Sex Work and Life with Dignity: Sex Work, HIV, and Human Rights Program in Peru

HIV and Most-at-Risk Populations in Peru

Approximately 0.5 percent of the adult Peruvian population lives with HIV, which in 2007 represented 76,000 individuals (UNAIDS 2010). Sexual transmission is the cause in an estimated 97 percent of cases (Ministry of Health [MOH] 2010). To date, close to 5,000 people are believed to have lost their lives to AIDS-related diseases in Peru.

Facilitators/participants of the trainings.

According to different sources, vulnerability to HIV in Peru is concentrated primarily among most-at-risk populations (MARPs), which include men who have sex with men and transgender people, some of whom also engage in sex work. HIV prevalence among men who have sex with men is 13.7 percent, and between 32 percent and 45 percent among transgender people (MOH 2010; UNAIDS 2010). The urban areas of Lima and Callao have the highest HIV prevalence, along with certain regions of Amazonia, including some areas in which the program is currently operational. However, there appears to be less accuracy in HIV prevalence estimates for the Amazonia region, as in the case of Pucallpa, particularly among MARPs.

Civil society, academic, and international organizations have responded vigorously to HIV in Peru; these include nongovernmental organizations, universities and research institutions, organizations of people living with HIV, and organizations for MARPs, such as REDTRANS and Miluska. U.N. agencies, primarily UNFPA and UNAIDS, also provide support. The majority of funding for HIV is from the Global Fund to Fight AIDS, Tuberculosis and Malaria, which has provided a total of approximately U.S.$60 million to Peru's HIV response, and U.S.$10 million was approved in Round 10 with a focus on MARPs.

Government leadership: The MOH and other government agencies have taken a leadership position in the response to the epidemic, primarily by providing such services as testing, counseling, and medical treatment. Particularly important in guiding the response is the National Health Strategy to Prevent and Control STDs and HIV, originally developed in 2004, which includes strategies for MARPs in prevention, treatment, care and support, and formative and operational research. Other sectors that work within the strategy are the Ministry of Education, the Ministry of Justice, the Ministry of Labor, and the Office of Public Defense (MOH 2010).

A milestone at the government level has been the Multisectoral Strategic Plan (MSP) to Prevent and Control STD-HIV/AIDS 2007–2011, which provides guidance for Peru's response to the epidemic. Among the MSP's goals are reduction of HIV among high-risk populations, including sex workers (U.S. Agency for International Development/Peru 2010). The MSP has not been evaluated, so at present it is difficult to know how well it has been implemented.⁽²⁾

However, in recent years the government has limited its response, particularly in prevention, because of the global economic crisis and a new presidential administration (U.S. Agency for International Development/Peru 2010). While the MOH continues to carry out HIV programming, other public health issues, such as maternal and child health and malnutrition, have received much more attention. Funding for MARPs programs is especially limited; some believe that stigma and the overall situation of gender inequality are some of the reasons why sex workers are not included as a priority in the political agenda.

Legal issues: The Peruvian constitution mandates equality for women and men. The government passed a law in 2000 that criminalizes gender-based discrimination, with penalties requiring offenders to provide 30 to 70 days of community service (Organisation for Economic Co-operation and Development 2011). Peru has adopted legal frameworks against gender discrimination, seen the emergence of progressive legislation on reproductive rights, and established national strategies for equal opportunity. There is also significant progress in the institutionalization of policies against GBV.

However, in Peru, as in other Latin American countries, society is still based on a structural context of gender inequality characterized by women's subordination in all spheres of social, cultural, and economic life. Gender discrimination is even more pronounced when it comes to reproductive rights and protection from violence, especially for specific groups of women: the indigenous, the poor, youth, and migrants. Findings from a World Health Organization multicountry study of violence against women show that violence against women in Peru remains a serious problem (García-Moreno et al. 2005). For example, 51 percent of ever-partnered women in Lima and 69 percent in Cuzco had experienced physical or sexual violence by a partner.

