The Smart Sex Worker’s Guide to SWIT

This is a web page version of the “Smart Sex Worker’s Guide to SWIT” developed by the Global Network of Sex Work Projects. See the Global NSWP website for the original PDF version.

Credits: This guide is supported by The Global Fund through Robert Carr civil society Networks Fund. NSWP is part of Bridging the Gaps – health and rights for key populations.

Contents

Introduction

Structure

2012 Recommendations

Addressing Violence Against Sex Workers

Community-Led Services

Condom and Lubricant Programming

Clinical and Support Services

Programme Management

Introduction

Sex workers are one of the populations most affected by HIV. There are many reasons for this, including but not limited to, unsafe working conditions, barriers to consistent condom use, and lack of access to health services. Sex workers include female, male and transgender adults and young people (over 18 years of age) who receive money or goods in exchange for sexual services, either regularly or occasionally.

What is the SWIT?

“Implementing Comprehensive HIV/STI Programmes with Sex Workers: Practical Approaches from Collaborative Interventions” also known as the Sex Worker Implementation Tool (SWIT), is a large document that provides recommendations for implementing HIV and STI testing, treatment and prevention strategies that are directed by and that empower sex workers. The SWIT was produced in 2013, by the WHO, UNFPA, UNAIDS, NSWP and The World Bank.

The recommendations in the SWIT are drawn from the WHO Guidelines on Prevention and Treatment of HIV and other Sexually Transmitted Infections for Sex Workers in low- and middle-income countries – Recommendations for a public health approach, which were informed by the preferences and values survey conducted by the NSWP.

The SWIT is designed to be used by public-health officials and managers of HIV, AIDS and
STI programme; NGOs, including sex worker led organisations; and health workers.

What is the Smart Guide?

This Smart Guide provides a short summary of the key points in the SWIT, in plain English. You may use this Smart Guide as a tool when advocating for rights based services.

You may refer to the SWIT for more in depth information on any of these topics. The SWIT is available to download (PDF) in English, French, Spanish and Russian.

Structure

The SWIT covers six broad topics that provide recommendations for implementing one or more of the 2012 Recommendations.

  1. Community empowerment
  2. Addressing violence against sex workers
  3. Community-led services
  4. Condom and lubricant programming
  5. Clinical and support services
  6. Programme management and organisational capacity-building

Graphic from the SWIT book showing six circles corresponding to steps in effective programming: 1) Community Empowerment 2) Addressing Violence against Sex Workers 3) Community-led services 4) Condom and lubricant programming 5) Clinical and support services 6) Programme and organisational capacity building

This illustration shows how these topics fit together. Community empowerment is at the core of all of the SWIT recommendations.

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2012 Recommendations

The 2012 Recommendations are divided into two types: good practice and evidence-based.

Good practice recommendations are broad principles based on common sense, ethics, and human rights. They are not based on scientific evidence, but are informed by the experiences of sex workers.

Evidence-based recommendations are technical recommendations based on scientific evidence. They have been evaluated through a formal process. Evidence-based recommendations are also informed by the experiences of sex workers.

Good practice recommendations:

  1. All countries should work toward decriminalisation of sex work and elimination of the unjust application of non-criminal laws and regulations against sex workers.
  2. Governments should establish antidiscrimination and other rights-
    respecting laws to protect against discrimination and violence, and other violations of rights faced by sex workers in order to realise their human rights and reduce their vulnerability to HIV infection and the impact of AIDS. Antidiscrimination laws and regulations should guarantee sex workers’ right to social, health and financial services.
  3. Health services should be made available, accessible and acceptable to sex workers based on the principles of avoidance of stigma, non-discrimination and the right to health.
  4. Violence against sex workers is a risk factor for HIV and must be prevented and addressed in partnership with sex workers and sex worker-led organisations.

