As a girl Ikka dreamed of becoming an accountant. She knew her parents could not afford to send her to university, so she resolved to pay for university herself by moving into a brothel. For almost three years she lived and worked there while studying.

Davi’s parents divorced when he was a baby and he was raised by caring grandparents. In high school he led lots of extracurricular activities. He was also gay. Just three months before his final exams Davi was raped by a teacher who threatened to “out” him. He ran away to the city. After a desperate search for work, he landed a job in a massage parlour.

From the Bangkok offices of Youth LEAD and the Asia Pacific Network of People Living With HIV and AIDS (APN+), the pair reflects on those chaotic adolescent years with halting candour. They unpack layers of vulnerability and abuse—the way poverty and trauma can propel young people toward sexual exploitation, higher HIV risk and a cascade of rights violations. And they say that the criminalisation of sex work only made their situations worse.    

“No one tells you anything other than that you need to please your client. Just be submissive and quiet. There’s no protection, no information, no nothing,” Ikka remembers.

The brothel would occasionally force the women to undergo HIV and STI testing. Saying ‘no’ wasn’t an option. But when Ikka went to a clinic on her own to get condoms or contraceptives, she was turned away.

Customers sometimes didn’t pay, became violent or refused to stop having sex after even two or three hours. Abusive clients routinely threatened to report them.

“If someone called the police, they would arrest the sex worker. The customer is king,” Davi says. “So silence is better.”

“The police wouldn’t take your report. They think they have more important cases than you,” Ikka adds.

UNAIDS Asia Pacific Human Rights and Law Adviser, Quinten Lataire, explained that criminal laws against sex workers make it very difficult for sex workers to demand basic rights, substantially increasing their risk for abuse and exploitation, such as from law enforcement officers.

“The criminalization of sex workers does not end sex work. It simply makes people go underground, putting them at higher risk of violence and HIV transmission. This has a devastating impact on the sex workers themselves, their clients and the society at large,” Mr Lataire said.  

Almost all (99%) new HIV cases in young people in Asia Pacific are amongst key populations and their sexual partners. In Cambodia, Indonesia, Lao PDR, the Philippines and Thailand, youth account for between 40% and 50% of new infections. Since 2010, HIV rates among young people have risen in Afghanistan, Fiji, Malaysia, Pakistan, Papua New Guinea, the Philippines and Timor-Leste.

At ages 18 and 19 respectively, both Ikka and Davi learned that they were HIV positive. In Ikka’s case she was tested as a VISA requirement for a student exchange programme. Her results were forwarded to her school even before she got them and she was kicked out. From breach of confidentiality to discrimination in both education and healthcare settings—one rights violation after another. Ikka had the agency to confirm her HIV status at a community-based sex worker clinic she’d looked up and immediately started treatment.

Davi voluntarily tested with a community organization that visited the massage parlour to conduct sensitization sessions and offer services. He kept his status a secret at work but began attending support meetings on the weekend. He sometimes told the pimp that he was going out to meet a client, handing over the stipend he got from the organization when he got back.

“For eight months after I knew I was positive, I felt like I didn’t want to do sex work, but I needed the money. I told clients to use condoms but some of them would give me more money not to,” Ikka remembers.

The events that finally prompted her to leave the brothel still evoke strong emotions. Her best friend there also contracted HIV.

“I told her, ‘let’s go together to get antiretroviral treatment’. I showed her my medication as evidence. But she didn’t want to go. She would not get support from her parents and if the pimp found out, he would kick her out. She felt it was better to die,” Ikka remembers. Her friend passed away just two months after her diagnosis.

In both cases these young people demonstrated incredible resilience and were supported by community-led organizations with tailored services for sex workers and people living with HIV. Ikka joined an organization addressing sex workers’ rights, health and social support needs. She quickly carved a niche representing the interests and perspectives of young sex workers. She would go on to lead national young key population organizations and sit on the Global Fund’s Youth Council. Today she is the Regional Coordinator of Youth LEAD.

