Study identifies racial/ethnic disparities in HIV care

Targeted clinical and public health interventions are needed to improve HIV care among older black men who have sex with men, young white women and middle-aged black men who have sex with women, researchers wrote in Clinical Infectious Diseases.

“Disparities between racial/ethnic groups have been a defining feature of the human immunodeficiency virus (HIV) epidemic in the United States,” Fidel A. Desir, PhD student in the department of epidemiology at Johns Hopkins Bloomberg School of Public Health, and colleagues wrote. “Given the disproportionate impact of HIV, targeted reductions in racial/ethnic disparities are one of the central tenets of the U.S. National HIV/AIDS Strategy (NHAS).”

According to Desir and colleagues, in 2015, the NHAS identified men who have sex with men (MSM), black and Hispanic men and women and young people with HIV as critical populations deserving special attention.

“Few studies, however, have sought to determine how sex, age, and sexual HIV acquisition risk interact to influence racial/ethnic disparities in the HIV care continuum,” they wrote.


For their study, Desir and colleagues included adults aged 18 years or older with HIV who initiated care between Jan. 1, 2004, and Dec. 31, 2014. Of the 19,521 patients entering HIV care in the North American AIDS Cohort Collaboration on Research and Design, 21.4% were women, 59% were MSM and 19.6% were men who have sex with women (MSW). Study participants were followed for 5 years, until the close of cohort observation or until the end of the study period, whichever came first.

Desir and colleagues found that white women aged 18 to 29 years spent 12% less person-time in care (95% CI, 1.1%-20.2%), 9.2% less time on ART (95% CI, 0.4%-20.4%) and 13.5% less time virally suppressed (95% CI, 2.7%-22.5%) compared with Hispanic women in the same age group. Among MSM aged 50 years or older, black men spent 6.3% less person-time in care (95% CI, 1.3%-11.7%), 11% less time on ART (95% CI, 4.6%-18.1%) and 9.7% less time virally suppressed (95% CI, 3.6%-16.8%) compared with white MSM. Additionally, compared with white MSM, black MSM aged 40 to 49 years spent 9.8% less person-time on ART (95% CI, 2.4%–16.5%) and 11.9% less person-time virally suppressed (95% CI, 3.8%-19.3%).

According to the study, black and white MSM spent a similar amount of person-time in care and on ART, but black MSM spent 4.7% less person-time virally suppressed. Hispanic and white MSM also spent a similar amount of person-time in care, on ART and virally suppressed, although Desir and colleagues observed that compared with black MSM, Hispanic MSM spent more time in each of the three stages. Furthermore, person-time spent in care and on ART was similar between black and white MSW, but black MSW experienced 6% less person-time virally suppressed.

When compared with white women, black women spent more person-time in care, on ART and virally suppressed. Specifically, black women spent 5.1% more person-time in care than white women. Although the differences were not statistically significant, among women aged 30 to 39 years, black and Hispanic women spent less person-time in care, on ART and virally suppressed than white women. Moreover, among women aged 18 to 29 years and 50 years and older, black and Hispanic women spent more person-time in care than white women.

Desir and colleagues said older black MSM, young white women and middle-aged black MSM as groups of people living with HIV “require special attention to ensure the NHAS goals of reducing racial/ethnic disparities are achieved.”

“Our findings demonstrate that age, sex, and sexual HIV acquisition risk are important modifiers of racial/ethnic differences in HIV care retention, ART use, and viral suppression among PWH entering HIV care,” they wrote. – by Marley Ghizzone


Starting from here – what PrEP programmes can learn from circumcision


Funders, health providers and advocates should take lessons from the rollout of voluntary medical male circumcision (VMMC) as an HIV prevention measure in Africa if they wish to hasten access to programmes providing pre-exposure prophylaxis (PrEP), researchers argue in the International Journal of STD and AIDS.

Their article adds to similar papers on the lessons that PrEP implementers can learn from the history of contraception.

Jason Reed of Jhpiego, Rupa Patel of Washington University in St Louis and Rachel Baggaley of the World Health Organization start by saying that VMMC and PrEP are very different HIV prevention measures. The first is a one-off medical intervention whose effects last for life, but whose efficacy is in the region of 60-70%. The other is a medication that needs to be taken daily or regularly, but which achieves almost 100% efficacy with good adherence. But, they add, there are many lessons from the implementation of VMMC programmes that can also apply to PrEP, particularly in the areas of sustainability, demand creation and community engagement.

As reported recently by from the International AIDS Conference, PrEP is slowly gaining a foothold in lower-income countries, though still largely as a series of demonstration projects. South Africa and Kenya both have national PrEP strategies they are beginning to implement, with smaller programmes underway in Zimbabwe, eSwatini (Swaziland) and Senegal. In Asia, Thailand and Vietnam have programmes for men who have sex with men and trans women, as well as pilot programmes for sex workers in India.

But we are a long way from the three million people UNAIDS has adopted as its target for PrEP access by 2020. And a number of national programmes are learning the hard way that PrEP can be offered but isn’t always taken, with retention a problem. As the authors of the present paper say, “It is challenging to engage healthy, HIV-uninfected people, many of whom are young, and to encourage them to consider a medical intervention to prevent something that may or may not happen at some future date.”

The original UNAIDS target for VMMC was 20.8 million males circumcised by 2016. Although this ambitious target was not reached, over 15 million men, almost all in Africa, have now been circumcised to reduce their and their communities’ vulnerability to HIV.

What lessons can be learned from the rollout of VMMC that might speed up the introduction of PrEP? The writers make ten points.

Ten points

1. Safety. This should be the first consideration in any medical intervention. It was for obvious reasons a worry with a surgical procedure like circumcision. But although tenofovir and emtricitabine, the drugs currently used as PrEP, have years of safety data behind them, as programmes expand, rare events such as kidney failure will happen. Comprehensive and reliable reporting systems need to be in place for these rare events. An example of an adverse event in VMMC that should have been reported earlier was one of two cases of tetanus infections that went unreported in 2012. They were only uncovered when a larger cluster of tetanus cases occurred in 2014.

The authors also suggest that drug resistance caused by people taking PrEP while in acute HIV infection should be reported as an adverse event, especially as this impacts on future treatment in settings where second- and third-line therapies may be harder to access. They do however emphasise that modelling studies suggest that PrEP use will contribute to less than 5% of the global burden of HIV drug resistance.

2. Engaging communities and governments. PrEP has only been adopted with enthusiasm by a few countries and many others continue to treat it with caution. Both VMMC and PrEP are controversial interventions or have a history of being so. It is notable that in countries where PrEP has been adopted, it has benefitted from local champions ranging from parliamentarians in Zimbabwe to traditional leaders in Zambia – and, one might add, supportive physicians and researchers.

3. Demand creation. One lesson from the rollout of VMMC is that it initially appeared that there was a high demand for it, due to uptake by men who had already heard about VMMC and wanted it. However, this relatively small pool of early adopters soon dried up, leaving clinics under-utilised. The authors advise that for PrEP to reach as many people as need it, innovative demand-creation campaigns should be introduced early to ensure they also want it. The authors argue that if demand-creation campaigns had started in the US earlier, PrEP uptake would have been faster. Even now, PrEP coverage amongst those in highest need is estimated at 30%, with much lower rates in young and ethnic-minority MSM and in women. In high-prevalence countries, PrEP awareness remains very limited.

