‘Key’ populations – such as sex workers – are now seen as crucial to turning the tide of the HIV epidemic. Given the recognized epidemiological potential of such marginalized groups to act as ‘bridging populations’ into the wider population, much importance has rightly been attached to countering the kind of routine violations of human rights that can effectively exclude such vulnerable populations from participation in health interventions designed to deal most effectively with the causes of the epidemic (UNAIDS Gap Report; UNAIDS (STI/blog). Amidst the talk of public health ‘strategies’, Speaking Out, a recent report based on the personal testimonies of 30 Kenyan sex workers, offers a powerful reminder that the problem of HIV in key populations is a cultural and social challenge before it is a technical one.  It is also a corrective to any strategy that would underestimate, in these days of expanded ART provision, the apparently softer but more complex challenge of cultural interventions to protect human rights. The report offers the results of one of the local community-led research projects supported in eleven countries by the Global Network for People Living with AIDS (GNP+).

At the heart of the problem of violations to the human rights of sex workers is the behaviour of health professionals. Officially, the human rights of such minorities are protected in Kenya by robust constitutional and legislative provisions; in practice, they are routinely flouted by everybody – including health workers. The authors of the report place violations in the following categories. Around HIV diagnosis. An attendee at an ante-natal clinic is HIV tested without her knowledge, and informed of the result in the presence of her current partner, who subsequently separates from her. Breach of confidentiality. On discovering the sex worker status of a positive-diagnosed attendee, a doctor scrolls down to ‘mama’ on the patient’s mobile and summons her mother to the hospital. Discrimination. A health worker who recognizes the status of a women attending with a stab injury announces to colleagues: ‘This is a sex worker who has been stealing other men’s husbands. Just stitch her. If it heals, well and good. If not, so be it’. Denial of services. A sex worker attending a facility following rape, is abused for her status, laughed at for claiming rape, and refused PEP on the grounds that it was not for ‘people like her’.

Such total disregard for the human rights of sex workers is shared by law enforcement officers who refuse to take seriously accusations or rape, refuse protection before the law for human rights violations, summarily arrest, then extort from, and sexually harass, their sex workers, inflict degrading treatment on them while they are in custody, and deny them access to treatment for the duration of their stay.

It is difficult to see how much progress is likely to be made in turning the tide of HIV in this particular ‘key population’ without a wholesale transformation of attitudes. The kind of abuses this study reveals are evidently paralleled in many countries. For example, Ndondo & Dlovu (STIs) and Jose & Nathan (STIs) draw attention, on the basis of qualitative survey evidence, to similar kinds of violations to sex workers’ human rights by law enforcement officers in Zimbabwe and East Timor, respectively. Mayhew & Hawkes (STIs) discuss violations in respect to a number of vulnerable groups including sex workers by both law enforcement officers and health professionals in Pakistan. It would seem that in many countries the UNAIDS strategy of controlling HIV in key bridging populations will encounter stiff cultural challenges.