMed, EMBASE, EBSCO, Global Health, SCOPUS, PsycINFO, Sociological Abstracts, CINAHL, Web of Science, and POPLine, prioritizing studies published between 2009 and 2014. Our search had two required components: sex work (“prostitute” [MeSH], “sex work”, “sex work*”, “female sex worker” “transgender sex worker” “male sex worker” “sex trade”, “survival sex”, “sexual exploitation”; “prostitution”), and human rights abuses and violations, including coercion, murder, police, violence, rape, assault, mandatory testing, mandatory registration, extortion, discrimination, human rights, rehabilitation, detention, raid, working conditions, condom confiscation, sex trafficking, abuse. We searched reference lists from retrieved manuscripts. Websites of key organizations, e.g., Human Rights Watch, were reviewed by hand to identify relevant reports. We prioritized and present primary quantitative data wherever possible.

Panel 2: Sex workers speak about health and human rights

“The police force us to pay money to them every day,” “If you have no money, they hold you in the police station for two days and force you to clean the station. Some policemen will only let you go if you have sex with them. – femalesex worker, Russia⁹³

And he pulled out a police badge and said “C’mon, you want me to take you in or screw you?” Iwas scared, and allowed him to screw me – female sex worker, Serbia³⁷

I was raped by the police and the prison officers, they cut my hair and beat me up badly. – TTT (travestis-transgender-transsexual sex worker) hairstylist, Zona Rosa, Mexico City⁴¹

“ The police, how they beat us. They killed everything in me. Killed, killed, killed us with beatings. Just transvestites... Arms, legs, torch into our eyes. A million times I've said ‘Take me away. Have you come to arrest me? Arrest me then. But, do not beat me’.” – transvestite Roma sex worker, Serbia⁵⁰

In the lockups police officers forcefully have sexual intercourse with me...we request them to use condoms but they disagree to use condom. Twice I was locked in police station, there 12 police officers beat me. They dragged me to the toilet and forcefully had sexual intercourse with me without using condom. When I requested them to use condom they threw [away] the condom that I had in my pocket. – Meti [transgender] sex worker, Nepal ⁴³

“If we insist on payment after the sexual act, clients follow us, beat us and take the money back. We cannot do anything as we will be reported to the police. If we are reported to the police, we will be prosecuted”. - female sex worker, Arusha Tanzania⁶⁵

[police] gave me no respect because I am Roma, a sex worker and homeless – Roma sex worker, Slovakia³²

“[police] came and asked for my bag. When I refused, they beat me, took my condoms and burned them and said I’m a bitch.” - Zambian sex worker living in Namibia,³⁸

“After the arrest, I was always scared...There were times when I didn’t have a condom when I needed one, and I used a plastic bag.” - female sex worker, USA²⁷

What I heard from the women... some sex workers were arrested. It's time for them to get ARV. They asked police, in polite way, to get ARV treatment and they are not allowing them. - Sex worker from Cambodia describingconditions following police raid and detention on new Koh Kong¹¹²

We work at the city centre itself, where we should not work [according to the police]. We are aware [of that]. But, if we go to another place, there are a lot of problems when it is night time, when it is in the late hours. Int.: What kind of problems? Well, the problems are you get beaten. They [clients] take away your money. They [clients] molest you”. –female sex worker in Serbia⁵⁰

“Most sex workers don’t know they have rights as citizens,” “They know their work is illegal, so they live in fear of the police, of clients, of everybody who passes on the street. It means they cannot defend themselves or struggle for their rights.” – Russian sex worker⁹³

“Another officer asked how a prostitute like me could beraped as I was used to all sizes. He told me in factthat man really spared me. He could have testedmy ass too. He ended asking me if my ass isalready opened. Never will I again go to report acase. I’d rather die.” -female sex worker, Mombassa, Kenya²⁹

“I cannot go and tell a health worker that I have a genital problem when she doesn’t know about my work. I expect to be abused and I have fear.” - female sex worker, Kampala, Uganda²⁹