Evidence-based recommendations:

  1. Offer a package of interventions to enhance community empowerment among sex workers.
  2. Promote correct and consistent condom use among sex workers and their clients.
  3. Offer periodic screening for asymptomatic STIs to female sex workers.
  4. Offer female sex workers, in settings with high prevalence and limited clinical services, periodic presumptive treatment (PPT) for asymptomatic STIs. (This recommendation is conditional. See Clinical and Support Services for more information.)
  5. Offer voluntary HIV testing and counselling to sex workers.
  6. Use the current WHO recommendations on the use of antiretroviral therapy (ART) for HIV-positive general populations for sex workers (and refer to the latest ones published in 2013, i.e. begin ART below a CD4 count of 500).
  7. Use the current WHO recommendations on harm reduction for sex workers who inject drugs (in particular needle and syringe programme and opioid substitution therapy).
  8. Include sex workers as targets of catch-up hepatitis B immunisation strategies in settings where infant immunisation has not reached full coverage.

Principles for Implementing Comprehensive HIV and STI Programmes with Sex Workers

These principles underlie the 2012 Recommendations and the recommendations in the SWIT:

  1. Community empowerment
  2. Community participation and leadership in the design, implementation, monitoring and evaluation of programmes
  3. Programmes should address structural barriers
  4. Programmes must operate at multiple levels, from the front-line to the national policy arena
  5. Programmes should be holistic – considering all the services sex workers need; and complimentary – finding ways to coordinate and integrate service delivery, to be more effective and accessible
  6. These recommendations and principles should be seen as a minimum global standard, applying equally to higher income countries and lower and middle income countries

Community Empowerment

Community empowerment is a process where sex workers take individual and collective ownership of programmes. In the values and preferences survey, sex workers agreed that community empowerment is an ‘absolutely necessary component’ of health and rights interventions.

Community empowerment for sex workers means:

  • Sex workers coming together for mutual assistance.
  • Removing barriers to full participation.
  • Strengthening partnerships between sex worker communities, government, civil society and local allies.
  • Addressing collective community needs in a supportive environment.
  • Leading the process: sex workers know best what their priorities are and how to address them in a context-appropriate way.
  • Meaningful participation and inclusion of sex workers in all aspects of programme design, implementation, management and evaluation.
  • Providing money and resources directly to sex worker organisations and communities.
The eight key elements of community empowerment are:
  1. Working with communities of sex workers
  2. Fostering sex worker-led outreach
  3. Developing sex worker collectives
  4. Adapting to local needs and contexts
  5. Promoting a human rights framework
  6. Strengthening the collective
  7. Shaping policy and creating enabling environments
  8. Sustaining the movement

community-empowerment

Sex workers must be meaningfully included in developing and implementing interventions. This may be a different style of working than many service providers are used to.

Meaningful participation means that sex workers:

  • Choose how they are represented and by whom
  • Choose how they are engaged in the process
  • Choose whether to participate
  • Have an equal voice in how partnerships are managed

Service providers who are working with sex workers should become familiar with the concept and key elements of community empowerment. They should agree on long-term goals that include programmes being run by sex workers, rather than done for sex workers.

Some strategies that can be used to strengthen the community empowerment process are:

  • Develop sex worker collective
  • Adapt to local needs and contexts: flexibility is important; goals must align with sex worker needs, even if these needs change over time
  • Promote a human rights framework: governments should establish laws that respect the human rights of sex workers and protect against discrimination and violence
  • Strengthen the collective through transparency in finances and decision making processes, ensuring sex workers are in control, supporting the growth of membership, building leadership and skills
  • Shape policy and create enabling environments: promote sex workers’ rights to government, law enforcement and other policy makers
  • Sustain the movement by operating in solidarity with other movements that advocate for human rights
  • Monitor progress

Indicators are information and facts that tell us how well our programmes are achieving their goals.

Some indicators of sex worker community empowerment include:
  • Inclusion in policies and programmes at all levels
  • Amount of funding allocated to sex worker-led group
  • Recognition of sex worker-led organisations at all levels
  • Number health-care providers, police and social service agents trained in sex worker rights
  • Level of sex worker involvement in design and delivery of services
  • Changes in attitudes and level of discrimination experienced from health-care providers, police and social service agents
  • Amount of sex worker participation inpublic life
  • Degree of social acceptance of sex workers
  • Number of safe spaces and sex worker-ledgroups created
  • Number of meetings, marches or rallies to promote sex worker rights

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Addressing Violence Against Sex Workers

Sex workers face high levels of stigma, discrimination, violence, and other human rights violations. Sex workers face many different forms of violence, including physical, sexual, emotional and psychological.

