RE: Unintended results of research (14 March 2009) by Druyts, Hogg, MontanerBritish Columbia Centre for Excellence in HIV/AIDS

We thank Dr. Goodyear for his response to our article. We fully agree with
his concerns surrounding the recent coverage of our work on HIV prevalence
in British Columbia, Canada. Dr. Goodyear has expressed difficulty in seeing
how this study will benefit the individuals who participated in the
research. Of note, estimates of HIV prevalence among at-risk groups are
vital in planning for the development and provision of appropriate policy
and programmatic responses. We wish to affirm that it is our overarching
goal to ensure that there are adequate services for all individuals living
with HIV infection in Vancouver. The WHO has consistently shown that less
than 10% of sex workers have adequate access to HIV prevention and care

Our paper did not aim to highlight HIV infection among sex workers in
particular. Instead, we sought to model the estimate of HIV prevalence at
the city level and related gaps in services in Vancouver. Also of note, all
the studies considered in our paper received institutional ethical approval.

We acknowledge that prevalence estimates are rarely perfect and are limited
by uncertainty surrounding population size and potential biases inherent in
source data. We would like to clarify that the estimate of HIV prevalence
among female sex workers in 2006 is based on data collected among survival
sex workers predominantly located in Vancouver’s Downtown Eastside, who live
in poverty and all who inject and/or smoke illicit drugs. This estimate
therefore does not reflect indoor sex workers, such as sex workers in
establishment-based venues, bars, or escort services. We are fully aware
that female sex workers in Vancouver do not constitute a homogeneous group.
This could have been further stressed in the published paper.

Perhaps most importantly, we recognize that sex workers have been unfairly
stigmatized in the past by medical research as vectors of disease, and it
was not our intention to perpetuate this in any way. We have acknowledged in
our article that detailed data on sex work clients were not available.
As a global assessment of HIV prevention needs, our article did not seek to
review the factors that enhance vulnerability to HIV infection among
marginalized populations, such as survival sex workers. However, as
mentioned by Dr. Goodyear, we feel it is important to acknowledge that many
pivotal studies both in Canada, including some of our own, and globally have
demonstrated that criminalized sex work legislation, enforcement-based
strategies and violence greatly reduces sex workers’
ability to safely negotiate condom use with clients as well as other HIV
risk reduction strategies.

Finally, we concur with UNAIDS and WHO that structural approaches to HIV
prevention are crucial both for the health of sex workers and clients.
This includes policy changes such as the removal of criminal sanctions
targeting sex workers.

Eric Druyts, Robert Hogg and Julio Montaner


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