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1.  Criminalisation of clients: reproducing vulnerabilities for violence and poor health among street-based sex workers in Canada—a qualitative study 
BMJ Open  2014;4(6):e005191.
Objectives
To explore how criminalisation and policing of sex buyers (clients) rather than sex workers shapes sex workers’ working conditions and sexual transactions including risk of violence and HIV/sexually transmitted infections (STIs).
Design
Qualitative and ethnographic study triangulated with sex work-related violence prevalence data and publicly available police statistics.
Setting
Vancouver, Canada, provides a unique opportunity to evaluate the impact of policies that criminalise clients as the local police department adopted a sex work enforcement policy in January 2013 that prioritises sex workers’ safety over arrest, while continuing to target clients.
Participants
26 cisgender and 5 transgender women who were street-based sex workers (n=31) participated in semistructured interviews about their working conditions. All had exchanged sex for money in the previous 30 days in Vancouver.
Outcome measures
Thematic analysis of interview transcripts and ethnographic field notes focused on how police enforcement of clients shaped sex workers’ working conditions and sexual transactions, including risk of violence and HIV/STIs, over an 11-month period postpolicy implementation (January–November 2013).
Results
Sex workers’ narratives and ethnographic observations indicated that while police sustained a high level of visibility, they eased charging or arresting sex workers and showed increased concern for their safety. However, participants’ accounts and police statistics indicated continued police enforcement of clients. This profoundly impacted the safety strategies sex workers employed. Sex workers continued to mistrust police, had to rush screening clients and were displaced to outlying areas with increased risks of violence, including being forced to engage in unprotected sex.
Conclusions
These findings suggest that criminalisation and policing strategies that target clients reproduce the harms created by the criminalisation of sex work, in particular, vulnerability to violence and HIV/STIs. The current findings support decriminalisation of sex work to ensure work conditions that support the health and safety of sex workers in Canada and globally.
doi:10.1136/bmjopen-2014-005191
PMCID: PMC4054637  PMID: 24889853
Sex work; Violence; Sexual Health; HIV/AIDS; Law
2.  Sex work and the 2010 FIFA World Cup: time for public health imperatives to prevail 
Background
Sex work is receiving increased attention in southern Africa. In the context of South Africa's intense preparation for hosting the 2010 FIFA World Cup, anxiety over HIV transmission in the context of sex work has sparked debate on the most appropriate legal response to this industry.
Discussion
Drawing on existing literature, the authors highlight the increased vulnerability of sex workers in the context of the HIV pandemic in southern Africa. They argue that laws that criminalise sex work not only compound sex workers' individual risk for HIV, but also compromise broader public health goals. International sporting events are thought to increase demand for paid sex and, particularly in countries with hyper-endemic HIV such as South Africa, likely to foster increased HIV transmission through unprotected sex.
Summary
The 2010 FIFA World Cup presents a strategic opportunity for South Africa to respond to the challenges that the sex industry poses in a strategic and rights-based manner. Public health goals and growing evidence on HIV prevention suggest that sex work is best approached in a context where it is decriminalised and where sex workers are empowered. In short, the authors argue for a moratorium on the enforcement of laws that persecute and victimise sex workers during the World Cup period.
doi:10.1186/1744-8603-6-1
PMCID: PMC2829543  PMID: 20181213
3.  Operationalising sexual and reproductive health and rights in sub-Saharan Africa: constraints, dilemmas and strategies 
Background
The continued poor sexual and reproductive health (SRH) outcomes in sub-Saharan Africa highlight the difficulties in reforming policies and laws, and implementing effective programmes. This paper uses one international and two national case studies to reflect on the challenges, dilemmas and strategies used in operationalising sexual and reproductive health and rights (SRHR) in different African contexts.
Methods
The international case study focuses on the progress made by African countries in implementing the African Union’s Maputo Plan of Action (for the Operationalisation of the Continental Policy Framework for Sexual and Reproductive Health and Rights) and the experiences of state and non-state stakeholders in this process. The case was developed from an evaluation report of the progress made by nine African countries in implementing the Plan of Action, qualitative interviews exploring stakeholders’ experiences and perceptions of the operationalisation of the plan (carried out as part of the evaluation) in Botswana and Nigeria, and authors’ reflections. The first national case study explores the processes involved in influencing Ghana’s Domestic Violence Act passed in 2007; developed from a review of scientific papers and organisational publications on the processes involved in influencing the Act, qualitative interview data and authors’ reflections. The second national case study examines the experiences with introducing the 2006 Sexual Offences Act in Kenya, and it is developed from organisational publications on the processes of enacting the Act and a review of media reports on the debates and passing of the Act.
Results
Based on the three cases, we argue that prohibitive laws and governments’ reluctance to institute and implement comprehensive rights approaches to SRH, lack of political leadership and commitment to funding SRHR policies and programmes, and dominant negative cultural framing of women’s issues present the major obstacles to operationalising SRH rights. Analysis of successes points to the strategies for tackling these challenges, which include forming and working through strategic coalitions, employing strategic framing of SRHR issues to counter opposition and gain support, collaborating with government, and employing strategic opportunism.
Conclusion
The strategies identified show future pathways through which challenges to the realisation of SRHR in Africa can be tackled.
doi:10.1186/1472-698X-11-S3-S8
PMCID: PMC3287464  PMID: 22376197
4.  "One country, two systems": Sociopolitical implications for female migrant sex workers in Hong Kong 
Background
Under the "two countries, one system" policy implemented by China to manage the return of Hong Kong's sovereignty, Hong Kong has maintained a comparatively prosperous economy within the Asian region. This has resulted in an environment which fosters migration from the mainland to Hong Kong, due largely to proximity, higher earning potential, common language, and a relaxing of border control measures. However not all mainland China citizens are equally able to access these new migration schemes and indeed a number of women such as sex workers are either migrating and/or working illegally and without occupational, legal and health protection within Hong Kong.
Discussion
Female migrant sex workers are exposed to a number of significant threats to their health, however their illegal status contributes to even greater vulnerability. The prevailing discourses which view these women as either "trafficked women" or as "illegal immigrants" do not adequately account for the complex situations which result in such women's employment in Hong Kong's sex industry. Rather, their position can best be understood within the broader frameworks provided by migration literature and the concept of "structural violence". This allows for a greater understanding of the socio-political issues which are systematically denying migrant sex workers adequate access to health care and other opportunities for social advancement. When these issues are taken into account, it becomes clear that the current relevant legislation regarding both immigration and sex work is perpetuating the marginalised and vulnerable status of migrant sex workers. Unless changes are made, structural barriers will remain in place which impede the ability of migrant sex workers to manage their own health needs and status.
Conclusion
Female migrant sex workers in Hong Kong are extremely vulnerable to a number of occupational health and safety hazards which have significantly detrimental effects on their health. These risks can best be understood within a broad framework of socio-political factors contributing to their vulnerability. Ensuring that migrant sex workers have adequate support for their health and legal rights requires require structural interventions such as decriminalisation and providing open and inclusive access to health service to counteract such factors.
doi:10.1186/1472-698X-8-13
PMCID: PMC2629761  PMID: 19077260
5.  Human rights abuses and collective resilience among sex workers in four African countries: a qualitative study 
Background
Sex work is a criminal offence, virtually throughout Africa. This criminalisation and the intense stigma attached to the profession shapes interactions between sex workers and their clients, family, fellow community members, and societal structures such as the police and social services.
Methods
We explore the impact of violence and related human rights abuses on the lives of sex workers, and how they have responded to these conditions, as individuals and within small collectives. These analyses are based on data from 55 in-depth interviews and 12 focus group discussions with female, male and transgender sex workers in Kenya, South Africa, Uganda and Zimbabwe. Data were collected by sex worker outreach workers trained to conduct qualitative research among their peers.
