提供性工作者減害和基於權利的方法以減少猴痘傳播
資料來源：Steffanie A Strathdee、Anna-Louise Crago、Kate Shannon / www.thelancet.com/infection 2022 年 10 月 12 日線上發布 https://doi.org/10.1016/S1473 -3099(22)00661-2 / 財團法人台灣紅絲帶基金會編譯
在 6 個月內（2022 年 5 月 6 日至 10 月 3 日），全球爆發的人類猴痘病毒已蔓延至 99 個非流行國家，並對邊緣化社區造成了不成比例的影響。儘管猴痘病毒對性工作者構成相當大的風險，但在公共衛生應對措施中很少或根本沒有關注性工作者。迄今為止，在大多數情況下，性工作者並未在疫苗接種活動中得到優先考慮，據報導男男性行為者 (MSM) 的接種機會和優先次序不均衡。HIV 和 COVID-19 大流行凸顯了性工作者在不同環境中的不成比例的感染負擔，以及在應對猴痘病毒時必須考慮的迫切需要解決性工作者未滿足的職業需求。提供與性工作社區的公共夥伴關係為基礎的減害和基於權利的方法至關重要，包括流動性工作者主導的疫苗接種活動。性工作的完全合法化和獲得工作場所保護，例如帶薪病假和更安全的工作環境，是保護性工作者健康的關鍵。
截至 2022 年 10 月 3 日，快速發展的人類猴痘病毒爆發已傳播到 99 個非流行國家。目前猴痘病毒的流行病學仍在調查中，但它似乎主要透過直接皮膚接觸或粘膜接觸傳播，但也可以透過污染物（例如，受污染的物體）、呼吸道分泌物 以及可能透過短程氣溶膠傳播。雖然猴痘病毒感染在歷史上曾發生在西非的地方病環境中，但近期大多數猴痘病例發生並非在西非之地方病環境中，由自我識別為男男性行為者報告了當前的爆發。2022 年 9 月，一份描述世衛組織歐洲地區 41 個國家猴痘病毒病例的報告發現，不到 3% 的感染歸因於污染物接觸；然而，一些傳播途徑是未知的。
非官方報告描述了在無家可歸和監禁期間生活的人感染猴痘病毒的情況，從而為生活在聚集環境中的人提供了指導。2022 年 9 月，發布了一份自稱是性工作者亦是男男性行為者的男性病例報告，他也同時感染了 HIV，並在其精液中釋放猴痘病毒 DNA 超過 3 週，這顯示猴痘病毒可以透過性傳播。在血液、糞便、唾液和鼻咽分泌物中也分離出了猴痘病毒，這引起了人們對病毒可能迅速傳播到其他易感人群的擔憂，例如中低收入和高收入國家的性工作者。
與 HIV 和性傳播感染 (STI) 不同，可以透過內部或外部保險套預防傳播，防止在性行為期間感染猴痘病毒可能會變得複雜，因為直接接觸身體任何部位的猴痘病毒病灶都可能傳播病毒。性工作通常涉及與多人長期和廣泛的面對面、皮膚對皮膚、粘膜對粘膜（例如，口腔、生殖器或肛門）接觸。與病灶接觸過的物體，如床上用品、毛巾或衣服，可能成為污染物——如果它們接觸粘膜（如性玩具），則更有可能傳播。對於吸毒的性工作者，共用注射或非注射吸毒用具（如煙斗、吸管和美元鈔票）理論上可以傳播猴痘病毒。由於猴痘病毒也可以穿過胎盤，因此需要考慮懷孕或可能懷孕的性工作者的生殖和性健康需求。
儘管目前供不應求，但兩劑 JYNNEOS 天花疫苗（巴伐利亞北歐，丹麥 Kvistgaard）可以為未暴露但處於高風險的人群提供保護，或者它可以用作暴露後預防。如果該疫苗可降低受感染人群中的猴痘病毒載量，還可減少持續傳播。然而，這種疫苗在接種第二劑疫苗後可提供最佳的免疫保護，第二劑疫苗應在第一劑疫苗接種後至少 4 週接種。如前所述，在大多數情況下，性工作者並未列入優先接種猴痘疫苗，而且疫苗短缺導致，有時這些運動有利於高收入和中等收入 MSM、白人 MSM、和非性工作者的 MSM，或者只包括順性別男性性工作者而排除順性別女性、變性女性和非二元性工作者。在某些情況下，疫苗接種需要健康保險、使用電腦或智能手機進行預約、固定地址、帶照片的身份證明、交通工具或需要排隊等候數小時的能力，其中任何一項對許多是低收入或沒有合法移民身份的性工作者來說都是相當大的障礙。此外，大多數性工作者生活在低收入和中等收入國家，那裡幾乎無法獲得疫苗接種和治療，甚至連最基本的醫療保健需求也得不到滿足。
持續的猴痘病毒大流行對 HIV 感染者的影響尤為嚴重，有時還伴有其他併發的性傳染病。這種差異可能顯示免疫抑制可能使個體易感染猴痘病毒，或者係 HIV 或 STI 是猴痘病毒傳播的輔助因素。 因此，猴痘病毒可能對所有性別的性工作者構成高風險，儘管地區內部和地區之間存在很大的異質性，但他們比一般人群具有更高的 HIV 和潰瘍性 STI 負擔。
除了生物途徑外，由於工作環境的結構性因素，性工作者可能特別容易感染猴痘病毒。例如，世衛組織和美國疾病控制與預防中心都建議有風險的人減少性伴侶的數量，在性行為前與伴侶談論猴痘，並避免與有症狀的伴侶發生性接觸。然而，對於依靠性交易來養活自己和家人的人來說，這個建議可能不可行，特別是對於更邊緣化的性工作者（例如，低收入和種族化的工作者，或吸毒的性工作者）。
