In recognition of International Women's Day 2016...

GSHI findings call for evidence-based policies and programs to better support women's sexual health & HIV care.

MARCH 8th, 2016 – In recognition of International Women’s Day, we would like to share with you some critical research from the BC-CfE’s Gender & Sexual Health Initiative (GSHI) that challenges harmful policies and practices and call for evidence-based responses to better support women’s sexual health and HIV care. Under leadership of director Dr. Kate Shannon, GSHI examines health and social inequities to inform evidence-based policy and practice in sexual health and HIV among marginalized populations. GSHI’s seminal work calls attention to the critical need for structural responses to ensure the health and human rights for all.

1. Gendered violence continues to drive HIV/ STI burden for women, sex workers, and is heavily shaped by socio-cultural contexts 

The team has published seminal research on how gendered violence impacts HIV/ STI risks among women and is heavily shaped by socio-cultural contexts for key sub-populations of women. Early peer review research in 2008 and 2009 demonstrated alarming rates of violence among street-involved women sex workers. The research demonstrated a disproportionate burden of violence among Indigenous women; embedded within systemic violence, international trauma, criminalization and police inaction on missing women. This work and others was featured in a BCCfE editorial in JAMA, and contributed to expert consultation and first-ever international guidelines by WHO/ UNAIDS on HIV/STI prevention, treatment and care among sex workers. Recent research by the GSHI/ BC-CfE team has shown concerning experiences of violence among trans persons and gender/sexual minority women; embedded within transphobia, criminalization, and stigma. For new im/migrant sex workers, the experiences of violence are often inaccurately conflated with sex trafficking (i.e. forced sexual labour); undermining accurate research and responses to violence against migrant sex workers and trafficking. Two critical editorials in the Lancet Global Health and Lancet Psychiatry by BC-CfE call attention to this concerning issue. In a study published in 2015from the Gulu Sexual Health Project, in partnership with the AIDS Support Organization and sex work community, migrant and formerly internally displaced women sex workers in northern Uganda reported alarmingly high rates of physical and sexual violence, with analyses showing violence was linked to rushed negotiations to avoid police and inconsistent condom use with clients. 

2. Criminal law and policing has not only been ineffective in protecting sex workers but has had devastatingly harmful effects on sex workers’ health, safety and human rights 

Over 40 peer-review publications from GSHI/ BC-CfE have demonstrated that legislation criminalizing sex work and enforcement-based approaches drive the sex industry to isolated street and hidden, indoor spaces and reduce sex workers ability to screen clients and negotiate terms of transactions, including client condom use. In a leading paper in British Medical Journal in 2009, enforcement of criminal laws were found to be directly linked to elevated risks for physical violence and rape. Editorials summarizing the evidence were published in leading medical and public health journals including Lancet Infectious Diseases and CMAJ. This work has been repeatedly shared with community, policy makers, government, and the public though media, press conferences, presentations and editorials, in partnership with sex work groups. To ensure this evidence was heard at the highest levels, GSHI/ BC-CfE researchers provided expert evidence and legally intervened in the landmark ‘Bedford’ case at the Supreme Court of Canada in 2013 that ultimately struck down Canada’s criminalized prostitution laws in an unanimous decision.

Based on the above evidence of the harmful impacts of criminalized approaches, and in response to the Conservative Government’s Bill C-36 and the Protection of Communities and Exploited Persons Act, the GSHI team organized an open letter signed by over 400 Canadian and International scientists and academics and shared with all Federal party leaders and Members of Parliament calling for the decriminalization of sex work in Canada, and opposing the criminalization of clients and third parties. The open letter was shared extensively via social media, an op-ed in the National Post, and was published in full by a number of media outlets, including the Georgia Straight.