Results
In describing their experiences of unlawful arrests and detention, violence, extortion, vilification and exclusions, participants present a picture of profound exploitation and repeated human rights violations. This situation has had an extreme impact on the physical, mental and social wellbeing of this population. Overall, the article details the multiple effects of sex work criminalisation on the everyday lives of sex workers and on their social interactions and relationships. Underlying their stories, however, are narratives of resilience and resistance. Sex workers in our study draw on their own individual survival strategies and informal forms of support and very occasionally opt to seek recourse through formal channels. They generally recognize the benefits of unified actions in assisting them to counter risks in their environment and mobilise against human rights violations, but note how the fluctuant and stigmatised nature of their profession often undermines collective action.
Conclusions
While criminal laws urgently need reform, supporting sex work self-organisation and community-building are key interim strategies for safeguarding sex workers’ human rights and improving health outcomes in these communities. If developed at sufficient scale and intensity, sex work organisations could play a critical role in reducing the present harms caused by criminalisation and stigma.
doi:10.1186/1744-8603-9-33
PMCID: PMC3750273  PMID: 23889941
Sex work; Prostitution; Violence; Human rights; Resilience; Kenya; South Africa; Uganda; Zimbabwe
6.  An Ethnographic Study of the Social Context of Migrant Health in the United States 
PLoS Medicine  2006;3(10):e448.
Background
Migrant workers in the United States have extremely poor health. This paper aims to identify ways in which the social context of migrant farm workers affects their health and health care.
Methods and Findings
This qualitative study employs participant observation and interviews on farms and in clinics throughout 15 months of migration with a group of indigenous Triqui Mexicans in the western US and Mexico. Study participants include more than 130 farm workers and 30 clinicians. Data are analyzed utilizing grounded theory, accompanied by theories of structural violence, symbolic violence, and the clinical gaze. The study reveals that farm working and housing conditions are organized according to ethnicity and citizenship. This hierarchy determines health disparities, with undocumented indigenous Mexicans having the worst health. Yet, each group is understood to deserve its place in the hierarchy, migrant farm workers often being blamed for their own sicknesses.
Conclusions
Structural racism and anti-immigrant practices determine the poor working conditions, living conditions, and health of migrant workers. Subtle racism serves to reduce awareness of this social context for all involved, including clinicians. The paper concludes with strategies toward improving migrant health in four areas: health disparities research, clinical interactions with migrant laborers, medical education, and policy making.
A qualitative study of migrant Triqui Mexicans in the western US and Mexico shows that structural racism and anti-immigrant practices lead to poor working and living conditions, and poor health.
Editors' Summary
Background.
For centuries, recent immigrants have experienced poorer living and working conditions than more established inhabitants, which in turn means that the health of immigrants is often worse. Immigrants often take on the very lowest-paid jobs. One might suppose that in more recent years the increasing prosperity of countries such as the United States and those of western Europe would have reversed this trend. But as recently as 2005 the New York–based Human Rights Watch published a report entitled “Blood, Sweat and Fear,” which documented appalling conditions for the mostly immigrant workers in the US meat and poultry industry. In the UK also, legislation has recently been introduced to try to regulate the activity of “gang masters” who control large groups of immigrant workers. This legislation was triggered by public horror about the deaths in 2004 of 21 immigrant cockle pickers who drowned in Morecambe Bay in Lancashire. A group of workers at particular risk of poor conditions because of the seasonal and uncertain patterns of work are those who work as farm laborers.
Why Was This Study Done?
There are relatively few studies that have looked in detail at the pattern of health problems among migrant farm workers in the US. Understanding the working conditions of these workers would be of help in understanding more about their health problems and, in particular, how to prevent them. One problem is that few of these workers are seen in the usual health-care settings; few of them have health insurance.
What Did the Researchers Do and Find?
The paper's author spent 15 months with a group of indigenous Triqui Mexicans as they migrated around the western US and Mexico working on farms. He used a type of research called qualitative research, which involved observing and interviewing more than 130 farm workers and 30 health workers on farms and in clinics. He found that working and housing conditions were organized according to ethnicity and citizenship, and that there was an unofficial hierarchy, with undocumented indigenous Mexicans having the worst health. Even worse, migrant farm workers were often blamed for their sicknesses by those in charge of them or those from whom they sought help.
What Do These Findings Mean?
The author concludes that “structural racism and anti-immigrant practices determine the poor working conditions, living conditions, and health of migrant workers.” Furthermore, it seems that “subtle” racism among all involved, including clinicians, reduces awareness and perhaps even allows tacit acceptance of these patterns of health. It seems that targets for specific health interventions for these workers will need to be closely integrated with a broader approach to improving migrant health including medical education and policymaking.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0030448.
Migration Dialogue regularly consolidates news related to immigration around the world
Global Exchange has information related to fair trade, CAFTA, and other related current events
United Farm Workers has information related to working conditions of migrant laborers
PCUN has information related to migrant laborers in the Pacific Northwest
The Border Action Network has information related to the US-Mexico border
Border Links provides education and experiential learning related to the US-Mexico Border
Tierra Nueva and the Peoples Seminary provide social services for migrant laborers in the Pacific Northwest and education related to the lives of migrant workers
The Pesticide Action Network of North America provides information related to pesticides and health
The Pesticide Education Center provides detailed lists of the contents of pesticides and their health effects
The Center for Comparative Immigration Studies conducts research and education projects related to international migration
Human Rights Watch publishes and campaigns on many issues, including conditions for workers, such as that on the US meat-packing industry
European Research Centre on Migration and Ethnic Relations has a range of information concerning migrants
doi:10.1371/journal.pmed.0030448
PMCID: PMC1621098  PMID: 17076567
7.  The evolution of HIV policy in Vietnam: from punitive control measures to a more rights-based approach 
Global Health Action  2010;3:10.3402/gha.v3i0.4625.
Aim
Policymaking in Vietnam has traditionally been the preserve of the political elite, not open to the scrutiny of those outside the Communist Party. This paper aims to analyse Vietnam's HIV policy development in order to describe and understand the policy content, policy-making processes, actors and obstacles to policy implementation.
Methods
Nine policy documents on HIV were analysed and 17 key informant interviews were conducted in Hanoi and Quang Ninh Province, based on a predesigned interview guide. Framework analysis, a type of qualitative content analysis, was applied for data analysis.
Results
Our main finding was that during the last two decades, developments in HIV policy in Vietnam were driven in a top-down way by the state organs, with support and resources coming from international agencies. Four major themes were identified: HIV policy content, the policy-making processes, the actors involved and human resources for policy implementation. Vietnam's HIV policy has evolved from one focused on punitive control measures to a more rights-based approach, encompassing harm reduction and payment of health insurance for medical costs of patients with HIV-related illness. Low salaries and staff reluctance to work with patients, many of whom are drug users and female sex workers, were described as the main barriers to low health staff motivation.
Conclusion
Health policy analysis approaches can be applied in a traditional one party state and can demonstrate how similar policy changes take place, as those found in pluralistic societies, but through more top-down and somewhat hidden processes. Enhanced participation of other actors, like civil society in the policy process, is likely to contribute to policy formulation and implementation that meets the diverse needs and concerns of its population.
doi:10.3402/gha.v3i0.4625
PMCID: PMC2932461  PMID: 20824159
policy analysis; health policy; HIV; Vietnam; health staff
8.  Sexuality, rights and personhood: tensions in a transnational world 
Background
This article discusses what happens when normative ‘global’ discourses of rights and individuated sexual identity confront the messiness of ‘local’ realities. It considers the tensions that emerge when the relationship between sexual and social identities is not obvious and the implications of such tensions for public health and sexual rights activism. These questions are addressed through debates over the naming of male-to-male sexualities and desires in the context of globalization and the growth of a large NGO (non-governmental organization) sector in urban Bangladesh.