“I told myself I needed to help my community,” Davi says. “I don’t want no more people in my situation; no more students becoming victims of sexual violence; no more 19-year-olds HIV positive. I just chose to leave (the parlour) and volunteer with the community organization instead.” Encouraged and supported by community, Davi would go on to graduate from high school and earn a sociology degree. He is now aiming for a Masters qualification while working as APN+’s Youth Officer.

The issues Ikka and Davi faced remain today.

“I still use a condom, but many clients refuse,” says Rara, a 22-year-old sex worker. “When we’re desperate for money, we have no choice but to agree. In addition to gonorrhea, I got syphilis and got treated for it. Thankfully I’m still HIV negative.”

UNAIDS and the Inter-agency Task Team on Young Key Populations are working to address the inequalities faced by young key populations in Asia Pacific. Learn more about their work.

GENEVA, 17 June 2022—UNAIDS applauds the decision by the Supreme Court to issue directions on protecting the wellbeing and fundamental rights of sex workers under the Indian constitution, including the right to life and liberty with respect for an individual’s dignity. 

“This historic order will save lives and help India advance towards the goal of ending AIDS as a public health threat by 2030,” said David Bridger, UNAIDS Country Director for India. “The evidence is clear— protecting the safety and human rights of marginalised people expands access to HIV services, accelerating progress in the response to HIV by increasing the number of people on treatment and reducing new infections.” 

In its ruling in Budhadev Karmaskar versus the State of West Bengal, Criminal Appeal No. 135 of 2010, the Supreme Court has issued directions that the police and other relevant authorities should receive appropriate training to ensure that they are aware of sex workers’ rights and ensure they are upheld. The ruling also calls for sex workers who experience sexual violence to have full access to protection and support services, ending practices that undermine access to existing survivor-friendly procedures and protocols available to the general population. The directions confirm that the possession of condoms should not be treated as a criminal matter. They also direct the authorities to issue Aadhar cards, key for accessing poverty alleviation support, to sex workers who are unable to provide proof of residence; and require the development of media guidelines to protect the privacy and confidentiality of sex workers, and to ensure sex workers are informed about their legal rights, including the right to justice.

“We hope that all the recommendations made by the Supreme Court will be followed by all, especially the police and the press, as reflected in the ruling,” said Bharati Dey, Ex-Secretary, Durbar Mahila Samanwaya Committee, and Bishakha Laskar, President of the Durbar Mahila Samanwaya Committee. “We hope that the recommendations will diminish stigma and discrimination experienced by sex workers.”  

Sex workers, along with other marginalized communities, often find it difficult to access essential services, such as health, because of criminalization, stigma and discrimination. This ruling further underlines how evidence-informed, people-centred approaches are key to widening access to HIV treatment, prevention and care services, and to ending the AIDS pandemic for everyone.  

The Supreme Court of India has played a significant role in protecting and upholding the rights of marginalized communities over the past decade, granting hijras and other transgender people the right to recognition as a third gender, outlawing HIV-related discrimination, and striking down the provision in the Penal Code that criminalized consensual same-sex sexual conduct. 

In every region of the world, there are key populations who are particularly vulnerable to HIV infection. One of the key populations is transgender women, who are at 34 times greater risk of acquiring HIV than other adults.

Discrimination, abuse, harassment and violence are distressingly common experiences for transgender people. They often face, from a young age, stigma, discrimination and social rejection in their homes and communities for expressing their gender identity. Such discrimination, violence and criminalization prevent transgender people from getting the HIV services they need to stay healthy.

Transgender women who also are involved in sex work are even more likely to be subjected to such treatment, as shown in a study from the Dominican Republic.

A pioneer of the HIV response in Madagascar, Réseau Association des Femmes Samaritaines (Réseau AFSA, the Association of Samaritan Women), an association of sex workers, was created following the discovery of the first case of HIV among sex workers, in 1987. For the past three decades, it has been focusing on the empowerment and social integration of sex workers, with the objective of preventing the transmission of HIV and other sexually transmitted infections.

But the COVID-19 pandemic brought with it a new tide of socioeconomic hardships that saw sex workers suffer the world over. Income losses and lockdown restrictions, along with ingrained societal and systemic stigma and discrimination, have posed unique challenges for sex workers to protect their health and safety. In line with these complex global challenges, marginalized communities from Madagascar, one of the world’s poorest countries, have been adversely affected during these uncertain times.