在全球範圍內，大多數國家將賣性、買性或在性工作中充當第三方（例如，經理或接待員）定為刑事犯罪。研究一直顯示，由於恥辱和歧視以及侵犯隱私，性工作者常常害怕向醫療保健提供者披露。 此外，性工作者擔心暴露會增加他們、他們的客戶或同事被捕的風險，以及他們工作場所關閉的風險，這將進一步阻礙獲得照護。 MSM 和跨性別性工作者也可能害怕成為恐同或恐懼跨性別之警察鎮壓或暴力的目標。由於高性伴侶數量以及保險套使用的結構性障礙同時存在，被視為犯罪之環境中的性工作者感染猴痘病毒的風險可能增加。這些結構性障礙包括缺乏工作場所保護、缺乏保險套以及治安策略將性工作推向地下。此外，缺乏支持性的監管環境可能會阻礙性工作者安全地拒絕有症狀的客戶或高風險活動的能力，這些活動會使他們接觸更多的皮膚或體液。在監管最嚴密的情況下，刑事定罪限制了性工作者對客戶的選擇（例如，能夠看到重複客戶相對於一次性客戶）以及他們花時間公開篩查客戶症狀的能力。同樣，在某些情況下，MSM 和跨性別性工作者特別成為警察鎮壓和根據反 LGBT 法律定罪的目標，這為獲得醫療服務和降低工作中的傳播風險造成了額外的障礙。
為性工作者制定有效的猴痘病毒預防計畫應考慮數十年的愛滋病毒預防經驗。 儘管數據顯示高收入國家的順性別女性性工作者對暴露前預防 (PrEP) 的接受度很高，但也有關於違反保密規定、污名化和暴力風險的報告，這阻礙了 PrEP 的獲取和採用。污名化男男性行為者和跨性別女性（包括性工作者）的同性戀恐懼症和跨性別恐懼症加劇了對隱私的擔憂。此外，與猴痘病毒的討論類似，大部分 PrEP 都是針對男男性行為者的性工作者實施的，很少關注順性別或跨性別女性之性工作
者。
COVID-19 大流行也有的教訓，它對中低收入和高收入國家的性工作者造成了不成比例的影響。 在一些研究中，性工作者的 SARS-CoV-2 盛行率高於其他弱勢群體（例如吸毒者和無家可歸者），可能是由於公共衛生建議（例如保持身體距離）對於面臨經濟困難和糧食不安全的性工作者來說是不切實際的。由於刑事定罪，大多數性工作者在 COVID-19期間無法享受帶薪病假或其他政府補貼，這將進一步使推薦的猴痘病毒 10 天隔離要求復雜化。幾項研究報告說，性工作者在 COVID-19 大流行期間獲得 HIV 關懷和預防服務（例如保險套和 HIV 檢測）的機會比以前少。
相較之下，在去罪刑化的環境中，儘管對醫療保健中的污名化的恐懼仍然是一個問題，性工作者報告說工作場所的健康和安全、訴諸司法的機會以及與公共衛生當局的合作得到了極大改善。與猴痘病毒預防有重要關聯的是，在一項薈萃分析中，低收入和中等收入國家性工作者採取社區賦權應對愛滋病毒的方法與愛滋病毒、淋病、衣原體和梅毒的減少有關。其他有前途的模型應擴展到猴痘病毒，包括與醫療或公共衛生人員合作在性工作場所提供以性工作者為主導的 COVID-19 或B型肝炎疫苗接種診所，與街頭護士合作在性工作和吸毒場所提供流動醫療服務，以及 COVID-19 大流行期間制定的向需要隔離的性工作者提供食物和收入支持等等的舉措。在性工作者工作場所舉辦的B型肝炎疫苗接種診所記錄的性工作者疫苗覆蓋率遠高於傳統醫療服務。移動醫療服務已被確定為低收入、中等收入和高收入環境的性工作者之性健康和生殖健康的關鍵介入措施。在一項社區隨機試驗中，性工作者的流動醫療服務與性傳播感染盛行率的降低相關。性工作者接觸外展服務（例如，街頭護士和流動外展）與積極的健康結果相關，例如增加子宮頸癌篩查。
HIV 和 COVID-19 大流行都強調了將性工作定罪和污名化的嚴重有害影響，以及解決性工作者未滿足的職業需求的迫切需要，這在應對猴痘病毒時必須予以考慮。在猴痘病毒的背景下，減害和基於權利的性工作方法勢在必行。這些方法需要將所有性別的性工作者——尤其是種族化和邊緣化的性工作者——納入公共衛生規劃和信息傳遞以及結構性介入措施。性工作的完全合法化和獲得工作場所保護（例如，帶薪病假和更安全的工作環境）是保護性工作者健康的關鍵。所有性別的性工作者往往是最先受到流行病襲擊的人，也是最後一個受到保護的人。——早就應該改變這種狀況了。
文章貢獻者：SAS 構思了個人觀點並起草了最初的手稿和修訂版。KS 和 A-LC 為手稿的撰寫、修訂和編輯做出了貢獻。
利益聲明：我們聲明沒有相互競爭的利益。
致謝：KS 得到美國國家衛生研究院 (NIH; R01DA028648) 的部分支持。SAS 的部分資金來自 R01 DA049644-03S3。NIH 沒有參與撰寫這份手稿或決定提交這份個人觀點以供發表。
本文中表達的個人觀點並不反映 A-LC 當前雇主的觀點。
Harm reduction and rights-based approaches to reduce monkeypox transmission among sex workers
