The politics of HIV/AIDS have evolved over the years, from division and public hysteria to a global movement for health justice. But despite progress in fighting the epidemic, one community still faces an acute HIV crisis, representing the social and public health challenges left yet unresolved. A study on the experience of transgender sex workers reveals the myriad risks facing a group who are systematically marginalized from the public conversation on HIV—when they should actually be at the center of it.

The report, published by Red Umbrella Project, National Center for Transgender Equality (NCTE), and Best Practices Policy Project (BPPP), analyzes recent survey data showing that “trans people with sex trade experience are over 12 times more likely to be living with HIV than trans people who have never been sex workers and 25 times more likely to be HIV positive than the general population in the United States.” In cities like Washington, DC, where nearly three quarters of trans sex workers report living with HIV, every time a sex worker gets harassed by beat cops, unfairly rejected for a job or denied appropriate medical care, she is pushed further into the social instability that exacerbates the HIV crisis. Yet advocates say that federal HIV/AIDS strategy continues to ignore their plight.

For transgender people already burdened by social stigma, critics argue that “pervasive profiling” by police further threatens safety and access to healthcare. Advocates have for years campaigned against particularly aggressive profiling practices, such as the use of condoms as evidence of prostitution. But despite some reforms aiming to curb anti-condom crusades in New York City, DC, and San Francisco, BPPP says these practices persist:

Because the criminalization of sex work is so entrenched nationwide, in practice the police continue to undermine sex workers’ safety with impunity even after these intensive campaigns to end the use of condoms as evidence and to improve police/community relations.

Rights activist Monica Jones sees the gap between policy and practice playing out in Phoenix, where a controversial anti-prostitution campaign, Project Rose, has led to mass arrests and coerced “rehabilitation” of women, including Jones herself. Police continue to target trans women, she says, based on appearance, race, or what’s in their purse: “Women and transpeople having condoms on them is criminalized, whereas a white cis male having condoms on him is looked at as safe-sex practice.”

Police aggression has taken more nuanced forms lately, according to advocates. As Ruby Corado, a DC-based transgender activist, observed: “We went from brutality to control.” Instead of beating up and jailing suspected sex workers, she claims, now cops are more likely to accost women and assertively “escort” them home, use undercover sting operations or root out condoms to “catch” them.

While the advent of prophylactic medication regimes known as PrEP offers hope of preempting HIV infection through daily treatments, sex worker advocates fear that, like condoms, sex workers will pay a high price for protection. Although the growing commercial availability of PrEP medications like Truvada are promising, Jones says, “if you don’t have money, you don’t have access to the drug… It’s a drug of privilege.” Moreover, focusing on medical access alone overlooks obstacles sex workers may face in using the drug due to law enforcement consequences. Between risks to health or risks of imprisonment, Jones says affordability and access “go hand in hand; once you have access to this drug, are we going to be criminalized for having this drug on us?”

The report recommends dismantling outmoded policies criminalizing HIV infection; that includes reforming draconian sex-offender registration systems and criminal penalties for engaging in sex work while HIV positive, along with immigration policies criminalizing migrants generally.

As co-author of the report Sharmus Outlaw explains, “The US is out of step with global acceptance of the need to bring a human rights focus to the issues of sex work and HIV, while moving away from criminalization.”

The stakes are especially high for the trans community, nearly three-quarters of whom report in BPPP surveys they have experienced incarceration. Often they are shunted into inappropriately gender-segregated facilities, to face extreme risk of assault or denial of healthcare. Similarly, advocates argue that trans women immigrants routinely suffer trauma and abuse in federal detention—although, paradoxically, many are seeking asylum on grounds of gender-identity-based persecution in their home countries.

Fighting these policies is just the first step toward building equity into healthcare systems, social-welfare institutions, and the workforce. According to NCTE’s 2015 national survey, nearly seven in 10 transgender adults reporting involvement in sex work recall “experiencing an adverse job outcome in the traditional workforce, such as being denied a job or promotion or being fired because of their gender identity or expression”—far higher than the already alarming rate of about 45 percent for non–sex workers.

While the mainstream debate on “prostitution” is reduced to simplistic binary views of choice versus “trafficking,” the experiences of trans community members show the complex interaction of economic oppression, social power, and sexual agency as factors driving trans people’s engagement in sex work.

Trans sex workers are socially overexposed yet invisible, treated by authorities as criminal subjects, social pariahs, or political irritants. Decent work, the right to health and bodily autonomy, and social dignity, fundamentals of citizenship, may be eclipsed by occasional flashes of glamour surrounding transgender identity in the celebrity world—but they are essential for transgender people to attain democratic control over their livelihoods and futures. BPPP argues trans sex workers must be engaged as “part of the solution in addressing HIV”; authorities simply cannot afford the lethal consequences of silencing them as political actors.

And officialdom has much to learn from the trans community. Trans sex workers, Jones says, undertstand how HIV “impacts people people of color, it impacts trans women, it impacts sex workers, it impacts [intravenous] drug users…. I think these minority groups are coming together and talking with each other.” As LGBT equality movements and public health efforts to stem HIV/AIDS both grapple with intersecting challenges, those living at the crossroads of those struggles know exactly what it takes to overcome the crisis—if only the “right” people would listen.