Through the UNAIDS Solidarity Fund, which was created to economically empower key populations through social entrepreneurship, Réseau AFSA developed small business activities in the Antananarivo region. Réseau AFSA is supporting 10 sex workers with businesses in the production of food and the sale of fruit, vegetables and clothing, who are also being taught simplified financial management skills to empower their individual businesses.

UNAIDS spoke to Rarivoharilala Esther, Technical Coordinator at Réseau AFSA, about how the Solidarity Fund project is building community resilience and the financial capacity of the community members.

What is the purpose of your social enterprise project?

Our main purpose is to enable sex workers to effectively manage and lead their own businesses, thereby earning a sustainable income.

The added value of the social entrepreneurship project is that each beneficiary is encouraged to save part of their revenue into a savings account to ensure the continuation of their enterprises. This was made possible through a collaboration with the Madagascan Ministry of Post and Telecommunications, which created the savings accounts.

What problem do you want to solve through your social enterprise?

Through the social entrepreneurship activities, we are supporting sex workers, including those who have children to take care of.

The income earned through the social enterprises helps them to support the care of their children. In addition, having savings can ensure the continuity of their enterprises and, potentially, sustained care for their children. 

What is your biggest concern about the project and how will you overcome it?

Our main concern now is to encourage the habit of continuous saving to ensure the sustainability of community-led enterprises. But with the response and improving management strategies we have seen from the community, I am confident that they are keen to continue these enterprises. Réseau AFSA is also committed to monitoring their enterprises and supporting them in the coming year. We are focused on mapping funders and partners to ensure the continuity of this project.

What do you want to achieve for the community in the future?

We hope that the benefits of this project extend to more community members. We also hope that the project reaches other regions or provinces of Madagascar.

As part of addressing hardships as a result of the COVID-19 pandemic, the Plateforme Océan Indien (Indian Ocean Platform) entrusted Réseau AFSA with the management and distribution of food, masks, soap and gels for more than one hundred sex workers as well as other key populations at higher risk of HIV and COVID-19, including lesbian, gay, bisexual, transgender and intersex people, people living with HIV and people who inject drugs. The network also improved access to health-care services and vaccines during the pandemic.

The next step in this inspiring journey remains to ensure the sustainability of the social enterprises and to look for partners who can enhance them. Instilling the habit of saving to foster the growth of their social enterprises and strengthen community members’ ability to care for their children is a first step in this direction.

Discriminatory experiences within health-care settings can be especially common and pernicious. Country data reported to UNAIDS show that the proportions of people belonging to key populations who avoid health-care services due to stigma and/or discrimination remain disconcertingly high. Across all key populations, at least one in three reporting countries stated that more than 10% of respondents avoided health care, including three in four countries for people who inject drugs.

Removing laws that harm, such as laws on sex work, same-sex sexual relations, the use or possession of drugs for personal use and the non-disclosure, exposure or transmission of HIV, is one way of overcoming stigma and discrimination and hence increasing the uptake of services by key populations.

Growing up in Jamestown, one of the oldest districts of Accra, Ghana, Susana Dartey saw the daily abuse and exploitation faced by female sex workers, which inspired her to set up the Women of Dignity Alliance (WODA) to empower female sex workers and fight the inequalities they face.

“Since sex work is illegal in Ghana, our members have been faced with a lot of abuse and cannot report this due to the fear of being arrested,” says Mrs Dartey, who serves as the Executive Director of WODA. WODA has grown from one member in 2016 to a team of 16 staff members, comprised of current and former female sex workers. “Belonging to the same neighbourhood, I found my voice through theatre and realized that I could use the same methodology or technique to give a voice to these women,” she added.

In Ghana, there are two categories of female sex workers—so-called roamers and seaters. Roamers are mobile and travel to clients, whereas seaters are stationary and work out of their homes or brothels. In 2020, HIV prevalence among female sex workers in Ghana was estimated to be 6.9%.