The Peruvian constitution and legal system do not criminalize voluntary male, female, transgender, and transsexual sex work. However, there are no regulations in place that protect the rights of sex workers. Because most sex workers in Peru enter sex work at an early age, they live in marginalized conditions most of their lives, have limited social security, and have grown up in an environment that offers few opportunities for education or development of skills for employment (Salazar and Silva 2009). It is within this context that civil society associations, together with United Nations agencies, have strongly advocated for putting sex work on human rights and public health agendas.

The Sex Work, HIV, and Human Rights Program

Current HIV activities for sex workers in Peru originate mainly from two sources: the MOH's program efforts, including peer education-based prevention in brothels, and organizations of sex workers that focus on protecting human rights and improving access to health services.

REDTRANS and Miluska staff.

In 2007, sex worker organizations sponsored a national conference in Lima on sex work, human rights, and HIV. This gathering was inspired by other international events on HIV and sex work carried out both in Latin America and globally. Participants included 98 representatives from sex worker organizations, 130 transgender persons, and 69 national and local authorities (Salazar and Villayzán 2010). Other participants included members of civil society associations, academic circles, and international organizations, such as CARE and the United Nations. The MOH, IESSDEH, REDTRANS, and Miluska coordinated the event.

Throughout the consultations, conference participants identified key priorities for the target populations and possible mechanisms to respond to their needs. The major achievement coming out of this event was the partnership of IESSDEH, REDTRANS, and Miluska, created to coordinate and implement the Sex Work, HIV, and Human Rights Program in Peru.

The program's goal is to contribute to the nation's response to the HIV pandemic by responding to the needs and vulnerabilities sex workers face, from a perspective that respects their human rights and involves sex workers in planning, implementation, and all other programming levels. At the individual level, the program's primary objective is to strengthen the capacities of sex workers to understand and exercise their rights.

At the community level, the focus is on strengthening the organizational skills of local transgender, transsexual, and female sex workers' groups, as well as raising awareness about human rights among regional and municipal officials and civil servants, especially the rights of sex workers. Improving the quality and efficiency of health services for sex workers is also a key community-level objective.

At the legal and political level, the program seeks to incorporate the specific needs of the sex worker population into the 2011–2015 National Strategic Plan. Advocacy for approval of a sex work bill that guarantees that population's human and labor rights is also a key objective.

IESSDEH: IESSDEH was created in 2007 as an agency of the Health, Sexuality and Human Development Unit, part of the UPCH School of Public Health. IESSDEH responds to the need to promote and implement evidence-based activities for groups that are at a social disadvantage. Its multidisciplinary work is very well known in the fields of health and sexuality, as is the support it provides to strengthen efforts to develop vulnerable communities. IESSDEH promotes evidence-based interventions that focus on improving public policies; the group works with different civil society associations and players that include artists and activists, among others.

REDTRANS: REDTRANS is a national network that was legally incorporated in 2006, although its work dates back to 2000. A member of the larger Latin American and Caribbean Network of Transgender People organization, it focuses on promoting the human rights of transvestite, transsexual, and transgender people by supporting community interventions and exercising political influence in the fields of health, education, and justice. It also conducts research and raises awareness about these populations.

Miluska: Founded in 2002 as a sex worker association, Miluska responds to violations of sex workers' human rights, primarily on the issue of violence. It also conducts a wide array of activities that include legal, financial, and psychological support for sex workers, and it trains sex workers about human rights, health, HIV, gender, GBV, sexual and reproductive health, and stigma. The organization goes beyond the individual and community levels to engage in advocacy efforts on a political level.

The Sex Work, HIV, and Human Rights Program is based on a democratic and participatory approach in which members of the three institutions and beneficiaries contribute equally in a joint process. The managers of the three institutions have established mechanisms to communicate the different developments of the program on a regular basis. Also, they try to ensure that beneficiaries' voices are taken into account.

