3.1.1 Distribution by Zone
A total of 201 commercial sex workers were enrolled in the study. Of these, 40.3% (81/201) were enrolled from Kimwanyi zone, 24.4% (49/201) from Soweto zone, 14.5% (29/201) from Busia zone and 11.9% (24/201) from Katale zone, while 8.9% (18/201) did not indicate their zone of residence.
3.1.2 Age Distribution
The age group of most of the sex workers was 15-24 years, which constituted 66.5% (131/197) of respondents. Those between 10-14 years constituted 5.6% (11/197), 15-19 years 36% (72/197), 20-24 years 28.4% (56/197), 25-29 years 15.7% (31/197), 30-34 years 9.6% (19/197), and 35-39 years 3% (6/197). The mean age of the respondents was 21.8 years. The youngest sex worker reported was aged 13 years, whereas the oldest was 39 years old.
3.1.3 Educational Status
The highest education level attained by the majority of the sex workers was skewed to primary school and nursery, 57.3% (114/199), or none, 26.6% (53/199), respectively. A few, 16.1% (32/199), had attained secondary school education.
3.1.4 Employment Status
Most of the sex workers were unemployed 41.9% (83/198), while others were involved in menial type of work such as petty trade 20.2 % (40/198), cooking and vending food 17.7% (35/198), barmaids 13.1% (26/198), selling enguli (local gin) 6.6% (13/198) and 0.5% or one sex worker was a student.
3.1.5 Religious Affiliation
The study population of sex workers was dominated mainly by Protestants 45.9% (89/194), followed by Catholics, 31.5% (61/198) and Moslems, 21.6% (42/198). 1% or 2 sex workers were affiliated to other religions.
3.1.6 Ethnic Origin
The majority of the sex workers belonged to the Baganda ethnic group 36.5% (73/200), followed by the Batoro 22.5% (45/200). Others were Banyankole 13.5% (27/200), Basoga/Bagwere 12/5% (25/200), Rwandese 7 % (14/200), Banyoro 3% (6/200), Lugbar 2% (4/200) and 3% (6/200) sex workers belonged to other ethnic groups.
3.1.7 Place of Origin
Out of a total of 194 sex workers who reported their original place of birth, 53.1% (103/194) were born in Central/Buganda region, followed by those from Southwestern Uganda, 34% (66/194). Others were from Eastern Uganda 10.3% (20/194), while 2.6% (5/194) were from other districts and outside Uganda.
3.1.8 Marital Status
Most sex workers, 61.7% (116/188), reported being unmarried while 22.9 % (43/188) were married, 9.6% (18/188) were divorced and 5.8% (11/188) were widows.
3.1.9 Fertility of Sex Workers
The majority of sex workers, 53.8% (107/199), had children (table 1). Mean number of children per sex worker was found to be one child per six workers.
Table 1. Number of children per sex worker
|
Number of children |
Frequency |
Percentage |
|
None |
92 |
46.2 |
1-2 |
71 |
35.7 |
3-5 |
30 |
15.1 |
More than 5 |
6 |
3.0 |
Total |
199 |
100.0 |
3.1.10 Dependents
Most of the sex workers, 89.5% (159/200), reported to have from 1 to more than 5 dependents (table 2). The mean number of dependents per sex worker was reported to be 3 people.
Table 2. Number of dependents per sex worker
Number of children |
Frequency |
Percentage |
|
None |
41 |
20.5 |
1-2 |
52 |
26.0 |
3-5 |
81 |
40.5 |
More than 5 |
26 |
13.0 |
Total |
200 |
100.0 |
3.2.1 Knowledge about Sexually Transmitted Diseases
It was found that almost all the sex workers, 98% (196/200), had heard about sexually transmitted diseases. Only 4 sex workers reported they had never heard about any STD.