Methods
The material in the paper draws on a research project undertaken in 2008-9 in Dhaka, Bangladesh. A fundamental objective was to produce a contextualized understanding of sexuality in Dhaka city. Methods used included structured interviews, focus group discussions and informal conversations with a range of participants (students, factory workers, public health professionals and sexual minorities). The aim was to generate a conceptual and analytical framework around sexuality and rights rather than to undertake an empirical survey of any one population.
Results
As descriptors, globalized identity categories such as Men who have Sex with Men (MSM), used by public health providers, the state and donors; and gay/lesbian, invoked by human rights activists and transnational NGOs, are too narrow to capture the fluid and highly context-specific ways in which gender and sexually nonconforming persons understand themselves in Bangladesh. Further, class position mediates to a significant degree the reception, appropriation or rejection of transnational categories such as MSM and Lesbian, Gay, Bisexual, Transgender (LGBT). The tension is reflected in the sometimes fraught relations between service providers to MSM, the people they serve and an emerging group who identify as LGBT.
Conclusion
A simple politics of recognition will be inadequate to the task of promoting health and human rights for all; such a strategy would effectively exclude individuals who do not necessarily connect their sexual practices with a specific sexual or social identity.
doi:10.1186/1472-698X-11-S3-S5
PMCID: PMC3287461  PMID: 22376124
9.  Priority interventions to reduce HIV transmission in sex work settings in sub-Saharan Africa and delivery of these services 
Introduction
Virtually no African country provides HIV prevention services in sex work settings with an adequate scale and intensity. Uncertainty remains about the optimal set of interventions and mode of delivery.
Methods
We systematically reviewed studies reporting interventions for reducing HIV transmission among female sex workers in sub-Saharan Africa between January 2000 and July 2011. Medline (PubMed) and non-indexed journals were searched for studies with quantitative study outcomes.
Results
We located 26 studies, including seven randomized trials. Evidence supports implementation of the following interventions to reduce unprotected sex among female sex workers: peer-mediated condom promotion, risk-reduction counselling and skills-building for safer sex. One study found that interventions to counter hazardous alcohol-use lowered unprotected sex. Data also show effectiveness of screening for sexually transmitted infections (STIs) and syndromic STI treatment, but experience with periodic presumptive treatment is limited. HIV testing and counselling is essential for facilitating sex workers’ access to care and antiretroviral treatment (ART), but testing models for sex workers and indeed for ART access are little studied, as are structural interventions, which create conditions conducive for risk reduction. With the exception of Senegal, persistent criminalization of sex work across Africa reduces sex workers’ control over working conditions and impedes their access to health services. It also obstructs health-service provision and legal protection.
Conclusions
There is sufficient evidence of effectiveness of targeted interventions with female sex workers in Africa to inform delivery of services for this population. With improved planning and political will, services – including peer interventions, condom promotion and STI screening – would act at multiple levels to reduce HIV exposure and transmission efficiency among sex workers. Initiatives are required to enhance access to HIV testing and ART for sex workers, using current CD4 thresholds, or possibly earlier for prevention. Services implemented at sufficient scale and intensity also serve as a platform for subsequent community mobilization and sex worker empowerment, and alleviate a major source of incident infection sustaining even generalized HIV epidemics. Ultimately, structural and legal changes that align public health and human rights are needed to ensure that sex workers on the continent are adequately protected from HIV.
doi:10.7448/IAS.16.1.17980
PMCID: PMC3589546  PMID: 23462140
sex work; prostitution; HIV; sub-Saharan Africa; HIV prevention; systematic review; condoms
10.  Access To Essential Maternal Health Interventions and Human Rights Violations among Vulnerable Communities in Eastern Burma 
PLoS Medicine  2008;5(12):e242.
Background
Health indicators are poor and human rights violations are widespread in eastern Burma. Reproductive and maternal health indicators have not been measured in this setting but are necessary as part of an evaluation of a multi-ethnic pilot project exploring strategies to increase access to essential maternal health interventions. The goal of this study is to estimate coverage of maternal health services prior to this project and associations between exposure to human rights violations and access to such services.
Methods and Findings
Selected communities in the Shan, Mon, Karen, and Karenni regions of eastern Burma that were accessible to community-based organizations operating from Thailand were surveyed to estimate coverage of reproductive, maternal, and family planning services, and to assess exposure to household-level human rights violations within the pilot-project target population. Two-stage cluster sampling surveys among ever-married women of reproductive age (15–45 y) documented access to essential antenatal care interventions, skilled attendance at birth, postnatal care, and family planning services. Mid-upper arm circumference, hemoglobin by color scale, and Plasmodium falciparum parasitemia by rapid diagnostic dipstick were measured. Exposure to human rights violations in the prior 12 mo was recorded. Between September 2006 and January 2007, 2,914 surveys were conducted. Eighty-eight percent of women reported a home delivery for their last pregnancy (within previous 5 y). Skilled attendance at birth (5.1%), any (39.3%) or ≥ 4 (16.7%) antenatal visits, use of an insecticide-treated bed net (21.6%), and receipt of iron supplements (11.8%) were low. At the time of the survey, more than 60% of women had hemoglobin level estimates ≤ 11.0 g/dl and 7.2% were Pf positive. Unmet need for contraceptives exceeded 60%. Violations of rights were widely reported: 32.1% of Karenni households reported forced labor and 10% of Karen households had been forced to move. Among Karen households, odds of anemia were 1.51 (95% confidence interval [CI] 0.95–2.40) times higher among women reporting forced displacement, and 7.47 (95% CI 2.21–25.3) higher among those exposed to food security violations. The odds of receiving no antenatal care services were 5.94 (95% CI 2.23–15.8) times higher among those forcibly displaced.
Conclusions
Coverage of basic maternal health interventions is woefully inadequate in these selected populations and substantially lower than even the national estimates for Burma, among the lowest in the region. Considerable political, financial, and human resources are necessary to improve access to maternal health care in these communities.
Luke Mullany and colleagues examine access to essential maternal health interventions and human rights violations within vulnerable communities in eastern Burma.
Editors' Summary
Background.
After decades of military rule, Burma has one of the world's worst health-care systems and high levels of ill health. For example, maternal mortality (deaths among women from pregnancy-related causes) is around 360 per 100,000 live births in Burma, whereas in neighboring Thailand it is only 44 per 100,000 live births. Maternal health is even worse in the Shan, Karenni, Karen and Mon states in eastern Burma where ethnic conflicts and enforced village relocations have internally displaced more than half a million people. Here, maternal mortality is thought to be about 1000 per 100, 000 live births. In an effort to improve access to life-saving maternal health interventions in these states, Burmese community-based health organizations, the Johns Hopkins Center for Public Health and Human Rights and the Global Health Access Program in the USA, and the Mae Tao Clinic (a health-worker training center in Thailand) recently set up the Mobile Obstetric Maternal Health Workers (MOM) Project. In this pilot project, local health workers from 12 communities in eastern Burma received training in antenatal care, emergency obstetrics (the care of women during childbirth), blood transfusion, and family planning at the Mae Tao Clinic. Back in Burma, these maternal health workers trained additional local health workers and traditional birth attendants. All these individuals now provide maternal health care to their communities.
Why Was This Study Done?