4. PrEP delivery. “Service delivery points need to be as varied as the populations they serve,” the authors write. The provision of HIV services in a wide variety of settings has long been a bone of contention when it comes to HIV testing, with testing expanding slowly from being administered by physicians in clinics, to nurse and trained volunteers in community clinics, and now self-testing. The authors say that even a surgical intervention like VMMC can be delivered in innovative ways such as in tents or retrofitted buildings, and by task-shifting from doctors to nurses and even volunteers. PrEP is much easier to provide in a variety of settings, and it is the HIV testing and kidney monitoring that may need imaginative delivery methods.

Another measure that has proved useful in circumcision, especially in spreading interest locally, is to introduce mobile, temporary circumcision clinics in different areas. While PrEP needs ongoing clinical support, the same methods could be used to generate interest. Clinics outside work hours are also important, not just to reach working men but also adolescents at school.

5. Supply chains. While supply chains for antiretroviral drugs are well-established – though in some places still susceptible to stockouts – it is the monitoring tests that, again, will need innovative supply chains. Tests formerly only administered by doctors including creatinine (for kidney function) and hepatitis B serology may need to be delivered in non-clinical settings.

6. Cost-effectiveness models. The authors say that cost-effectiveness models – which should be continually refined as new data arrives – have been a vital part of making the case for VMMC and will continue to be for PrEP. Because of this, work needs to be put into framing them in different ways for different audiences. They comment that “health policy leaders as well as economists” need to be able “to readily appreciate the substantial benefits” of both VMMC and PrEP. For instance, refining one model down to the single statement that nine circumcision procedures would be needed to stop one HIV infection over one decade proved to be helpful in convincing politicians.

Cost-effectiveness models for PrEP need to be developed that include the ‘collateral benefits’ of PrEP such as increased rates of HIV testing and diagnosis. They should also have geographical sensitivity so that they can track changes in risk in particular areas or groups.

7. Sustainability. A major topic at the International AIDS Conference this year was the sustainability of HIV funding in a world where global HIV financing initiatives are increasingly leaving the funding of treatment to national governments. This is still a problematic and slow-moving area in the field of HIV prevention and few VMMC programmes have reached the level of maturity that would imply sustained support via national health services. PrEP’s initial outlay cost is probably lower than VMMC but the question of its sustainability is clearly even more crucial. One way to ensure its continued sustainability is to make sure it is integrated into existing, routine adult and adolescent healthcare settings such as STI, family planning and school clinics.

8. Advances in technology. New ways of supplying biomedical HIV prevention are currently being developed including injectables and vaginal rings. It is important, say the authors, both to hasten the development of interventions that may circumvent the difficulties oral PrEP has with retention and adherence, but also to recognise that they may come with their own problems. An example from VMMC is that a couple of new devices (the Shang Ring and PrePex) were promoted and adopted in circumcision programmes because early evidence suggested that they were easier for non-surgeons to use and probably safer. It was only after considerable initial outlay that it became clear that in certain conditions of use, these newer devices were associated with an increase in rare adverse events, including tetanus.

Similarly, while injections, vaginal rings and so on initially seem to be safe, issues such as STI infections, and HIV infection and resistance after stopping PrEP, may emerge. It is important that promotion and safety surveillance programmes operate at the same pace, alongside each other.

9. PrEP spin-offs. One notable ‘side-effect’ of VMMC is that it has reached men and engaged them in other care programmes. As well as bringing men, who usually test later than women, into HIV testing and STI services, VMMC has been a gateway to other health and social provision for men and has enabled programmes on mental health, masculinity, gender-based violence and other issues. PrEP will reach a variety of different populations. As well as being integrated into contraception, family planning and harm reduction services, it may be a way of introducing reticent users to them.

10. Strengthening global advocacy. Circumcision was an HIV prevention method of proven effectiveness, but also one that required new thinking and consistent advocacy to realise. PrEP, like VMMC, challenges conservative thinking and old models. This however is as much an opportunity as a challenge if it enables coalition-building between national health ministries, normative bodies such as the World Health Organization, national and regional surveillance programmes such as the CDC (Centers for Disease Control and Prevention) and ECDC (European Centre for Disease Prevention and Control), and community-based advocacy organisations such as AVAC. If handled well, PrEP could re-energise HIV advocacy and activism by creating new engagement with key affected populations and bolster the fight against HIV at a time when it is feared that some gains made in the last two decades could be lost.

Author: Gus Cairns


Elton John AIDS Foundation to Honor Patricia Hearst, Sheryl Crow to Perform

Event will also honor Ford Foundation’s Darren Walker and DDG’s Joe McMillan; last year’s gala featured the last public performance by Aretha Frankin.


In its 26th annual ceremony on Nov. 5, the Elton John AIDS Foundation will honor Ford Foundation President Darren Walker, philanthropist Patricia Hearst and DDG investment and real estate firm chairman/CEO Joe McMillan with EJAF’s Enduring Vision Award.

Sheryl Crow will be the special musical guest, and Bryan Stevenson, founder and executive director of the Equal Justice Initiative and the new National Memorial for Peace and Justice in Montgomery, Alabama, will be the featured speaker. “CBS This Morning” co-anchor Gayle King will host the event.

Last year’s gala featured the last public performance by Aretha Franklin, who played a stately nine-song set that was frequently mentioned in statements and comments after her passing last month.

Patricia Hearst is indeed the granddaughter of William Randolph Hearst, who was kidnapped by the radical Symbionese Liberation Army in the 1970s and was imprisoned for her activity with the group. After serving nearly two years her sentence was commuted by President Jimmy Carter, and she has since become a philanthropist with a particular focus on children suffering from AIDS.

“At this time of great uncertainty in the world, EJAF’s work is more important than ever, and we remain steadfastly committed to addressing the unmet needs of people living with and affected by HIV/AIDS and fighting stigma as a major driver of the global AIDS epidemic,” said EJAF Founder Sir Elton John. “We believe everyone living with HIV/AIDS should have immediate access to high quality medical care and all people at risk of HIV should be empowered with the best knowledge and tools available to prevent transmission no matter who they are, who they love, what they believe, where they come from, or what they do.”

American Airlines, Bvlgari, Robert K. Kraft, and the Leonard and Judy Lauder Fund are the presenting sponsors for this year’s gala. Co-sponsors are Gilead Sciences and The John R. Eckel, Jr. Foundation. Gold sponsors are the Hearst Foundation and MAC Viva Glam. Silver sponsors are Salah Bachir and Jacob Yerex, Merck, and James L. and Margo Nederlander.


Brotherhood of Man: My Experience at a Spiritual Retreat for HIV-Positive MSM

Participants of the International Brotherhood Retreat weekend
Participants of the International Brotherhood Retreat weekend (Credit: Credit: Claes Lilja)

On a warm weekend in July, 19 gay men living with HIV gathered in the Pocono Mountains in Pennsylvania for a retreat. I was one of them.

I’d found out about The International Brotherhood Retreat weekend through a group on Facebook and was intrigued. The Brotherhood Retreat is a three-day body-mind-spirit weekend that happens a few times per year at the beautiful and serene Kirkridge Retreat and Study Center.

I wasn’t sure what to expect from the retreat. According to the website, “Everybody is welcome, regardless of age, nationality, looks, etc. The only requirements to attend are that you are over 18 years old and identify as a gay or bisexual man.” I figured it would be a nice weekend away from the hustle and bustle of New York City; I’d meet some new folks and breathe some fresh air.