Gonorrhea, 84% (168/200), Syphilis 74% (149/200), and AIDS 62.5% (125/200), were the commonest STDs known to the sex workers. Other STD's mentioned were Lymphogranuloma Venereum, 8% (16/200), Chanchroid 6.5% (13/200), and skin rashes 1.5 % (3/200).
The commonest symptoms of sexually transmitted diseases known by sex workers included vaginal discharge 52% (104/200), skin rash 43% (86/200), frequency and pain while urinating 36.5% (73/200), and genital sores 25.5% (51/200). Other symptoms mentioned were weight loss 6.5% (13/200) and abdominal pain 2.5% (5/200). 14.5% (29/200) sex workers didn't know of any symptom.
3.2.2 Sources of Information about STD
The major sources of information about STD were friends and peers 61% (112/200), followed by relatives 35% (70/200) and radio 27.5 % (55/200). Other sources mentioned included health workers 11% (22/200), teachers 9% (18/200), books 7.5% (15/200), parents 5.5% (11/200) and women's clubs 4.5% (9/200).
Similarly, most sex workers 55% (110/200) discussed about sexually transmitted diseases with friends or peers, 22% (44/200), with no one 10 % (20/200), with health workers 8% (16/200), with clients another 8% (16/200), with women's clubs 5% (10/200) with social workers and 2% (4/200) with others.
3.2.3 Risky Sex Practices and Behavior Related to STD among Sex Workers
45% (87/192) of the sex workers reported they had contracted a sexually transmitted disease implying that many sex workers were involved in unprotected sex. The mean number of STD episodes per sex worker who had contracted an STD in the past one year was 2.5.
Sex workers who had contracted an STD were asked how they came to know they had contracted a sexually transmitted disease. 87.4% (76/87) of them reported they had experienced vaginal discharges, followed by pain while urinating 52.9% (46/87), and genital sores 391% (34/87). Other symptoms experienced were weight loss 10.3% (9/87) and abdominal pain 4.6% (4/87).
The sex workers who had contracted an STD were again asked where they sought treatment when they had an STD. 48.3% (42/87) had sought treatment from a hospital, 44.8% (39/87) from a private clinic and 21.8% (19/87) from shops. A few, 3.4% (3/87), had used local herbs to cure their ailment.
Sex workers who had contracted an STD were asked about their sexual behavior when they had an STD. Most of them 69% continued with sex work during that period. Of these, 57.1% (48/84) used condom during this period whereas 11.9% (10/84) sex workers continued with unprotected sex as usual. Only 31% (26/84) abstained from sex during this period.
3.3.1 Sources of Information about HIV/AIDS
The first sources of information about AIDS were peers 52.2 % (104/198), radio 41.9% (83/198) and relatives 37.9% (75/198). Other sources mentioned included books 11.1% (22/198), parents 9.6% (19/198), teachers 9.1% (18/198), women's club 9.12% (18/198) and health workers 6.6 % (13/198).
When asked about the common source of information about AIDS, the majority were getting it from radio 85.6 % (170/198), followed by friends 66.2 % (131/198), books 11.6% (23/198).
3.3.2 Knowledge about HIV/AIDS Transmission
All sex workers were aware about the presence of AIDS. They also knew all the major modes of transmission (table 3): having unprotected sex with infected person, infected pregnant mother passing to unborn baby, transfusion with infected blood and sharing skin-piercing objects. As is apparent from their comments, almost all the sex workers (98.5%) knew about HIV/AIDS transmission through unprotected sexual intercourse:
· "I think as long as the semen or vaginal secretions are there, there is a possibility of getting AIDS" (35 year old sex worker).
· "AIDS is transmitted through sexual intercourse mainly [sic]" (24 year old sex worker).
Table 3. Knowledge about AIDS transmission
Mode of transmission |
Frequency |
Percentage |
Having unprotected sex with infected person |
195 |
98.5 |
Sharing piercing objects |
120 |
60.6 |
Infected blood |
48 |
24.2 |
Sharing utensils |
27 |
13.6 |
Infected mother passing it to her unborn baby |
23 |
11.6 |
I don't know |
3 |
1.5 |
Note: The percentage has been calculated on each individual's mode of transmission
ut of the 198 respondents who acknowledged having heard of AIDS.