The effectiveness of the MOM project can only be evaluated if accurate baseline information on women's access to maternal health-care services is available. This information is also needed to ensure the wise use of scarce health-care resources. However, very little is known about reproductive and maternal health in eastern Burma. In this study, the researchers analyze the information on women's access to reproductive and maternal health-care services that was collected during the initial field implementation stage of the MOM project. In addition, they analyze whether exposure to enforced village relocations and other human rights violations affect access to maternal health-care services.
What Did the Researchers Do and Find?
Trained survey workers asked nearly 3000 ever-married women of reproductive age in the selected communities about their access to antenatal and postnatal care, skilled birth attendants, and family planning. They measured each woman's mid-upper arm circumference (an indicator of nutritional status) and tested them for anemia (iron deficiency) and infection with malaria parasites (a common cause of anemia in tropical countries). Finally, they asked the women about any recent violations of their human rights such as forced labour or relocation. Nearly 90% of the women reported a home delivery for their last baby. A skilled attendant was present at only one in 20 births and only one in three women had any antenatal care. One third of the women received postnatal care and only a third said they had access to effective contraceptives. Few women had received iron supplements or had used insecticide-treated bednets to avoid malaria-carrying mosquitos. Consequently, more than half the women were anemic and 7.2% were infected with malaria parasites. Many women also showed signs of poor nutrition. Finally, human rights violations were widely reported by the women. In Karen, the region containing most of the study communities, forced relocation tripled the risk of women developing anemia and greatly decreased their chances of receiving any antenatal care.
What Do These Findings Mean?
These findings show that access to maternal health-care interventions is extremely limited and that poor nutrition, anemia, and malaria, all of which increase the risk of pregnancy complications, are widespread in the communities in the MOM project. Because these communities had some basic health services and access to training in Thailand before the project started, these results probably underestimate the lack of access to maternal health-care services in eastern Burma. Nevertheless, it is clear that considerable political, financial, and human resources will be needed to improve maternal health in this region. Finally, the findings also reveal a link between human rights violations and reduced access to maternal health-care services. Thus, the scale of human rights violations will need to be considered when evaluating programs designed to improve maternal health in Burma and in other places where there is ongoing conflict.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0050242.
This research article is further discussed in a PLoS Medicine Perspective by Macaya Douoguih
The World Health Organization provides information on all aspects of health in Burma (in several languages)
The Mae Tao Clinic also provides general information about Burma and its health services
More information about the MOM project is available in a previous publication by the researchers
The Burma Campaign UK and Human Rights Watch both provide detailed information about human rights violations in Burma
The United Nations Population Fund provides information about safe motherhood and ongoing efforts to save mothers' lives around the world
doi:10.1371/journal.pmed.0050242
PMCID: PMC2605890  PMID: 19108601
11.  Advancing sexual health through human rights: The role of the law 
Global Public Health  2014;10(2):252-267.
Since the International Conference on Population and Development, definitions of sexuality and sexual health have been greatly elaborated alongside widely accepted recognition that sexual health requires respect, protection and fulfilment of human rights. Considerable progress has also been made in enacting or changing laws that affect sexuality and sexual health, in line with human rights standards. These measures include legal guarantees against non-discrimination and violence, decriminalisation of consensual sexual conduct and guaranteeing availability, accessibility, acceptability and quality of sexual health information and services to all. Such legal actions have had positive effects on health and specifically on sexual health, particularly for marginalised populations. Yet in all regions of the world, laws still exist which jeopardise health, including sexual health, and violate human rights. In order to ensure accountability for the rights and health of their populations, states have an obligation to bring their laws into line with international, regional and national human rights standards. These rights-based legal guarantees, while insufficient alone, are essential for effective systems of accountability, achieving positive sexual health outcomes and the respect and protection of human rights.
doi:10.1080/17441692.2014.986175
PMCID: PMC4318115  PMID: 25539286
sexual health; human rights; law; non-discrimination; accountability
12.  Reframing the Interpretation of Sex Worker Health: A Behavioral–Structural Approach 
The Journal of Infectious Diseases  2011;204(Suppl 5):S1206-S1210.
Expanding sexually transmitted infection (STI) epidemics in many parts of Asia increase the importance of effective human immunodeficiency virus (HIV)/STI prevention programs for female sex workers. Designing sex worker health research and programs demands a well-stated conceptual approach, especially when one is interpreting the relationship between local policy environments and sex worker health. However, the core principles of the 2 most common conceptual approaches used in sex worker health programs—abolitionism and empowerment—have frequently divergent assumptions and implications. The abolitionist approach sees major aspects of the sex industry as fundamentally coercive and exploitative of women and supports dismantling all or parts of the sex sector. The empowerment approach strengthens sex workers’ agency and rights in order to build collective self-efficacy and have women invested in implementing their own HIV/STI prevention programs. This review compares these approaches using implication analysis and empirical cases from Asia. The misperception of an unresolvable gap between the 2 approaches ignores common ground that forms the basis of a new behavioral–structural conceptual framework. Explicitly accounting for the interaction between female sex worker behaviors and larger structures and policies, a behavioral–structural approach may provide a solid foundation for sex work research and programs.
doi:10.1093/infdis/jir534
PMCID: PMC3205084  PMID: 22043033
13.  Framing rights and responsibilities: accounts of women with a history of AIDS activism 
Background
In South Africa, policy with respect to HIV/AIDS has had a strong rights-based framing in line with international trends and in keeping with the constitutional overhaul in the post-Apartheid era. There have also been considerable advances since 1994 towards legal enshrinement of sexual and reproductive health rights and in the provision of related services. Since HIV in this setting has heavily affected women of reproductive age, there has been discussion about the particular needs of this subgroup, especially in the context of service integration. This paper is concerned with the way in which HIV positive women conceptualise these rights and whether they wish and are able to actualise them in their daily lives.
Methods
In 2003 a group of women involved with the Treatment Action Campaign and Medicines Sans Frontières participated in an initiative to ‘map’ their bodies as affected by the virus. A book containing the maps and narratives was published and used as a political tool to pressure the government of the day to roll out antiretroviral therapy (ART) to the population. In 2008, the authors coordinated an initiative that involved conducting follow-up in-depth interviews in which five of these women reflected on those body maps and on how their lives had changed in the intervening five years since gaining the right to treatment through the public sector.
Results
Drawing upon this qualitative data and published sources, these new accounts are analysed in order to reflect the perspectives of these women living with chronic HIV with respect to their sexual relations and fertility desires. The paper reveals difficulties faced by these women in negotiating sexual relationships and disclosure of their HIV positive status. It focuses on how they perceive relative responsibilities in terms of taking preventative measures in sexual encounters. Women adopt tactics within a context characterised by various inequalities in order to ‘make do’, such as by remaining silent about their status. Concerns about childbearing can be addressed by information and support from a health care worker.
Conclusions
Women’s experience of HIV as a chronic illness and the need to adhere to ART, is linked to the way in which the language of responsibility can come to counter-balance a language of rights in treatment programmes.
doi:10.1186/1472-698X-11-S3-S7
PMCID: PMC3287463  PMID: 22376178
14.  Sex worker-led structural interventions in India: a case study on addressing violence in HIV prevention through the Ashodaya Samithi collective in Mysore 
Background & objectives:
Structural interventions have the capacity to improve the outcomes of HIV/AIDS interventions by changing the social, economic, political or environmental factors that determine risk and vulnerability. Marginalized groups face disproportionate barriers to health, and sex workers are among those at highest risk of HIV in India. Evidence in India and globally has shown that sex workers face violence in many forms ranging from verbal, psychological and emotional abuse to economic extortion, physical and sexual violence and this is directly linked to lower levels of condom use and higher levels of sexually transmitted infections (STIs), the most critical determinants of HIV risk. We present here a case study of an intervention that mobilized sex workers to lead an HIV prevention response that addresses violence in their daily lives.
