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close this bookCommunity-Led HIV Prevention by Southern African Sex Workers (UNAIDS - Best Practice Digest, 2000, 3 p.)
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Community-Led HIV Prevention by Southern African Sex Workers

Extracted from an article ‘Community-led HIV prevention by southern African sex workers’, by Zodwa Mzaidume, Catherine Campbell and Brian Williams (e-mail: bgwillia@csir.co.za) in Research for Sex Work 3, June 2000.

The field of HIV prevention has seen a trend towards community development approaches seeking to ‘empower’ members of disadvantaged grass-roots target groups - through maximising their leadership and participation in the implementation of health promotion programmes. Empowerment is important because people are more likely to feel that they can take control over their sexual health if they feel that they are in control of other aspects of their lives.

In practice, there are many constraints inherent in working for the ‘empowerment’ of disadvantaged community members living in conditions of poverty or social disruption. In an ongoing HIV prevention programme led by sex workers in a southern African industrial community* several ways have been sought to work with some of these constraints. Almost seven out of ten sex workers in the region are HIV- positive, and these women face multiple layers of disempowerment:

· they are women in a fiercely hierarchical and male-dominated community, living in conditions of poverty

· they are working in what they describe as a highly stigmatised profession, in a country where their profession receives no legal recognition, and where there is no formal recognition of their rights to work-related health and safety.

*In order to protect sex workers’ confidentiality, the names of the project and its locations were not given. The programme forms a small part of a large HIV prevention project in a southern African industrial community which employs a large number of migrant workers.

Aims of the programme

The aims of the programme include working with women to overcome some of the obstacles to condom use, and to contribute to the development of a supportive community for those who are already HIV-positive. It is run by women working from a small shack settlement, near a large industry that employs thousands of migrant men.

One of the first challenges for the programme co-ordinator (a local woman employed by the NGO that runs the project) was to build confidence and teamwork skills amongst sex workers with little previous experience of shared responsibilities within a structured programme. Women were trained in participatory education skills (for example, role-plays) and given access to unlimited supplies of condoms. The NGO co-ordinator visits the community two or three times a month to support peer educators, and this local peer education team networks closely with similar sex worker teams in the region.

Findings of in-depth interviews

Two sets of detailed, in-depth interviews were conducted with sex workers - six months and 18 months after the programme started.

The first interview study revealed that condom use was extremely rare, despite the fact that most people knew the ‘facts’ about AIDS. Levels of perceived vulnerability were low, and people living with AIDS tended to conceal the nature of their illness.

Women said they lacked the economic power to insist on condom use if paying clients refused to use them. They also lacked the psychological confidence to insist on condom use in a strongly male-dominated culture. They referred to a lack of unity amongst the sex workers, who are competing for a short supply of paying clients. If a woman refused sex without a condom, the client would simply find a more willing woman in the shack next door. They said that unless they could present a united front against clients, a condom programme would never succeed.

In the early stages, there was some scepticism about the programme. Nothing like it had ever been run in the community before and people felt it was just a passing ‘fad’. Furthermore, given the low esteem in which some women held themselves and their colleagues, they were sceptical of the ability of anyone of their rank and profession to have anything of value to teach anyone else.

The results of the interviews conducted one year after the first set suggested that, while a number of serious obstacles still stood in the way of the project, it had made a series of gains. Attitudes to the programme were extremely positive. Levels of sex workers’ perceived vulnerability to HIV were much higher, and there was growing peer pressure to use condoms.

Coincidentally, the previously self-selected all-male group of community leaders had been replaced by an elected group, including some women. So women now exercised leadership both through the HIV prevention programme and in the community.

But it remains to be seen how much the programme will lead to positive sexual health through the empowerment of the women. There is a number of problems which hinder the programme’s progress; the women often drink alcohol excessively and then are less likely to use condoms. There is still an extremely negative attitude to people who are HIV positive, and almost all the sex workers said they would not tell anyone if they were. A two-tier system had developed among the sex workers because so many clients were reluctant to use condoms; women charged extra for unprotected sex.

Much work needs to be done using such programmes as vehicles for mobilising a broader constituency of southern African sex workers to lobby for official recognition of their profession and of their rights to healthy and safe working conditions.