Violence can happen in the workplace, from intimate partners and family, by people in public spaces, by organised groups (extortion groups, religious extremists, ‘rescue’ groups), and by the state (police, military, prison guards, border guards).

Laws and policies that criminalise sex work or that discriminate against transgender individuals or men who have sex with men may make sex workers more vulnerable to violence.

Values and principles recommended for addressing violence against sex workers:

Core values:
  • Promote the full protection of sex workers’ human rights
  • Reject interventions based on the notion of rescue and rehabilitation
  • Promote gender equality
  • Respect the right of sex workers to make informed choices about their lives
Programming principles:
  • Gather information about local patterns of violence against sex workers
  • Use participatory methods to involve sex workers in identifying and finding solutions to their problems
  • Design holistic programmes that include health and legal services and are community based
  • Build capacity of programme staff to understand and address the links between violence against sex workers and HIV
  • Prepare for the possibility that programmes may have unintended harmful impacts
  • Evaluate programmes.
Promising interventions and strategies for addressing violence against sex workers include:
  • Community empowerment
  • Building the capacity of sex workers
  • Advocating for policy and legal reforms
  • Fostering police accountability
  • Promoting the safety and security of sex workers
  • Providing health services to sex workers who experience violence
Once a programme is implemented it should be monitored and evaluated. This process is important because:
  • Data on violence is needed to plan and design appropriate strategies.
  • Interventions may result in unintended harmful consequences for sex workers, such as ‘backlash’ violence. Programmes must be aware of these consequences so that they can plan ways to address them.
  • Evidence on violence faced by sex workers is a powerful tool advocacy tool, for law reform promoting the human rights of sex workers.

Before scaling up or expanding a programme, it should be evaluated.

There are no internationally agreed-upon indicators, specific to violence faced by sex workers, to evaluate the impact of interventions. Indicators used to evaluate strategies to address violence against women can be adapted.

You may need to do qualitative research, in addition to gathering data from surveys.

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Community-Led Services

Community-led services are services in which sex workers take the lead in delivering and overseeing an HIV prevention programme. Community-led services have significant benefits in HIV prevention and enabling sex workers to realise their human rights.

Many community-led services are started by NGOs, and primarily staffed by non-sex workers. However, programmes should be designed so that sex workers can quickly be recruited, trained and take increasing responsibility and control.

Three elements of community-led services are:

  • Community-led outreach
  • Safe spaces (drop-in centres)
  • Community committee and advisory groups

Community-Led Outreach

Community-led outreach is an essential link between the community and the HIV
prevention, care and treatment offered by a programme. It empowers sex workers to draw on their experiences to problem-solve with members of their community, strengthen access to services and make HIV prevention, care and treatment possible.

A community outreach worker is a sex worker who does outreach to other sex workers.

Outreach workers build rapport with other sex workers, understand their needs as individuals, regularly provide or link them to services.

Strategies for implementation of community outreach:

  • Map the community and design the outreach strategy with sex workers
  • Recruit and train community outreach workers
  • Implement and manage outreach
  • Foster leadership opportunities for community outreach workers

Mapping must be done in a way that respects the needs and safety of sex workers. Mapping information should be kept confidential. Law enforcement and other authorities could use this information to directly harm sex workers so data must be kept safely and securely.

Community outreach workers should always be compensated for their work. Some approaches may be problematic: for example, paying community outreach workers for each individual they bring to the clinic or drop-in centre for services can distort demand and lead to coercion. More effective incentives include phone credit, non-monetary gifts, leadership opportunities and recognition that is not linked to the number of sex workers who are brought to the programme. Offering the chance to participate in national or international trainings and meetings may also be an effective way of recognising outstanding community outreach workers.

Safe Spaces

‘Safe spaces’ (or drop-in centres) are rooms rented by the programme that provide community members with a comfortable place to relax, rest, get information and interact with each other and with the programme.