Methods:
This study draws on ethnographic research and project monitoring data from a community-led structural intervention in Mysore, India, implemented by Ashodaya Samithi. Qualitative and quantitative data were used to characterize baseline conditions, community responses and subsequent outcomes related to violence.
Results:
In 2004, the incidence of reported violence by sex workers was extremely high (> 8 incidents per sex worker, per year) but decreased by 84 per cent over 5 years. Violence by police and anti-social elements, initially most common, decreased substantially after a safe space was established for sex workers to meet and crisis management and advocacy were initiated with different stakeholders. Violence by clients, decreased after working with lodge owners to improve safety. However, initial increases in intimate partner violence were reported, and may be explained by two factors: (i) increased willingness to report such incidents; and (ii) increased violence as a reaction to sex workers’ growing empowerment. Trafficking was addressed through the establishment of a self-regulatory board (SRB). The community's progressive response to violence was enabled by advancing community mobilization, ensuring community ownership of the intervention, and shifting structural vulnerabilities, whereby sex workers increasingly engaged key actors in support of a more enabling environment.
Interpretation & conclusions:
Ashodaya's community-led response to violence at multiple levels proved highly synergistic and effective in reducing structural violence.
doi:10.4103/0971-5916.93431
PMCID: PMC3307193  PMID: 22382190
Community-led; empowerment; HIV/AIDS; India; sex work; structural violence
15.  Sexual and reproductive health and rights of adolescent girls: Evidence from low- and middle-income countries 
Global Public Health  2015;10(2):189-221.
This paper reviews the evidence on sexual and reproductive health and rights (SRHR) of adolescent girls in low-income and middle-income countries (LMIC) in light of the policy and programme commitments made at the International Conference on Population and Development (ICPD), analyses progress since 1994, and maps challenges in and opportunities for protecting their health and human rights. Findings indicate that many countries have yet to make significant progress in delaying marriage and childbearing, reducing unintended childbearing, narrowing gender disparities that put girls at risk of poor SRH outcomes, expanding health awareness or enabling access to SRH services. While governments have reaffirmed many commitments, policy development and programme implementation fall far short of realising these commitments. Future success requires increased political will and engagement of young people in the formulation and implementation of policies and programmes, along with increased investments to deliver at scale comprehensive sexuality education, health services that are approachable and not judgemental, safe spaces programmes, especially for vulnerable girls, and programmes that engage families and communities. Stronger policy-making and programming also require expanding the evidence on adolescent health and rights in LMICs for both younger and older adolescents, boys and girls, and relating to a range of key health matters affecting adolescents.
doi:10.1080/17441692.2014.986169
PMCID: PMC4318087  PMID: 25554828
adolescent girls; sexual and reproductive health; low- and middle-income countries
16.  Changes to the law on consent in South Africa: implications for school-based adolescent sexual and reproductive health research 
Background
The National Health Act, No 61, 2003 in South Africa is the first effort made by the government to protect health-related research participants under law. Implemented on March 1, 2012, the law mandates active consent from a parent or legal guardian for all research conducted with research participants under the age of 18 years. This paper focuses on the Act's implications for school-based adolescent sexual and reproductive health research.
Discussion
Although well intentioned, the added legal protections in the National Health Act may have the unintended consequence of reducing participation rates in school-based adolescent sexual and reproductive health research, thereby excluding the most at-risk students. The Act may also compromise adolescents' right to dignity and privacy, especially considering the personal nature of research on sex and sexuality. Devolved, discretionary decision-making, which empowers local human research ethics committees to permit a wider range of protective measures, including passive consent, independent adolescent consent or community consultation ought to be considered. The continued and direct involvement of young people in their sexual and reproductive health and well-being is an important principle to uphold.
Summary
This paper calls for a re-examination of section 71's ethical guidelines relating to informed consent in the National Health Act, No 61, 2003 in South Africa in order to better serve the interests of South African adolescents in sexual and reproductive health research.
doi:10.1186/1472-698X-12-3
PMCID: PMC3353180  PMID: 22490444
17.  Impact of Community-Based Maternal Health Workers on Coverage of Essential Maternal Health Interventions among Internally Displaced Communities in Eastern Burma: The MOM Project 
PLoS Medicine  2010;7(8):e1000317.
Mullany and colleagues report outcomes from a project involving delivery of community-based maternal health services in eastern Burma, and report substantial increases in coverage of care.
Background
Access to essential maternal and reproductive health care is poor throughout Burma, but is particularly lacking among internally displaced communities in the eastern border regions. In such settings, innovative strategies for accessing vulnerable populations and delivering basic public health interventions are urgently needed.
Methods
Four ethnic health organizations from the Shan, Mon, Karen, and Karenni regions collaborated on a pilot project between 2005 and 2008 to examine the feasibility of an innovative three-tiered network of community-based providers for delivery of maternal health interventions in the complex emergency setting of eastern Burma. Two-stage cluster-sampling surveys among ever-married women of reproductive age (15–45 y) conducted before and after program implementation enabled evaluation of changes in coverage of essential antenatal care interventions, attendance at birth by those trained to manage complications, postnatal care, and family planning services.
Results
Among 2,889 and 2,442 women of reproductive age in 2006 and 2008, respectively, population characteristics (age, marital status, ethnic distribution, literacy) were similar. Compared to baseline, women whose most recent pregnancy occurred during the implementation period were substantially more likely to receive antenatal care (71.8% versus 39.3%, prevalence rate ratio [PRR] = 1.83 [95% confidence interval (CI) 1.64–2.04]) and specific interventions such as urine testing (42.4% versus 15.7%, PRR = 2.69 [95% CI 2.69–3.54]), malaria screening (55.9% versus 21.9%, PRR = 2.88 [95% CI 2.15–3.85]), and deworming (58.2% versus 4.1%, PRR = 14.18 [95% CI 10.76–18.71]. Postnatal care visits within 7 d doubled. Use of modern methods to avoid pregnancy increased from 23.9% to 45.0% (PRR = 1.88 [95% CI 1.63–2.17]), and unmet need for contraception was reduced from 61.7% to 40.5%, a relative reduction of 35% (95% CI 28%–40%). Attendance at birth by those trained to deliver elements of emergency obstetric care increased almost 10-fold, from 5.1% to 48.7% (PRR = 9.55 [95% CI 7.21–12.64]).
Conclusions
Coverage of maternal health interventions and higher-level care at birth was substantially higher during the project period. The MOM Project's focus on task-shifting, capacity building, and empowerment at the community level might serve as a model approach for similarly constrained settings.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Every minute, somewhere in the world, a woman dies of complications related to pregnancy and childbirth. Access to essential maternal and reproductive health care (including family planning) is particularly bad in war-torn countries. In Burma, for example, where there have been decades of conflict between the military junta and ethnic minority resistance groups, the maternal mortality rate (the number of deaths among women from pregnancy-related causes per 100,000 live births) is around 380, whereas in neighboring Thailand it is only 44. Maternal health is even worse in the Shan, Mon, Karen, and Karenni regions of eastern Burma where ethnic conflicts and enforced village relocations have internally displaced more than half a million people. Here, the maternal mortality rate is around 1,200. In an effort to improve access to maternal health services in these regions, community-based organizations in Burma, the Johns Hopkins Center for Public Health and Human Rights, and the Global Health Access Program undertook an innovative pilot project—the Mobile Obstetric Medics (MOM) project—between 2005 and 2008. Local health workers from 12 communities in eastern Burma received training in antenatal care, obstetrics (the care of women during childbirth), postnatal care, and family planning at the Mae Tao Clinic in Mae Sot, Thailand. These “maternal health workers” then returned to Burma where they trained local health workers and traditional birth attendants to provide maternal health care to their communities.