3. Community and peer-led strategies remain critical to an effective response to reducing inequities in women’s sexual health and HIV care 

In 2009, GSHI/ BC-CfE team published an evaluation of a peer-driven intervention among women living with HIV demonstrating the critical role that peer support plays in supporting WLWH’s engagement and retention in HIV care and adherence to antiretroviral therapy. The GSHI/BC-CfE researchers went on to evaluate a number of innovative community-led interventions, including mobile peer/sex worker-led outreach and low-threshold women-only drop-in centres that provide critical safety and respite for women, and link women to sexual and reproductive health services and addiction treatment. These papers are particularly noteworthy through their extensive collaboration and co-authorship with community, and demonstrate the importance of ensuring affected communities engagement and voices throughout research. In 2015, the GSHI/ BC-CfE team extended the work on peer support to published research that evaluated the crucial role of social cohesion among sex workers (e.g. level of trust, mutual aid and support among workers) in supporting negotiation of safer sexual practices with clients. This study received substantial medial attention, including the CBC and a top story in the Globe and Mail with joint comments from co-authors from Sex Workers United Against Violence.

4. Women-centred housing models reduce gender inequities in health 

In 2011, the team published two papers evaluating how all-gender low income and transitional housing within largely male-dominant street cultures can create unsafe conditions for women, including threats of eviction, gendered rules on visitors and guest fees and heightened risks for violence and exploitation by male residents and staff. In contrast, gender-specific and women-centred services hold promise and need to be further evaluated across health and social supports and supported to scale-up reach for diversity of marginalized women. In two follow-up peer-reviewed publications, the BC-CfE team demonstrated how supportive women-centred housing models that included women only staff, protections from violence (e.g. supportive guest policies for dates, partners) and increased self-determination of policies was linked to reduced violence and increased access to sexual and reproductive health services and police protections. The first of these papers in the American Journal of Public Health evaluating the innovative women-centred housing models led by RainCity Housing and ATIRA Women’s Resource Society demonstrated how these housing programs created safer indoor work spaces for women sex workers and reduced violence and increased control of safer sexual practices. These publications led to briefings with policy-makers and were submitted in expert evidence to the Supreme Court of Canada in Bedford, as well as through a press conference and joint media effort with community partners.

5. Even when considering biomedical advancements, full decriminalization of sex work could have the largest impact on the HIV epidemic in sex work, averting 33-44% of HIV infections over the next decade

In 2014, the BC-CfE led the first review paper in The Lancet Special Issue on Sex Work and HIV, in co-authorship with 11 academic and community co-authors from global south and north. The seminal paper modeled the impact of structural factors and biomedical interventions in diverse settings of Kenya, India and Canada, and demonstrated that even beyond impacts of ART, the decriminalization of sex work could have the largest impact on course of HIV epidemics in sex work; averting 33-46% of HIV infections over the next decade. The paper was shared at a major Lancet session at the World AIDS Conference in Melbourne in 2014, and was cited in over 60 media pieces across 20 countries, including a lead article in the Washington Post. The paper continues to be cited in major policy documents, and has been shared at regional launches globally, as well as an op-ed in the Huffington Post in evidence-based support of the Amnesty International policy on sex work. 

6. Criminalization and migration linked to HIV treatment gaps for marginalized women living with HIV 

A BCCfE study published in 2015 found that one-third (38%) of marginalized women living with HIV experienced significant gaps in adherence to antiretroviral therapy. Of significant concern, younger women, mobility/migration outside of Vancouver, and exposure to incarceration were linked to increased gaps in retention in HIV care. These early findings were critical to informing our SHAWNA Project and support calls for policies and community programs that better address the HIV care needs and diversity of women living with HIV. To better understand and address these issues, in the fall of 2015, the SHAWNA Project and Women, HIV and the Law Project teams of BC-CfE co-hosted a high level roundtable on Criminalization of HIV Non-Disclosure and Women together with the Positive Women’s Network and Canadian HIV/AIDS Legal Network, with planning committing of BC Women’s/ Oak Tree, International Community of Women Living with HIV, BC Civil Liberties Association, and Pacific AIDS Network. The roundtable set research and advocacy priorities to address community, law reform and clinical practice in criminalization of HIV and women; and create better mechanisms to share evidence-based practice on criminalization of HIV and the law.