Rapid Assessment of HIV Risk Behavior in Drug-Using Sex Workers
Rapid Assessment of HIV Risk Behavior in Drug-Using Sex Workers
A rapid assessment was undertaken with drug using commercial sex workers (CSWs) to investigate practices putting them at risk for contracting HIV. It included key informant (KI) (N = 67) and focus group (N = 10) interviews in locations with a high prevalence of drug use in Cape Town, Durban and Pretoria, South Africa. HIV testing of KIs was conducted. Cocaine, Ecstasy, heroin and methaqualone are used by CSWs prior to, during and after sex. Drugs enhance the sexual experience and prolong sex sessions. Interviews revealed inconsistent condom use among CSWs together with other risky sexual practices such as needle sharing. Among CSWs who agreed to HIV testing, 34% tested positive. Barriers to accessing drug treatment and HIV treatment and preventive services were identified. Interventions recognizing the role of drug abuse in HIV transmission should be prioritized, and issues of access to services, stigma and power relations must be considered.
South Africa's HIV epidemic is currently one of the worst in the world with approximately 5.5 million people living with the human immunodeficiency virus (HIV) or acquired immune deficiency syndrome (AIDS) (UNAIDS 2006). The HIV prevalence rate for persons aged 15–49 years is estimated to be 19–20% (Shisana et al. 2005; UNAIDS 2006). As in other sub-Saharan African countries, the primary mode of HIV transmission is via heterosexual intercourse followed by mother-to-child transmission (Shisana et al. 2005). Government HIV intervention efforts have focused on the general population and two key high-risk groups, namely youth and pregnant women. Little attention has been given to preventing HIV among drug using commercial sex workers.
Injection drug use (IDU) is experienced in a growing number of African countries (Adelekan and Lawaal 2006; Abdool et al. 2006), and is therefore becoming increasingly recognized as an important mode of HIV transmission (Dewing et al. 2006). Concurrently, there is growing interest in the relationship between alcohol/drug use and sexual risk behavior, both in African countries (Morris et al. 2006) as well as in South Africa (Simbayi et al. 2006; Morojele et al. 2006). In most countries the HIV prevalence among drug using populations such as commercial sex workers (CSWs) is higher than among the general population not only because they engage in behaviors that put them at higher risk for infection, but because they are among the most marginalized and discriminated against populations and often lack access to basic healthcare services (UNAIDS 2006). Recently a distinction has been made between those (women) engaging in CSW and those (women) engaging in "transactional" or "survival" sex (Wojcicki 2002), as female drug users in African countries often trade sex for drugs (Timpson et al. 2006). This paper focuses specifically on CSWs, that is men and women who self-identify as CSWs and engage in commercial, professional sex-for-money exchanges. Many South African women engaging in CSW are from disadvantaged backgrounds (Wechsberg et al. 2006) and experience the same barriers to healthcare as a large proportion of the rest of the population (e.g., location of services and opening hours) (Fick 2005). Where the transmission of HIV is predominantly sexual, CSWs are considered both a high-risk population and a "core transmitter group", playing an important role in the transmission of the virus to the general population (Rees et al. 2000). Estimates of the prevalence of HIV/AIDS among women working as CSWs in mining communities around Johannesburg suggest that over 25% are HIV positive (Campbell 1998a in Wojcicki and Malala 2001) while a 1999 survey by Williams (Campbell 2000) revealed that 69% of CSWs working in one particular mining community were HIV positive. In addition, between 45 and 50% of CSWs working in the urban areas of Johannesburg have been found to be HIV positive (Wojcicki and Malala 2001; Rees et al. 2000; Dunkle et al. 2005).
In South Africa qualitative research among CSWs in Durban has documented that drug use, and particularly the use of crack cocaine, in this population is very common (Leggett 2001a). Internationally there is growing concern about the possible effects of drug use on sexual behavior. The use of certain drugs such as methamphetamine and cocaine is known to produce an increase in sexual arousal and pleasure and decrease sexual inhibition, and drug use has, in some cases, been found to impair judgment, negatively impacting responsible sexual behavior, and condom use (De Graaf et al. 1995; Leggett 1999; Kingree and Betz 2003; Woody et al. 2003; Lejuez et al. 2005; Semple et al. 2006; CDC 2006).
Drug use among CSWs is thought to compound the risk for contracting HIV in a number of ways. For example, CSWs with drug addictions are thought to require more customers to fund their drug habit, thus increasing their exposure to HIV and other sexually transmitted infections, and are more likely to forego condom use for more money and in order to secure customers (Karim et al. 1995; Leggett 1999, 2001a). International research regarding sex work is increasingly emphasizing the context in which sex is bought and sold as the crucial factor controlling exposure and vulnerability to the harms that sex work may introduce (Cusick 2006). In South Africa, the low socio-economic status of women as well as cultural beliefs around sex and the use of condoms have been found to impact negatively on female CSWs' ability to sustain safer sex behaviors (Campbell 2000; Wojcicki and Malala 2001; Leggett 2001b; Wojcicki 2002). For example, it has been found that "flesh-to-flesh" sex is intimately related to notions of masculinity for some men in Southern Africa (Webb 1997).
Based on a larger study, this paper aims to describe the nature, extent and context of drug use, and sexual behavior among drug using CSWs in Cape Town, Durban, and Pretoria and to understand the drug using and sexual behaviors that increase their vulnerability for HIV infection. It also aimed to assess their knowledge and understanding of HIV, drug, and HIV services and explore their views on how to improve access to services. While there are advocacy groups that seek to highlight the needs of sex workers, this is a group that is generally under serviced (Pauw and Brener 2003). Therefore, the final objective of the study was to identify possible strategies for introducing and scaling up sustainable interventions designed to reach drug using CSWs.