Why Was This Study Done?
Before the MOM project started, nearly 3,000 women living in the study communities were surveyed to evaluate the coverage of essential antenatal care interventions such as urine testing for infections during pregnancy, screening for malaria, and deworming; Urinary tract infections, malaria, and hookworm infections all increase the risk of poor maternal and neonatal outcomes. The preproject survey also evaluated how many births were attended by people able to deal with complications, and the provision of postnatal care and family planning services. In this study, the researchers undertake a similar postproject survey to evaluate the impact of MOM on the coverage of essential maternal health interventions among internally displaced communities in eastern Burma.
What Did the Researchers Do and Find?
Between October 2008 and December 2008, trained survey workers asked nearly 2,500 ever-married women of reproductive age from the project's study communities about their access to antenatal and postnatal care, skilled birth attendants, and family planning. The results of the postproject survey were then compared with those of the “baseline,” preproject survey. The general characteristics (age, marital status, ethnicity, and literacy) of the women included in the two surveys were very similar. However, 71.8% of the women whose most recent pregnancy occurred during the implementation period of the MOM project had received antenatal care compared to only 39.3% of women surveyed at baseline. Similarly, among the women questioned during the postproject survey, 42.4% had had their urine tested and 55.9% had been screened for malaria during pregnancy compared to only 15.7% and 21.9%, respectively, of the women questioned in the preproject survey. Deworming had increased from 4.1% to 58.2% during the project, postnatal care visits within 7 days had doubled, and attendance at birth by people trained to deal with obstetric emergencies had increased 10-fold from 5.1% to 48.7%. Finally, the use of modern contraception methods (slow-release contraceptives, oral contraceptives, and condoms) had increased from 23.9% to 45.0%.
What Do These Findings Mean?
These findings reveal a substantial improvement in access to maternal and reproductive health care in the study communities during the MOM project. However, because the study compared two independent groups of women before and after implementation of the MOM project rather than concurrently comparing groups of women who did and did not receive the services provided by the MOM project, this study does not prove that the MOM approach was the cause of the changes in the coverage of essential maternal health care. Nevertheless, these findings suggest that the type of approach used in the MOM project—the expansion of interventions (including components of emergency obstetric care) delivered outside healthcare facilities by community-based providers—might be an effective way to deliver maternal and reproductive health services in other parts of Burma and in other places where there are ongoing conflicts.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000317.
More information about the MOM project is available in previous publications by the researchers in PLoS Medicine, in Reproductive Health Matters, and in Social Science and Medicine
Additional resources are also available on the MOM Project
The Reproductive Health Response in Conflict Consortium provides information on how conflicts affect reproductive health
The World Health Organization provides information on all aspects of health in Burma (in several languages)
The Mae Tao clinic also provides general information about Burma and its health services
The Burma Campaign UK and Human Rights Watch both provide detailed information about human rights violations, including those that affect maternal health in Burma
The United Nations Population Fund provides information about safe motherhood and maternal and reproductive health during conflicts and among refugees (in several languages)
doi:10.1371/journal.pmed.1000317
PMCID: PMC2914639  PMID: 20689805
18.  Positioning women's and children's health in African union policy-making: a policy analysis 
Background
With limited time to achieve the Millennium Development Goals, progress towards improving women's and children's health needs to be accelerated. With Africa accounting for over half of the world's maternal and child deaths, the African Union (AU) has a critical role in prioritizing related policies and catalysing required investments and action. In this paper, the authors assess the evolution of African Union policies related to women's and children's health, and analyze how these policies are prioritized and framed.
Methods
The main method used in this policy analysis was a document review of all African Union policies developed from 1963 to 2010, focusing specifically on policies that explicitly mention health. The findings from this document review were discussed with key actors to identify policy implications.
Results
With over 220 policies in total, peace and security is the most common AU policy topic. Social affairs and other development issues became more prominent in the 1990s. The number of policies that mentioned health rose steadily over the years (with 1 policy mentioning health in 1963 to 7 in 2010).
This change was catalysed by factors such as: a favourable shift in AU priorities and systems towards development issues, spurred by the transition from the Organization of African Unity to the African Union; the mandate of the African Commission on Human and People's Rights; health-related advocacy initiatives, such as the Campaign for the Accelerated Reduction of Maternal Mortality in Africa (CARMMA); action and accountability requirements arising from international human rights treaties, the Millennium Development Goals (MDGs), and new health-funding mechanisms, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria.
Prioritization of women's and children's health issues in AU policies has been framed primarily by human rights, advocacy and accountability considerations, more by economic and health frames looking at investments and impact. AU policies related to reproductive, maternal, newborn and child health also use fewer policy frames than do AU policies related to HIV/AIDS, tuberculosis and malaria.
Conclusion
We suggest that more effective prioritization of women's and children's health in African Union policies would be supported by widening the range of policy frames used (notably health and economic) and strengthening the evidence base of all policy frames used. In addition, we suggest it would be beneficial if the partner groups advocating for women's and children's health were multi-stakeholder, and included, for instance, health care professionals, regional institutions, parliamentarians, the media, academia, NGOs, development partners and the public and private sectors.
doi:10.1186/1744-8603-8-3
PMCID: PMC3298467  PMID: 22340362
African Union; Millennium Development Goals (MDGs); policy-making; women's and children's health
19.  Knowledge about childhood autism and opinion among healthcare workers on availability of facilities and law caring for the needs and rights of children with childhood autism and other developmental disorders in Nigeria 
BMC Pediatrics  2009;9:12.
Background
In designing programs to raise the community level of awareness about childhood autism in sub-Saharan Africa, it is logical to use the primary healthcare workers as contact point for education of the general public. Tertiary healthcare workers could play the role of trainers on childhood autism at primary healthcare level. Assessing their baseline knowledge about childhood autism to detect areas of knowledge gap is an essential ingredient in starting off such programs that would be aimed at early diagnosis and interventions. Knowledge of the healthcare workers on availability of facilities and law that would promote the required interventions is also important. This study assessed the baseline knowledge about childhood autism and opinion among Nigerian healthcare workers on availability of facilities and law caring for the needs and rights of children with childhood autism and other developmental disorders.
Method
A total of one hundred and thirty four (134) consented healthcare workers working in tertiary healthcare facilities located in south east and south-south regions of Nigeria were interviewed with Socio-demographic, Knowledge about Childhood Autism among Health Workers (KCAHW) and Opinion on availability of Facilities and Law caring for the needs and rights of children with Childhood Autism and other developmental disorders (OFLCA) questionnaires.
Results
The total mean score of participated healthcare workers on KCAHW questionnaire was 12.35 ± 4.40 out of a total score of 19 possible. Knowledge gap was found to be higher in domain 3 (symptoms of obsessive and repetitive pattern of behavior), followed by domains 1 (symptoms of impairments in social interaction), 4 (type of disorder autism is and associated co-morbidity) and 2 (symptoms of communication impairments) of KCAHW respectively among the healthcare workers. Knowledge about childhood autism (KCA) as measured by scores on KCAHW questionnaire was significantly associated with age group distribution of the healthcare workers, with those age group of fourth decades and above more likely to have higher mean score (p = 0.004) and previous experience of managing children with autism spectrum disorders (ASD) (p = 0.000). KCA showed near significant association with area of specialty, with those healthcare workers in psychiatry compared to pediatrics having higher mean score (p = 0.071) and also with years of working experience of the healthcare workers (p = 0.056). More than half of the healthcare workers subscribed to the opinion that facilities and law caring for the needs and rights of children with childhood autism and other developmental disorders are lacking in Nigeria.