3.3.3 Knowledge about Signs and Symptoms of HIV/AIDS
Sex workers who acknowledged that they had heard about AIDS were asked if they knew of any symptoms of AIDS. 81.3% (161/198) knew of skin rashes, followed by weight loss 56.1% (111/198). Other symptoms mentioned were diarrhea 36.4% (72/198), fever 34.8% (69/198), sores in the mouth 25.8% (51/198), cough 24.2% (48/198) and hair loss 10.6% (21/198).
Information was also sought from the sex workers regarding their knowledge about the a-symptomatic nature of infection with AIDS virus. Over 98% (153/156) knew that it was possible for the AIDS virus to be in the body for some time before a person starts to show any symptom of being sick.
3.3.4 Knowledge about AIDS Cure
Almost all sex workers, 97.5% (191/198), were aware that currently there is no cure for AIDS. However, a small number, 1.5% (3/198), thought that AIDS could be cured using traditional medicine and 1% (2/198) did not know.
3.3.5 Knowledge about Prevention of AIDS
Sex workers were asked if they knew of any way of avoiding getting infected with the AIDS virus. 81.3% (161/198) mentioned condom use followed by having one faithful sexual partner, 38.4% (76/198). Other ways mentioned included avoiding sharing skin-piercing objects, 17.2% (34/198), having sex within marriage partners only 8.6% (17/198), avoiding contact with infected persons 7.1% (15/198) and avoiding casual sex 6.1% (12/198). However, many sex workers were concerned about the difficulty of avoiding AIDS infection among married women from their husbands who are unlikely to use condoms. As a 19-year old sex worker who participated in a focus group discussion put it: "If you are married, it is impossible to avoid getting AIDS".
3.4.1 Behavioral Patterns
As implied by their comments from the focus group discussions, sex workers revealed that risky practices to STD and HIV/AIDS were highly prevalent in their community:
· "Multiple sex relations are rampant in this community" (32 year old sex worker).
· "Whenever a new girl who looks good comes to this community, every one uses her" (20 year old sex worker).
· "Many girls are not prevented by any one from sex work, and brings in more than five men anyhow" (28 year old sex worker).
· "There are young girls who enjoy paid sex, so one girl can get six men in a day" (22 year old sex worker).
84.2% (165/196) respondents had regular sex partners with whom they had regular sex during the last year. The mean number of clients was 2 per day and the maximum reported was 15 clients in the last one month. The mean age for first sex intercourse for most sex workers was reported to be 14.7 years, with the lowest age reported to be 9 years.
3.4.2 Reasons for Engaging in Sex Work
Sex workers engaged in paid sex for many various reasons as revealed in their responses in focus group discussions:
· "Money is the main reason for getting involved in this practice" (29 year old sex worker).
· "Some one may say, I am already infected and I have no job so if I can get quick money, why not give in?" (18 year-old sex worker).
· "My husband died of AIDS" (32 year old sex worker).
· "Many men divorce their wives after marrying them. These women cannot return to the homes of their parents and so they engage in paid sex" (32 year old sex worker).
· "We cannot fulfill all our needs so we look for money through other ways like prostitution. The standards these days are high and we have to raise them" (25 year old sex worker).
· "We sleep in a small room, so the rule is to find a client to spend away a night with" (24 year old sex worker).
Sex workers were asked to give the single most important reason why they engage in paid sex. The major reason for most sex workers was need of money for survival 52.3% (104/199), followed by death of parents or husband 19.6% (39/199), peer pressure or just wanted 15.9% (30/199), poverty 10.6% (21/199) and 2.8% (5/199) were involved in paid sex because they were not married.