Claes Lilja started the retreats in 2008. “The idea for the retreat hit me like a lightning bolt,” Lilja remembers. “I was taking a shower, and the idea came with such strength and clarity that I knew I just had to do this. I stepped out of the shower without fully drying off, went to my computer, and typed out the schedule.”

The experience was designed to help gay men living with HIV, giving them spiritual and emotional healing through meditation, touch exercises, breathwork, and fellowship. Although the retreat is focused on gay and bisexual men living with HIV, they welcome HIV-negative men, as well, in order to accommodate serodiscordant couples and to help heal the divide between HIV-positive and HIV-negative men.

Lilja facilitates the weekends. He leads many meditations and exercises designed to help each participant gain more insight into his own mind-body-spirit connection, as well as gain connection to others and to the community. This is a weekend where gay men gather in a non-sexual situation, without benefit of recreational chemicals or alcohol to lubricate or numb emotions. Each participant is challenged to be authentic, genuine, and truthful in the deepest sense.

I rode up to the Poconos with two other participants. The retreat officially started in the late afternoon of July 20, but there was an optional breathwork session with Juan Andreas Wolf offered earlier in the day. My driver wanted to be there for it, and I thought, “Why not?” I didn’t know what I was in for. Once we arrived at the retreat center and checked in, we headed straight for the breathwork session. I had never done any kind of soulful breathwork, but a handful of us, guided by Juan, lay down on mats and did intensive, rhythmic breathing for 30 minutes.

Each of us had unique, emotional responses to the work. For me, I discovered something profound that’s hard to describe. We started the breathing, and at first, I struggled to keep it going. I finally relaxed into it and decided to allow the experience to happen. Somewhere in those 30 minutes, unbidden and not conjured by me, came a physical and emotional release. It was a deep, rushing letting go of something I felt like I had been holding onto since I was a small child. The physical feeling was deep in my guts, down past my belly, almost all the way down to my groin. And it clicked in me that I first tightened up that part of me sometime when I was four or five. As little boy, I looked around and realized I was different. I can’t say that I recognized myself as gay, because I didn’t know what that was, but something in me knew that I needed to protect myself and that I was the only one who could. Ever since then, I’ve been holding tight, deep inside myself. That breathwork helped me to discover and release it. It was intense, emotional, and overwhelming, and my face was wet with tears. The experience left me feeling more exposed than I like to be, but aware of something new inside me, and it was probably a good way to start a meditation weekend.


After the powerful breathwork and the time recuperating, the rest of the group started to arrive, and we had our first group session. We were all so different: some long-term survivors of HIV, some newly diagnosed; some partnered, some single; young, middle-aged, older; and of varied economic and educational backgrounds. Our common denominator was that we’re all living with HIV as gay men, and that commonality gave us an openness and an understanding of one another that was truly beautiful.

Across the three days, Claes took us through meditations that kept us in touch with our breath. The weekend was composed of group meditations, small group conversations, shared meals. I had to trust these strangers, as I was feeling vulnerable and tender. Fortunately, these men were all gathered to experience a healing, reflective weekend. Across the weekend, each of us experienced an emotional break through, a realization of something hidden deep inside. It was an amazing thing to be a part of and to witness.

For me, the meditations meant a continual examination of that release I felt during the breathwork. I started to feel less sadness for that little boy I had been, who felt that he needed to protect himself, and more pride that I had the strength inside me to keep going all these years — and that I had the strength now to release that tension. I also acknowledged a deep loneliness that I don’t like to talk about and most often hide or make fun of. While in the company of these sensitive fellows, I was able to let myself show how deeply I long for a love in my life. It’s not easy to admit that vulnerability.

One of the more moving meditations was outside. Claes explained to us that in the days of the AIDS crisis, many families of AIDS casualties were so distraught that they wouldn’t even accept the ashes of those who’d died. The Kirkridge Center accepted those ashes and created a memorial garden. We silently walked into the wooded memorial area, clearing weeds and debris from the garden while remembering those who passed away from HIV and honoring those of us still fighting.

When we had free time and during meals, we were able to find common ground with each other, and I felt a kinship with each of these terrific guys. Saturday night, we had a social where we binged on candy, Doritos, cake, soda, and so many belly laughs. I can honestly say that every man I met has a special place in my heart.

The Brotherhood Retreat was a big, emotionally fraught weekend: loving, scary, intimate, and transformational. As I left the mountains on Sunday afternoon, I knew there had been a change in me. I felt healing that I hadn’t known I needed. It’s not often that gay men get an opportunity to commune together in this kind of shared spiritual experience, and for me, it was precious and profound.



What do older people living with HIV do to look after their own mental health?

Older people living with HIV describe a range of strategies to maintain or improve their mental health and emotional wellbeing, according to an English study published in AIDS Care. Many people said they shifted the focus of their attention away from HIV to other aspects of their lives. Getting support from external agencies and from other people living with HIV was also extremely important for many.

Dana Rosenfeld and colleagues conducted in-depth interviews with 76 people living with HIV for the HIV and Later Life (HALL) study. Participants were asked to describe their typical day, personal and medical histories, social relations, social support, and discuss living and ageing with HIV.

While all participants were over the age of 50 and the oldest was aged 87, half were in their early or mid-fifties and half had been living with HIV for ten years or less. Reflecting the largest groups in the UK epidemic, participants were a mix of white gay men, black African heterosexual men and women, and white heterosexual men and women.

Over half lived alone, half were not in paid work and half had an annual income of less than £10,400.

Participants often put their concerns in perspective by comparing their health with that of other people. For example, this man compared ageing with HIV with ‘normal ageing’:

“For a lot of older people, life’s a severe challenge anyway… there are plenty of other severely challenging conditions.” [gay man, fifties, diagnosed in the past decade]

Other comparisons were with specific people. This man viewed his own health through the lens of a life-long friend’s “terrible problems with his joints”. When he last saw his friend, he thought “I’m HIV, but look at him, he’s worse than me”. [gay man, fifties, diagnosed in the past decade]

For several participants, volunteering provided a focus, purpose, and opportunities to make a social contribution.

“As a survivor who was helped by my consultant, nurses, relatives, friends, I felt if they did that to me, why can’t I do it to others? … You can’t just receive and then you don’t give away”. [African woman, fifties, diagnosed in the past decade]

Interviewees said that volunteering helped keep them active, both physically and mentally. Several emphasised the value of leaving the house, shifting the focus from their own circumstances to the wider world. This man started volunteering at an HIV organisation when he realised:

“I can’t stay at home not doing anything… if I stay at home, that could lead to depression for me, just sitting down”. [African man, fifties, diagnosed in the past decade]

Many interviewees made a point of taking note of and focusing on positive aspects of their lives – for example, actively valuing and pursuing relationships and activities that improved wellbeing. While some spoke about the importance of friends or partners, others described simple pleasures:

“New things, little things, just going down to the river and having a walk.” [gay man, fifties, long-term diagnosed]

One man explained his philosophy:

“Live in the moment; enjoy what you’ve got; accept what you’ve got, accept what your life is”. [gay man, fifties, diagnosed in the past decade]

Although the challenges and disruptive impact of HIV is often emphasised, some interviewees actively valued their ability to maintain their previous activities, identities, and roles.

