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        The human immunodefi ciency virus, which causes the acquired immuno-
defi ciency syndrome (HIV and AIDS), is a pandemic that militates against 
public health policy and practice on a global scale. The sex industry is 
frequently cited as one of the growth factors contributing to increased HIV 
and AIDS transmission, as well as the spread of sexually transmitted infec-
tions across international lines. Therefore, the prevention of HIV and AIDS 
among commercial sex workers is a major goal of the public health operations 
of both U.S. and foreign-based organizations working in the sex sector. As it 
stands, current U.S. laws and policies that dictate the funding of organizations 
working with sex workers are deleterious to public health and run counter to 
best practices that prevent the global spread of HIV and AIDS, as well as 
human rights norms. This article is centrally concerned with the public health 
implications of the Anti-Prostitution Pledge, which requires foreign NGOs 
and U.S.-based NGOs working abroad to explicitly oppose the practice of 
prostitution in order to receive U.S. federal funding for HIV and AIDS 
prevention among commercial sex workers. Policy prescriptions concerning the 
public health dimensions of commercial sex work will be offered based on the 
analysis.

  perating from the premise that prostitution is conjoined with 
traffi cking in persons for commercial sex, the U.S. government is prohibiting 
the award of federal funds to foreign non-governmental organizations (NGOs) 
that appear to promote or support prostitution (The State Department’s Offi ce to 
Monitor and Combat Traffi cking in Persons, 2004). U.S. legislation and policies 
like the President’s Emergency Plan for AIDS Relief (PEPFAR), Leadership 
against HIV and AIDS, Tuberculosis, and Malaria Act (AIDS Leadership Act), 
and Traffi cking Victims Protection Reauthorization Act (TVPRA) require that 
foreign NGOs and U.S.-based NGOs working abroad make an Anti-Prostitution 
Pledge, which explicitly opposes prostitution, in order to receive U.S. federal 
funding for HIV and AIDS prevention targeted at sex industry workers.
   The Anti-Prostitution Pledge has negative public health 
consequences for sex workers at risk of HIV and AIDS transmission as it 

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prohibits recipients of U.S. federal funds from using best practices, such as harm 
reduction and empowerment strategies to prevent HIV among high risk 
populations. Sex workers are defi ned as “female, male and transgendered adults 
and young people who receive money or goods in exchange for sexual services, 
either regularly or occasionally, and who many or may not consciously defi ne 
those activities as income-generating” (UNAIDS, 2002). This article will consider 
aspects of the Anti-Prostitution Pledge, including arguments advanced in 
support of and in opposition to this policy. Recommendations will be offered on 
the policy level based on the analysis of the global public health implications of 
the Anti-Prostitution Pledge.

Best Practices in Public Health and Human Rights to Counter HIV and AIDS

Harm Reduction Model
        Best practices in public health and human rights norms suggest that harm 
reduction is effective in stymieing the spread of HIV and AIDS among 
commercial sex workers (Rekart, 2005). Harm reduction as an approach to HIV 
and AIDS prevention is considered to be a simple, safe, and inexpensive line of 
response to HIV and AIDS infection that helps avert risk, mitigate harm, and 
save lives. According to Rekart (2005), HIV and AIDS infection risks associated 
with commercial sex are reduced using an empowerment-oriented harm 
reduction model in public health practice with sex industry workers. Harm 
reduction practices include: occupational health and safety guidelines for brothels, 
distribution of male and female condoms, training in condom-negotiating skills, 
and safety tips for street-based sex workers regarding HIV and AIDS preventative 
strategies.

Empowerment: A Harm Reduction Tool
      Empowerment and harm reduction share a synergistic relationship. One 
of the hallmarks of harm reduction is respect for the individual’s right to self-
determination, which is also a core concept of empowerment (Newman, 2003). 
The harms associated with sex work can be minimized through the empowerment 
of sex workers. The goal of empowerment is to provide real opportunities for sex 
workers through services, such as job training, language skills, access to health 
services, and protection from violence.