3.4.3 Types of Sexual Client
· "Men from Half London, Speke Hotel (Nile Avenue), or even in Katanga if they can afford our prices" (16 year old sex worker).
· "Rich men, and if you can get a white man, that would be better" (18 year old sex worker).
· "Customers, when I started selling enguli (local gin), it is the way how I can get many customers" (25 year old sex worker).
This is how sex workers described the types of their client: 29.3% (55/188) said any man with money, 26.1% (46/188) said businessmen, 17.6% (33/188) said drivers and 16% (30/188) said men resident in their zones. Other reported clients included barmen, students, professionals and white men.
Sex workers were also asked if they choose among their clients, and if so, which ones they refuse. 54.6 % said they choose among their clients while 45.4 % said they accept any clients, as long as they have money.
Sex workers who reported they refuse some clients did so for various reasons: the majority, 59.3% (48/81), refused those with no money. Other clients refused included, those who were drunkards 12.3% (10/81), those who knew the sex workers 9.9% (8/81), those who refused to use condoms 4.9% (4/81), those whom they did not trust 9.9% (8/81) and those who used every other girl 3.7% (3/81). Other reasons for refusing some of their clients were depicted in their comments from focus group discussions:
· "I refuse those who want to make a love affair with me" (31 year old sex worker).
· "I refuse black men, I want white ones, and they know how to make love. For us we want white men" (18 year old sex worker).
3.4.4 Sex Work Transactions
Sex workers transacted their trade in several ways and clients paid sex workers in various forms. The majority of the clients paid in cash, 70.4% (140/199). Others, who could not always afford cash, paid in various forms that included paying for house rent 23.6% (47/199), paying other bills 22.1% (44/199), buying food 21.6% (43/199), buying dresses 14.1% (28/199) and others, as sex workers commented in focus group discussions:
· "A Katanga man cannot give you more than Shs 5,000. What will he eat if he gave you that money" (18 year old sex worker).
· "Me I have four boy friends (clients), 2 are steady and the other two I only visit them when I like in town. The reason why we get outsiders is that our fellow Katangees (men from Katanga) can only offer little money of 500-2000/=" (25 year old sex worker).
Almost all, 97 % (191/197) of sex workers, had heard about condoms.
3.5.1 Sources of Information about Condoms
Sex workers who admitted that they heard about condoms were asked about their sources of information. Most of them, 72.3% (138/191), first heard about condoms from friends, followed by those from radio 48.2% (92/191). Other sources mentioned included health workers 10.5% (20/191), women's club 10.5% (20/191), teachers 8.4% (16/191), books 7.9% (15/191), social worker 3.1% (6/191), parents 1.6% (3/191) and others, 2.6% (5/191).
3.5.2 Knowledge about Condom Use
Sex workers were also asked to tell us the important uses of condom: 92.6% (177/191) said for prevention of sexually transmitted diseases including HIV/AIDS, and 58.1% (111/191) said to avoid pregnancy.
It was found that accurate information and knowledge about correct use of condoms was still lacking as revealed in their responses when they were asked to explain how the condom is used.
· "First get the condom and pour some water and you see if there are holes and you use with your partner" (29 year old sex worker).
· "You get the condom and blow air in it in order to see if there is no hole and use it (39 year old sex worker).
· "The man wears it like a glove, then the process begins" (22 year old sex worker).
However, some sex workers knew of what precautions to take before using a condom as shown in their responses from qualitative interviews:
· "First check the date and if there is air in the packet, then open it and fit it on the penis yourself (18 year old sex worker).
· "The man puts it on the penis and removes it after one round" (25 year sex worker).
3.5.3 Patterns of Condom Use
Sex workers who had heard about condoms were asked if they had ever used condoms. 72.3% (138/191) reported having used a condom before, while 27.7% (53/191) or almost a third had never used condoms before.
