Vijeyarasa, Ramona; Stein, R.A --- "HIV and Human Trafficking-Related Stigma: Health Interventions for Trafficked Populations" [2010] UTSLRS 5; (2010) 304(3) The Journal of the American Medical Association 344

Last Updated: 17 May 2017

Draft Edited file 6/20/10

HIV and Human Trafficking-Related Stigma:

Health Interventions for Trafficked Populations



Ramona Vijeyarasa, LLM, LLB, BA¹
Richard A. Stein, MD, PhD²






Author affiliations: ¹School of Social Sciences and International Studies, University of New South Wales, Sydney, Australia, and ²Department of Molecular Biology, Princeton University, Princeton, NJ ([e-mail]).

Corresponding Author:
Richard A. Stein, MD, PhD, Princeton University, Department of Molecular Biology, One Washington Road, LTL320, Princeton, NJ 08544

Despite potential overlapping causes and consequences of HIV infection and human trafficking, including poverty, discrimination, and marginalization,¹ there is only limited recognition of the links between the two. The limited research that exists on trafficking for sexual exploitation (and not labor exploitation more generally) suggests that trafficked individuals face increased risks of HIV infection, and that there is stigmatization associated with the convergence between HIV and human trafficking. HIV awareness-raising interventions are needed among potential trafficked populations and migrant sex workers alike during the pre-departure stage, and increased access to health care and voluntary HIV screening is needed for all migrant populations, including trafficked individuals, in countries of origin and destination. All such interventions must give sufficient attention to stigma-reduction strategies.

Trafficking, Migration, and Sex Work
There are important similarities and differences in the circumstances of trafficked individuals and migrant sex workers. The 2000 UN Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women and Children, defines trafficking as the movement of people through various means, including threats, force, or coercion, for the purpose of exploitation.² $$$AU: Reference okay? (see Reference list)$$$ [Reference amended-see below] While useful to conceptualize trafficking, the definition is of limited value in ensuring rights-based interventions and in recognizing how initially voluntary movement can lead to exploitative and trafficking-like working conditions.³
To the contrary, migrant sex workers are engaged in voluntary movement, although their status is often similarly undocumented, which leads to increased risk of exploitation by clients, brothel owners, and others in destination countries. Despite the differences, interventions that raise awareness of the risks of HIV infection are of benefit to both trafficked women and migrant sex workers, particularly given that both groups experience similar health risks and barriers to health services.¹

HIV, Trafficking, and the Current Evidence Base
The lack of scientific research on the bi-directional relationship between trafficking and HIV impedes the design of public policies and interventions to address this intersection. Furthermore, most studies on the relationship between HIV/AIDS and trafficking focus only on South and Southeast Asia, the second most HIV-infected region globally, and one for which the epidemic is characterized by spreading predominantly through heterosexual transmission and intravenous drug use.
The most intuitive relationship between trafficking and HIV/AIDS is the risk of infection that trafficked individuals face in destination countries. Two studies from 2006⁴ and 2009⁵ $$$AU: References were reordered in the reference list to match the order in the text$$$ [References has been reordered so that 2006 comes first] report HIV infection in 22.9% to 45.8% of human trafficking victims. A study by Dharmadhikari et al from 2009, focusing on the trafficking of Nepalese women and girls to India, revealed lower but significant rates of infection, with 15 of 287 trafficked individuals, aged 7 to 32 years at the time of being trafficked, returning home HIV-positive.⁶
Though surprising, the interrelationship between HIV and human trafficking could in fact be bidirectional. While it is less likely that a woman who is ill would choose to migrate for work, the stigma associated with HIV/AIDS may force a woman to leave her community and risk unsafe migration and trafficking-like conditions, with at least one example having been documented.¹ Further research will be required to substantiate the contention that women living with HIV/AIDS face an increased risk of trafficking and unsafe migration.
Furthermore, although there are limited data on the relationship between other infectious diseases and trafficking, the study by Dharmadhikari et al revealed that 17 of the 287 victims in the study had tuberculosis.⁶ In addition to HIV, interventions should therefore address other infectious diseases.⁷
The extent to which trafficked individuals and migrant sex workers face increased vulnerability to HIV/AIDS and tuberculosis varies and is influenced by a multitude of factors. These include the level of pre-departure knowledge concerning the virus, clients’ attitudes towards condom use, and the level of negotiating power, if any, that trafficked individuals and sex workers alike are able to exercise regarding condom use. Other factors include the number of clients serviced daily, and the risks of forced sex during menstruation, all of which increase exposure and mistreatment. A further consideration is the extent to which clean syringes are used in places where trafficked individuals, sex workers, and clients have been identified as injecting drug users. It is important that research is undertaken in countries where some of the risk factors that increase exposure to HIV are evident.