“I can still function, I can think, I can create, I can take photos, I can go out for dinner, I can cook dinner – I can do what normal, or non-HIV people, do. We, apart from pills, are non-HIV people”. [gay man, sixties, diagnosed in the past decade]

While recognising the benefits and necessity of HIV treatment, some participants found their daily medication a painful reminder of living with HIV. They took steps to ensure that their pills took on benign meanings, were embedded into daily routines or became part of the background.

“[I take] the pills like I do cholesterol pills. I don’t say, ‘Oh, those are the pills of HIV’, or ‘Look, every morning I’m HIV’”. [gay man, sixties, diagnosed in the past decade]

As well as shifting their focus away from HIV and their own concerns, many participants spoke about the benefit of the support they got from their HIV clinicians and from mental health services.

“My HIV brought me depression. Psychiatric, it helps. Now I’m okay. You become cool, they give you medication, you become all right, they advise you what to do.” [African woman, fifties, long-term diagnosed]

Many people sought therapies to supplement support from partners, friends or family.

“I’m a bit mixed up and sometimes I just find it useful talking to a third person who is completely removed from my personal life; who isn’t trying to go, no of course you’ll be all right, because they’re my friend or my family.” [gay man, fifties, long-term diagnosed]

For most participants, HIV organisations and support groups improved their wellbeing by providing practical help and guidance regarding benefits, adherence, disclosure and other issues. HIV-specific support also provided connections to other people living with HIV which countered participants’ isolation and distress, especially in the period immediately following their diagnosis.

“I’m not totally isolated because I’m connected to HIV people, HIV groups… The fundamental connection from one human being to another is absolutely imperative to being alive and feeling alive, and pursuing or finding happiness.” [white woman, sixties, diagnosed in the past decade]

There were a few interviewees who chose to avoid HIV groups because they wanted to minimise HIV’s role in their lives. They may have found groups helpful for a period after diagnosis but did not want to endlessly focus on the issue.

“The less you talk about it, the less you think about it.” [white man, sixties, diagnosed in the past decade]

Author: Roger Pebody


Study finds no link between transgender rights law and bathroom crimes

Some activists are hoping to undo the state transgender antidiscrimination law through a ballot question.
Some activists are hoping to undo the state transgender antidiscrimination law through a ballot question.

A first-of-its-kind study being released Wednesday refutes the premise that the state’s transgender antidiscrimination law threatens public safety, finding no relation between public transgender bathroom access and crimes that occur in bathrooms.

Researchers at the Williams Institute, a think tank focused on gender identity at the UCLA School of Law, examined restroom crime reports in Massachusetts cities of similar size and comparable demographics and found no increase in crime and no difference between cities that had adopted transgender policies and those that had not. The data were collected for a minimum of two years before a statewide antidiscrimination law took effect in 2016.

Activists who want to undo that state law through a ballot question in the Nov. 6 election have focused their campaign message on bathroom safety concerns. They suggest that a new right for transgender people infringes on everyone else’s privacy rights, and could be abused by men who want to prey upon women and children in ladies’ rooms. The vote is being closely watched nationwide because it offers the nation’s first public referendum on transgender rights in the state that first introduced gay marriage.

Transgender activists bristle at the idea that the campaign casts them as potential sexual offenders and have argued that there is no evidence that the law threatens anyone’s safety.

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A spokesman for the Freedom for All Massachusetts campaign, which is working to preserve the law, said the Williams Institute study reaffirms that stance.

“It really takes the wind out of the sails of our opponents who have been trying to paint this false picture,” said spokesman Matthew Wilder.

Yvette Ollada, a spokeswoman for the “Vote No on 3” campaign, said she could not speak to the study before reviewing it, but she questioned its objectivity since the opposing campaign was anticipating its release.

“If it’s unbiased, wouldn’t they send it to both campaigns?” Ollada said.

Wilder said his group was notified that the study would be released only after it was complete. “This was a completely independent research project,” he said. “We didn’t even know it was underway.”

The Williams Institute studies gender identity and sexual orientation, but the lead researcher maintained that its work is not always positive for the LGBTQ community.

“We talked about it before we started this research: What happens if we find out there is some sort of danger in this law?” said lead author Amira Hasenbush “If we had found one, we would have published that, too.”

The peer-reviewed study, published in Sexuality Research and Social Policy, focused on the years before Massachusetts adopted a statewide law prohibiting discrimination in public accommodations based on gender identity. Prior to that time, select municipalities had adopted local ordinances that had a similar effect: allowing transgender women into ladies’ rooms and transgender men into men’s rooms.

“Massachusetts was like this perfect petri dish,” said Rachel Dowd, a spokeswoman for the Williams Institute. “Different localities started to adopt it, and there was enough that allowed us to look at crime statistics over two years. And right as we were wrapping up our research, Massachusetts passed the statewide law.”

Under the 2016 Massachusetts law, any public place with separate areas for men and women must let people use the space consistent with their gender identity — a term that refers not to their biology, but to their sincerely held gender identity, appearance, or behavior. The activists who want to repeal the law say it could be abused by male predators and threaten privacy and safety of women and girls.

But until now there has been no empirical data to bolster or negate their concerns.

To establish the scope of the issue, researchers used public records requests to obtain police incident reports and compare bathroom crime data in cities with antidiscrimination laws — Medford, Melrose, and Newton — with comparable towns that lacked them. They paired each city with communities that were comparable based on a host of data, including crime and population demographics, poverty, and voting trends.

Medford was compared to Beverly and Watertown; Melrose was compared to Beverly; and Newton was compared to Brookline and Arlington.

Then, rather than looking at numbers alone, the researchers compared the differences in each locality over time to judge whether a change in bathroom crime could be attributable to the enactment of a transgender accommodation law.

“We did pretty much the most comprehensive study you could do for the state of Massachusetts,” said Hasenbush .

The study notes its limitations — largely on the quality of the data. Each police department had a different system for record-keeping; some were able to search manually, some electronically, and the researchers had to review the records to identify the incidents.

Still, researchers concluded that there was no statistically significant relationship either in the number of crimes occurring in any individual locality with a transgender accommodations law or in comparison to its matched pair. In fact, the average number of restroom incidents was higher in localities without transgender accommodations laws.

Moreover, the study noted: “Reports of privacy and safety violations in public restrooms, locker rooms, and changing rooms are exceedingly rare.”

That’s not to say that incidents don’t ever happen, however, the authors note.

Beyond the study, police departments report that they are seeing more “peeping Tom” cases — a factor they attribute less to gender politics than to advancing technology and the tiny cameras that are increasingly being used to spy on women in bathrooms. In June, a woman reported that a man seemed to be using a pen-like device to videotape her through a hole in the wall of a bathroom at the Garment District, the resale clothing store near Kendall Square, said Cambridge police spokesman Jeremy Warnick. Police were able to identify, but not apprehend, a suspect.

However, anecdotal reports of crimes in bathrooms seldom involve suspects who are — or are pretending to be — transgender.

And anyone, regardless of gender identity, can be arrested for criminal activity in a bathroom, Wilder said.

“If people — transgender or not — go into these spaces with the intent of committing a crime, they are still going to be prosecuted,” Wilder said. “There are still laws that prohibit that.”