Panel 3. Trafficking & sex work: the need for rights to address the wrongs

Trafficking is a human rights abuse that is distinct from sex work.⁵ Yet historically, the rights of trafficked individuals and sex workers have been pitted against one another, ultimately failing both. A primary issue has been the conflation of trafficking with sex work, or the idea that sex work and trafficking are one in the same. This conflation defies both international guidance and law that distinguishes these experiences. Transnational aid policy over the past decade fueled this conflation and hampered meaningful, reasonable policy. The far-reaching 2003 United States President's Emergency Plan for AIDS Relief (PEPFAR) included a policy known as the anti-prostitution loyalty oath (APLO), which required beneficiaries to explicitly oppose prostitution, its legalization, and sex trafficking, in effectconflating the two.The APLO, coupled with the United States Trafficking In Persons (TIP) Index which grades countries’ anti-trafficking efforts, prompted conflationarylaws, policies and practices abroad with significant harm to sex workers. Guatemala, Korea and Cambodia increased sex work criminalization legislation following low-tier placement on the US TIP Index.Zambia launched mass incarcerationof young women suspected or considered at risk of selling sex. Cambodia's large-scale anti-trafficking police raids targeted sex workers without assessing trafficking status, and resulted in the arrest, detention and widespread abuse of sex workers.³³ These interventions, predicated on the conflation of trafficking with sex work,enable severe human rights violations against sex workers and fail in assisting individuals in trafficking situations by diverting resources.

Epidemiologic research confirms the distinction of trafficking and sex work. In broader samples of sex workersin India, Thailand, the US-Mexico border, and Nicaragua, an estimated 1.6% to 43%,^113-121 reporttrafficking into the sex industry via force or coercion. Such experiences are associated with sexual risk, ^116-118,120 and further physical and sexual abuse.^116,118,120 Limitations include inconsistencies in trafficking definitions across studies and in relation to national and international law, particularly with regard to minors. Challenges remain in assessing coercion as well as the trafficking of those already involved in sex work. Nonetheless, this research demonstrates the distinction of sex work and trafficking, in turn, conflation is inconsistent with the best available evidence.

Sex worker rights and the elimination of trafficking need not be oppositional. Rather, they can and must be aligned. Sex workers are well-positioned to identify those in trafficking situations. Where sex workers are free to accesspolice without fear of arrest or interference, they will be able to share information about potential trafficking scenarios. By contrast, criminalization of sex work can hamper trafficking interventions, and foster fear of police exploitation among both sex workers and trafficked persons alike.Notably, sex workers are at risk for trafficking, and can be targeted for trafficking based onperceived lack of police protection where sex work is criminalized.⁴⁹ Research from Calcutta illustrates the promise of approaches that align sex worker rights with anti-trafficking efforts. A sex worker-led program successfully implemented a screening protocol that identified trafficked individuals and minors, and referred them for care and support.¹²² This example provides guidance for interventions that uphold the distinction of trafficking and sex work rather than their conflation.

In 2013, the APLO was deemed unconstitutional by the US Supreme Court. While other policies of conflation persist, this US Supreme Court ruling should pave the way for a new era of policy and practice that uphold the rights of both sex workers and trafficked persons. Its implementation remains to be seen, including its influence on practices at non-American NGOs. The Global Commission on the HIV/AIDS and the Law recommendsa rights-based approach that simultaneously respects and actively supports those willfully in sex work, while identifying, supporting and protecting those forced or defrauded into sex work against their will.¹¹ Thus a rights-based approach to sex workdoes not undermine the rights of trafficked persons,nor the fight to diminish trafficking, but rather strengthens it.^9,11,18,20

Key Messages.

• Sex workers are rarely addressed in international human rights law. Yet fundamental rights and protections set forth by international covenants and declarations are not abrogated by status as a sex worker; human rights law applies to everyone.

• Published research documents widespread human rights violations against sex workers, perpetrated by both state and non-state actors. These violations increase HIV vulnerability, and undermine effective HIV prevention and intervention. Violations include homicide, physical and sexual violence from law enforcement, clients and intimate partners, unlawful arrest and detention, discrimination in accessing health services, and forced HIV testing.

• Significant gaps exist in a rights-based response to HIV among sex workers. The HIV impact of human rights violations demands a shift in global policies and practices. We must acknowledge, address and prevent violence, abusive police practices and other human rights violations to ensure rights and achievepublic health goals.

• Without addressing human rights violations among sex workers, simply providing HIV prevention and treatment services will remain an insufficient and misguided response. HIV responses for sex workers must ensure human rights though active promotion of equality and non-discrimination in accessing prevention and interventions across the full continuum of care.

• Human rights violations against sex workers are most profound in criminalized policy regimes. The solution requires reformnot only to policy, but additionally its implementation through abusive practices.

• Policy reform and sex worker mobilization and grass-roots organizing, are essential and mutually-reinforcing strategies that have achieved success inhealth and human rights promotion for sex workers.