The COVID-19 pandemic has been challenging for sex workers in Ghana, with lockdown restrictions hampered their ability to work. Sex workers in the country have also reported feeling left out of the official support being given to society as a whole during the pandemic.

In the face of these obstacles, Mrs Dartey is determined to empower female sex workers to become role models for women in their community through the Women Empowered Through Social Entrepreneurship project, which is supported by the UNAIDS Solidarity Fund.

To address the socioeconomic problems brought about by the COVID-19 pandemic, WODA is nurturing promising social enterprises that are established, led, sustained and scaled up by the sex workers themselves, with the aim of empowering up to 400 sex workers, either directly or indirectly.

The three areas addressed by the programme are training on sustainable income generation, facilitation of COVID-19 prevention among sex workers and creating an opportunity for sex workers to be agents of change within their communities.

Mrs Dartey explained how the sex workers are undergoing training in skills as diverse as beauty treatment, soap-making, confectionery production, breadmaking and floral decoration. The beneficiaries of the project are educated in the operating practices of social enterprises and are given opportunities to learn entrepreneurial skills from experts.

“As a roamer for eight years, I have never experienced the kind of hardship COVID-19 has brought to my work. Before COVID-19 set in, I could make up to 230 Ghana cedis daily, but these days it’s very difficult to even make 50 Ghana cedis. When Susana informed me about the UNAIDS Solidarity Fund supported initiative, I was so glad. I love to make ladies look good, so I am eagerly looking forward to acquiring skills in pedicure, manicure and make-up artistry to earn a livelihood,” said one of the beneficiaries.

A part of enabling key populations and vulnerable communities to survive the hardships brought about by the COVID-19 pandemic is to support sustainable income-generating solutions that emerge from those communities. The UNAIDS Solidarity Fund was established to highlight the ingenuity of key populations by enabling access to finance for establishing sustainable social enterprises.

“My hope is to bring these women together to set up a goal for themselves. This project is looking at their future and at the end of the project the sex workers will have set up social enterprises that belong to them,” said Mrs Dartey when asked about her hopes for the project.

A beneficiary of the project who aspires to establish a make-up studio said, “I met Susana in the early part of 2021 and that was the beginning of a new me. Through WODA, I can now boast of some skills in make-up artistry and wig cap-making.” She also calls for sex work to be legalized. “I want sex work to be made legal so that the police will stop arresting and abusing us,” she added.

The UNAIDS Key Populations Atlas is an online tool that provides a range of information about members of key populations—sex workers, gay men and other men who have sex with men, people who inject drugs, transgender people and prisoners—worldwide, together with information about people living with HIV.

Information about gay men and other men who have sex with men has been expanded with the inclusion of 11 new indicators from the EMIS and LAMIS projects. Under funding from the European Commission, EMIS-2017 collected data from gay men and other men who have sex with men in 50 countries between October 2017 and January 2018. LAMIS is the Latin American version of EMIS and finished data collection across 18 additional countries in May 2018.

The 11 new indicators shown in the Key Population Atlas—on syphilis, symptomatic syphilis, gonorrhoea, symptomatic gonorrhoea, chlamydia, symptomatic chlamydia, sexually transmitted infections testing, syphilis partner notification, gonorrhoea partner notification and hepatitis A and B vaccination—were chosen because of their high relevance to the communities.

Community-led and community-based infrastructure is essential for addressing the inequalities that drive pandemics such as the AIDS and COVID-19 pandemics, as well as for ensuring the continuity of health services and protecting the rights and livelihoods of the most vulnerable. The EMIS and LAMIS findings will be important for informing civil society organizations working on sexual health, HIV prevention and sexual minority rights and for policymakers, non-community prevention planners, epidemiologists and modellers.

“To leave no one behind, we need people-centred data collection that spotlights the inequalities that are hampering access to services. It is critical to understand who are the most affected and unable to access services. This will enable the European Commission, European Union Member States and civil society and community organization alike to address the specific needs of gay men and other men who have sex with men,” said Jantine Jacobi, the UNAIDS representative to the European Union.

Civil society and community-based organizations, especially those led by key populations, can complement traditional health systems’ pandemic responses, but this requires that they be treated as full partners—involved in governing, designing, planning and budgeting pandemic responses––with the technical and financial support to do so effectively.