Human Rights Framework 
    The view that positive public health outcomes can be produced by 

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linking global health policy with respect for human rights is gaining increased 
acceptance (Loff, et al., 2000). The relationship between human rights abuses
and HIV and AIDS transmission among sex workers is bidirectional. 
Discrimination and human rights abuses are the cause as well as result of HIV 
and AIDS (Csete, 2004). Many public health interventions, such as the AIDS 
Leadership Act, consider sex workers hazards to society (Woffers & Beelen, 
2003). Restrictive policies around sex work, such as the Anti-Prostitution 
Pledge, increases stigma driving sex work further underground and increases 
the likelihood that sex workers will avoid state institutions, including those that 
deliver health care (Wolffers & Beelen). 

Anti-Prostitution Laws and Policies: PEPFAR, AIDS Leadership Act, 
and TVPRA

PEPFAR
        PEPFAR is an executive directive aimed at stemming the spread of HIV 
and AIDS throughout the world. President Bush recognized HIV and AIDS 
as a harbinger of a “severe and urgent crisis abroad” in his 2003 State of the 
Union Address and proposed PEPFAR as a solution (Alliance for Open Society 
International, Inc. & Open Society Institute, 2005). PEPFAR mandates 
U.S. funding restrictions on organizations that do not adopt a pro-abstinence 
approach to the practice of commercial sex work. The executive directive does 
not consider the human rights standards and best practices in public health 
discussed above.

AIDS Leadership Act
     PEPFAR has given impetus to the creation of a cluster of laws and 
policies, one of which is the AIDS Leadership Act. In May 2003, the U.S. 
Congress passed the AIDS Leadership Act (22 U.S.C. §§ 7601-7682, 2003), 
which bars the use of federal funds to “promote, support, or advocate the 
legalization or practice of prostitution or sex traffi cking” (22 U.S.C. § 
7631(e), 2003). The law requires organizations receiving U.S. HIV and AIDS 
funding to agree with the Anti-Prostitution Pledge and adopt a policy explicitly 
opposing prostitution and sex traffi cking. Organizations that do not denounce 
prostitution could continue to lose billions of dollars in U.S. federal funding, 
thus impeding their efforts to prevent the spread of HIV among sex workers and 
undermining efforts to promote the fundamental human rights of all persons 
(CHANGE, 2005). T

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    The AIDS Leadership Act is currently applicable to foreign NGOs 
receiving bilateral U.S. HIV and AIDS funds and U.S.-based NGOs working 
abroad. Although the restrictions of the law do not currently apply to multilateral 
organizations, there is considerable concern that the extension of the restrictions 
is inevitable (CHANGE, 2005). In May 2005, the Centers for Disease Control 
implemented funding restrictions on the Joint United Nations Programme on 
HIV and AIDS (UNAIDS) and World Health Organization sub-grantees, which 
were later abrogated after widespread public denunciation (CHANGE).

TVPRA
        The TVPRA prohibits U.S. federal funding for organizations that tacitly 
“promote, support, or advocate the legalization or practice of prostitution” (22 
U.S.C. §§ 7101-7110, 2003). The funding restrictions mandated by the TVPRA 
bar organizations that work with traffi cking victims from employing a range of 
modalities to improve the public health of this group using a human rights-based 
framework. Due to the confl ation of prostitution with traffi cking in persons, 
organizations working to aid and empower victims of traffi cking lose necessary 
funding to stave off health harms surrounding sex work (Ditmore, 2003).

