Report delves into HIV risks of sex workers and their clients

They sell sex for money or goods. It's a risky business - and illegal in Botswana - but female sex workers are out there, and so are the clients who keep them in business.

Until now, not much was understood about sex workers in Botswana: what risks they take and what motivates them, but a recent report, HIV Needs Assessment of Female Sex Workers in Major Towns, Mining Towns, and Along Major Roads in Botswana, has taken a comprehensive look at how the world's oldest profession is practiced here.

The research was carried out by a team from the International Training and Education Center on HIV (I-TECH) at the University of Washington, with the assistance of the Matshelo Community Development Association, a non-governmental organisation (NGO) that works with sex workers in Francistown, a northern border town with the highest HIV infection rate in the country, and in 15 other locations.

"I was never interested in this job, and never thought I can do it," said one woman, explaining why she had taken up sex work. "A man came up to me and offered to have sex and give me something. I thought, 'life is good'. I was given 600 pula [US$99]."

With funding from the US President's Emergency Plan for AIDS Relief (PEPFAR) and support from the BOTUSA Project, a collaboration between the US Centers for Disease Control and Botswana's Ministry of Health, the report examines the risks of HIV infection and transmission; access to prevention and treatment services by female sex workers (FSWs) and their clients; and suitable interventions for reducing HIV/AIDS transmission in both groups.

The assessment was conducted in six different locations around the country in 2006.

"It was not difficult to get FSW or men to talk to us and, yes, they were frank," said Anjali Sharma, an I-TECH researcher and an author of the report. "It was more the NGOs and HCPs [health care providers] who were guarded - maybe because the illegality of sex work plays more on their minds."

Motivations

Women said the reasons they had gone into sex work were because male partners failed to provide for them adequately, poor education, limited work opportunities and low wages.

For 250 pula, I won't risk him spreading AIDS to me, but if he offers 500 pula, I will do it.

Male clients often believed that their manliness was determined by the number of women with whom they were seen. "In culture past ... a man ... had a number of wives - a rich man had seven wives," One man explained. "It still exists today. To recognise that this is a dangerous guy, he must have all of these women around him, and we should be able to see that he can take anyone."

About a third of the women interviewed had income-producing jobs besides sex work, such as selling vegetables, washing cars and hairdressing, but these activities did not provide enough money to buy basic necessities.

"It's not easy in jobs," said one woman. "I was working in a shop. At month-end the owner accused us of stealing and we each got 30 [pula] to 50 pula [$5 to $8]. Can you imagine working every day and getting 50 pula at month end? In this job [sex work], I can get 50 pula in one day!"

Participants reported earning an average of 700 pula [$115] per month from sex work. Most said they did not enjoy sex with clients, but relied on the money, often using it to support their entire extended family.

Condom negotiation, healthcare and support

Both men and women said condom use depended on individual ability to insist on it, client agreement and the negotiated price. Of the 24 women with regular customers, 12 always used condoms, nine sometimes did and three never used them. About half the 30 women interviewed reported always using condoms with casual customers, while the others reported intermittent use.

"The men are strangers. They can kill you and throw you in the bush and no one will even know what happened. He does not want to use condoms - [he] just [wants] to enjoy sex. For 250 pula [$41, I won't risk him] spreading AIDS to me, but if he offers 500 pula [$82], I will do it," a woman told the researchers.

The women thought healthcare in Botswana was equitable but did not specifically target high-risk populations, such as sex workers. They also feared taunts from healthcare providers if they took too many condoms.

They believed education about HIV prevention and testing was best conveyed by their peers. "I think sex workers just need support from others ... they need education [but] it's very difficult, as you cannot go to bars and say 'you, prostitute, come here. I want to tell you something'", said one woman.

The Matshelo Community Development Association (MCDA) is one of the very few organisations in Botswana that targets sex workers, but it has received little support from government or non-government partners.

MCDA offers counselling and treatment for HIV and other sexually transmitted infections (STIs), harm reduction for substance use, and advice on how to reduce client numbers and negotiate consistent condom use.

"The biggest challenge is the unwillingness to test the law: people fear that helping sex workers is tantamount to illegal activity," Sharma said. "Also, the mix of transactional, part-time and commercial sex makes it difficult for people to accept that sex workers have special health and prevention needs, compared to women in the general population."

Researchers noted the need for discreet public or non-governmental clinics that catered to sex workers. "Targeted interventions at female sex workers are relatively easy to implement and have a high impact on STI/HIV prevalence rates in this and the general population," Sharma said.

She pointed out that interventions that targeted men were also necessary, because "the success of such interventions would depend on the solidarity [agreement on condom use and price] between female sex workers, their clients [men], healthcare providers and the police."

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