IESSDEH plays the role of main coordinator of the program and also provides technical assistance to REDTRANS and Miluska to strengthen their programmatic and monitoring and evaluation capacities. IESSDEH also facilitates the dialogue between the three organizations, providing a physical space for the planning, debating, and coordinating efforts. REDTRANS and Miluska provide management and leadership of the program at the grassroots level. The three organizations participate equally in the design and implementation of the program and have the same level of decision-making influence.

Both UNFPA and UNAIDS have supported the program since its inception with technical and financial assistance. These agencies and other institutions believe that the program—with its gender perspective and HIV components—is a new way to defend the human rights of Peruvian sex workers. Although it is a new program, it has demonstrated great commitment in responding to the varying needs of sex workers, such as health, safety, and education, in different regions across the nation in a short period of time.

Program Activities

Some of the most important activities of the program during its initial years include:

• Preparing, reviewing, discussing, and disseminating information on a proposed bill supporting sex workers' rights on a national and regional level, with the active participation of sex workers and their leaders.
• Facilitating dialogue in regional workshops among key stakeholders—local authorities, civil society associations, and sex workers—on the rights of sex workers and HIV prevention. For example, regional consultations among 202 representatives from 69 local and regional institutions and from civil society associations in all four regions have been conducted with the aim of raising the visibility of sex workers and their needs.
• Mapping locations where sex workers work and conducting a survey of the socioeconomic characteristics in the regions where the program is implemented. The information has been used to fine-tune program strategies. A document titled Final Report on the Situational Mapping and Socio-demographic Survey of Sex Work in Four Cities in Peru (Salazar and Silva 2009) has been published.
• Training sex workers—both leaders and beneficiaries—on gender, human rights, sexual diversity, self-esteem, and HIV, based on a peer education approach.
• Training of regional and municipal government officials on sex work, human rights, HIV, and legislation regarding sex work.
• Supporting sex workers by providing information on health services available to respond to violence and HIV.

Legislative activity: The program drafted a bill for a law that acknowledges the human and labor rights of sex workers. The bill focuses on gender equality, reduction of stigma and discrimination, protection from violence, and labor rights. The Peruvian Parliament discussed the legislation but so far has not been willing to pass the bill. Despite this, IESSDEH, REDTRANS, and Miluska continue lobbying for the bill and more generally for sex workers' rights through campaign and advocacy efforts.

Peer education: One of the most important components of the program is a peer education approach that enhances the capacity of sex workers to assert their rights. In the first phase of the program, sex worker leaders from all regions where the program is implemented received training to become facilitators for workshops for sex workers. These leaders now facilitate two-day workshops in different venues. At present, at least 79 sex workers have been trained.

Different key actors—researchers, policymakers, service providers, beneficiaries—involved in the sex worker project piloted and validated a specific methodology for the workshops. The workshops include a theoretical and practical session that introduces the concepts of gender, human rights (with particular emphasis on sexual and reproductive rights), GBV, sexuality, and sexual identity. It also includes sessions about self-esteem and leadership. Hands-on activities include painting, writing, and role play.

The workshops address violence against female, transgender, and transsexual sex workers through different strategies that emphasize empowerment. They provide a unique, supportive space where sex workers have the opportunity to learn, interact, and share their experiences with their peers, as well as discuss other strategies to advocate for their own rights. In each workshop there are sex workers who volunteer to join the peer education program and to undergo training to become future facilitators.

Educating gatekeepers and communities: The program also organizes workshops aimed at developing the capacity of duty bearers, rights holders, local authorities, and service providers in defending the rights of sex workers, particularly related to GBV. The workshops for the security forces, including the police, are of particular value to the program. At present, more than 40 regional and municipal officials in the four regions and 28 law enforcement agents have been trained.

A new curriculum is being developed for online workshops with these groups; the goal is to improve knowledge, skills, and attitudes, as well as the capacity to respond to cases of GBV against female, transgender, and transsexual sex workers.