Unstable housing associated with low CD4 cell count and detectable viral load for HIV-positive women in US

Unstable housing is associated with an increased risk of a detectable viral load and low CD4 cell count among HIV-positive women, according to US research published in Social Science & Medicine. Women with unstable housing were around 50% more likely to have adverse HIV treatment outcomes than women living in more secure accommodation. Reasons for the poorer outcomes observed in women with unstable housing included poorer continuity of health care.

“We find that unstable housing drastically reduces both HIV suppression and CD4 T-cells for PLHIV [people living with HIV]; thus worsening clinical outcomes and further exacerbating health disparities,” write the investigators. “We show specific pathways for the effects, including use of any mental health/counselling, any healthcare, and continuity of care.”

Understanding the impact of socio-economic factors, including housing, on health is a research priority. Previous research has shown that PLHIV are at increased risk of experiencing unstable housing. However, the impact of homelessness on key HIV outcomes including viral load and CD4 cell count is unclear.

Investigators from the US therefore used data obtained from the large Women’s Interagency HIV Study (WIHS) and funding data from the Housing Opportunities for People with AIDS (HOPWA) programme to determine the relationship between unstable housing, a detectable viral load (above 200 copies/ml) and low CD4 cell count (below 350 cells/mm3).

The study population consisted of 3082 WIHS participants who received care between 1995 and 2015 at sites in the Bronx, Brooklyn, Chicago, Washington DC, Los Angeles and San Francisco. Unstable housing was defined as living in the previous 12 months on the street, beach, a shelter, a welfare hostel, a jail or correctional facility, or in a halfway house.

About a third of participants were high school graduates, 57% were African American and 23% Hispanic, 33% were married or living with a partner, 30% had ever injected drugs and three-quarters reported using recreational drugs.

The availability of resources to address housing instability among people living with HIV was estimated with funding allocations to Housing Opportunities for Persons with AIDS (HOPWA). This is a federal programme which provides housing and supportive services (such as substance abuse treatment, job training and assistance with daily living) to people living with HIV who have a low income.

For each location and each year, the researchers calculated HOPWA funding per 1000 people newly diagnosed with HIV. There was considerable variability in HOPWA funding between study sites.

The investigators’ model examined the impact of unstable housing on the two key HIV treatment outcomes after taking into account HOPWA funding allocations.

The study participants attended 57,323 follow-up appointments. Unstable housing was reported at 4.8% of these visits. Viral load was suppressed at 48% of visits, with CD4 cell count was above 350 cells/mm3 at 56% of visits.

The probability of unstable housing fell with increasing HOPWA funding. Lower HOPWA funding allocations were strongly associated with an increased likelihood of unstable housing, a relationship that remained robust after taking into account covariates such as age, education, relationship status and drug use.

The investigators’ calculations showed that unstable housing had a negative impact on health, decreasing the probability of viral suppression and of an adequate CD4 cell count, both by 8%. When HOPWA allocations were included as the key variable, unstable housing reduced viral suppression by 51% and it decreased the likelihood of having a CD4 cell count above 350 cells/mmby 53%.

The authors also examined the potential pathways between unstable housing and adverse viral load and CD4 cell outcomes. Unstable housing was shown to affect use of healthcare resources and continuity of care. It was associated with 25% less use of counselling and mental health services, 37% less use of any healthcare services and a 76% reduction in the probability of seeing the same provider.

“This paper shows a strong negative effect on viral suppression and adequate CD4 cell count, and it elucidates specific channels by which unstable housing can affect these HIV treatment outcomes,” conclude the researchers. “These findings suggest that increasing efforts to improve housing assistance, including HOPWA allocations, and other interventions to make housing more affordable for low-income populations, and HIV-positive populations in particular, may be warranted not only for the benefits of stable housing, but also to improve HIV-related biomarkers.”

Author: Michael Carter


This is what Ontario elementary school students will learn in sex ed — and what they used to learn

Here’s everything parents need to know about what kids will learn about sex versus what they learned under the 2015 curriculum

Under Premier Doug Ford, Ontario elementary schools have ditched the 2015 sex ed curriculum. Instead, they’re using an interim document from 2010, which is an updated version of the 1998 health and physical education curriculum. (High schools will continue to use the 2015 version.) Here’s everything parents need to know about what kids will learn about sex versus what they learned under the 2015 curriculum.


2015 curriculum:
Grade 1: how to identify major body parts using proper names, including penis, testicles, vagina and vulva.

Grade 5: students learn the male and female reproductive systems, including how to identify the uterus, clitoris, scrotum and testicles.

Interim curriculum:
No reference to proper names of genitalia anywhere in the curriculum.


2015 curriculum:
Grade 4: physical changes during puberty, including breast development in females.

Grade 5: male and female reproductive systems, including in-depth explanations of menstruation, ejaculation and egg fertilization.

Interim curriculum:
No reference to breast development anywhere in the curriculum.

Grade 5: students learn about menstruation and spermatogenesis, but it’s not clear in how much detail.


2015 curriculum:
Grade 6: students learn about wet dreams and vaginal lubrication and that masturbation is a normal, healthy way to discover one’s body.

Interim curriculum:
No reference to masturbation anywhere in the curriculum.


2015 curriculum:
Grade 3: students learn that gender identity and sexual orientation make people unique.

Grade 6: stereotypes based on gender and/or sexual orientation are harmful.

Grade 8: students learn about gender identities, including male, female, two-spirit, transgender, transsexual and intersex.

Interim curriculum:
Grade 7: students learn it’s harmful to use homophobic put-downs.

The introduction states students of all genders and sexual orientations should feel included in health-related activities and discussions. But there is no reference to gender stereotypes or specific gender identities, including transgender, anywhere in the curriculum.


2015 curriculum:
Grade 2: students consider Indigenous teachings to learn about basic human development.

Grade 4: students learn about various cultural traditions associated with puberty.

Grade 6: students consider Indigenous teachings, including the Medicine Wheel metaphor, as a way of learning about healthy relationships.

Grade 8: students learn about Indigenous two-spirit gender identity.

Interim curriculum:
Grade 4: students learn Indigenous teachings that can help strengthen relationships; no examples are given.


2015 curriculum:
Grade 4: students learn that internet and cellphone use may expose them to people who ask for sexual pictures.

Grade 5: students learn about sexual harassment and that sharing sexual photos of others online is illegal.

Grade 7: students learn about the risks of sexting and how this can affect one’s well being, as well as future relationships and/or jobs.

Interim curriculum:
Grade 4: students learn about risks of using the internet, including “online predators.”

Grade 7: students learn that sending sexually explicit photos (the term sexting is not used) can affect future relationships and/or jobs.


2015 curriculum:
Grade 7: students learn that abstinence can mean different things for different people, and they should be clear about what they are comfortable with.

Grade 8: identify and explain factors that affect decisions about sexual activity, including personal limits, peer pressure, desire, acceptance of gender identity and sexual orientation and risk of pregnancy.

Interim curriculum:
Grade 7 and 8 students learn about the possible consequences of “risky (sexual) behaviours” and are taught abstinence is a “positive choice” for adolescents.


2015 curriculum:
Grade 7 and 8: students learn the proper names for STIs, including HPV, herpes, chlamydia, gonorrhea, Hepatitis B, and HIV and AIDS. They also learn how to identify STI symptoms, and how to prevent STIs and pregnancy.

Interim curriculum:
Grade 7 and 8: how to identify and prevent “common” sexually transmitted diseases (using the non-preferred term STDs). Students also learn about HIV and AIDS and how to prevent pregnancy.