Conclusion
The correlates of KCA may help in selection of those tertiary healthcare workers that would best fit the role of trainers. It is important to update the knowledge gaps of those healthcare workers who scored low in different domains of KCAHW questionnaire. It is imperative for policy makers in Nigeria to advocate and implement multidisciplinary healthcare service system that would ensure early diagnosis and interventions. Nationally representative baseline epidemiological data that would guide policy and planning are also desirable.
doi:10.1186/1471-2431-9-12
PMCID: PMC2650693  PMID: 19216754
20.  Health and Human Rights in Chin State, Western Burma: A Population-Based Assessment Using Multistaged Household Cluster Sampling 
PLoS Medicine  2011;8(2):e1001007.
Sollom and colleagues report the findings from a household survey study carried out in Western Burma; they report a high prevalence of human rights violations such as forced labor, food theft, forced displacement, beatings, and ethnic persecution.
Background
The Chin State of Burma (also known as Myanmar) is an isolated ethnic minority area with poor health outcomes and reports of food insecurity and human rights violations. We report on a population-based assessment of health and human rights in Chin State. We sought to quantify reported human rights violations in Chin State and associations between these reported violations and health status at the household level.
Methods and Findings
Multistaged household cluster sampling was done. Heads of household were interviewed on demographics, access to health care, health status, food insecurity, forced displacement, forced labor, and other human rights violations during the preceding 12 months. Ratios of the prevalence of household hunger comparing exposed and unexposed to each reported violation were estimated using binomial regression, and 95% confidence intervals (CIs) were constructed. Multivariate models were done to adjust for possible confounders. Overall, 91.9% of households (95% CI 89.7%–94.1%) reported forced labor in the past 12 months. Forty-three percent of households met FANTA-2 (Food and Nutrition Technical Assistance II project) definitions for moderate to severe household hunger. Common violations reported were food theft, livestock theft or killing, forced displacement, beatings and torture, detentions, disappearances, and religious and ethnic persecution. Self reporting of multiple rights abuses was independently associated with household hunger.
Conclusions
Our findings indicate widespread self-reports of human rights violations. The nature and extent of these violations may warrant investigation by the United Nations or International Criminal Court.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
More than 60 years after the adoption of the Universal Declaration of Human Rights, thousands of people around the world are still deprived of their basic human rights—life, liberty, and security of person. In many countries, people live in fear of arbitrary arrest and detention, torture, forced labor, religious and ethnic persecution, forced displacement, and murder. In addition, ongoing conflicts and despotic governments deprive them of the ability to grow sufficient food (resulting in food insecurity) and deny them access to essential health care. In Burma, for example, the military junta, which seized power in 1962, frequently confiscates land unlawfully, demands forced labor, and uses violence against anyone who protests. Burma is also one of the world's poorest countries in terms of health indicators. Its average life expectancy is 54 years, its maternal mortality rate (380 deaths among women from pregnancy-related causes per 100,000 live births) is nearly ten times higher than that of neighboring Thailand, and its under-five death rate (122/1000 live births) is twice that of nearby countries. Moreover, nearly half of Burmese children under 5 are stunted, and a third of young children are underweight, indicators of malnutrition in a country that, on paper, has a food surplus.
Why Was This Study Done?
Investigators are increasingly using population-based methods to quantify the associations between human rights violations and health outcomes. In eastern Burma, for example, population-based research has recently revealed a link between human rights violations and reduced access to maternal health-care services. In this study, the researchers undertake a population-based assessment of health and human rights in Chin State, an ethnic minority area in western Burma where multiple reports of human rights abuses have been documented and from which thousands of people have fled. In particular, the researchers investigate correlations between household hunger and household experiences of human rights violations—food security in Chin State is affected by periodic expansions of rat populations that devastate crop yields, by farmers being forced by the government to grow an inedible oil crop (jatropha), and by the Burmese military regularly stealing food and livestock.
What Did the Researchers Do and Find?
Local surveyors questioned the heads of randomly selected households in Chin State about their household's access to health care and its health status, and about forced labor and other human rights violations experienced by the household during the preceding 12 months. They also asked three standard questions about food availability, the answers to which were combined to provide a measure of household hunger. Of the 621 households interviewed, 91.9% reported at least one episode of a household member being forced to work in the preceding 12 months. The Burmese military imposed two-thirds of these forced labor demands. Other human rights violations reported included beating or torture (14.8% of households), religious or ethnic persecutions (14.1% of households), and detention or imprisonment of a family member (5.9% of households). Forty-three percent of the households met the US Agency for International Development Food and Nutrition Technical Assistance (FANTA) definition for moderate to severe household hunger, and human rights violations related to food insecurity were common. For example, more than half the households were forced to give up food out of fear of violence. A statistical analysis of these data indicated that the prevalence of household hunger was 6.51 times higher in households that had experienced three food-related human rights violations than in households that had not experienced such violations.
What Do These Findings Mean?
These findings quantify the extent to which the Chin ethnic minority in Burma is subjected to multiple human rights violations and indicate the geographical spread of these abuses. Importantly, they show that the health impacts of human rights violations in Chin State are substantial. In addition, they suggest that the indirect health outcomes of human rights violations probably dwarf the mortality from direct killings. Although this study has some limitations (for example, surveyors had to work in secret and it was not safe for them to collect biological samples that could have given a more accurate indication of the health status of households than questions alone), these findings should encourage the international community to intensify its efforts to reduce human rights violations in Burma.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001007.
The UN Universal Declaration of Human Rights is available in numerous languages
The Burma Campaign UK and Human Rights Watch provide detailed information about human rights violations in Burma (in several languages)
The World Health Organization provides information on health in Burma and on human rights (in several languages)
The Mae Tao clinic also provides general information about Burma and its health services (including some information in Thai)
A PLoS Medicine Research Article by Luke Mullany and colleagues provides data on human rights violations and maternal health in Burma
The Chin Human Rights Organization is working to protect and promote the rights of the Chin people
The Global Health Access Program (GHAP) provides information on health in Burma
FANTA works to improve nutrition and global food security policies
doi:10.1371/journal.pmed.1001007
PMCID: PMC3035608  PMID: 21346799
21.  The Experiences of Violence and Occupational Health Risks of Sex Workers Working in Brothels in Ankara 
Balkan Medical Journal  2012;29(2):153-159.
Objective:
The aim of this study was to reveal and discuss occupational health risks, violence against sex workers working in brothels and their working conditions in Ankara.
Materials and Methods:
The study included 138 sex workers. Data were collected at face to face interviews with a questionnaire composed of 40 questions about socio-demographic features, familial characteristics, reasons for becoming a sex worker, experiences of violence and occupational health risks.
Results:
Twenty-two point five percent of the women were aged 21–30 years and 39.9% were aged 31–40 years. The mean time of education was 5.9±3.5 (0–14) years. Forty-eight point five percent of the women were exposed to physical abuse and 13% of the women had been exposed to sexual abuse in their childhood. Fifty-five point eight percent of the women reported that their clients always used condoms, but 97.1% of the women noted that their clients insisted on not using a condom. Fourteen point five percent and 70.3% of the women were exposed to physical and verbal violence respectively from their clients. Ten point one percent of the women suffered sexual assault while working.