Things to consider for establishing safe spaces include:

  • Sex worker consultation and mapping: provides information on where to locate the space, which services to provide, staffing and hours. Services should be available when sex workers most need them
  • Location: consider accessibility to sex workers, visibility to the public, and the response from the wider (non-sex worker) community around the space.
  • Lease agreements and landlords: Maintaining a fixed location for the safe space is important to prevent disruption of services. The lease agreement with the landlord should clearly state the duration of the agreement, and the hours and nature of use.
  • Infrastructure and safety: The safe space should ideally have at least two rooms: one that can be used for one-on-one meetings or counselling, and one for community activities. The safe space should have with basic equipment to handle fires and other emergencies.
  • Designing the space: The space should be both functional and inviting. Couches or mattresses can make the room comfortable. Meeting tables and chairs can be set up when needed. Walls may be painted or decorated with art made by the community.

Things to consider for operating the space:

  • Management: Sex workers should take a lead role in decisions about the space and management.
  • Service promotion: Promote the safe space using flyers, SMS messages and community.
  • House rules: Develop rules with the sex workers who will use the space.
  • Relationships with neighbours: Make plans to manage relationships with neighbours and those outside the sex worker community, e.g. offer clean up around the centre.
  • Scheduling: Activities in the space that involve a limited number of participants should be scheduled during off-peak hours so that sex workers who need to access the space can do so.
  • Programme use: Growing organisations may want to use the safe space for other activities or as offices; these activities should be avoided or kept to a minimum.
  • Sustainability: Safe spaces can be financially sustainable when managed by the community. Income can be generated by renting out the space on a limited basis, or through activities managed by the community, e.g. developing catering services for events at safe space.

Other activities in the safe space could include:

  • Classes in literacy, numeracy, information technology, nutrition and dance
  • Classes on beauty tips specific to different groups
  • Walk-in general health exam
  • Showers and laundry facilities
  • Lockers to store belongings while community members are working
  • Sleeping/resting areas
  • Use of the computer and Internet
  • Crèches (child care) for children of sex workers.
diagram showing a sample floor plan for a drop-in centre featuring a common area, shower and toilet, private counselling area, and a kitchen area
Sample floor plan for a drop-in center

Community Committee and Advisory Groups

Community committees can be the main way for communities to provide feedback and shape the quality of programme services.

Community committees:

  • Allow community members to bring important issues, problems and solutions to the attention of the programme on a routine basis
  • Review clinical services, resource distribution, the functioning of safe spaces, and initiatives to address structural barriers
  • Should meet monthly to consider issues and report to the community and programme
  • Share results from previous actions taken to address community concerns
  • Share monitoring data with the community

Members of the committee should be elected by the community on a regular basis, e.g. annually.

Other community-led approaches to ensuring quality of services include:

  • Obtain agreements with clinics and medical personnel to display a patients’ charter of rights and information on patients’ right to confidentiality
  • Design ways to share information about trustworthy and reliable services in the community
  • Educate the community on their rights
  • Have regular contact between committee members and the chief medical officer; introduce committee members to health service providers

All programmes should be monitored and evaluated regularly. Some indicators are:

  • Number of outreach workers to sex workers
  • Number of sex workers reached through one-to-one outreach each month
  • Average number of condoms distributed per sex worker each month
  • Number of sex workers who have attended STI or voluntary HIV testing and counselling (HTC) clinics
  • Number of sex workers receiving routine STI and HIV testing
  • Number of HIV positive sex workers with access to health support

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Condom and Lubricant Programming

The effective supply, distribution and promotion of condoms and lubricant are essential to successful HIV prevention among sex workers. Condoms are the most effective tools for sex workers to prevent HIV transmission.

Successful condom programming means sex workers have a stable and adequate supply of condoms and lubricant. Programmes should also address social and legal barriers to condom use.

Three steps in effective condom and lubricant programming are:

  • Establish accessible supplies
  • Multi-level promotion
  • Creating an enabling environment

An effective supply chain has the following components:

  • Forecasting
  • Procurement
  • Quality assurance
  • Warehousing and storage
  • Distribution
  • Logistics management

Multi-level promotion includes community-led condom promotion and destigmatising condoms in the broader social environment.

An enabling environment for strong condom programming ensures that:

  • Policy, legal and regulatory frameworks support condom programming
  • These frameworks are properly enforces
  • Key organisations and individuals support condom programming and access for sex workers

Condom promotion and distribution programmes should always be free of coercion. 100% condom use policies should be avoided, as they restrict individual freedoms and violate human rights. When condoms are easily accessible, coercive policies are not necessary.

