What Works for Women and Girls

protective. In an analysis of 100% condom use policies (CUP), CASAM found that “whilenot all aspects of 100% CUP are negative, there exists a need to re-center HIV programmingtargeting sex workers within the framework of a rights-based and justice-based sex workerempowerment model” (CASAM, 2008: 2). A sex worker women’s group in Mongolia reportedthat violence by both clients and intimate partners were significant barriers to condom usewhen a 100% CUP was implemented (Jamts, 2008). Also, because 100% CUP programstend to target sex workers rather than their male clients, these programs have not necessarilyaffected condom use in regular (non-transactional) partnerships.Yet, programs that facilitate increased condom use among sex workers during commercialsex, as well as during sex with regular partners are critical—from both public health and humanrights perspectives. Condom negotiation skills are essential skills for sex workers. A study inSouth Africa found that “sex workers identify demands for unprotected sex as one of theirmost significant problems” (Gould and Fick, 2008: 52). Sex workers reported a high proportionof clients seek unprotected sex. As one sex worker put it: “We haven’t really got problemswith the clients here, except with the ones we call ‘condommissions’, because it’s a real mission to get them to use the“The problem is not sex—it is lack of condoms.”(Reynaga, 2008)condoms. You would be surprised how ignorant they are.You actually have to educate them about condoms… you sayto them you have a wife and family to worry about” (Gouldand Fick, 2008: 74). Most cases of violence were triggeredby the refusal of the sex worker to comply with a demandfor unprotected sex, with a third of street-based sex workers reporting being raped by a client.They did not expect any help from the police (Gould and Fick, 2008).Female sex workers do adopt safer sex behavior after educational interventions, and manyprograms have succeeded in encouraging sex workers to negotiate condom use with clients.A systematic review of published evidence from 1998 to 2006 on condom use found thatfifteen of the 19 studies of condom use in commercial sex reported significantly increasedlevels of condom use (Foss et al., 2007). However, programs need to support sex workers touse condoms with regular clients as well as in their personal relationships as they are lesslikely to use condoms with their husbands, boyfriends and partners. Sex workers need accessto condoms and appropriate water-based lubricants (Arnott and Crago, 2009).Protecting Human Rights and Empowering Sex Workers are VitalPrograms that take a human rights and empowerment approach, such as the Sonagachi Projectand Sagram in India, have been shown to create better working conditions and be the mosteffective to reduce HIV acquisition among sex workers and (Pillai et al., 2008; Gooptu andBandyopadhyay, 2007). Sex workers themselves have led some of the most effective, evidencebasedresponses (Reynaga, 2008). Evidence suggests that empowering sex workers withagency is important both for the health of the sex worker herself and for effective HIV preventionprograms. In contrast, punitive and mandatory measures—such as when governmentshave imposed compulsory HIV testing of sex workers, a measure that does not respect their78 CHAPTER 4 PREVENTION FOR KEY AFFECTED POPULATIONS