Sex workers who used condoms were again asked why they used it. Most of them 53.6% (128/138) used it to avoid sexually transmitted diseases and AIDS, followed by those who wanted to avoid pregnancy 45.6% (109/138) and those who just wanted to experiment with it 0.8% (2/138).
Sex workers were again asked how often they used condoms. Most of the sex workers, 58.3% (77/132), used condoms occasionally while 41.7% (56/132) used them all the time.
Sex workers who reported that they used condoms on a few occasions were asked why they did so. 59% (36/61) did so because of clients' refusal, followed by 14.8% (9/61) who reported they used them only with casual clients, and 14.8% (9/61) did not because condoms were not available. Sex workers who participated in focus group interviews further emphasized their reasons for using condoms occasionally:
· "I cannot use a condom with my husband. I only use it with my boy friends" (25 year old sex worker).
· "Because there are occasions when my partner wants to have sex live" (31 year old sex worker).
· "There is a time when I want live sex" (18 year old sex worker).
· "Not all men allow using condoms" (22 year old sex worker).
· "My husband died of AIDS, so I have nothing to do" (33 year old sex worker).
· "Sometimes I may not have condoms, but when I have them I use them" (18 year old sex worker).
Sex workers who reported that they used condoms always did so because they mainly feared AIDS 52.7 % (29/55), pregnancy 49.1% (27/55), and because the clients liked them 12.7% (7/55). The various reasons were further confirmed in focus group interviews:
· "I am still young, I have to use condom to avoid AIDS and pregnancy" (19 year old sex worker).
· "Condom is the only way how to keep myself [safe]" (21 year old sex worker).
· "Because I fear to get AIDS, and [as] I am divorced my husband may laugh at me" (21 year old sex worker).
Sex workers who used condoms were further asked to describe the clients they used condoms with. 63.7% (79.124) reported to be using with all clients, 16.1% (10/124) with steady clients, 12.9% (16/124) with any client who allows it, and 7.3% (9/124) with casual partners.
Sex workers were also asked to tell who suggested condom use when they used them. 66.4% (91/137) said it was usually the sex worker herself, followed by either of them 24.8% (34/137) and less often the client 8.8% (12/137).
Regarding who made the final decision to using the condom, it was reported, mostly the sex worker 56.7% (80/134), followed by either of them 26.1% (35/134), and the client 14.2% (19/134).
Regarding who normally provided the condom, 52% (68/132) reported the sex worker herself, while 19% (32/132) were by the client, and 19% (32/132) by any of them.
Information was also sought on who exactly fitted the condom on the clients' penis. In most of the cases, 51.5% (67/130) it was the client, followed by the sex worker 26.9% (35/130) and any of them 20.8% (27/130).
3.5.4 Condom Storage and Disposal
58.6% (78/133) of the sex workers who used condoms kept them in their houses, while 41.4% (55/133) reported they didn't.
They were further asked to explain how and where exactly they stored condoms. 34.6% (27/78) kept them in suitcases, 26.9% (21/78) said in a cold place, 19.2% (15.78) said under their pillowcases, 16.7% (13/78) said in a dry place, 15.4% (12/78) said in their bags and 7.7% (6/78) said out of reach of children.
Sex workers were also asked to explain how they disposed of condoms after use. Most of them threw them in the pit latrine, 50.7% (70/138) or rubbish pit, 24.6% (34/138). Other methods mentioned included, burning them 13.8% (19/138), throwing them in drainage channels 9.4% (13/138), burying them in earth 3.6% (5/138), and client taking the condom after use 2.9% (4/138).
3.5.5 Condom Availability
Condoms were reported to be readily available in this community and one could easily get them from shops, 83.3% (115/138), followed by private clinics 27.5% (38/138). Other sources mentioned included hospitals 17.4% (24/138), friends 10.4 % (14/138) and social workers 5.8% (8/138). One sex worker commented in a focus group discussion: "Yeah, even malayas (prostitutes) sell them. It is a business here these days to sell condoms. People just don't use them" (22 year old sex worker).
