The US Anti-Prostitution Pledge: A Call for Cooperation

We would like to thank Jay Silverman and Michele Decker for their thoughtful contribution to the public health discussion regarding commercial sex work and the grave issues of child prostitution and sex trafficking [1]. As the correspondents rightly assert, trafficking in persons is a criminal and human rights offense and should be vigorously opposed and its victims provided services. This is not a domain of any real contention in the public health or human rights communities. Nevertheless, the conflation of all forms of sex work with human trafficking, which they contend is an outcome of the essential inseparability of these two phenomena, does remain contentious. And, as with our paper, their work does not, arguably, resolve this contention. For the population of consenting adults who sell sex of their own volition, in settings as divergent from the India–Nepal context where Silverman et al. have worked as Washington D. C. or Amsterdam, sex workers and their advocates claim a domain of prevention and engagement that also uses human rights language, albeit the language of workers' rights and empowerment, to argue for services. And there is ample evidence to suggest that empowerment and an end to police harassment can improve health outcomes, including HIV. 
 
It may be that the most important issues in sex work and sex trafficking are contextual. In Silverman and Decker's recent work, funded by the Office to Monitor and Combat Trafficking in Persons of the Bush Administration's Department of State, they reviewed medical documentation and case record materials for 287 sex-trafficked and repatriated Nepalese girls and women who received services at Maiti Nepal between January 1997 and December 2005. Their findings revealed that 109 (38.0%) women and girls were HIV positive [2]. In our own work, perhaps 60% of ethnic Shan women living in Burma who were trafficked to Thailand may be HIV infected [3]. In both these Asian communities, the contexts of poverty (Nepal and Burma relative to India and Thailand, respectively) and the very low status both of women and girls and illegal aliens more generally, makes it almost impossible for any sex work not to be profoundly exploitative. 
 
In contrast, our work with AIDS service organizations in Moscow, Russia has taken place in a markedly different context [4]. The majority of women we encountered were adults when entering sex work, and over 80% indicated willingly entering into sex work and even coming to Moscow seeking such work. High rates of unemployment among women in the former Soviet Union, due to economic depression and gender discrimination, have brought these women to the Moscow sex trade seeking income. These economic factors are compounded by the fact that the majority of women in our sample were financially assisting or fully supporting family members. The fact that people besides themselves were dependent on the income of many of the sex workers must be taken into consideration in programs aimed at cessation of sex work. But none of the women interviewed were Moscow residents before entering the Moscow sex industry. Lack of legal status is perhaps the largest barrier preventing sex workers from receiving many important services and social benefits such as free and anonymous medical treatment, a steady job (outside of sex work), protection from the police, lodging, and psychological assistance. This is not a function of the legality of prostitution (sex work is not illegal in the Russian Federation), but of not having legal residency. 
 
This example illustrates the highly contextual nature of sex work, and indeed, of trafficking, and perhaps argues against a “one size fits all” approach to these difficult problems.


The US Anti-Prostitution Pledge: Authors' Reply
We would like to thank Jay Silverman and Michele Decker for their thoughtful contribution to the public health discussion regarding commercial sex work and the grave issues of child prostitution and sex trafficking [1].As the correspondents rightly assert, trafficking in persons is a criminal and human rights offense and should be vigorously opposed and its victims provided services.This is not a domain of any real contention in the public health or human rights communities.Nevertheless, the conflation of all forms of sex work with human trafficking, which they contend is an outcome of the essential inseparability of these two phenomena, does remain contentious.And, as with our paper, their work does not, arguably, resolve this contention.For the population of consenting adults who sell sex of their own volition, in settings as divergent from the India-Nepal context where Silverman et al. have worked as Washington D. C. or Amsterdam, sex workers and their advocates claim a domain of prevention and engagement that also uses human rights language, albeit the language of workers' rights and empowerment, to argue for services.And there is ample evidence to suggest that empowerment and an end to police harassment can improve health outcomes, including HIV.
It may be that the most important issues in sex work and sex trafficking are contextual.In Silverman and Decker's recent work, funded by the Office to Monitor and Combat Trafficking in Persons of the Bush Administration's Department of State, they reviewed medical documentation and case record materials for 287 sex-trafficked and repatriated Nepalese girls and women who received services at Maiti Nepal between January 1997 and December 2005.Their findings revealed that 109 (38.0%) women and girls were HIV positive [2].In our own work, perhaps 60% of ethnic Shan women living in Burma who were trafficked to Thailand may be HIV infected [3].In both these Asian communities, the contexts of poverty (Nepal and Burma relative to India and Thailand, respectively) and the very low status both of women and girls and illegal aliens more generally, makes it almost impossible for any sex work not to be profoundly exploitative.
In contrast, our work with AIDS service organizations in Moscow, Russia has taken place in a markedly different context [4].The majority of women we encountered were adults when entering sex work, and over 80% indicated willingly entering into sex work and even coming to Moscow seeking such work.High rates of unemployment among women in the former Soviet Union, due to economic depression and gender discrimination, have brought these women to the Moscow sex trade seeking income.These economic factors are compounded by the fact that the majority of women in our sample were financially assisting or fully supporting family members.The fact that people besides themselves were dependent on the income of many of the sex workers must be taken into consideration in programs aimed at cessation of sex work.But none of the women interviewed were Moscow residents before entering the Moscow sex industry.Lack of legal status is perhaps the largest barrier preventing sex workers from receiving many important services and social benefits such as free and anonymous medical treatment, a steady job (outside of sex work), protection from the police, lodging, and psychological assistance.This is not a function of the legality of prostitution (sex work is not illegal in the Russian Federation), but of not having legal residency.
This example illustrates the highly contextual nature of sex work, and indeed, of trafficking, and perhaps argues against a "one size fits all" approach to these difficult problems.