2015 curriculum:
Grade 6: students learn that general consent is defined as a clear “yes” and that “no” or an uncertain response is understood as no consent.

Grade 7: students learn about clear communication with romantic partners.

Grade 8: students learn about consent during sex, and that consent to one sexual activity doesn’t mean consent to all sexual activities.

Interim curriculum:
No mention of consent.

Author: Alexa Taylor

There Might Be an Alternative AIDS Conference in 2020



na Brown of the Southern AIDS Coalition (left) and Charles King of Housing Works protest the AIDS 2020 conference location
Gina Brown of the Southern AIDS Coalition (left) and Charles King of Housing Works protest the AIDS 2020 conference location while attending AIDS 2018 in Amsterdam, the Netherlands (Credit: Sean Black for A&U)

“You need to know how sad I am about where we find ourselves,” says George Ayala, Psy.D., executive director of the Oakland, California-based MPact Global Action for Gay Men’s Health and Rights. “How did we get to a place in the global HIV response where the needs and desires of public health elites matters more than the concerns of people around the world who are actually living with or at risk for HIV?”

Ayala is talking about the decision on the part of the International AIDS Society to hold the 2020 edition of the biennial International AIDS Conference (IAC) — the world’s largest forum about the epidemic, drawing some 20,000 people — in the U.S., specifically in California’s Bay Area. That decision, announced in March, drew an immediate backlash, with a wide array of HIV/AIDS activists in the U.S. and abroad saying that it was wrongheaded and even dangerous to hold the conference in the U.S. while the Trump administration is pursuing policies hostile to immigrants, foreign visitors (particularly from majority-Muslim countries), LGBTQ people, and HIV high-risk and high-incidence populations, including sex workers and drug users.

Major protests over the decision broke out at the 2018 IAC in Amsterdam. And now, even as IAS says it is going forward with plans to hold the conference in both San Francisco (wealthy, expensive, touting dramatic HIV reductions in recent years) and Oakland (poorer and more people of color, with only a fraction of San Francisco’s HIV resources), Ayala and a broad network of activists worldwide are moving forward with planning a simultaneous conference outside the U.S., likely in Mexico City or Tijuana. Thatconfab, they say, will prioritize the concerns and solutions of communities affected by HIV over those of researchers and public health officials.

A Diverse Outcry

Activists point out that the majority of global networks of people living with HIV or at high risk — including MPact, Positive Women’s Network, Positive Trans, International Treatment Preparedness Coalition, and International HIV/AIDS Alliance — oppose the conference being held in the Bay Area. The primary objection appears to be against holding it in the U.S. at all during the Trump era, given the difficulties that many people from poorer countries may have obtaining visas in the first place — or actually getting into the country upon arrival.

On top of that, “All that has to happen to put the HIV entry ban back on is an executive order,” says JD Davids (a staffer at TheBody who will be transitioning out in mid-September), a trans HIV activist who is part of an emerging coalition, HIV Power Shift, seeking to center affected communities over policymakers and researchers. And, based on precedent, it’s highly conceivable that Trump might reinstate the ban by tweet perilously close to the conference date in order to sow bureaucratic chaos and curry favor with his base. If that happens, “conference organizers would seriously weigh the impact of this policy change,” Megan Warren, the IAC conference organizer, wrote in an email. But activists wonder how the IAC — a massive feat of planning, contracts, and budgets — could change its location on such short notice.

Protesting IAC Conference Locations Is Not New

This is not the first time that the location of the IAC has drawn ire from activists. First imposed in 1987, at the height of AIDS-phobia, the U.S. ban on HIV-positive people coming into the country led to major protests of the IAC when it was held in San Francisco in 1990 — and to moving the 1992 conference site from Boston to Amsterdam. In 2000, many protested the IAC taking place in South Africa while its president, Thabo Mbeki, was publicly denying that HIV caused AIDS — but South African AIDS activists demanded it be held there as a global rebuke to Mbeki’s denialism. In 2012, Obama finally ended the U.S. HIV travel ban in time for the conference to be held in Washington, D.C. However, ceding to conservatives, he still banned entry to sex workers and drug users, few of whom managed to attend, with the rest holding their own conferences in Kolkata, India, and Kiev, Ukraine, respectively.

That particular ban still stands; such folks would have to lie on U.S. visa applications — a risk if customs and border entry officials scan their online or social media presence. According to New Orleans-based Kelli Dorsey, an independent sex-worker activist who was formerly the executive director of Different Avenues, an advocacy group for girls and women who engage in underground trades such as sex work, that’s exactly what’s been happening recently to Canadian sex workers who have been stopped at the U.S. border.

To have only a handful of sex workers and drug users at IAC 2020 would be “a dramatic loss,” says Dorsey. “We’ll miss out on learning how those folks are running programs in order to strengthen our own programs.”

The inability of foreigners to get to the conference is not the only reason many activists oppose it being held in the Bay Area. They worry that, media-wise, it will be completely overshadowed by the Democratic National Convention (DNC), which takes place the following week.

“Who [in the media] will have time to go all-in on the AIDS conference?” asks Dázon Dixon Diallo, M.P.H., who heads Atlanta-based SisterLove, which supports women of color living with or at risk for HIV, and is founder and convener of Women NOW, a global HIV/AIDS conference for women of African descent. “The opposition! They’ll say, ‘Look at all the crazies coming to that sanctuary city in Nancy Pelosi’s backyard.’ We would rather the international AIDS community come to the U.S. when we have different national leadership and we’ve cleaned up our house.”

Diallo is also among those who feels that, if the conference has to be in the U.S., it should be in a city in the South, which is still struggling with its epidemic, rather than San Francisco, which has been able to get its HIV epidemic relatively under control due to its disproportionate whiteness and wealth (and which is also expensive for visitors). “The minute you nationalize San Francisco’s story of ‘the epidemic is over,’ it will silence the voices of millions of others over the world. It’s not time to tout success until we’re all reaching it.”


Voices of Support

All this is not to say that everyone in the U.S. HIV community opposes IAC coming to the Bay Area, which hosted the conference in 1990. “This is a really important moment to reflect on the progress we’ve made here in San Francisco since then and to share best practices, as well as to highlight the disparities between us and Oakland and the rest of the U.S.,” says Joe Hollendoner, the new CEO of San Francisco AIDS Foundation (SFAF), which lobbied hard to have the conference in the area.

According to Hollendoner, “Wherever you have the conference, there are challenges for people gaining entry.” He says that when the IAC was held in Toronto in 2006, more visa requests were rejected by Canada than were by the U.S. in 2012 when the conference was in D.C. He says that U.S. Representatives Nancy Pelosi and Barbara Lee have promised to do everything they can to get as many conference-goers into the country as possible. And he says he is confident that, should Trump capriciously reinstate the HIV travel ban shortly before the conference, “we have a base of support of elected officials who will fight like hell to make sure that Trump’s tweet will not become a reality.”

Says Rob Newells, executive director of AIDS Project of the East Bay, which serves a large clientele of color: “I’m OK with it being here. I’m born and raised in Oakland, I’m a militant person by nature, and this is a place about resistance and protest. And my perspective is that, yes, there all these issues with the conference being in the U.S. and, yes, the U.S. is perpetrating lots of bad things now — and we need the international community to come in ahead of the DNC and help us push on these issues like sex work and drug use. We can’t separate our HIV activism from our political activism. Running away from these issues doesn’t help solve them.”