Most sex workers, 98.4% (121/123), paid for condoms. The cost of condoms ranged between Shs. 100/= for each condom to Shs. 700/= per packet of three condom with a median cost of Shs. 500/= per packet, a price which most sex workers felt was reasonable as one commented in a focus group discussion: "The price is not so bad, Shs. 300/=. But people just neglect to use them" (24 year old sex worker).
Most sex workers, 81.5% (88/108), reported that they get enough condoms, although 18.5 % felt that they were not enough.
3.5.6 Barriers to Condom Use
In order to establish some of the barriers to consistent use of condoms among the sex workers, we sought information regarding sex workers' views about condom use and problems experienced while using condoms. Sex workers who admitted using condoms were asked to tell us about any problem they had heard of related to using condoms. 35.5% (49/138) mentioned the condom's getting stuck in the uterus, followed by those who mentioned condom bursting 22.5% (31/138). Other problems mentioned were that condoms have holes 8.7% (12/138), cause pain 8.7% (12/138) and cost expensive 4.3% (6/138). 27.5% (38/138) said they had not heard of any problem.
Some sex workers expressed their feelings in their comments during qualitative interviews about condoms:
· "They are expensive. Some of them are even expired" (24 year old sex worker).
· "Some clients don't enjoy sex with condoms. Others cause pain and genital sores" (35 year old sex worker).
They were then asked if they had experienced any of these problems. Most of those who answered this question had experienced none of the problems, 62.5% (40/64). The most frequent problem experienced was condom bursting 21.9% (14/64), followed by pain 9.4% (6/64) and condom's getting stuck in the vagina 6.2% (4/64).
To establish if clients also contributed to failure of consistent use of condoms among sex workers, information was sought on whether any of their clients ever refused to use a condom. Most of the sex workers, 66.9% (89/135), reported that their clients had done so.
Reasons given by most clients for refusing to use condom were because they did not enjoy sex using a condom 47.4% (36/76), followed by those who gave no reason 32.9% (25/76), and those claiming to be trusted 10.5% (8/76).
10.5% (8/76) refused condoms because they claimed they trusted the sex worker, 6.6% (5/76) said condoms were expensive, and 2.6% (2/76) did not know how to use condoms. Sex workers who participated in qualitative interviews emphasized this:
· "They say they trust me" (14 year old sex worker).
· "A man may refuse that with a condom he takes long to ejaculate" (18 year old sex workers).
· "They say that for them they don't enjoy sex with a condom" (20 year old worker)
Sex workers were then asked what they did with clients who refused to use a condom. 45.9% (39/85) refused sex, while 35.3% (30/89) had sex without condom. 14.1% (12/85) reported that they raised the fee for sex without a condom and 4.7% (4/85) reported that their action depended on the client. Sex workers who refused sex had various reasons, which were elicited from participants in focus group discussions:
· "I can't play sex without a condom. When I talk to him and he refuses, I leave him" (20 year old sex worker).
· "I refused because I don't want to kill my husband and my children" (25 year old sex worker).
· "I refused to play sex with him until we go for a blood AIDS test" (20 year old sex worker).
· "I refused to have sex. I am a married woman and I have to be very careful" (19 year old sex worker).
Those who continued to have sex without a condom did so mainly because they were desperate to get money as depicted in their responses:
· "I asked for more money" (31 year old sex worker).
· "I just allowed him because I had nothing to do so long as he gave me cash" (25 year old sex worker).
· "I agreed because I wanted money" (18 year old sex worker).
· "Since he was also infected with HIV, we played sex without a condom" (33 year old widow who reported to be HIV+).
Finally sex workers who reported they had never used condoms were asked why they had not done so. Most of them, 37.7% (20/53) claimed they did not, because they trusted their clients, followed by those who reported that clients did not want them, 28.3% (15/52). Some sex workers said they just did not bother to use them 22.6% (12/53), while others said they feared them 15.1% (8/53) or did not know about them 13.2% (7/53). A few sex workers claimed condoms were expensive or that they didn't know how to access them.
