Should stereotypes about African sex workers be rallied to bolster HIV prevention advocacy?
Article photo by Annie Spratt on Unsplash
HIV PrEP lenacapavir could fundamentally change the trajectory of HIV globally – should stereotypes about African sex workers be rallied to bolster advocacy for a price reduction?
Amidst exciting new options to prevent HIV transmission, stereotypes about African sex workers entrench representations of Africans as poor, vulnerable and dependent on global charity and activism for their wellbeing. This is harmful and perpetuates negative tropes about Africa – all the more ironic considering that African scientists are world leaders in health research on HIV and AIDS.
In July 2024, the 24th International AIDS Conference brought momentous news: clinical trial results showed that long-acting injectable lenacapavir used as pre-exposure prophylaxis (PrEP) is highly effective in preventing HIV in cisgender women. Not one person in the lenacapavir arm of the randomised controlled trial seroconverted in the PURPOSE 1 trial! Yet lenacapavir's current price is eye-watering: the US pharmaceutical company Gilead sells it for $42 250 per patient for the first year in the US.
Fortunately, research also presented at the conference showed that with voluntary licensing to generic companies, this price could eventually be lowered to $40 per person per year (and that Gilead would still be able to profit at that price).
In announcing this news, the British free-to-air public broadcast television channel, Channel 4, aired an 7 min documentary summarising the exciting research results. It placed lenacapavir against the background of the on-going struggle of activists like the Treatment Action Campaign to ensure that essential treatment and prevention technology are available to those most need it. Whilst the documentary skilfully makes a persuasive argument for bringing down the price of lenacapavir, it does so by drawing on and perpetuating tired stereotypes of African sex workers.
The documentary is anchored in the brief story of a sex worker called 'Aamina' whose village forms the backdrop of the opening and closing shots of the film. Aamina's representation is sadly in the tradition of what Charani and colleagues call the creation of images that enforce the "persistent dehumanisation of people of colour, and populations in LMICs, generating pity rather than empathy, demeaning rather than empowering, and commercialising rather than representing the featured groups."
Aamina is described and presented as a sex worker who lives in dire poverty in a rural Malawian village. She is presented as an inevitable 'victim' for the intended UK audience of the documentary: a 'young girl' (she is clearly an adult in the documentary) without agency. The interview is filmed in a public space in the middle of the village within earshot of passers-by; during the interview, intimate and very personal aspects of her life are opened up for everyone's view. The film features a condescending close-up shot of her informal flip-flop shoes, perhaps suggesting to the viewer a lack of sophistication in preparing for the filming of her interview or a lack of knowledge of documentary film conventions, or of her poverty. As such, the representation of Aamina is strongly within the tradition of the 'colonial gaze', which perpetuates harmful colonial binaries of 'us and them', 'poor and rich', 'European and African', and 'modern and traditional'.
These dichotomies are strongly at play in the documentary. For instance, in stark contrast to the way in which Aamina is presented, the male academic experts speak from carefully curated private spaces. They are named in full with their academic titles and are in charge of their own narratives. It is inconceivable that they would be asked about how they have sex or protect themselves from HIV, or that shots of their shoes would be included in their inserts.
Malawi (the location of the documentary), South Africa and Uganda (the research sites of PURPOSE 1 trial) are all former British colonies. For many people watching the documentary from the African continent, this history and the particular set of power relations embedded within the documentary would be foremost in their minds and reinforced by the choices made on representation within the film. Yet the main audience of this documentary – presumably people based in the UK, would probably just see their stereotypes of African sex workers as inevitably 'sick, poor and hopeless victims' reinforced.
An alternative framing would be of Aamina – or other women like her – as often resourceful and resilient people who have to make difficult choices to provide a livelihood for themselves and their dependents, within a deeply inequitable socio-political context and history that is not of their making.
I believe the film missed an opportunity to problematise and challenge harmful, one-dimensional stereotypes of sex workers. There are a number of African sex worker rights advocates who would speak to the issue of HIV prevention and the material realities of sex workers with eloquence and confidence, and who could (also) have been included. If the perspective of a rural sex worker was essential to the narrative frame of the documentary, Aamina could have been invited to choose the location of the interview, the way in which questions were asked, and to indicate upfront which topics were disrespectful and 'off limits' for her. This would have been in line with guidance drafted for journalists on respectful reporting on sex work issues, and other ethical codes.
Regrettably, the documentary exemplifies how "deeply embedded the existing tropes and prejudices are within global health images" following Alenichev and colleagues. While Key Populations collectively probably have the most to gain from the rapid roll-out of affordable and effective PrEP such as lenacapavir, it does not follow that disrespectful representation of such groups is justified in bolstering the argument for a rapid reduction of prices.
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Update on 24 September 2024: Three organisations—the African Sex Worker Alliance, Sisonke Sex Worker Movement, and the Sex Workers Education and Advocacy Taskforce—wrote to the show's producer on 22 August 2024 and 6 September 2024 to raise some of these concerns. Regrettably, no response has been received.