Other considerations for condom programming include:

  • Condom programming for male and transgender sex workers: Female, male and transgender sex workers may provide different sexual services. Programmes should work with these communities to understand their needs.
  • Condom negotiation strategies
  • Condom programming with clients of sex workers
  • Condom social marketing programmes: Sell lower-priced, subsidised condoms and lubricants to individuals. These programmes can help improve the sustainability of condom programming and provide a range of condom and lubricant choices.

Condom programming is managed through partnerships and coordination with organisations at multiple levels of government and NGOs. Programmes should be monitored and evaluated regularly.

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Clinical and Support Services

Providing appropriate, accessible, acceptable and affordable clinical and support services for sex workers presents unique challenges because of the stigma and discrimination often faced in clinical settings. However, clinical services can be a focus for community empowerment if sex workers are involved in their design, implementation and monitoring.

Key principles for designing and delivering services to sex workers are:

  • Voluntary and informed consent: Sex workers have the right to decide on their own treatment and the right to refuse services. Health-care providers should explain all procedures and respect the sex worker’s choice if he or she refuses examination or treatment.
  • Confidentiality: Confidentiality of patient information, including clinical records and laboratory results, should always be maintained to protect the privacy of sex workers. Sex workers should be allowed to provide identifying information other than their official birth name (identification papers or biometric data should not be required). Assigning an enrolment number can provide continuity of service.
  • Appropriate services: Clinical services should be effective, high quality, provided in a timely manner and address the needs of sex workers. Health services should be in line with international standards, current best practices and guidelines.
  • Accessible services: Clinical services should be offered at times and places convenient for sex workers. Where possible, services should be integrated or closely linked so that a broad range of health services can be accessed at a single visit.
  • Acceptable services: Health-care providers should be discreet, non-judgemental, non-stigmatising and trained to address the special needs of sex workers.
  • Affordable services: Services should be free or affordable, bearing in mind the cost of transport and lost income opportunities for sex workers visiting a service provider

Voluntary HIV Testing and Counselling

Voluntary HTC services should be part of an integrated programme of HIV prevention, care and treatment. Sex workers, their partners and their families should have access to HTC as frequently as required, at times and locations that are convenient

Preparation:

  • Community awareness and building demand: Community members should be informed about the benefits of knowing one’s HIV status and about the availability of treatment if they are infected.
  • Training providers and community outreach workers following national and international standards.
  • Location and timing of services: Consult with sex workers and consider their needs and requests for service provision.
  • Procuring essential supplies.

HTC Service Delivery:

  • Pre-test information: Focus on basic HIV information and information about the test process. Ensure that all testing is done voluntarily.
  • Post-test counselling: This counselling is provided when the test results are ready to be given to the client. People who are HIV-positive should receive immediate referral for long-term care and treatment, and counselling about how to avoid transmitting HIV. All people should receive risk-reduction information, access to condoms and lubricant, and counselling on strategies to negotiate safer sex.
  • Repeat testing: Sex workers who test negative should be advised to return for repeat testing
  • Partner and family testing: Sex workers living with HIV should receive support to disclose their results to trusted family members if they wish to. Voluntary HTC should be available to their partners, children and other family members.

Follow-up:

  • Prevention services: All people should be informed about prevention services, including condoms and lubricants.
  • Connection to care and supportive services: Every person who tests HIV-positive should be offered care, support and treatment that is respectful and acceptable.

Voluntary HTC services may be provided by community outreach workers.

Antiretroviral Therapy

Sex workers may face greater challenges than the general population in accessing HIV care and treatment service. This is often because of stigma and discrimination, and inflexible, inconvenient services.

Factors, including flexible clinic hours, services near sex work sites, drop-in services (no appointment required), ‘emergency’ drug pick-ups, and respectful staff attitudes can make access to ART easier.

The most recent WHO ART guidelines should be used for all people living with HIV, including sex workers.

Tuberculosis and Sex Workers

TB diagnosis, prevention and treatment for sex workers should follow the most recent national and international guidelines for TB in other adults.