Proponents of the Anti-Prostitution Pledge

       In a December 2002 National Security Presidential Directive, the U.S. 
Government adopted an abstinence-based and abolitionist position against 
legalized prostitution. This position was adopted based upon the premise that 
prostitution is a harmful and dehumanizing practice that stimulates human 
traffi cking, and the vast majority of sex workers want to escape from this 
practice (The State Department’s Offi ce to Monitor and Combat 
Traffi cking in Persons, 2004). From the vantage point of the U.S. Government, 
legalization of prostitution increases the demand for commercial sex work, thus 
providing market opportunities for criminals who traffi c people into prostitution. 
Furthermore, the U.S. Government contends that legalized prostitution makes 
it diffi cult for law enforcement offi cials to identify and penalize criminals who 
engage in traffi cking (The State Department’s Offi ce to Monitor and Combat 
Traffi cking in Persons). Based on this confl ation between prostitution and 
traffi cking, the U.S. Government decided to implement restrictions on HIV and 
AIDS funding to organizations that work with sex workers.
   Anti-Prostitution Pledge advocates, also known as abolitionists, 
further argue that abstinence from sex and abolition of prostitution should 

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underpin the HIV and AIDS prevention efforts of organizations working in the 
sex sector. Abolitionists view sexual commerce as degrading and dehumanizing, 
characterizing sex work and traffi cking in persons as a form of modern day 
slavery (The State Department’s Offi ce to Monitor and Combat Traffi cking in 
Persons, 2004). Many ideologues from the Christian Right, as well as several 
radical feminists endorse this view of commercial sex work. Radical feminists 
who support the Anti-Prostitution Pledge view prostitution as a coerced form 
of male-dominated wage slavery, as well as a feminized type of exploitation 
refl ecting patriarchy, which is harmful to all women (Jaggar, 1997). Similarly, 
members of the Christian Right supporting the Anti-Prostitution Pledge oppose 
sex work on moral grounds because these members defi ne legitimate sexual 
contact as relations between two married people of the opposite sex for purposes 
of procreation only (CHANGE, 2004). 
    Anti-Prostitution Pledge advocates assume that all sex workers are 
perforce victimized, do not choose to engage in sex work, and seek to escape 
this practice. In addition, they argue that traffi cking in persons is bound up and 
inextricably linked with the sex trade. Furthermore, abolitionists reason that 
the harm reduction model of prostitution encourages the practice of sex work 
and increases the market demand for the profession, causing a rise in persons 
traffi cked into commercial sex on the supply side (The State Department’s 
Offi ce to Monitor and Combat Traffi cking in Persons, 2004).

Opponents of the Anti-Prostitution Pledge

    Public health practitioners working with sex workers suggest that 
the U.S. government’s pro-abstinence, anti-prostitution stance towards HIV-
prevention aid is a paternalistic and unrealistic approach (Ditmore, 2005). 
Therefore, pro-Anti Prostitution Pledge arguments require a more complicated 
and human rights based understanding of sexual commerce.

Harm Reduction Approach
      Opponents of the Anti-Prostitution Pledge argue that harm reduction is 
a best practice and funding should not be eliminated for organizations 
implementing this approach (CHANGE, 2004). As discussed earlier, empirical 
evidence of public health operations involving sex workers suggests the greater 
effi cacy of the harm reduction model in countering the spread of HIV and AIDS 
among sex workers (Newman, 2003). For example, by bringing a harm reduction 
model to bear on public health interventions in India, the Sonagachi Project, an T

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HIV-prevention program in Calcutta, signifi cantly lowered HIV seroprevalence 
rates among sex workers in the city (Newman). The Sonagachi Project couples 
harm reduction principles with empowerment strategies to minimize the health 
risks of sexually transmitted diseases among sex workers. Human Rights Watch 
estimates that the Sonagachi Project’s harm reduction approach has impacted 
more than 30,000 sex workers at risk for HIV and AIDS (Human Rights Watch, 
2005). UNAIDS has also credited the Sonagachi Project as a best practice model 
for the proven effects in public health.
    Furthermore, harm reduction is the precipitating factor behind the 
successful public health outcomes achieved among sex workers in many 
countries. For example, in Brazil, harm reduction and HIV and AIDS 
prevention programs have been lauded by the United Nations as among the 
best in the developing world (Reel, 2006). Current estimates indicate that there 
are less than 600,000 HIV-infected people in Brazil, which is half the number 
forecasted by the World Bank a decade ago. Through state-funded sex education 
and prevention workshops, the distribution of free condoms, and informational 
pamphlet dissemination, Brazil has managed to effectively reduce the HIV and 
AIDS rate in the country (Reel). 