Steffanie A Strathdee, Anna-Louise Crago, Kate Shannon / www.thelancet.com/infection Published online October 12, 2022 https://doi.org/10.1016/S1473-3099(22)00661-2
Within 6 months (May 6–Oct 3, 2022), the global outbreak of human monkeypox virus has spread to 99 non-endemic countries and disproportionately affected marginalised communities. Although monkeypox virus poses a considerable risk to sex workers, there has been little to no attention to sex workers in the public health response. To date, sex workers have not been prioritised in vaccination campaigns in most settings, with uneven access and prioritisation for men who have sex with men (MSM) being reported. The HIV and COVID-19 pandemics have highlighted the disproportionate burden of infection to sex workers across diverse settings and the urgent need to address the unmet occupational needs of sex workers that must be considered in the monkeypox virus response. Harm reduction and rights-based approaches grounded in public partnership with the sex work community are crucial, including mobile sex worker-led vaccine campaigns. Full decriminalisation of sex work and access to workplace protections, such as paid sick leave and safer work environments, are key to protecting sex workers’ health.
A rapidly evolving outbreak of human monkeypox virus has spread to 99 non-endemic countries up to Oct 3, 2022. The epidemiology of the current monkeypox virus is still under investigation, but it appears to be primarily spread through direct skin-to-skin or mucosal contact, but can also be transmitted through fomites (eg, contaminated objects), respiratory secretions, and possibly through short-range aerosols. Although monkeypox virus infections have historically occurred in endemic settings in west Africa, most monkeypox cases in the current outbreak have been reported among selfidentifying MSM in non-endemic settings. In September, 2022, a report characterising monkeypox virus cases in 41 countries in the WHO Europe region found that less than 3% of infections were attributed to fomite exposure; however, some transmission routes were unknown.