Multiple experiences of stigma
Attention must be given to the relationship between stigma related to both trafficking and HIV/AIDS.⁸ Stigma concerns the labeling of those who are “different” as undesirable. Stigmatization is linked to social, economic, and political power that allows us to identify differences, construct stereotypes, label groups, and execute rejection.⁹ If labeled as disease carriers, discrimination, marginalization, and abuse may be aggravated for trafficked individuals. Shame associated with HIV and trafficking, known as internalized or felt stigma, may prevent individuals living with HIV and/or returned trafficked individuals from seeking treatment and other health care interventions.¹ For trafficked individuals returning home HIV-positive, the challenge of integration into their former community, or a new one, will be exacerbated in countries that are known to show a lack of respect for the rights of persons living with HIV/AIDS.
Required Interventions
A number of factors should be considered when developing health interventions to address the relationship between infectious diseases and trafficking. Public messaging directly linking trafficking with vulnerability to HIV may result in increased stigma and discrimination against both formerly trafficked persons, who will consequently be perceived as HIV-positive, and women already living with HIV/AIDS, who will then be perceived as having been trafficked or involved in sex work. HIV-prevention and stigma-reduction strategies should be simultaneously incorporated into pre-departure awareness-raising interventions for potential migrants.
Health care services in destination countries also must be made accessible. In some instances, HIV status is used as a basis for the expulsion of trafficked individuals $$$AU: Okay?$$$ from destination countries. Legislative and policy reforms are essential to eliminate such responses and ensure access by migrant sex workers and trafficked individuals to health care services in destination countries. Traffickers’ desire to keep women in destination countries hidden from authorities may further act as a barrier to accessible health care. Consequently, HIV interventions in destination countries may be inaccessible to trafficked women due to restrictions on their movement.⁴ $$$AU: Reference correct?$$$ [Yes]
HIV prevention and treatment for trafficked individuals and sex workers alike should be integrated with comprehensive reproductive and other sexual health services and guidance, to which these populations may not have had access prior to migrating. A focus solely on HIV interventions, while ignoring reproductive and other sexual health needs, perpetuates the notion of returning trafficked individuals as disease carriers and fails to provide access to holistic health care.
Health interventions are essential to overcome risks of HIV infection and tuberculosis among mobile populations, and to address the consequences of infection, including increased stigma, discrimination, and further human rights violations.¹⁰ In cases in which trafficked individuals return home with HIV infection, they are potentially burdened by both trafficking and the HIV/AIDS-related stigma. Without adequate interventions in destination countries and upon return, the stigma faced by returning trafficked individuals living with HIV/AIDS will only act to exacerbate marginalization and perpetuate denial of fundamental human rights, including access to health care services.
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Financial Disclosures:
R Vijeyarasa-None
R.A. Stein-None
Funding/Support:
R Vijeyarasa-Australian Postgraduate Award (Australian Government) and Scholarship, Faculty of Arts and Social Sciences, University of New South Wales
Role of the Sponsor:
R Vijeyarasa-None

Additional Contributions: The authors would like to thank Dr Helen Pringle and José-Miguel Bello y Villarino for their valuable comments on earlier drafts of this paper.

References

1. Zimmerman C, Yun K, Shvab I, et al. The health risks and consequences of trafficking in women and adolescents: Findings from a European study. London: London School of Hygiene & Tropical Medicine (LSHTM), 2003. http://genderviolence.lshtm.ac.uk/files/health_risks__consequences_trafficking.pdf. Accessed June 2, 2010.
2. The Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women and Children, supplementing the United Nations Convention against Trans-National Organized Crime, 2000, G.A. Res. 55/25, opened for signature 12 December 2000, (entered into force 25 December 2003).
3. Vijeyarasa R. The State, family and language of “social evils”: Re-stigmatising victims of trafficking in Vietnam. Culture, Health and Sexuality. 2009; i-first: 1-14.
4. Silverman JG, Decker MR, Gupta J, et al. HIV prevalence and predictors among rescued sex-trafficked women and girls in Mumbai, India. Journal of Acquired Immune Deficiency Syndrome. 2006; 43(5):588-93.
5. Gupta J, Raj A, Decker MR, Reed E, Silverman JG. HIV vulnerabilities of sex-trafficked Indian women and girls. International Journal of Gynecology and Obstetrics. 2009; 107(1):30-4.
6. Dharmadhikari AS, Gupta J, Decker MR, et al. Tuberculosis and HIV: a global menace exacerbated via sex trafficking. International Journal of Infectious Diseases. 2009; 13(5):543-6.
7. Infectious Disease Society of America (IDSA), HIV Medical Association, The Forum for Collaborative HIV Research, The Forum for Collaborative HIV Research. HIV/TB coinfection: basic facts; 2007. http://www.hivforum.org/storage/hivforum/documents/HIV_TB_Fact%20Sheet.pdf. Accessed May 25, 2010.
8. Huda S. Sex trafficking in South Asia. International Journal of Gynecology and Obstetrics. 2006; 94(3):374-381. $$$AU: Not cited in the text – needed?$$$
9. Link BG, Phelan JC. Conceptualizing stigma. Annual Review of Sociology. 2001; 27:363-85.
10. Stein RA. HIV: The Hidden Face of Human Trafficking. World Medical & Health Policy. 2010. http://www.psocommons.org/wmhp/vol2/iss1/art7.

$$$AU: Are old references #8 and #9 needed? They are not cited in the text$$$
I would like to keep in the Huda reference. The Huda reference is valuable for a number of reasons. First, it is one of few articles that explore the gynecological consequences of human trafficking. Secondly, Sigma Huda was the former UN Special Rapporteur on Trafficking and has specifically highlighted the idea of multiple burdens of stigma.