International Human Rights Violations
       Opponents to the Anti-Prostitution Pledge contend that this policy is in 
violation of the fundamental human rights of sex workers and in confl ict 
with a corpus of international human rights instruments and laws, such as the 
Universal Declaration of Human Rights (UDHR) (CHANGE, 2005). The rights 
emanating from the UDHR, including the right to “security of person,” freedom 
from “inhuman or degrading treatment,” and “equal protection of the law,” are 
eroded by the Anti-Prostitution Pledge (Butcher, 2003). Whereas international 
human rights laws lack enforcement power, as their implementation rests on 
governing bodies, laws and policies issuing from the U.S. federal government 
compel observance due to the threat of loss in funding.
        It is evident that multinational institutions, including the United Nations 
and foreign national leaders in HIV- and AIDS-affected countries exert little 
pressure on U.S. federally-funded HIV and AIDS programs (Csete, 2004). 
Through its proscription of harm reduction as an approach to the public health of 
sex workers, the Anti-Prostitution Pledge counteracts human rights. 
         Furthermore, access to healthcare is a fundamental human right as stated 
in Article 25 of the UDHR (UDHR, 1948) and the constraints wrought by the 
Anti-Prostitution Pledge deprive sex workers of their basic right to health. The 

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limited range of public health interventions sanctioned by the AIDS Leadership 
Act fl y in the face of best practices and human rights standards forcing recipient 
organizations of U.S. funding to adopt less effective HIV and AIDS preventive 
strategies. 

U.S. Constitutional Concerns and Challenges
      Opponents of the Anti-Prostitution Pledge raise constitutional concerns 
about this policy, arguing that it violates the right to freedom of speech 
enshrined in the First Amendment (Human Rights Watch, 2005). By forcing 
organizations to explicitly oppose prostitution, the Anti-Prostitution Pledge 
compels speech, thereby violating the First Amendment to the Constitution by 
requiring domestic and foreign-based organizations working in public health 
to align with the U.S. government’s policy position. Anti-Prostitution Pledge 
advocates also believe that funding restrictions under the AIDS Leader-
ship Act violate the First Amendment because the vagueness of the Pledge 
requirement allows the law to be applied arbitrarily (Open Society Institute, 
2005). Finally, organizations working with sex workers contend that the Anti-
Prostitution Pledge unconstitutionally undermines public health interventions 
by forcing them to either adopt an anti-prostitution policy or forego federal 
funding, which may limit the effectiveness of their HIV and AIDS prevention 
efforts (Alliance for Open Society International, Inc. et al., 2005).

Public Health Implications of the Anti-Prostitution Pledge
       Opponents of the Anti-Prostitution Pledge argue that current legislation 
is antithetical to best practices that promote empowerment (CHANGE, 2005). 
Empowerment strategies intended to provide commercial sex workers with 
economic alternatives to sexual commerce are being affected by the 
government policy. For example, NGOs in Cambodia have stopped providing 
avenues out of sex work, such as English-language classes, for fear they would 
be seen as promoting prostitution (CHANGE). Additionally, the intervention 
strategies of EMPOWER Thailand, an organization that helps sex workers 
obtain high school diplomas and employment skills, were jeopardized as a result 
of the Anti-Prostitution Pledge (CHANGE, 2003). In short, the Anti-Prostitution 
Pledge can be said to have a perverse effect on the public health operations of 
organizations working with sex workers.                     
       Furthermore, opponents of the Anti-Prostitution Pledge suggest that the 
pro-abstinence agenda is myopic insofar as it alienates sex workers, the 
very population essential to prevent further spread of HIV and AIDS, by T

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stigmatizing commercial sex work and calling for its abolition (CHANGE, 2005). 
Implicit in the Anti-Prostitution Pledge is the denial of the lived and embodied 
experiences of commercial sex workers. The condemnation of sexual commerce 
that organizations working with sex workers are compelled to adopt under U.S. 
laws and policies ratchet up the stigma around this line of work (CHANGE). 