Unofficial reports describe monkeypox virus infection among people living through homelessness and incarceration, leading to guidance for people living in congregate settings. In September, 2022, there was a case report published of a man who self-identifies as a sex worker and MSM, who is living with HIV and who shed monkeypox virus DNA in his semen for more than 3 weeks, suggesting that monkeypox virus could be sexually transmitted. Monkeypox virus has also been isolated in blood, faeces, saliva, and nasopharyngeal secretions, which raises concerns that the virus could spread quickly to other susceptible populations, such as sex workers in lower-middle-income and high-income countries.
Unlike HIV and sexually transmitted infections (STIs), whereby transmission can be prevented by internal or external condoms, preventing monkeypox virus acquisition during sex might be complicated by the fact that direct contact with monkeypox virus lesions anywhere on the body could potentially transmit the virus.2,3 Sex work often involves long-lasting and extensive face-to-face, skin-to-skin, mucosa-to-mucosa (eg, oral, genital, or anal) contact with multiple people. Objects that have come into contact with a lesion such as bedding, towels, or clothing could serve as fomites17—and could be more likely to transmit if they touch mucosa (eg, sex toys). For sex workers who use drugs, sharing injection or non-injection drug paraphernalia (eg, pipes, straws, and dollar bills) could theoretically transmit monkeypox virus. Since monkeypox virus can also cross the placenta,18 the reproductive and sexual health needs of sex workers who are pregnant or might become pregnant need to be considered.
Although it is currently in short supply, the two-dose JYNNEOS smallpox vaccine (Bavarian Nordic, Kvistgaard, Denmark) could confer protection for people who are unexposed but at high risk, or it could be used as postexposure prophylaxis.19,20 If the vaccine results in a decreased monkeypox viral load among people who become infected, it could reduce ongoing transmission as well. However, this vaccine offers optimal immunological protection after receiving the second dose, which should be administered at least 4 weeks after the first dose.19 As mentioned, sex workers have not been prioritised for monkeypox vaccination campaigns in most settings, and vaccine shortages have led to uneven access.21 At times these campaigns have favoured high-income and middleincome MSM, White MSM,22 and MSM who are not sex workers, or have only included cisgender male sex workers to the exclusion of cisgender women, transgender women, and non-binary sex workers. In some settings, vaccination requires health insurance, access to a computer or smartphone to make appointments, a fixed address, photo identification, transportation, or the ability to wait in line for many hours, any of which represent considerable barriers for many sex workers with low incomes or without legal migration status. Furthermore, most sex workers live in low-income and middle-income countries where access to vaccination and treatment is almost non-existent, and where even their most basic health-care needs are not being met.
The ongoing monkeypox virus pandemic has disproportionately affected people living with HIV infection, sometimes with other concurrent STIs. This disparity could suggest that immunosuppression might predispose individuals to monkeypox virus infection, or that HIV or STIs are cofactors of monkeypox virus transmission. Thus, monkeypox virus could pose a high risk to sex workers of all genders who have much higher HIV and ulcerative STI burdens than the general population, although there is substantial heterogeneity within and across regions.
Apart from biological pathways, sex workers could be especially susceptible to monkeypox virus infection due to structural factors in their work environments. For example, both WHO and the US Center for Disease Control and Prevention have advised people at risk to reduce their number of sexual partners, to talk to their partners about monkeypox before sex, and to avoid sexual contact with symptomatic partners. However, for people who rely on sexual transactions to financially support themselves and their families, this advice is probably not feasible, particularly for more marginalised sex workers (eg, low-income and racialised workers, or sex workers who use drugs).