The local MOH offices have a group of young volunteers who carry out activities to inform communities about these subjects, specifically about how and where they can access HIV services. IESSDEH, REDTRANS, and Miluska work to make sure sex workers are represented, both within the group of young people and those who benefit from the program.

The program has succeeded in taking a first step to make visible the obstacles that sex workers face when they exert their rights and to include gender in the agenda of local sex worker organizations. The program has also raised awareness among officials about the need to respond to the issues sex workers face. It has created a dialogue about how best to respond to the needs of sex workers among regional and municipal officials, law enforcement agents, civil society association representatives, and sex workers themselves. According to one government official:

The program helps open up a topic this society generally considers taboo. The barriers are slowly breaking down. This is a definite advantage.

On an individual level, sex workers involved with the program have learned that they have rights that must be respected. They believe they have become more empowered to assert their rights, thanks to the activities implemented by the program. They agree that this has helped empower them to report violence from different perpetrators, even when the person responsible for the violence is an intimate partner. As one program beneficiary said:

This is helping some of the sex workers with abusive and violent husbands report these men, and even leave them.

Some of the sex worker facilitators also spoke about the personal satisfaction they have obtained from their active participation in the program, even though it can mean an extra effort in their daily lives.

I feel good about strengthening and helping my co-workers. I feel happy because I learn and teach at the same time.

What Works Well

The different stakeholders agree that this is an innovative program that establishes a strong foundation in programming for sex work, HIV, and human rights in Peru.

"Horizontal" program implementers with different strengths: IESSDEH is experienced in terms of research and evidence-based programming on gender. REDTRANS and Miluska, on the other hand, are experienced in working at the ground level with female, transgender, and transsexual sex workers in different parts of the country. UNFPA provides technical assistance to the program to ensure integration of the gender perspective. The three implementing organizations have equal standing in the decision-making process.

Direct participation of sex workers in program design, implementation, and decision making: The program is notable because of its participative process, which involves the participation of several sex workers full-time (most of whom are members of REDTRANS or Miluska). This has been vital to creating a sense of ownership and facilitating the development and implementation of program activities. This builds the foundation for the sustainability of the program in the long run.

Multilevel work: By working at the policy, community, and individual levels, this program is comprehensive and thus more likely to make an impact.

Ongoing advocacy efforts at the national, regional, and local levels: Advocacy efforts have been key to gaining consistent support from authorities at different levels, especially because they have provided evidence on the condition of sex workers in Peru based on the mapping and survey activities.

Challenges

Sustainability: First, financial resources—many provided by United Nations agencies—are limited. For the time being, it will be difficult for the three implementing organizations to generate sufficient funds for long-term maintenance of programming. One option is for national and local authorities to provide support; however, despite the work the program has done on advocacy with policymakers, this issue does not appear to be a priority on most agendas. The government's budget for HIV-related matters and MARPs remains extremely limited.

Second, the local base organizations need to raise the capacity of their members, not only in terms of providing training on the subjects of HIV, gender, and human rights, but also of organizational management, generation of independent resources, and dissemination of their activities. Most of the members have very low levels of formal education and have had very few opportunities to develop skills valuable for organizational work.

Patriarchal gender norms: Patriarchal gender norms and stigma and discrimination are strong barriers that inhibit political leaders from supporting sex workers and prevention of HIV among them from a human rights perspective. Subjects related to sex work continue to be taboo and stigmatized in Peru, which creates barriers in responding to issues sex workers face. In fact, some officials interested in supporting the program do not necessarily take the gender perspective into account and maintain their traditional and stereotypical views of sex work.

The general patriarchal context impacts the effectiveness of efforts to raise awareness and train public officials and staff. It is difficult to transform attitudes and behaviors based on workshops alone, especially given the gender inequality structure that continues to prevail in Peru. Ongoing training efforts to raise awareness among service providers, law enforcement agents, sex workers, and the community at large are needed to make changes that truly represent support and safety for sex workers.

