296   The Global HIV Epidemics among Sex Workers
Telles et al. 2008), even in this climate of social advances and reductions in stigma. Police violence towards sex workers continues to be a major concern of the sex workers movement and commercial activities associated with prostitution (such as owning a brothel or pimping) remain illegal. Thus, as external pressures and larger structural changes have affected the organization and activism of both the NGOs and government HIV prevention actions, sex worker activists and government officials are increasingly redefining their strategies in an effort to continue to strengthen the human and labor rights approach to HIV prevention with sex workers that initially earned Brazil international recognition.
Discussion These case studies illustrate a range of structural changes achieved and sustainability of responses based on the parties most responsible for developing and implementing HIV risk reduction efforts for sex workers. We synthesize these differences, and compare and contrast the nature of intervention targets, sustainability of responses, and level of structural change achieved based on the parties involved, and describe themes with regard to the legal, political and social backdrops to these responses. Overall, findings illustrate that sex worker leadership is critical both to creating the structural changes necessary for HIV prevention, including promotion of health, human rights and well-being, and in ensuring sustainability. Findings hold significant global relevance. As the HIV epidemic enters its third decade, and as evidence confirms the unique HIV burden of sex workers worldwide, efforts to reduce HIV risk and promote testing and treatment for sex workers remain a global priority. Achieving these goals requires continued attention to structural issues for sex workers; critical review of lessons learned in early HIV responses for sex workers serves as a powerful tool for the next generation of approaches which seek to sustain high levels of knowledge, continue to promote condom use, and ensure access to HIV testing and treatment as means to stem the continued spread of HIV. The nature of response to HIV among sex workers appears to reflect the priorities and knowledge of the parties involved; in turn this imparts differences in the level of structural change achieved. Where sex workers are involved in shaping the HIV response, as in the cases of Brazil and Sonagachi in India, responses are comprehensive and include addressing underlying social and structural factors associated with sex workers vulnerability to HIV, and providing other health and support services to sex workers. In contrast, Thailand’s approach, characterized by its predominant governmental origins, prioritized condom use as the primary focus. While it took a