Abstract and Introduction
Abstract
A rapid assessment was undertaken with drug using commercial sex workers (CSWs) to investigate practices putting them at risk for contracting HIV. It included key informant (KI) (N = 67) and focus group (N = 10) interviews in locations with a high prevalence of drug use in Cape Town, Durban and Pretoria, South Africa. HIV testing of KIs was conducted. Cocaine, Ecstasy, heroin and methaqualone are used by CSWs prior to, during and after sex. Drugs enhance the sexual experience and prolong sex sessions. Interviews revealed inconsistent condom use among CSWs together with other risky sexual practices such as needle sharing. Among CSWs who agreed to HIV testing, 34% tested positive. Barriers to accessing drug treatment and HIV treatment and preventive services were identified. Interventions recognizing the role of drug abuse in HIV transmission should be prioritized, and issues of access to services, stigma and power relations must be considered.
Introduction
South Africa's HIV epidemic is currently one of the worst in the world with approximately 5.5 million people living with the human immunodeficiency virus (HIV) or acquired immune deficiency syndrome (AIDS) (UNAIDS 2006). The HIV prevalence rate for persons aged 15–49 years is estimated to be 19–20% (Shisana et al. 2005; UNAIDS 2006). As in other sub-Saharan African countries, the primary mode of HIV transmission is via heterosexual intercourse followed by mother-to-child transmission (Shisana et al. 2005). Government HIV intervention efforts have focused on the general population and two key high-risk groups, namely youth and pregnant women. Little attention has been given to preventing HIV among drug using commercial sex workers.
Injection drug use (IDU) is experienced in a growing number of African countries (Adelekan and Lawaal 2006; Abdool et al. 2006), and is therefore becoming increasingly recognized as an important mode of HIV transmission (Dewing et al. 2006). Concurrently, there is growing interest in the relationship between alcohol/drug use and sexual risk behavior, both in African countries (Morris et al. 2006) as well as in South Africa (Simbayi et al. 2006; Morojele et al. 2006). In most countries the HIV prevalence among drug using populations such as commercial sex workers (CSWs) is higher than among the general population not only because they engage in behaviors that put them at higher risk for infection, but because they are among the most marginalized and discriminated against populations and often lack access to basic healthcare services (UNAIDS 2006). Recently a distinction has been made between those (women) engaging in CSW and those (women) engaging in "transactional" or "survival" sex (Wojcicki 2002), as female drug users in African countries often trade sex for drugs (Timpson et al. 2006). This paper focuses specifically on CSWs, that is men and women who self-identify as CSWs and engage in commercial, professional sex-for-money exchanges. Many South African women engaging in CSW are from disadvantaged backgrounds (Wechsberg et al. 2006) and experience the same barriers to healthcare as a large proportion of the rest of the population (e.g., location of services and opening hours) (Fick 2005). Where the transmission of HIV is predominantly sexual, CSWs are considered both a high-risk population and a "core transmitter group", playing an important role in the transmission of the virus to the general population (Rees et al. 2000). Estimates of the prevalence of HIV/AIDS among women working as CSWs in mining communities around Johannesburg suggest that over 25% are HIV positive (Campbell 1998a in Wojcicki and Malala 2001) while a 1999 survey by Williams (Campbell 2000) revealed that 69% of CSWs working in one particular mining community were HIV positive. In addition, between 45 and 50% of CSWs working in the urban areas of Johannesburg have been found to be HIV positive (Wojcicki and Malala 2001; Rees et al. 2000; Dunkle et al. 2005).
In South Africa qualitative research among CSWs in Durban has documented that drug use, and particularly the use of crack cocaine, in this population is very common (Leggett 2001a). Internationally there is growing concern about the possible effects of drug use on sexual behavior. The use of certain drugs such as methamphetamine and cocaine is known to produce an increase in sexual arousal and pleasure and decrease sexual inhibition, and drug use has, in some cases, been found to impair judgment, negatively impacting responsible sexual behavior, and condom use (De Graaf et al. 1995; Leggett 1999; Kingree and Betz 2003; Woody et al. 2003; Lejuez et al. 2005; Semple et al. 2006; CDC 2006).
Drug use among CSWs is thought to compound the risk for contracting HIV in a number of ways. For example, CSWs with drug addictions are thought to require more customers to fund their drug habit, thus increasing their exposure to HIV and other sexually transmitted infections, and are more likely to forego condom use for more money and in order to secure customers (Karim et al. 1995; Leggett 1999, 2001a). International research regarding sex work is increasingly emphasizing the context in which sex is bought and sold as the crucial factor controlling exposure and vulnerability to the harms that sex work may introduce (Cusick 2006). In South Africa, the low socio-economic status of women as well as cultural beliefs around sex and the use of condoms have been found to impact negatively on female CSWs' ability to sustain safer sex behaviors (Campbell 2000; Wojcicki and Malala 2001; Leggett 2001b; Wojcicki 2002). For example, it has been found that "flesh-to-flesh" sex is intimately related to notions of masculinity for some men in Southern Africa (Webb 1997).
Based on a larger study, this paper aims to describe the nature, extent and context of drug use, and sexual behavior among drug using CSWs in Cape Town, Durban, and Pretoria and to understand the drug using and sexual behaviors that increase their vulnerability for HIV infection. It also aimed to assess their knowledge and understanding of HIV, drug, and HIV services and explore their views on how to improve access to services. While there are advocacy groups that seek to highlight the needs of sex workers, this is a group that is generally under serviced (Pauw and Brener 2003). Therefore, the final objective of the study was to identify possible strategies for introducing and scaling up sustainable interventions designed to reach drug using CSWs.