It is “Suicide” to Ignore Sex Workers

William Smith's excellent piece on the impact the PEPFAR prostitution pledge is having on HIV/AIDS prevention work in Kafue, Zambia made me wonder how my home city of St. Louis, Missouri, would respond given the same conditions and limitations. Would an HIV/AIDS service organization (ASO) err on the side of caution or the true fulfillment of their mission? And what impact would those choices have on my community and my city?

HIV/AIDS is a global disease and St. Louis, like all cities, has residents at risk for HIV/AIDS infection and residents who are HIV positive or have AIDS. Also like most cities, St. Louis has prostitution.

Remove Zambia and insert America…remove Kafue and insert St. Louis…and the PEPFAR prostitution pledge still won't make sense because building a program that says people will have access to HIV/AIDS education, prevention and contraception unless they are prostitutes will never make sense regardless of where those people live.

I can't figure out if, by denying funds to groups that provide prevention outreach to sex workers, PEPFAR is trying to punish sex workers or terrorize people considering becoming sex workers. Either way, the prostitution pledge assumes that sex workers are less than human and outreach promotes prostitution. Both assumptions are wrong. Sadly, it is all too easy to attach different standards to the care of strangers far away in Africa. But Americans don't have to travel to examine the impact and need for outreach to commercial sex workers communities.

I reached out to two local St. Louis ASOs, St. Louis Effort for AIDS and Williams and Associates, Inc., to find out what kind of HIV/AIDS prevention outreach they are doing to commercial sex workers and what they think of the prostitution pledge recipients of PEPFAR funding have to take.

Williams and Associates, Inc. seeks to "provide preventive health education, disease prevention, health promotion and care services that address the health disparities of minorities in the St. Louis Bi-State region, with particular regard to African-Americans." African-Americans comprise 51 percent of the population of St. Louis city and the offices of Williams and Associates, Inc. are located in the heart of predominately black North St. Louis city. The organization is funded by private foundations and receives some federal funds indirectly through the state.

Since being founded five years ago, Williams and Associates, Inc. has done outreach to the sex worker community. With a staff of four and several local volunteers, the program provides information on the importance of negotiating safer sex with clients. They provide testing and condoms and recruit people to participate in group programs designed to build self esteem.

When I asked Chief Executive Officer Erise Williams for his thoughts on the importance of HIV/AIDS prevention outreach to the sex worker community he said, "I think prevention is very vital. When we talk about HIV prevention we are really talking about risk reduction. I think it is very effective for this population because each time they engage in sex they are putting themselves at risk. You have a group of people who are putting themselves at risk more so than the average person. Any prevention we can do to reduce risk, change behavior and change lifestyle is a good thing. It has become more challenging because HIV prevention has become more political."

And then I asked Mr. Williams how he would feel if he were told that he could not do prevention outreach to the sex worker community or that doing such work would put his funding at risk.

"It would be suicide to be asked to not do outreach to sex workers. True, we have a significant number of HIV cases in St. Louis but I think it would be worse if we did not do prevention outreach."

St. Louis Effort for AIDS is the most comprehensive ASO in the metropolitan St. Louis area. Founded in 1985 by a group of concerned volunteers, Saint Louis Effort for Aids (EFA) provides education on the prevention of HIV/AIDS and comprehensive support services for those affected by the disease. Cyrano Jones of EFA works with commercial sex workers in St. Louis three days a week using a mobile testing unit. The unit varies the days of the week and strives to provide services during the day, afternoon and evening.

Jones says that most mobile outreach clients depend on prostitution as their sole source of income. If they have a substance abuse problem EFA will try to lead them to treatment. If they are in need of treatment services, EFA will provide them, and if they need assistance developing life skills, EFA will also help with that too.

Most importantly, EFA creates a risk reduction plan to help empower individuals to seek safer and healthier lifestyles.

"I feel I'm making a difference," said Jones, who has been doing prevention outreach to commercial sex workers since 1989, "The numbers are coming down and people are more educated about the virus and protection."

The women of my family have a saying that no cook should take a dish to a potluck she wouldn't serve her own family. Similarly, the US should not require pledges of organizations in other countries it wouldn't require of organizations here at home. The prostitution pledge only works to stigmatize sex workers and keep them separate from their communities and the HIV/AIDS service organizations there to serve them. People are not empowered through condemnation and communities are not empowered by this pledge. It's time to remove the limitations of the prostitution pledge and allow for comprehensive prevention outreach to commercial sex workers abroad.

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  • invalid-0

    While PEPFAR is extremely problematic in many respects, it DOES NOT “deny[] funds to groups that provide prevention outreach to sex workers.” It DOES deny funds to brothels and pimps. Organizations that agree not to promote prostitution CAN and DO receive funds to provide services to prostituted women. Please do some research and stop spreading misinformation like this.

  • invalid-0

    The “no promotion of prostitution pledge” is NOT a gag rule. It is a requirement that government funds not be used to fund pimps and prostitution directly. NGOS that sign on to the pledge can AND DO still provide condoms, education and ofher assistance to sex workers. PEPFAR has a lot of bad aspects, but there is no reason to lie about what it does, and doesn’t do.