Demands on sex workers' time: The program requires the participants' ongoing and long-term dedication; however, many are unable to devote time and energy to training and facilitation. Earning an income, caring for their home and children, and meeting other needs are some of the reasons why many sex workers cannot be more active in the program's activities even if they would like to be.

Recommendations

Monitor the progress of the program: The program is an innovative approach for Peru that has the potential to achieve its objectives to substantially modify conditions for sex workers in the regions implementing the program. However, it has not yet been evaluated. Both the donors and the organizations implementing the program are aware of this and are starting to discuss the design of a strategic monitoring and evaluation plan. The design of a rigorous evaluation design is recommended to evaluate the process, outcomes, and impact of the program. The monitoring and evaluation plan will provide more substantial information on the aspects of the program that work best and which aspects should be modified. This information will be very useful to the design of the program's subsequent phases and the possibility of it being replicated in other regions, while attracting the government's interest and possibly generating a stronger interest among likely donors.

Support the development of sex workers' abilities: To guarantee sustainability, ongoing work is necessary to continually reinforce local organizations in the regions that are implementing the program. This calls for developing capabilities not only in terms of gender and human rights, but also in areas that support the organizations, such as computer and internet skills; program administration, coordination, and implementation; and financial and administrative operations.

The program's long-term vision is that local sex worker organizations will be fully capable of running the program independently. Aside from developing the organizational capabilities of sex workers, it is also necessary to invest in the institutional strengthening of the organizations by supporting their legal charters and creating a physical space for an operations center.

Working with men: Many interviewees stressed the importance of working with men, both with those involved in the sex work industry (clients, pimps, bartenders, among others), as well as law enforcement and public service agents, who are often violently aggressive.

There are currently several programs in Peru and elsewhere in Latin America that are working to involve men in sex worker programming. Such activities need to focus primarily on long-term efforts that include discussions on the importance of transforming established gender roles that have a negative impact on both men and women's lives. These programs should include components that offer men the opportunity to reflect on the costs of hegemonic masculinity and gender inequality. Work with men must also include an emphasis on HIV prevention, as well prevention of teen violence.

It is especially important to work with male officials and security agents, including the police force. Short-term training and awareness efforts are not sufficient. Changing attitudes and behaviors require long-term advocacy and training on human rights, gender, and masculinity issues, which must be based on peer education strategies with special emphasis on leaders and young staff members. A holistic intervention should also go hand-in-hand with reforms to institutional norms regarding the treatment of sex workers by duty bearers and service providers, with sanctions for those who commit abuses.

Improve services that address violence and sexual and reproductive health needs: The program offers information and services for sex workers on matters related to violence and sexual and reproductive health. However, the program does not directly provide services. These regions generally lack high-quality comprehensive services for sex workers. These services must be offered primarily by the different government sectors but receive reinforcement through technical support provided by the program implementers.

Collaborate with other sectors: Stronger involvement and collaboration with the educational and legal sectors is necessary. Advocacy efforts must target these sectors on national, regional, and local levels. The MSP should be used as the guideline for this process.

Advocate for the approval of the sex work bill: All organizations interested in this field should continue supporting the proposed bill. The bill specifically includes the need to respect the rights of sex workers and punish those who perpetrate violence against them.

Future Programming

The program is poised to consolidate in the regions in which it is implemented and to become independently capable in planning and management, and in procuring both medium- and long-term funding.

In the short- and medium-term, IESSDEH, REDTRANS, and Miluska plan to continue implementing the program with the same strategies to ensure stability and continuity in intervention areas. To further strengthen the project, the organizations will hope to establish permanent groups of young sex worker leaders from different cities who can volunteer part-time to coordinate different activities, including training. To strengthen capacity, peer educators will work within their cities and then move to other cities where the program is implemented.