A Bay Area conference is also supported by Marsha Martin, D.S.W., formerly D.C.’s AIDS czar and now community coordinator for the Fast-Track East Bay Getting to Zero initiative to end the epidemic. “A joint conference collaboration between two cities, as in San Francisco and Oakland, has never been done before,” she notes, saying that the conference will “absolutely” be evenly mixed between the two cities and that non-science sessions will not be marginalized to Oakland so that researchers and VIPs won’t have to go there. “No one wants San Francisco to dominate,” she says.

“Both cities’ long history of activism and commitment to change is really important now in our country,” she continues. “If we don’t have it here, I believe we’ll miss an opportunity, much like when the conference went to South Africa in 2000” to rebuke HIV denialists.

Unanswered Questions

Of course, it’s too early to say whether immigration policies or other circumstances in the U.S. could worsen to the point where having the conference in the Bay Area becomes completely untenable. And it’s also too early to know exactly what the possible alternate conference in Mexico might look like or how it will get people there, although Ayala says he envisions it being much smaller — perhaps 2,500 to 5,000 people — and that he and others are already talking with the IAC about making some satellite connections between the Bay Area and Mexico.

But Ayala stands by his decision to spearhead what might add up to a boycott of IAC by at least some U.S. activists. “It is not OK for IAS to continue with business as usual,” he says. “Not OK for them to continue to justify to themselves the need for large, trade-show style conferences in the global north, to select host countries that are overtly hostile to people living with HIV and key populations” (such as sex workers and drug users).

And, in many ways, it appears that in this most fraught time in the U.S., the split over AIDS 2020 is a split between the large, well-funded institutions of HIV/AIDS — the pharma companies, the big research centers, and the major AIDS service organizations, such as SFAF and the IAS itself — and networks made up primarily of individuals living with, or at risk for, the virus itself, often in poor parts of the world.

“Even if they can get visas, what’s going to happen to them when they arrive at our border for the conference?” asks Diallo. “This controversy isn’t really just about the conference. It’s about who has the power to decide where these conferences are held. We have to open up the table and share more of that power to make these decisions.”

Tim Murphy has been living with HIV since 2000 and writing about HIV activism, science and treatment since 1994. He writes for and has been a staffer at POZ, and writes for the New York Times, New York Magazine, Out Magazine, The Advocate, Details and many other publications. He is also the author of the NYC AIDS-era novel Christodora.



Governments have failed Canada’s sex workers—and they’re running out of patience

The Conservatives’ Bill C-36 made it harder for sex workers to do their job safely—and despite their promises, the Liberals haven’t fixed the problem, either

Traffic moves along a street on Feb. 25, 2002, in the Downtown Eastside of Vancouver. (Don MacKinnon/Getty Images)

“Am I next? Is he watching me now?”

For years, Sarah De Vries was a sex worker in Vancouver’s now-infamous Downtown Eastside. In her diary, she chronicled her struggles with addiction, as well as the situation in the neighbourhood, in which police were either ever-present—arresting drug users and sex workers wherever they congregated, or belittling them for their profession—or simply nowhere to be found. Still, she had plans to get her life together and get out of the neighbourhood. But as she wrote in her diary, she worried she’d never get the chance.

“So many women, so many I never even knew about that are missing in action,” she wrote in that same entry, in December 1995. “It’s getting to be a daily part of life. That’s sad.”

De Vries disappeared three years later. Police believe that she was murdered on Robert Pickton’s farm, east of the city. She was one of the many women whose disappearances remain, on paper, unsolved; while Pickton was charged with her death, her case was eventually stayed.

De Vries’s journal, read aloud by her sister at a commission of inquiry into Vancouver’s missing women, was cited directly in the commission’s final report. Wally Oppal, who headed up that commission, would describe the neighbourhood as a “zone bereft of justice and outside the rule of law” where, for decades, the murder of sex workers was just a “daily part of life.”

But surprisingly— incredibly—there’s been good news, recently: There hasn’t been a recorded murder of a sex worker in Vancouver in nearly a decade.

“It has been a long hell of a journey,” says Susan Davis, the director of the B.C. Coalition of Experiential Communities, who has worked as a sex worker in Vancouver for more than three decades.

The changes can be traced back to 2012, when Vancouver police drafted a new policing strategy that completely overhauled how they deal with sex workers, and the sex trade more broadly. The new strategy was the direct result of the commission of inquiry, the one headed by Oppal and informed by De Vries’ diary. These guidelines—which outline how police should “use discretion” in dealing with complaints regarding prostitutions, has meant that in Vancouver, sex work is effectively decriminalized.

“No sex workers on the street have been arrested in Vancouver on the street in a very long time,” Davis says. “The john stings, as they’re called, do not occur here either.” It’s not perfect, she says—but it’s been a success.

But Vancouver is a lone exception to the rule in Canada. Go outside Metro Vancouver—where police, by their own policy, are largely unconcerned with enforcing Canada’s laws around sex work—and it’s a totally different scenario.

An escort who gave her name as SB is silhouetted against a window as she poses at a downtown Vancouver apartment, Feb. 12, 2017. (Jonathan Hayward/CP)

Across Canada, sex workers are still regularly being charged with crimes because of their profession. Their clients, too, are being targeted by police. A safe, indoors working environment is inaccessible to many women and men who work in the trade. And although statistical reporting is sparse, violence against sex workers has certainly not stopped in the rest of Canada like it largely has in Vancouver. Indeed, in 2017 alone, there were the murders of Sisi Thibert, a transgender sex worker in Montreal; Victoria Head, a sex worker and a mother from St. John’s; and Josie Glenn, a 26-year-old from London.

According to a research project conducted by York University masters student Arlene Jane Pitts in 2015, sex workers have in recent years “not witnessed any decrease in police harassment and instead stated it had increased,” largely pointing to enforcement of other criminal prohibitions, like drug possession.

Pitts’s research, comprised of in-depth interviews with six street-involved sex workers, suggests that Canada’s new laws—ones that supposedly decriminalized sex work, complying with a major Supreme Court ruling on the matter—have only made things worse.

That legislation, Bill C-36, came into effect in 2014 under Stephen Harper’s Conservative government, and it was opposed by all opposition parties at the time, including Justin Trudeau’s Liberals, who contended that the legislation was unconstitutional and failed to comply with that Supreme Court rulingDuring the 2015 federal election campaign, Trudeau vowed to undo or fix various criminal justice reforms brought in by his predecessor, painting the Tories’ tough-on-crime agenda as heartless and damaging. And when they won, they affirmed that work would be under way on these issues. “I definitely am committed to reviewing the prostitution laws, and sitting down with my officials to assess the best options, and with those they affect directly,” Justice Minister Jody Wilson-Raybould told the Tyee in 2015, shortly after her appointment to cabinet.

But now—three years after the Liberals won a majority government, four years after C-36 came into force, five years after the Supreme Court ruled that Canada’s long-standing prostitution laws were unconstitutional, and six years after shifts in policing strategy started producing meaningful change in Vancouver—any plans for reform appear to have stalled, despite government consultations about a year ago. And now, with just a year left before the next election, there is scant time left to introduce new legislation.

In short, sex workers feel like they’ve been forgotten—again. “It’s very difficult to be on the outside with people talking all about you, with people making decisions about your life, and having no say whatsoever,” says Davis.