    The only NGO refused funds because it refused to sign the pledge is run by a pornographer, Philip Harvey, who SELLS (rather than gives) condoms to people in poor countries via DKT International. He was involved in promoting in brothels abroad, and therefore could not sign the pledge. You may belive that direct subsidization of brothels by US taxpayer funds (of which Harvey was keeping a big chunk for himself) is the correct thing to do but surely you can understand why so many politicians from both parties do not. Read more here:

    and here

  • scott-swenson

    Dear Anonymous,


    First, the only time we delete comments is when they are outside the bounds of propriety and/or stigmatizing to marginalized populations. Many of our readers actually encourage us to delete far more comments than we do. Unlike many web sites, we encourage respectful dialog on these sensitive issues. If your comments have been deleted, there was good reason, not because we disagreed.

    As to the anti-prostitution pledge, the reality of the US government's policy has been a sharp reduction in outreach efforts through PEPFAR funded programs to this most vulnerable population. This report says it best,

    How has the pledge requirement actually affected programs? While we found few published studies, several cases do suggest possible implications. In our view, the pledge has the potential to restrict programs for those it seeks to protect. Changes in policy have forced some non-US-based projects, such as the Médecins Sans Frontières–run Lotus Project in Svay Pak, Cambodia, to close [24]. Interviews with some 100 women in Svay Pak revealed that only a small number felt they had been forced into sex work, and a significant percentage sought to improve working conditions and safety. The Lotus Project began by offering a range of services to sex workers, from primary health care to English and computer lessons, while receiving funds from USAID for operations research. Within two years after the project's launch, Médecins Sans Frontières handed it over to a local organization, whose funding came primarily from USAID, in an effort to ensure sustainability. Around the same time, the Lotus Project had come on the radar of US activists working on human trafficking issues. After a number of raids on brothels in the area by US-funded anti-trafficking groups, sex workers experienced severely restricted mobility, resulting in limited access to health care and a reduced ability to earn a livelihood. The project's ability to respond effectively to the new situation was hindered by fear of being seen as promoting prostitution. Their freedom to deliver services based on best practices was limited. Eventually, funding from USAID diminished and the Lotus Project closed [24]. The experience of the Lotus Project contradicts a principal argument used in a friend of the court brief in support of USAID. This argument stated that “Organizations can oppose the prostitution industry without stigmatizing the individuals bought and sold in it‥Helping victims while opposing the industry that exploits them is the best way to prevent HIV/AIDS, the best way to advance human rights, and the best way to fulfill the intent of the Act” [25]. We agree. Yet we would argue that the evidence suggests that as long as prostitution and sex trafficking remain conflated, women and men who voluntarily sell sex may be at risk of further marginalization and may, as witnessed by the Lotus Project, be less likely to receive the health, social, and education services they need to eventually move out of the industry. In this polarized debate, neither side has been ready to surrender what it believes to be the best approach to HIV prevention among sex workers. Public health professionals have an obligation to demand that funding be driven by evidence-based strategies for addressing health and social problems, but evidence does not function in a political vacuum. The history of HIV prevention is all too full of programs that have proven to be politically unfeasible in the US despite overwhelming scientific evidence in their favor, such as the efficacy of needle and syringe exchange programs as HIV prevention tools for injecting drug users. The Federal Government continues its ban on federal funding for this intervention, despite endorsements from the Institute of Medicine, the US Surgeon General, and all of the major health professional associations [26]. These political realities have complicated responses to HIV prevention for sex work as well as for injection drug use. While sex work may be seen by some as inherently degrading, it is nevertheless the case that in many settings sex workers choose to continue to work and to demand preventive and other health services. The provision of support, goods, and services to sex workers who want and need them is a compelling ethical and public health priority. Building trust and showing care by providing sex workers with the tools necessary to stay alive, whether they be condoms, counseling, or a safe place to receive medical attention, is our duty as health professionals and as human beings. Whether these goals can be met if we must “oppose prostitution” is actively being argued in the courts, and perhaps more vitally, in the many settings where sex workers provide services societies continue to disdain and demand.



    Be the change you seek,

    Scott Swenson, Editor

  • invalid-0

    Ms. Merritt, you seem like an intelligent, moral person. I beseech you to do some research, rather than accepting the falsehoods of Smith and Swenson.

    Consider the following excepts from Swenson’s post above, with responses:

    1. “Interviews with some 100 women in Svay Pak revealed that only a small number felt they had been forced into sex work, and a significant percentage sought to improve working conditions and safety.”

    This is in conflict with the vast majority of research which shows that most prostitutes DO NOT want to do sex work. I absolutely agree that condoms education, and medical care should be provided to all prostitutes and all women generally but the pledge DOES NOT PREVENT THIS. It prevents the PROMOTION of prostitution, meaning those actively recruiting poor people to sell their daughters into prostitution cannot receive USAID funds.

    2. “After a number of raids on brothels in the area by US-funded anti-trafficking groups, sex workers experienced severely restricted mobility, resulting in limited access to health care and a reduced ability to earn a livelihood.”

    The “raids” were related to TRAFFICKING, which is FORCED PROSTITUTION. It is regrettable that pimps restricted the mobility of prostitutes in the wake of action against TRAFFICKERS but is that a reason not to try to free women held in sex slavery? What kind of people think sex slavery is okay, as long as you give the women condoms? In places where prostitution is legal, raids are conducted to free sex slaves, especially children.

    3. There is no evidence that any person has been denied anything at all due to “the pledge” and the people who object to the pledge are making money off of prostitution. They have incentives to lie, and they are indeed lying.