Funding:
The authors received no specific funding for this article.

Competing Interests:
The authors have declared that no competing interests exist.

Tobacco Substitutes: Snus and Harm Reduction Maia Szalavitz
How can you even have a debate over whether to publish data on snus [1]?No medical journal even contemplated not publishing data on needle exchange to prevent HIV-which continues addiction just as surely as snus does, while similarly producing a dramatic reduction in the risk of death.Journals don't censor data on nicotine replacement or methadone maintenance or buprenorphine or even heroin maintenance, which continue physical dependence if not always addiction.They even publish data on amphetamine maintenance!What kind of bizarre political correctness would even suggest not publishing data that could show whether snus improves or harms health?You may want to debate whether or not tobacco should be advertised, whether or not the industry should be banned and replaced by government control of nicotine delivery-devices, even whether tobacco should be prohibited entirely.But not publish data on what appears to be from existing data an amazingly successful public health intervention?What kind of a "public library of science" would even contemplate that?Maia Szalavitz (maiasz@gmail.com)Statistical Assessment Service New York, New York, United States of America

Should the Health Community Promote Smokeless Tobacco (Snus): Comments from British American Tobacco Justine Williamson, Christopher Proctor
Chapman and Freeman question the tobacco industry's aims on snus, and whether these aims can be consistent with harm reduction [1].We cannot speak on behalf of the industry as a whole.However, we at British American Tobacco understand that cigarette smoking is a major cause of serious and fatal diseases, and we believe that the use of Swedish-style snus products, while not harmless, is substantially less harmful than cigarette smoking [2].We are piloting snus in several countries outside of Sweden as a response to those public health stakeholders who have told us they believe that snus, properly regulated, can contribute to reducing the net public health impact of tobacco use.
We believe adult consumers of tobacco products would benefit from the enactment of a regulatory framework that facilitates consistent, accurate, and meaningful communications on the relative health risks of smoking, using snus, or abstaining entirely from tobacco use.While ideally this framework would be developed and agreed upon under the Framework Convention for Tobacco Control, the recent second Conference of the Parties to the Framework Convention did not address oral tobacco products and has not assigned a high priority to tobacco product regulation in this area.Given this, we think national governments should develop a regulatory framework for snus.In doing so, we think that governments should be mindful of the concerns expressed by Chapman and Freeman.
We agree with the recently released preliminary report from the European Union's Scientific Committee on Emerging and Newly Identified Health Risks, which states that "the balance of these effects [beneficial versus adverse effects on smoking prevalence] will be highly dependent upon the marketing of the product, the health messages delivered with it, and the extent to which switching to smokeless tobacco products as a harm reduction strategy is endorsed by health professionals and their organisations" [3].
We acknowledge that some have concerns with regard to our interest in snus as a less harmful alternative to cigarettes.We seek to work with the public health community and regulators to achieve a reduction in the public health impact of tobacco use.

Justine Williamson (justine_williamson@bat.com) Christopher Proctor
British American Tobacco London, United Kingdom Beyrer Nicole Masenior (nfranck@jhsph.edu)Johns Hopkins Bloomberg School of Public Health Baltimore, Maryland, United States of America Citation: Beyrer C, Masenior N (2007) The US anti-prostitution pledge: Authors' reply.PLoS Med 4(10): e318.doi:10.1371/journal.pmed.0040318Copyright: © 2007 Beyrer and Masenior.This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.