Policy Recommendations

            In consideration of the sex work harms and public health concerns that this 
government policy engenders, we offer the following policy recommendations 
to the federal government of the United States:

Amendment of the AIDS Leadership Act with a View towards Greater 
Conformity with Constitutional Guarantees, Human Rights Norms, and Best 
Practices in Public Health
    When sex workers are denied access to condoms or any other 
prevention technology or strategy, it violates both human rights principles 
and medical ethics (CHANGE, 2004). Furthermore, a reliance on abstinence 
will leave millions of people without the knowledge, information, and skills 
necessary to prevent infections (CHANGE). Hence, U.S. government 
commitment is required to maintain funding for condom procurement and 
delivery to decrease behavioral risk of HIV and AIDS infection among sex 
workers globally. 

Revoke the Anti-Prostitution Pledge and Have a Re-authorization Act Excluding 
the Opposition to Sex Work
     There is concern in policy and public health circles that the Pledge 
requirement undermines HIV and AIDS prevention programs specifi c to sex 
industry workers and that organizations working with sex workers will abandon 
innovative and effective programs for fear of losing funding. As a result, the 
Pledge requirement could further stigmatize commercial sex workers, leading 
to disastrous consequences for global public health. Hence, a revocation of the 
Anti-Prostitution Pledge is needed.   

Include Commercial Sex Workers Affected by Laws and Policies Germane to 
Prostitution in Policy Decisions Concerning the Sex Trade
   Sex industry workers affected by laws and policies concerning 
prostitution should be included in policy decisions about transactional sex 

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because they are associated with the transmission and prevention of HIV 
and AIDS. The Pledge requirement alienates sex workers who are already 
socially marginalized because of widespread stigma and discrimination. Evidence 
suggests that public health interventions repudiating targeted populations 
produce ineffective outcomes. Including sex workers in policy making about 
people-in-prostitution reduces social stigma.  

Broad-based Consultation with Experts across the Professional Spectrum
        Consult with a broad range of experts including but not limited to social 
work practitioners, public health professionals, and organizations working in the 
sex sector, to effectively create an overarching policy that productively stems 
the spread of HIV and AIDS. Broad-based consultancy ensures transparency in 
policymaking, consistency with U.S. and international human rights law, and the 
promotion of best practices in public health (CHANGE, 2005).

Avoid Confl ating Sex Work with Traffi cking
         The U.S. government must avoid confl ating sex work with traffi cking as 
it ignores other categories of traffi cking, including traffi cking for forced labor. 
The confl ation between human traffi cking and traffi cking for sex eclipses other 
forms of internal and cross-border traffi cking, which promotes a narrow view of 
this transnational activity. Linking traffi cking uniquely to sex work is harmful 
on the policy level as it may encourage situations of abuse for persons traffi cked 
into other industries to go unnoticed and unaddressed (Ditmore, 2002). 

Provision of U.S. Funding to Organizations Working with Sex Workers That Do 
Not Espouse a Specifi c Policy on Prostitution
      Retract current funding restrictions in legislation and espouse a harm 
reduction model and human rights based approach to sex work. Specifi cally, 
amend the TVPRA with a greater conformity towards human rights standards 
and best practices in public health.