Implementers also envision increasing the scope of their work by including activities to increase access for sex workers to income and productive resources, including education or training in vocational skills. At the individual level, this will enhance the capacity of sex workers to exert their rights at an institutional level and will strengthen local sex worker organizations.

Finally, an evaluation of the program is planned, which will provide valuable data before replication in other regions can be considered.

References

CARE. 2009. Empoderamiento de las Mujeres Trabajadoras Sexuales en el Perú y Prevención del VIH y Sida [The Empowerment of Sex Workers in Peru and the Prevention of AIDS and HIV]. Estudio de Impacto Estratégico [Strategic Impact Study]. Lima, Peru: CARE.

García-Moreno, C., H. Jansen, M. Ellsberg, et al. 2005. WHO Multi-country Study on Women's Health and Domestic Violence Against Women: Initial Results on Prevalence, Health Outcomes and Women's Responses. Geneva, Switzerland: World Health Organization.

Joint U.N. Programme on HIV/AIDS. 2002. Sex Work and HIV. Geneva, Switzerland: Joint U.N. Programme on HIV/AIDS Technical Update.

Joint U.N. Programme on HIV/AIDS. 2010. Global Report. UNAIDS Report on the Global AIDS Epidemic 2010. (accessed September 2011)

Ministry of Health. 2010. Informe Nacional Sobre los Progresos Realizados en la Aplicación del UNGASS [National Report on the Progress Made on the UNGASS Application. Period: January 2008–December 2009]. Lima, Peru: Ministry of Health, Head Office for the Health of Individuals.

Organisation for Economic Co-operation and Development. 2011. "Social Institutions and Gender Index: Gender Equality and Social Institutions in Peru." Paris, France: Organisation for Economic Co-operation and Development Center. (accessed September 2011)

Salazar, X., and A. Silva. 2009. Informe Final de Mapeo y Encuesta Sociodemográfica del Trabajo Sexual en Cuatro Ciudades del Perú [Final Report on the Socio-demographic Mapping and Survey of Sex Work in Four Cities in Peru]. Lima, Peru: Instituto de Estudios en Salud, Sexualidad y Desarrollo Humano, National Network for the Rights of Transgender People, Transvestites, and Transsexuals of Peru, Miluska, and U.N. Population Fund.

Salazar, X., and J. Villayzán. 2010. Outlines for Multisectorial Work with Transgender Populations, Sex Work, and HIV/AIDS. Lima, Peru: Instituto de Estudios en Salud, Sexualidad y Desarrollo Humano, Latin American and Caribbean Network of Transgender People, and U.N. Population Fund.

U.S. Agency for International Development/Peru. 2010. HIV/AIDS Health Profile. Lima, Peru: USAID/Peru.

Whittle, S. 2002. Respect and Equality: Transsexual and Transgender Rights. London, England: Cavendish Publishing Limited.

Acknowledgements

The author would first like to thank the IESSDEH staff members for their support in preparing this case study and their great hospitality during the field work. A special thanks to Ximena Salazar, an IESSDEH researcher, for her cooperation throughout the process. Another special thanks to Jana Villayzán of REDTRANS for the support she provided during the field work stage and her contributions while discussing the different subjects. Thanks to Angela Villon of Miluska and Christina Tang for their support in organizing the focus groups. A huge thanks to the Pucallpa workshop facilitators and participants for allowing the opportunity to speak to them about the program and attend the workshop. The author expresses appreciation for the time spent and contributions made by the former program collaborators, government and international agency officials, and the program's service providers, as well as the beneficiaries who participated in the interview processes. Thanks also to the U.S. President's Emergency Plan for AIDS Relief Gender Technical Working Group for their support and careful review of this case study.

Recommended Citation

Contreras, Manuel. 2011. Sex Work and Life with Dignity: Sex Work, HIV, and Human Rights Program in Peru. Case Study Series. Arlington, VA: USAID's AIDS Support and Technical Assistance Resources, AIDSTAR-One, Task Order 1.