After years of patience with the Liberals, sex workers are beginning to speak out again, frustrated by the lack of outcome from the consultations. A constitutional challenge to the Harper-era laws is facing a Charter challenge in a London, Ont. courtroom, which promises to extend into years of further legal wrangling. The Pivot Legal Society, an intervenor in the Bedford case, told the National Post in January that it was considering another challenge.

“We always have to force our way to the table,” Davis says.

Susan Davis.

Things were different in 2013, when sex workers in Canada were optimistic. In what is now known as the Bedford ruling, the Supreme Court ruled in favour of a coalition of sex workers in declaring the existing criminal regime around sex work unconstitutional, striking down the previous criminal prohibitions as directly and indirectly harmful to sex workers, and concluding that any societal benefit that may come from ending the sex trade cannot be comparable to the damage caused to sex workers by criminalization. The country’s highest court gave Ottawa a one-year grace period to revise the laws, if they so wished; if they did nothing, as many sex work advocacy groups recommended, sex work in Canada would be decriminalized and unregulated at the national level, akin to what is happening in Vancouver.

While research is limited, some peer-review studies back up the assertion that decriminalization does reduce violence and improve health outcomes for sex workers. A 2016 study, published in peer-reviewed medical journal The Lancet, studied the correlation between HIV transmission rates amongst sex workers and government policies on the sex trade.

Controlling for a variety of other factors, the researchers write that “countries which have legalized some aspects of sex work have significantly lower HIV prevalence among sex workers than those which have not.”

Real-world examples, including Vancouver, appear to be evidence to that end. New Zealand decriminalized sex work more than a decade ago, with a 2012 parliamentary report from that country concluding, despite setbacks, “key evidence indicates that the decriminalization of prostitution has impacted favourably on various aspects of sex work for many.”

“Decriminalization is the only way forward,” Davis says.

Harper’s Conservative government had other ideas. It was after the Bedford ruling that the government brought in Bill C-36, an act which sought to comply with the letter of Bedford by criminalizing not the workers themselves, but their clients, which is generally referred to as the Nordic Model, so named after countries like Iceland and Sweden that have moved to criminalize the purchasing of sex work. The model aims to support the women and men of the sex trade, without putting their safety in jeopardy.

MacKay stressed the Conservative government’s solution would be a made-in-Canada approach, but it took inspiration from that model, adding a section to the Criminal Code which punishes purchasing sex work with a maximum penalty of five years in prison. And it did produce some change: In 2015, not long after the new legislation came into effect, police in Cape Breton arrested 27 men in a prostitution sweet they dubbed “John B Gone.” Police in Edmonton have run similar stings with some regularity. Other police forces across the country may be running similar operations, although public reporting on these operations is spotty, and can often be lumped in with operations to break up human trafficking rings.

But the made-in-Canada portion of the law goes beyond simply criminalizing the purchasing of sex. Bill C-36, among other things, criminalizes advertising someone’s sexual services, or accepting money to place such an ad, as well as profiting from someone’s sexual services. Those prohibitions technically exempt sex workers and some direct staff they may hire. But the bill also criminalizes communicating for the purposes of prostitution anywhere next to a schoolground, playground, or daycare, with a maximum penalty of six months in prison. Those conditions cover, of course, wide swaths of urban Canada.

Monica Forrester, who works at Maggie’s, a Toronto-based outreach and advocacy group for sex workers, says C-36 has made life even harder for Canadian sex workers. The law’s prohibition on advertisements have made it “impossible” for self-employed workers who operate out of their own homes, she says. Workers who look for clients on the street, meanwhile—many of whom are “survival” sex workers, meaning they are often working in the trade out of necessity—have had to deal with johns afraid of being “targeted and criminalized” because they are seeking out sex workers.

“What have these new laws done to protect sex workers?” Forrester asked. “Nothing.”

Meanwhile, despite their campaign rhetoric about Bill C-36, the Liberals have yet to follow through with their promised reforms. When Maclean’s requested an interview with the justice minister over her government’s plans to fix the legislation, her office refused. Asked why the minister was unwilling to speak to the issue, her director of communications, David Taylor, wrote simply: “Not in the mandate letter. Not in the platform.”

Instead, the Department of Justice wrote a statement, telling Maclean’s that “this issue is challenging, but it is incredibly important and as such, it is something our government is committed to continue working on.” The justice minister’s office did confirm they held consultations on the law, but there has been no clear outcome or public report from those meetings. They provided no specifics, no timeline, and no commitment to follow through on their promise for a legislative fix. Davis, who was a part of those consultations, was encouraged by the government’s willingness to listen, but says she has not received any update or follow-up from Ottawa in the years since.

This inaction has had real-world impact. In the three years since Bill C-36 has come into force, the statistics show that prosecution for prostitution offences have slowed significantly, but they’ve not stopped. From 2015 to 2017, according to Statistics Canada, 166 people have been charged with prostitution-related offences, with most facing charges for communicating for the purposes of sex work or blocking traffic in order to communicate for sex work, a law that was not part of the Supreme Court challenge. For the sake of comparison, more than 2,000 people were charged with prostitution-related offences in 2010 alone.

But the statistics may not be telling the whole story. Many sex workers have said turning the criminal focus onto the johns means they have been more skittish to purchase sex, and thus have required increasing discretion. That makes screening clients hard, and pushes sex workers, especially those most vulnerable, further into the shadows.

And things have gotten even harder for sex workers worldwide recently, as U.S. law enforcement recently moved to shut down sites like Backpage and the personals section of Craigslist. A new package of laws, which purport to take aim at human trafficking, has made operating those websites virtually impossible. Without those platforms, screening clients is all the more difficult.

“Until the community is decriminalized, how are we to freely associate and ensure safety and work?” Davis asked.

Liberal Leader Justin Trudeau asks a question during Question Period in the House of Commons on Parliament Hill in Ottawa, Wednesday Oct 29, 2014. (Adrian Wyld/CP)

When I spoke to Davis, she was fatalistic about why sex workers have had so few political victories.

“In the end, it’s political gold for the Conservatives,” she says. As for Trudeau? “I understand why the Liberals are reluctant to go down this road.” In other words: Decriminalizing sex work doesn’t win many votes. Cracking down on it does.

“We need somebody to have the courage to do the right thing,” she says. But she isn’t optimistic that somebody is coming.

Even though Trudeau and his justice minister had endorsed changes to the laws brought in under C-36, his party nevertheless endorsed the idea underpinning the legislation, the Nordic model; their concerns were with the implementation. This, despite the fact that Liberal Party members, in April, voted to endorse a resolution calling on the government, their own party, to decriminalize sex work. Party leadership has not responded to it.

While one might expect the NDP to be the voice for decriminalization in this debate, the party is similarly unmoored in terms of specifics on the matter. Their membership, too, has tried to bring forward resolutions calling for the decriminalization of sex work, but the party has kiboshed efforts to actually have those resolutions adopted.

Maclean’s asked a spokesperson for leader Jagmeet Singh whether the party had adopted a specific position on sex work, but did not receive a reply.

Ultimately, sex workers don’t get to write the law in Canada—they just have to grapple with it.

“Sex workers are resilient and resourceful,” Forrester says. Sex workers, she adds, will look out for one another, even if the government won’t.

“And that will continue as long there’s a demand for sexual services in this business.”