Conclusion

      Productive public health outcomes can be achieved more successfully 
through human rights and empowerment mechanisms coupled with harm 
reduction models rather than an anti-prostitution and abstinence-only approach 
to commercial sex work. HIV and AIDS is a public health concern of global 
proportions. As it stands, the AIDS Leadership Act will accelerate the T

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transmission of HIV and AIDS, increasing morbidity and mortality rates among 
sex workers as well as the larger population. Therefore, a rethinking of U.S. 
government policy with regard to HIV and AIDS prevention is in order.
    At this writing, several U.S.-based NGOs including Alliance for 
Open Society International, Pathfi nder International, Open Society 
Institute, and DKT International have fi led suit in New York and Washington 
D.C. District Courts arguing that the Anti-Prostitution Pledge violates their 
constitutionally-protected right to free speech (Bristol, 2006). District court 
judges in New York and Washington D.C. decreed that enforcement of the 
Anti-Prostitution Pledge would cause the plaintiff organizations to suffer 
irreparable harm, thus violating the First Amendment of the U.S. Constitution 
(05-cv-8209 (S.D.N.Y.)). While this ruling provides plaintiff U.S.-based NGOs 
with a legal remedy, it does not provide legal relief to foreign NGOs who do 
not have U.S. constitutional rights and are potentially gagged by the Pledge 
requirement (Bristol, 2006). 
     On February 27, 2007, a federal appellate court for the District of 
Columbia upheld the constitutionality of the Pledge requirement overturning the 
lower court’s decision (Brennan Center for Justice, 2007). Circuit judges of a 
U.S. Court of Appeals decided that the funding conditionality under the AIDS 
Leadership Act does not compel appellate organization, DKT International, to 
advocate the government’s position on prostitution and sex traffi cking, but rather 
communicates the message the government chooses to fund (06-cv-5225 (D.C. 
Cir. 2007)). At this writing, it is uncertain as to whether or not DKT International 
will appeal the ruling concerning the Pledge requirement at issue. The judicial 
outcome of a separate action brought by the U.S. government appealing the 
decision of the New York district court also remains to be seen.      
       With more than 40 million HIV- and AIDS-infected people worldwide 
and the loss of funding from the U.S., one of the largest donors of HIV and 
AIDS prevention funding globally, implications for the public health of 
sex workers are disastrous (Bristol, 2006; Open Society Institute, 2004). 
Human suffering caused by the scourge of HIV and AIDS can be more 
effectively prevented on the local, national, and international level if the Pledge 
requirement is jettisoned for evidence-based, best practices in public health.

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7101-7110 (2003) [hereinafter, TVPRA].

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Best Practice Collection. 

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2003, 22 U.S.C. §§ 7601-7682 (2003) [hereinafter, AIDS LeadershipAct]

United States Leadership against HIV/AIDS, Tuberculosis, and Malaria Act of 
2003, 22 U.S.C. § 7631(e) (barring use of funds to “promote or advocate 
the legalization or practice of prostitution or sex traffi cking”)

Universal Declaration of Human Rights. Retrieved March 14, 2007, from 
http://www.un.org/Overview/rights.html.

Weitzer, R. (2006). Moral Crusade against Prostitution. Society, 43(3), 33.
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Sex Workers. The Lancet, 361, 1981.

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54

JOURNAL OF STUDENT 
SOCIAL WORK, VOL. V     

DEVIKA IYER is a second year master’s student at Columbia University’s 
School of International and Public Affairs, and her focus is Economic and 
Political Development. She has recently worked as a Research intern at the 
Bureau for Development Policy, UNDP and at the Human Development Report 
Offi ce, UNDP. She is a graduate of Rutgers University with a bachelor’s degree 
in Psychology. Her email address is ds2417@columbia.edu.

TAIMUR KHAN is a second-year master’s student at the Columbia 
University School of Social Work with a practice method in Social Enterprise 
Administration. He is also a degree candidate in International Affairs at the 
Columbia University School of International and Public Affairs. Currently, he 
is completing his fi eld placement at the New York Resettlement Offi ce of the 
International Rescue Committee. He holds a bachelor’s degree in English and 
Political Science with a French minor from the University of North Carolina, 
Greensboro. He is interested in international social welfare. His e-mail address 
is trk2103@columbia.edu.

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