Conclusion:
Sex workers, like other people, should have human rights, all types of violence that they face should be eliminated and the social conditions they are exposed to should be improved. Sexually transmitted diseases, the most important health risk of sex workers, should be considered as occupational diseases in the new regulations.
doi:10.5152/balkanmedj.2011.018
PMCID: PMC4115845  PMID: 25206986
Prostitution; sex worker; violence against woman; human rights; sexual transmitted diseases
22.  Experience of violence and adverse reproductive health outcomes, HIV risks among mobile female sex workers in India 
BMC Public Health  2011;11:357.
Background
Female sex workers (FSWs) are a population sub-group most affected by the HIV epidemic in India and elsewhere. Despite research and programmatic attention to FSWs, little is known regarding sex workers' reproductive health and HIV risk in relation to their experiences of violence. This paper therefore aims to understand the linkages between violence and the reproductive health and HIV risks among a group of mobile FSWs in India.
Methods
Data are drawn from a cross-sectional behavioural survey conducted in 22 districts from four high HIV prevalence states (Andhra Pradesh, Karnataka, Maharashtra, Tamil Nadu) in India between September 2007 and July 2008. The survey sample included 5,498 FSWs who had moved to at least two different places for sex work in the past two years, and are classified as mobile FSWs in the current study. Analyses calculated the prevalence of past year experiences of violence; and adjusted logistic regression models examined the association between violence and reproductive health and HIV risks after controlling for background characteristics and program exposure.
Results
Approximately one-third of the total mobile FSWs (30.5%, n = 1,676) reported experiencing violence at least once in the past year; 11% reported experiencing physical violence, and 19.5% reported experiencing sexual violence. Results indicate that FSWs who had experienced any violence (physical or sexual) were significantly more likely to be vulnerable to both reproductive health and HIV risks. For example, FSWs who experienced violence were more likely than those who did not experience violence to have experienced a higher number of pregnancies (adjusted odds ratio [OR] = 1.2, 95% confidence interval [CI] = 1.0-1.6), ever experienced pregnancy loss (adjusted OR = 1.4, 95% CI = 1.2-1.6), ever experienced forced termination of pregnancy (adjusted OR = 2.4, 95% CI = 2.0-2.7), experienced multiple forced termination of pregnancies (adjusted OR = 2.2, 95% CI = 1.7-2.8), and practice inconsistent condom use currently (adjusted OR = 1.97, 95% CI: 1.4-2.0). Among FSWs who experienced violence, those who experienced sexual violence were more likely than those who had experienced physical violence to report inconsistent condom use (adjusted OR = 1.8, 95% CI: 1.4-2.3), and experience STI symptoms (adjusted OR = 1.3, 95% CI: 1.1-1.7).
Conclusion
The pervasiveness of violence and its association with reproductive health and HIV risk highlights that the abuse in general is an important determinant for reproductive health risks; and sexual violence is significantly associated with HIV risks among those who experienced violence. Existing community mobilization programs that have primarily focused on empowering FSWs should broaden their efforts to promote reproductive health in addition to the prevention of HIV among all FSWs, with particular emphasis on FSWs who experienced violence.
doi:10.1186/1471-2458-11-357
PMCID: PMC3116498  PMID: 21599984
23.  Sex Work during the 2010 FIFA World Cup: Results from a Three-Wave Cross-Sectional Survey 
PLoS ONE  2011;6(12):e28363.
Background
In the months leading up to the 2010 FIFA World Cup in South Africa, international media postulated that at least 40,000 foreign sex workers would enter South Africa, and that an increased HIV incidence would follow. To strengthen the evidence base of future HIV prevention and sexual health programmes during international sporting events, we monitored the supply and demand of female sex work in the weeks before, during and after the 2010 FIFA World Cup.
Methodology/Principal Findings
We conducted three telephonic surveys of female sex workers advertising online and in local newspapers, in the last week of May, June and July 2010. The overall response rate was 73.4% (718/978). The number of sex workers advertising online was 5.9% higher during the World Cup than before. The client turnover rate did not change significantly during (adjusted rate ratio [aRR] = 1.05; 95%CI: 0.90–1.23) or after (aRR = 1.06; 95%CI: 0.91–1.24) the World Cup. The fraction of non-South African sex workers declined during (adjusted odds ratio [aOR] = 0.50; 95%CI: 0.32–0.79) and after (aOR = 0.56; 95%CI: 0.37–0.86) the World Cup. Relatively more clients were foreign during the World Cup among sex workers advertising in the newspapers (aOR = 2.74; 95%CI: 1.37–5.48) but not among those advertising online (aOR = 1.06; 95%CI: 0.60–1.90). Self-reported condom use was high (99.0%) at baseline, and did not change during (aOR = 1.07; 95% CI: 0.16–7.30) or after (aOR = 1.13; 95% CI: 0.16–8.10) the Word Cup.
Conclusions/Significance
Our findings do not provide evidence for mass-immigration of foreign sex workers advertising online and in local newspapers, nor a spike in sex work or risk of HIV transmission in this subpopulation of sex workers during the World Cup. Public health programmes focusing on sex work and HIV prevention during international sporting events should be based on evidence, not media-driven sensationalism that further heightens discrimination against sex workers and increases their vulnerability.
doi:10.1371/journal.pone.0028363
PMCID: PMC3233553  PMID: 22163298
24.  Police violence and sexual risk among female and transvestite sex workers in Serbia: qualitative study 
Objective To explore female and transvestite sex workers’ perceptions of risk in the sex work environment in Serbia.
Design Qualitative interview study.
Setting Street based locations for sex work in Belgrade and Pancevo, Serbia.
Participants 31 female and transvestite sex workers.
Results Violence, including police violence, was reported as a primary concern in relation to risk. Violence was linked to unprotected sex and the reduced capacity for avoiding sexual risk. Participants reported that coerced sex was routinely provided to the police in exchange for freedom from detainment, arrest, or fine, and was enforced by the perceived threat of violence, sometimes realised. Accounts contained multiple instances of physical and sexual assault, presented as abuses of police authority, and described policing as a form of moral punishment. This was largely through non-physical means but was also enforced through physical violence, especially towards transvestite and Roma sex workers, whose experience of police violence was reported as relentless and brutal and connected with broader social forces of discrimination in this setting, especially towards Roma.
Conclusion Preventing violence towards sex workers, which can link with vulnerability to sexually transmitted infections, is a priority in Serbia. This requires monitoring perpetrators of violence, providing legal support to sex workers, and creating safer environments for sex work.
doi:10.1136/bmj.a811
PMCID: PMC2492575  PMID: 18667468
25.  Advancing sexual and reproductive health and rights in low- and middle-income countries: Implications for the post-2015 global development agenda 
Global Public Health  2015;10(2):137-148.
The papers and commentaries in this special issue illuminate progress made by low- and middle-income countries towards implementation of the Programme of Action (PoA) agreed by 179 countries during the International Conference on Population and Development in Cairo in 1994. The PoA presents a path-breaking sexual and reproductive health and rights (SRHR) framework for global and national population and health policies. While progress towards implementation has been made at global, regional and national levels, continuing and new challenges require that high priority be given to SRHR for all, particularly women and girls, during the remaining months of the millennium development goals and in the United Nations post-2015 development agenda. This paper highlights three critical gaps, raised in other papers: inequalities in access to sexual and reproductive health (SRH) information and services; the widespread need to improve SRH services to meet public health, human rights and medical ethics standards for quality of care; and the absence or inadequate use of accountability mechanisms to track and remedy the other two. We discuss priority actions to achieve equality, quality and accountability in SRHR policies, programmes and services, especially those that should be included in the post-2015 development agenda.
doi:10.1080/17441692.2014.986177
PMCID: PMC4318089  PMID: 25628182
sexual and reproductive health and rights; low- and middle-income countries; post-2015 global development agenda; equality of access to SRH services; quality of SRH services; monitoring and tracking of SRH services

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