People living with HIV are more likely to develop TB. Ideally, co-treatment for TB and HIV should be available at the same time and place.

Additional Services for Sex Workers Who Inject Drugs

In some areas of the world, there is substantial overlap between communities of people who inject drugs and sex workers. Sex workers who inject drugs should have full access to HIV prevention, treatment, support and care. Support and voluntary treatment for drug dependence should also be available.

Opioid substitution therapy, and needle and syringe programmes are highly effective at reducing the transmission of HIV.

STI Services

Screening and treatment for STIs is important to prevent the spread of infection. STI services should be a priority, and should be human rights based, confidential, and voluntary.

Regular screening for asymptomatic infections, using laboratory tests, is cost-effective and can reduce STI prevalence over time. Where laboratory diagnosis is available, they should be staffed with qualified personnel. Quality assurance systems should be in place.

Sex workers should still be screened for STIs, even if laboratory testing is not available. A regular STI check-up is an opportunity to talk about prevention. A check-up may involve discussing symptoms and doing an examination to check for signs of infection.

Providing effective services to sex workers with symptoms should be a priority. In settings where testing is not possible, the WHO recommends a syndromic approach to manage symptomatic infections.

Four elements of STI services are:

  1. Designing STI services: Assess current services, define essential STI service package and other services for sex workers, and organise STI services.
  2. Implementing and managing STI services: Set up STI services. Establish STI health care-seeking behaviour as the norm. Address structural barriers to accessibility and acceptability. Involve sex workers and community outreach workers in clinic operations. Provide an appropriate and high quality service package. Link and integrate services.
  3. Periodic presumptive treatment (PPT): PPT should only be used as a short-term measure, where STI prevalence is high (>15%). PPT should only be offered as part of comprehensive sexual health services. PPT should be phased out as soon as possible. Sex workers reported harmful consequences from the use of PPT. It should only be offered when sex workers are fully informed, and must be voluntary.
  4. Viral hepatitis: Sex workers should be included in HBV immunisation strategies, in settings where infant immunisation has not reached full coverage.

Addressing Sexual and Reproductive Health Needs of Sex Workers

Sex workers of all genders have SRH needs and the same reproductive health rights. Clinical services should consider:

  • Family planning and contraceptive counselling, including emergency contraception
  • Safe pregnancy
  • Abortion and post-abortion care
  • Reproductive tract cancer screening
  • Clinical care for survivors of sexual assault
  • Counselling on hormone use and referral to other gender enhancement services for transgender sex workers

Mental Health

Mental health is an important to an individual’s ability to live a fulfilling life. Sex workers may be particularly vulnerable to mental health problems because of poverty, criminalisation and discrimination.

Poor mental health may be a barrier to accessing and continuing with HIV treatment and care. Programmes should monitor for and address obstacles or mental health.

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Programme Management

Comprehensive STI/HIV programmes for sex workers are complex and have many aspects that must be addressed at the same time. Establishing services outside the government or private sector requires building management processes and structures. Funding may come from multiple sources, each with different reporting requirements.

Management approaches should address the specific needs of sex worker programmes,
such as:

  • Coverage: High coverage is essential to achieve impact at a population level.
  • Mobility and migration: Sex workers may move within a city, country or across borders. Flexibility is required to meet the varying demand for outreach and resources, and to serve sex workers who do not speak the local language.
  • Sex worker leadership: Programme design should incorporate meaningful positions for sex workers in managing and monitoring.
  • Addressing structural constraints: HIV interventions should address the broader factors that contribute to sex workers’ vulnerability, e.g. criminalisation, discrimination, poverty.
  • Strict confidentiality and protection of data: detailed information about sex work locations and the community is necessary for programme design and management. This information must be protected from groups or individuals who might harm sex workers.
  • Flexibility and continuous programme learning: The sex work environment changes rapidly. It is important to develop systems to adjust the programme when necessary.

Programme management is essential for developing programmes that are sustainable and scalable. Having a management system in place will help ensure that your programme has and is meeting clearly defined goals and objectives, is meeting standards for quality, and has established processes. Effective programme management will include data tracking and reporting. This is particularly important for sustaining funding
and partnerships.