The findings of the new indicators will help to increase the role of partnerships and communities across each country and will serve as the basis for decision-making and policy planning. For example, in Ireland, the EMIS-2017 National Report acknowledges that, “there has been an increase in HIV and STI testing compared to previous surveys and this is in some part due to the positive interventions carried out by stakeholders and the MSM [men who have sex with men] community in response to findings from previous surveys. Some of these positive interventions in relation to HIV testing can also be attributed to the increased availability of community testing.”

For Ruma Khatri, the social entrepreneurship initiative by Usha Multipurpose Cooperative Society Limited is an opportunity to earn a livelihood in the face of the COVID-19 pandemic and the resulting income loss.

“I have been working with the sex worker community supported by Usha Multipurpose for the past 10 years. I work at the parlour instituted by Usha. But due to the COVID-19 pandemic restrictions, I took part with the community in the production of sanitizer and masks through Usha to earn supplemental income. Through this social entrepreneurship project, I hope to set an example and further empower the sex worker community,” Ms Khatri said. Established with the support of the UNAIDS Solidarity Fund, Usha Multipurpose’s social entrepreneurship initiative engages sex workers in producing masks, hand sanitizer and personal protective equipment kits in Kolkata, India.

Sex workers in several parts of the world have faced a huge economic impact due to COVID-19-related restrictions on physical contact and movement. Additionally, the criminalization of sex work in many countries has disproportionately given way to stigma, discrimination, violence and inability to access essential health-care services. Sex workers have also been left out of financial and social support schemes by many governments. These factors, among others, make it challenging for sex workers to engage in supplemental income generation activities.

In response to these challenges, several grantees of the UNAIDS Solidarity Fund are supporting the economic capacity of sex workers across five pilot countries. The Solidarity Fund was set up to provide grant seed funding to empower social entrepreneurs from key populations to scale up existing or develop new business initiatives that can generate sustainable economic value and social impact for their communities.

In northern Uganda, the sex worker and lesbian, gay, bisexual, transgender and intersex communities supported by the Health and Rights Initiative (HRI) recently produced their first set of shea-based products and acquired new machinery to scale up production. Through comprehensive market analysis, they identified the potential of processing shea-nut seeds to create value-added products, such as lotions, bathing oils, soaps and hair oils.

“Small-scale production and sales of shea nut products change the outlook for the members of the sex worker community. Through the support of the UNAIDS Solidarity Fund, our organization can act as a safety net to protect the business and community members as they implement the joint enterprise,” said Lucy Akello, the Executive Director of HRI.

Above, beneficiaries of HRI with shea-based products produced through their social enterprise. Credit: Health Rights Initiative

While production of tangible items is one aspect, the Alliance of Women Advocating for Change (AWAC), also in Uganda, is empowering more than 20 adolescent girls and young women, especially those living with disabilities, to set up social enterprises built on skills such as tailoring and designing. Talking about the Make Her Visible project, Macklean Kyomya, the Executive Director of AWAC, said, “Adolescents and young women, including those with disabilities, are at particular risk due to the socioeconomic impact of COVID-19. Risks include heightened destitution, violence, stigma and discrimination. The Make Her Visible project supports their economic capacities to help them better respond to these challenges.” The young sex workers are also being trained in financial management involving credit and savings along with business plan development to effectively manage these enterprises.

Above, young women being trained in tailoring as a part of the 'Make Her Visible' social entrepreneurship project of AWAC. Credit: Alliance of Women Advocating For Change

Creating strategic market linkages has been the focus of India-based Asha Darpan, a female sex worker-led community-based organization that is creating micro-entrepreneurs out of sex workers based in Mumbai. Their Shakti project is focused on empowering women between the age of 18 and 49 years from urban and semi-urban settings and living in lower-middle class and poor environments to establish their own footwear manufacturing business. Devta Metri sees growth in the future of these enterprises. She said, “No one foresaw the COVID-19 pandemic. The need for sustainable income sources for the sex worker community was amplified when we saw a loss in income sources. My hope is to see our social enterprise grow. In the next few months, our aim is to increase sales of footwear we produce, make a name for Asha Darpan and provide a sustainable income source for the members.”

