In humanitarian emergencies impoverished women may turn to sex work as a way of feeding themselves and their families; without the usual health services and given the often low education of those involved, sex is frequently unprotected, exposing them and their clients to sexually transmitted infections (STIs), including HIV.
"The needs of sex workers are often not met in emergencies. Sex workers are left out at all stages of planning," Sathya Doraiswamy, senior regional HIV officer for the UN Refugee Agency (UNHCR), told IRIN/PlusNews after a September workshop on HIV in emergencies held in Nairobi.
"Due to their added risk for unintended pregnancies, STIs and HIV, they need access to sex worker friendly comprehensive reproductive health services including counselling services at locations of their choice… During emergencies sex workers need consistent access to condoms… Barriers to access condoms increase their risks of pregnancy, STIs and HIV."
In 2010, UNHCR launched guidelines on HIV and sex work in refugee situations; these are currently being piloted in three countries in the East and Horn of Africa region. The guidelines call for, among other things, awareness-raising and buy-in among the community and sex workers, identification and mapping of hotspots, protection for sex workers, provision of health services and the formation of sex worker peer-led systems.
In Kenya's Dadaab refugee complex, home to close to half a million mainly Somali refugees, training of peer educators is ongoing. "We are training peer leaders of sex workers on how to reach out to them, educate them on safe sex and refer them to where they can receive reproductive health and HIV services," Geoffrey Lutthah, reproductive health and HIV focal point person for UNHCR in Dadaab, told IRIN/PlusNews.
"We conduct risk assessment when we receive commercial sex workers to know how many partners they have in a particular period and whether they use condoms and we counsel them to help reduce their risks," said Emmy Silayi, most-at-risk populations officer with the NGO Africa Development and Emergency Organization, which works with sex workers in Dadaab.
"Women may be forced to engage in sex to secure their livelihood or that of their family or in return for safe passage, food, shelter or other resources… The deteriorating economy pushes young women and girls into patterns of sex work that expose them to HIV infection," said a 2009 briefing paper on HIV and emergencies by the UK based think tank Overseas Development Institute.
The paper, noted, for instance, that sex workers were less likely to use condoms due to competition over dwindling clients.
Newcomers at greater risk
UNHCR's Doraiswamy said many women who take up sex work during emergencies were new to the practice, and found it more difficult to network with other sex workers and to negotiate safer sex, putting them at higher risk of acquiring STIs and HIV.
Mohamed Ibrahim, a peer counsellor working at a youth centre in Dadaab, said sex work in the camp was shrouded in secrecy, and fear of violence and stigma tended to prevent sex workers from seeking health services.
“They are not sure how they will be treated if they say who they are. Many are faced with language barrier to even communicate, and they decide to suffer in silence. They get HIV or other STIs simply because they can't tell a client to use a condom or they don't know where to get that condom,” Ibrahim, told IRIN/PlusNews.
A 2010 HIV Behavioural Surveillance Survey conducted by the UNHCR and the Intergovernmental Authority on Development in Dadaab found that 3 percent of sexually active respondents reported transactional sex for money, gifts or favours.