Sex Worker Leadership in Responding to HIV and Promoting Human Rights   301
rights that can reduce stigma and discrimination, and providing the necessary infrastructure for STI and HIV testing. The consistent themes of stigma and discrimination, criminalization, and violence and condom-related coercion overwhelmingly illustrate the need for continued efforts to intervene on these levels to both protect the health and human rights of sex workers and to reduce the burden of HIV. The social, political and legal backdrops to sex work and HIV-related responses are relevant to understanding how, when, and why these responses occurred. The lessons learned from these early responses to HIV among sex workers impart important lessons for the international community, including low and middle income countries with varying levels of infrastructure and emerging economies that are in the earliest phases of building an HIV response infrastructure. Current evidence that significant change can be achieved through grass-roots, civil society, sex worker community responses, and that supportive government involvement can bolster and extend these benefits through collaborative, engaged partnerships between government and community-based organizations, highlights the need to invest in developing the sex worker community infrastructure. The cases reviewed illustrate that broader socio-political factors will have an influence on the outcome of such investment, e.g., whether a community-led response can create sustainable change alone, as in the case of Sonagachi, vs. in close collaboration with the government as in the case of Brazil. The Thailand case illustrates the unintended consequences that can occur in the absence of sex worker engagement. The need to create a forum for sex workers to organize, prioritize their needs, and formally communicate with government actors is increasingly relevant for growing epidemics in which heterosexual sex and sex workers are increasingly implicated, as in the case of the Eastern Europe/Central Asia region. Sex work constitutes a dominant transmission pathway in generalized epidemics (Nagelkerke, Jha et al. 2002). So too, these lessons are relevant to generalized epidemics in which sex workers remain uniquely impacted, as in much of sub Saharan Africa. In light of the burden of HIV among sex workers in these settings, the lack of an internationally recognized response to HIV among sex workers in sub Saharan Africa is surprising and suggests the need for significant investment in this region. National and international means of addressing structural issues for sex workers are increasingly important as HIV testing and treatment interventions are prioritized as prevention measures. Testing and treatment relies heavily on sex worker trust and access to safe clinical services, thus climates of criminalization, marginalization, harassment and abuse are inherently counterproductive to these goals. Sex worker leadership is critical to developing and