These are thoughts echoed by Sanyu Hajjara Batte, the Executive Director of Lady Mermaid, which is supporting 168 female sex workers organized in 10 Women-Up groups in Uganda. “We have to support sex workers’ entrepreneurship skills if we truly want to create supplemental income sources for the community. Lady Mermaid is working to rebuild the sex worker community from COVID-19 pandemic effects through economic recovery programmes,” said Ms Batte. Through the grant received by the Solidarity Fund, sex workers are being trained in setting up demand-based social enterprises in areas including food selling, renewable charcoal-making, briquette-making, liquid soap-making and baking, among others. The initiative supports government registration, financial management and implementation to ensure sustainability of the enterprises.

Above, beneficiaries of Lady Mermaid engaged in briquette-making as a part of supplemental income generation through social entrepreneurship. Credit: Lady Mermaid

The Solidarity Fund grantees clearly highlight the ingenuity and leadership role that key population-led organizations and networks play when it comes to building community resilience and supporting communities during the pandemic. As the COVID-19 pandemic remains intertwined with daily realities, communities must be at the centre of pandemic response and preparedness. The response calls for critical action grounded in human rights principles, to protect the health and rights of sex workers. The provision of seed funding enables innovative business ideas owned by key populations to flourish and the creation of sustainable supplemental revenues to empower key populations most affected by the pandemic.

“I am 18 years old, and I am already thinking about getting married. In our area, girls get married early. I’m afraid that with my positive HIV status I won't be able to find a boyfriend, which means I won’t have a family,” said Sayora Akmatova (not her real name), a participant of a training on sexuality education for adolescents living with HIV, held in Osh, Kyrgyzstan.

More than 60 young people living with HIV and their parents from different regions of Kyrgyzstan recently participated in a series of trainings for adolescents and young people living with HIV on sexuality education, reproductive health and prevention of violence conducted by Araket Plus and the Reproductive Health Alliance Kyrgyzstan.

“Adolescents and young people living with HIV are exposed to various types of violence, so there is a need to integrate HIV prevention and treatment programmes with programmes on sexuality education, reproductive health and gender equality. Through such courses we wanted to ensure that teenagers living with HIV received a comprehensive training package, including leadership skills, how to identify and address violence and how to overcome self-stigma,” said Meerim Sarybaeva, the UNAIDS Country Director for Kyrgyzstan.

During the parallel training for parents of adolescents living with HIV, issues such as psychological challenges and personal boundaries, the importance of interpersonal communication and the need to communicate difficult and sensitive topics with children, such as contraception, condom use and sexually transmitted infections, were discussed.

Uluk Batyrgaliev, a sexual and reproductive health trainer at the Reproductive Health Alliance Kyrgyzstan worked with a group of parents and talked about how the fears of parents of children living with HIV are most often associated with their future.

“I was surprised to hear those parents of HIV-positive children agree in advance between themselves to marry their children to each other, so not to infect the “clean”,” said Mr Batyrgaliev. “The word “clean” is used by the parents to describe people who are HIV-negative. This is incredibly self-stigmatizing.” 

Galina Chirkina, the Executive Director of the Reproductive Health Alliance Kyrgyzstan, emphasized that the relationship between sexual and reproductive health problems and HIV is evident to professionals but is not always apparent to others or adolescents living with HIV.

“We teach young people living with HIV to have a common understanding of how they can have a successful sexual life, and how they can plan their future and family. Realizing the right to reproductive health and the future starts with sexual education.”

The education system in Kyrgyzstan doesn’t include sexuality education courses for young people in schools. However, as optional courses, teachers can choose healthy lifestyle courses that include special sexuality education lessons for high school students. A healthy lifestyle curriculum was developed in 2014 with United Nations system support in Kyrgyzstan and was recommended for all schools in the country.

The trainings were organized within the regional cooperation programme on infectious diseases, implemented by the UNAIDS Country Office for Kyrgyzstan and funded by the Government of the Russian Federation.