**4. Prevalence of HIV in Ireland**

276 Immunodeficiency

risk [7].

work.

treatment, care and support.

protected against gender-based violence.

**3. Irish government policy response to HIV** 

and transgender sex workers and the importance of universal access to HIV prevention,

The overall growth of the HIV global AIDS epidemic seems to have stabilized. There has been a steady decline in the number of new HIV infections since the late 1990s; and due to antiretroviral therapy fewer AIDS-related deaths have occurred. The UNAIDS vision is zero new HIV infections, zero discrimination and zero AIDS-related deaths. That said, new HIV infections are still high and worldwide there has been an increase in the number of people living with HIV. The population under discussion in this paper remain at particularly high

The UNAIDS report (2010) states that there are three high risk behaviours associated with the spread of HIV are injecting drug use, practising unprotected paid sex, and men having sex with men [7]. There are also risks in discordant heterosexual relationships where one partner is HIV positive and risks transmitting the virus to the other partner in a long term relationship. It emphasizes the importance of couples testing for HIV. Becoming sexually active at a young age is also a risk factor; the report states that young people still lack the information and the necessary tools to practice HIV risk-reduction strategies. There is a lack of provision of harm reduction materials such as condoms and lubrication, and sterile needles. It argues that in order to protect women and girls from HIV they need to be

The UNAIDS Advisory Group Report [7] noted that sex workers often face widespread and interconnected human rights violations which impede both their effective participation in HIV responses and their right to access HIV and other health and social services. It stated that societal stigma and discrimination against sex workers results in repressive laws, policies and practices, and the economic disempowerment of sex workers. The Report warns countries against the persecution of sex workers and the conflation of trafficking with sex

In Ireland, in response to the HIV epidemic in the 1980s the then Eastern Health Board [1] (now the Eastern Region Health Service Executive) established two specialised drugs intervention clinics (one for female sex workers and one for gay men and male sex workers) in the capital city, Dublin. These clinics provide free HIV screening and other harm reduction services such as needle exchanges and methadone maintenance for intra-venous drug users. In 1987 the Dublin Aids Alliance (DAA), a voluntary non-governmental organisation with charitable status, was set up to improve conditions for people living with or affected by HIV and AIDS. DAA is; provides front line services, such as counselling, outreach and condom distribution. It is the representative for the eastern region of Ireland on the Department of Health and Children's National AIDS Strategy Committee (NASC) and its Education and Prevention Subcommittee. NASC was established in 1991 and published its first Strategic Report in 1992. It took a multi-disciplinary approach involving Figures published by the Health Protection Surveillance Centre [11] on newly diagnosed HIV infections in Ireland in 2011 showed that there were 152 new HIV diagnoses in the first six months of 2011 (less than the 166 cases reported in Q1&2 2010 and the 164 in Q3&4 2010). This brought the cumulative total number of HIV infections reported in Ireland to more than 6,120. The HPSC notes that, as regards new cases:


#### **5. Risk environment**

The 'risk environment' is a simple model or explanatory framework developed by Tim Rhodes [12] to examine the multiple environmental factors that produce health and other types of risk. There are four types of environmental influences: physical, social, economic and policy in the context of three levels of environmental influence – micro, meso and macro. The risk environment is made up of the risk factors that are external to the individual; these risks can mediate the individual's capacity to reduce the risk of harm. For example, if a country provides free needle exchange programs or opiate substitution programs they help the individual user to reduce the harms associated with intravenous opiate use.

Although harm reduction is most commonly applied to reducing harms related to drug use (especially intravenous drug use), harm reduction principles are increasingly being applied to sex work. The harms associated with sex work include the vulnerabilities that may lead to sex work, the harms that are introduced by engaging in sex work such as stigma [13], criminalisation, and the mutually reinforcing harms such as problem drug use and in particular injecting drug use [14]. The nature and extent of harms associated with sex work varies with the type of sex market they work in e.g. brothels, massage parlours, escorts, street work, however, the harms are greatest in street-based sex markets [15] and where sex workers' pre-existing vulnerabilities can be exploited [16].

What I Knew was What I Learnt on the Street!