Globally, most countries criminalise selling sex, purchasing sex, or acting as a third party (eg, manager or receptionist) in sex work. Research has consistently shown that sex workers often fear disclosure to healthcare providers due to stigma and discrimination and breach of privacy. In addition, sex workers fear that exposure would increase the risk of arrest for them, their clients, or their colleagues, and closure of their workplaces, which would further impede access to care. MSM and transgender sex workers might also fear being targeted by homophobic or transphobic police repression or violence. Sex workers in criminalised settings are probably at increased risk for monkeypox virus infection due to high sex partner concurrency combined with structural barriers to condom use. These structural barriers include scarce workplace protections, scarce condom access, and policing tactics that drive sex work underground. Furthermore, the absence of a supportive regulatory environment can hinder sex workers’ ability to safely refuse symptomatic clients or high-risk activities that expose them to more contact with skin or bodily fluids. In the most policed contexts, criminalisation restricts sex workers’ choice of clients (eg, ability to see repeat clients vs one-time clients) and their ability to take time to openly screen clients for symptoms. As well, in some contexts, MSM and transgender sex workers are particularly targeted with police repression and criminalisation under anti-LGBT laws, creating an additional barrier to accessing health services and to reducing transmission risks at work.
Developing effective monkeypox virus prevention programmes for sex workers should consider decades of experience in HIV prevention. Despite data showing high acceptability of pre-exposure prophylaxis (PrEP) among cisgender female sex workers in high-income countries, there are also reports of breaches of confidentiality, stigma, and risk of violence, which impeded PrEP access and uptake. Stigma and concerns of privacy have been compounded by homophobia and transphobia for MSM and transgender women, including sex workers. Furthermore, similar to monkeypox virus discourse, much of PrEP access has been implemented with MSM sex workers, with little attention to cisgender or transgender women sex workers.
There are also lessons from the COVID-19 pandemic, which have disproportionately affected sex workers in lower-middle-income and high-income countries. In some studies, sex workers had higher SARS-CoV-2 prevalence than other vulnerable populations (eg, people who use drugs and people who are homeless), probably due to the fact that public health recommendations (eg, physical distancing) were not realistic for sex workers who faced economic hardships and food insecurity. As a result of criminalisation, most sex workers did not have access to paid sick leave or other government subsidies during COVID-19, which would further complicate the recommended 10-day isolation requirements for monkeypox virus. Several studies reported that sex workers had less access to HIV care and prevention services (eg, condoms and HIV tests) during the COVID-19 pandemic than they had before.
By contrast, in decriminalised settings, although fear of stigma in health care remains a concern, sex workers report greatly improved workplace health and safety, access to justice, and partnership with public health authorities. Of key relevance to monkeypox virus prevention, in a meta-analysis, community empowerment approaches to HIV responses among sex workers in lowincome and middle-income countries were associated with reductions in HIV, gonorrhoea, chlamydia, and syphilis. Other promising models that should be extended to monkeypox virus include sex-worker led COVID-19 or hepatitis B vaccination clinics offered in sex work venues in partnership with medical or public health staff, mobile health services in sex work and drug use establishments in partnership with street nurses, and initiatives providing food and income support to sex workers needing to quarantine that were developed during the COVID-19 pandemic. Hepatitis B vaccination clinics held in sex worker workplaces recorded far higher vaccine coverage for sex workers than traditional health services. Mobile health services have been identified as key interventions for sexual and reproductive health for sex workers in low-income, middle-income, and high-income contexts. In a community randomised trial, mobile health services for sex workers were associated with a decrease in STI prevalence. Sex worker contact with outreach services (eg, street nurses and mobile outreach) was associated with positive health outcomes, such as increased cervical screening.
Both the HIV and COVID-19 pandemics underscore the severely harmful effects of the criminalisation of sex work and stigma and the urgent need to address the unmet occupational needs of sex workers that must be considered in the monkeypox virus response. Harm reduction and rights-based approaches to sex work in the context of monkeypox virus are imperative. These approaches need to include sex workers of all genders—particularly racialised and marginalised sex workers—in public health planning and messaging alongside structural interventions. Full decriminalisation of sex work and access to workplace protections (eg, paid sick leave and safer work environments) are key to protecting sex workers’ health. Sex workers of all genders have often been among the first hit by epidemics and the last to be protected—it is long past time to change that.
Contributors
SAS conceived the Personal View and drafted the initial manuscript and revision. KS and A-LC contributed to the writing, revisions, and editing of the manuscript. Declaration of interests We declare no competing interests.
Acknowledgments
KS is partly supported through the National Institutes of Health (NIH; R01DA028648). SAS is partly funded by R01 DA049644-03S3.
The NIH had no involvement in the writing of this manuscript or the decision to submit this Personal View for publication.
The views expressed in this Personal View do not reflect that of A-LC’s current employer.