3.6.1 Perception of Risk of HIV Infection
In order to establish the sex worker's perceptions of their risk to HIV/AIDS, information was sought on whether they perceived their risk to acquiring HIV/AIDS, and whether they took any safeguards to protect themselves from the disease.
Sex workers were asked if they thought their present sexual behavior might lead them to getting infected by the AIDS virus in the future. The majority of them, 56.9% (74/130), thought they may easily get infected while 43.1% (56/130) did not think so.
Those who perceived their risk to future infection gave a number of reasons, which were further emphasized by participants in focus group discussions:
· "Yes, because I haven't been using condoms" (17 year old sex worker).
· "Yes, I failed to use condoms as you may end up being operated when it sticks in you" (24 year old sex worker).
· "Yes, because I love many men" (18 year old sex worker).
· "Yes, you never know what happens since condoms are not 100% safe and some men are malicious, they can put it off" (19 year old sex workers).
· "Not sure, the reason is that there are some men you can see who don't look healthy, and you tell them to use a condom" (16 year old sex worker).
The majority of them, 36.5% (27/74), said they thought they might get infected because they do not use condoms, 31% (23/74) said their partners are not faithful, 24.3% (18/74) said they had many clients, and 8.1% (6/74) reported that sometimes condoms burst, while 20.7% (15/74) did not give any reason.
43.1% (65/130) of the sex workers who thought their behavior might not lead them to getting infected in future revealed the safeguards they were taking. One sex worker commented: "No, because I am going to use condoms until I get married" (18 year old sex worker).
Sex workers were again asked to judge, if by their past sexual behavior, they thought they might already have been infected by the AIDS virus. 37.5% (39/104) admitted they might have been infected, while 62.5% (65/104) did not think they were infected as yet.
Those who thought they might already have been infected gave several reasons:
· "Yes, because I do not use condom with all clients" (31 year old sex worker).
· "Yes because my husband died of AIDS" (32 year old sex worker who had tested HIV+).
· "Not sure; at times I use condoms, at times I do not use" (23 year old sex worker).
· "Not sure because I have not gone for a blood test" (18 year old sex worker).
Among the sex workers, 25.6% (10/39) indicated that they might be infected with HIV/AIDS because they were not using condoms consistently, 17.9% (7/39) said their clients were not faithful, 15.4% (6/39) revealed they had many clients, 12.8% (5/39) indicated a lover who had died, while 12.8% (5/39) reported they had not gone for a blood test. 12.8% (5/39) said they didn't know if they were infected.
Sex workers who thought they might not be infected also gave several reasons: 73.8% (31/42) indicated they trusted their clients, 23.8% (10/42) said their clients were still alive. One sex worker summed up their general perception of the risk of infection by saying: "No, all my former boy friends (clients) are still alive with their wives and children" (19 year old sex worker).
3.6.2 Perception on Safer Options
Information was sought on sex worker's perceptions and attitudes to various safer sex options as predictors of future safe sexual behavior. When asked whether they perceived having one trusted sexual partner as a practical protective option against HIV/AIDS, 65.3% (109/167) thought it was practical, while 34.7% (58/167) thought it was not a practical option. Some sex workers expressed their reservations towards this opinion:
· "No, because the two of you have casual sex partners so in the end you get infected" (25 year old sex worker).
· "No, I was with one partner but I am now infected" (28 year old sex worker).
· "No, I trusted my husband but he cheated me" (32 year old sex worker who tested HIV+ and whose husband died of AIDS).
· "No, you can't have only one man" (16 year old sex worker).
Sex workers were further asked if they perceived condom use as a practical protective option against HIV/AIDS. 67.1% (104/155) considered it as a practical option while 32.9% (51/155) felt it was not. Sex workers who felt condom use was not protective expressed their feelings:
· "But you know they also burst or roll off, so it's only God who protects, there is no protective measure" (16 year old sex worker).
