An analysis of the implementation of PEPFAR's anti‐prostitution pledge and its implications for successful HIV prevention among organizations working with sex workers

Abstract

IntroductionSince 2003, US government funding to address the HIV and AIDS pandemic has been subject to an anti-prostitution clause. Simultaneously, the efficacy of some HIV prevention efforts for sex work in areas receiving US government funding has diminished. This article seeks to explain why.MethodsThis analysis utilizes a case story approach to build a narrative of defining features of organizations in receipt of funding from the President's Emergency Plan for AIDS Relief (PEPFAR) and other US funding sources. For this analysis, multiple cases were compiled within a single narrative. This helps show restrictions imposed by the anti-prostitution clause, any lack of clarity of guidelines for implementation and ways some agencies, decision-making personnel, and staff on the ground contend with these restrictions.ResultsResponses to PEPFAR's anti-prostitution clause vary widely and have varied over time. Organizational responses have included ending services for sex workers, gradual phase-out of services, cessation of seeking US government HIV funds and increasing isolation of sex workers. Guidance issued in 2010 did not clarify what was permitted. Implementation and enforcement has been dependent in part on the interpretations of this policy by individuals, including US government representatives and organizational staff.ConclusionsDifferent interpretations of the anti-prostitution clause have led to variations in programming, affecting the effectiveness of work with sex workers. The case story approach proved ideal for working with information like this that is highly sensitive and vulnerable to breach of anonymity because the method limits the potential to betray confidences and sources, and limits the potential to jeopardize funding and thereby jeopardize programming. This method enabled us to use specific examples without jeopardizing the organizations and individuals involved while demonstrating unintended consequences of PEPFAR's anti-prostitution pledge in its provision of services to sex workers and clients.

The impact of end-demand legislation on sex workers’ access to health and sex worker-led services: A community-based prospective cohort study in Canada

“…However, criminalization, stigma, and a lack of funding to support sex worker-led programs continue to impede collectivization among sex workers [1,24]. Akin to the US PEPFAR anti-prostitution pledge, the PCEPA reduces access to community-led services and jeopardizes funding for and development of critical sex workerled supports, in addition to further conflating sex work with trafficking [6,10,27,28]. Legislative reform to sex work laws in New Zealand and parts of Australia exemplify the benefits of decriminalizing all aspects of sex work for enabling safer occupational conditions for sex workers, with demonstrated impacts on increased access to health services and improved workplace safety [29][30][31].…”

Expanding the Space: Inclusion of Most-at-Risk Populations in HIV Prevention, Treatment, and Care Services

“…Allman et al (2010) reported significant confusion among HIV prevention implementation partners supported by the United States as a result of the 2005 Anti-Prostitution Pledge policy of the US PEPFAR program. 22 Many organizations were reportedly unclear whether and how they might provide services to SW, and some reported avoiding the provision of such services to SW so as to comply with the pledge, despite the fact that PEPFAR permit SW services. 23 In India, negative attitudes and practices of government health care workers toward SW have been shown to be a significant barrier to accessing antiretroviral drugs (ARV).…”

An action agenda for HIV and sex workers

“…12 The advent of the 2003 “Prostitution Pledge” policy requirement for U.S. Federal (PEPFAR) funding reduced programmatic engagement with SW in some settings. 3,13,14 This has been associated with reduced financing of HIV programs for SW, particularly programs which funded SW-led organizations. 15 Finally, the very high HIV incidence among women in Southern Sub-Saharan Africa in 2001–2005, meant that HIV studies which required HIV sero-conversion endpoints (microbicides, HIV vaccines, PrEP)) could be conducted among the general population of reproductive aged women, markedly reducing the necessity of recruiting SW.…”