Irish Drug Using Sex Workers Accounts of How They Contracted HIV and Hepatitis C 279

The focus of this research was to gain an understanding of drug-using sex workers' lived experience of risk, in order to understand how the local risk environment (i.e. the physical, social, economic and policy environment) produces risks in their daily life and work contexts, and how drug-using sex workers implement strategies to manage and reduce the risk of harm. A qualitative methodology was chosen as being the most appropriate to answer the research question. Ethical permission for the study was sought and granted from

A purposive sample (4 men and 31 women: n=35) of drug-using sex workers was selected. They were located for the research by key service providers and by an agency which offers specialist support to drug using sex workers. In order for sex workers to be eligible for inclusion in the study they had to self identify as a problematic drug user as defined by the Irish National Drug Strategy – i.e. their drug use caused them social, psychological, physical or legal difficulties, and they were involved in sex work or had recently given up sex work

Two research instruments were utilised to register these sex workers' accounts. A topic guide was designed for use in in-depth face-to-face interviews, and a short survey was used to gather biographic and demographic information and to record current drug use frequency and any associated criminal activity over the previous 90 days. The interviews were conducted in a number of different venues: some in rooms provided by an agency, some in cars, some in prison and some in cafés. In keeping with NACD policy all

In order to comply with ethical guidelines, prior to conducting the interview, the research was explained to the participant, who signed a consent form and was assured that they could withdraw from the study at any time and that all information was confidential and anonymous. Their permission to audio record the interview was also sought; all agreed to

The interviews lasted 45 minutes to an hour and the data quality was good. Generally speaking, the sex workers were very open and viewed the interview as a way of helping out, or doing the researcher a favor. Ethical guidelines were complied with in relation to storage of the data on a password protected computer; all personal identifiers were removed from the data. The data were anonymized, each sex worker was given a pseudo-name (in alphabetical order). Hard copies of the data were stored in a locked filing cabinet. Data was

participants were recompensed for their time with a voucher for a local chain store.

the Drug Treatment Centre Board in Dublin and also from the Prison services.

**6. Methods** 

**7. Sample** 

be recorded.

after a prolonged period of sex working.

only used for the purpose of the research.

**8. Research instruments** 

There are a number of layers in the risk environment in Ireland. In terms of sex work, there is the legal environment which criminalizes sex workers if they work in brothels or if they solicit sex on the streets[17]. Due to policing, risks are increased because sex workers cannot take time to negotiate with clients and assess the safety aspect of the transaction. To decrease their visibility on the street, there is the added risk of sex workers working in badly lit and remote areas where they are more likely to be victims of violent clients. Due to the societal disapproval of sex work, there is the risk of stigma[13] or public disclosure. The use of crack cocaine has been shown to be associated with street sex working in Dublin [18].

In response to the heroin epidemic in the 1980s in Dublin drug treatment clinics and harm reduction services (methadone maintenance, needle exchange programs etc.) were established [19] within a risk environment where illicit drug use is criminalized[17]. Despite the criminality associated with drug use, reported levels of cocaine use in Ireland are above the European average [20] and Ireland also reports the highest estimate of opioid use in the European Union [20]. The Irish Health Service Executive [21] reports that there are 9,264 people in methadone maintenance treatment, whilst it is estimated that there are another 10,000 heroin users who are not in treatment [22]. In the past heroin use was concentrated in Dublin however now it is spreading all over Ireland. Disadvantaged communities are hardest hit.

A tragic consequence of illicit drug use is early death. In Ireland in 2009 (the latest figures available) there were 357 deaths due to illicit drug use. Cocaine was implicated in 52 of these, heroin was implicated in 108 and methadone in 66 [23]. Poly substance (heroin and methadone) use was implicated in 117 deaths. The majority of those who died were aged between 25 and 44 years; the median age was 38 years. Delays in service provision are clearly a factor: drug users seeking treatment have to wait an average of three to 18 months for opioid substitute treatment depending on the area of Ireland they live in [20].

Although there are adequate health services available for sex workers in Dublin, sex workers are stigmatized [13] on many levels (due to injecting drug use, HIV or HCV infections, and sex working) and may hide their work from health personnel. There is also a high incidence of HCV (70%) among injecting drug users in Ireland [13]. Whilst it is not possible to ascertain the prevalence of HIV among drug using sex workers in Ireland and it is certainly unjust to consider them as vectors of disease, one fifth of the sex workers in our study [13] self-reported as being HIV positive.