· "No, when you know how to use it, but most people don't know how to use condoms" (18 year old sex worker).
· "Some men damage condoms through piercing with needles, cutting them, using Vaseline to damage them and some times removing them during the time of intercourse (22 year old sex worker).
It was also revealed from focus group discussions that a number of sex workers practiced masturbation and perceived it as a safer sex option that could protect them from risky practices to HIV/AIDS:
May be masturbation could help. I have to do it because my clients sometimes are away or irregular, so I have to find a way of satisfying myself. So when I think and think about some one who is not around, I find my hand moving to the act of masturbation. Sometimes I use warm water to reduce the urge (18 year old sex worker).
3.7.1 HIV/AIDS in the Community
Sex workers were asked if they knew of anyone with AIDS in their community. The majority, 98% (190/194), knew of someone with AIDS, suggesting that HIV/AIDS was a major health problem.
3.7.2 Predictors of Behavioral Change
In order to establish the impact of the AIDS scourge on individual behavior, specific information was sought on sex work practices thought to predict future risky behavior. Sex workers were asked if they had ever sought for HIV/AIDS counseling from anywhere. 55.2% (106/192) had not done so while 44.8% (86/192) had received counseling before.
It was found that only 15% (28/187) had ever gone for an HIV/AIDS test, while the majority 85% (159/187) had never done so. Among those who had an HIV/AIDS test, 10.7% (3/28) of the sex workers reported they tested positive for the HIV/AIDS virus while 67.9 % (19/28) of the sex workers reported they tested negative. The rest, 21.4% (6/28), did not reveal their status.
3.7.3 Impact on Sex Work Practice
Sex workers who participated in focus group discussions disclosed several ways in which the spread of HIV/AIDS has affected their sex work practices:
· "I cannot allow anyone to play sex with me without a condom" (18 year old sex worker).
· "I have no love for any man, I just play sex because of my children's needs" (35 year old sex worker).
· "It affected me very much and not I fear a bit [sic], but it is because of money for my children" (25 year old sex worker).
· "I fear my sisters died of HIV/AIDS. I have tried to stick to condom and to select my clients" (16 year old sex worker).
· "I fear HIV/AIDS but have nothing to do because I have no help" (25 year old sex worker).
Sex workers were further asked if they had reduced the number of sexual clients due to the AIDS scourge. 63.1% (4/149) reported having done so while 36.9% (55/149) had not. Some sex workers who participated in focus group discussions revealed:
· "I try to have one client per day just for survival" (20 year old sex worker).
· "I get two or one client just for survival" (16 year old sex worker).
The m
ean number of clients before reduction was 3 per day while after reducing the number of clients it was reported to be 2 per day. Those who had not reduced the number of their clients gave a number of reasons as expressed in their responses:
· "I have not changed, because when I meet with my clients I use condoms" (19 year old sex worker).
· "It is the only work which gives money without fail" (25 year old sex worker).
· "Where can I get money if I change? I have nothing to eat so I can not change" (17 year old sex worker).
· "I don't have too many clients (2 per day), what can I reduce? It is my only job, where can I get clean money" (24 year old sex worker).
· "Because my husband died" (32 year old HIV+ sex worker whose husband died of HIV/AIDS).
Among those who had not reduced on the number of their clients, 71.8% (28/39) said it was because sex work was a paying job while 28.2% (11/39) said because they were now using a condom with their clients. Most of the sex workers had reduced their clients between late 1994 and early 1996.
3.8.1 AIDS Control Activities among Sex Workers
In order to get baseline information for future AIDS control activities among sex workers, information was sought on what AIDS control activities had been initiated and implemented in their community. 45.1% (78/173) reported that AIDS seminars had been conducted while 5.1% (9/173) reported gospel messages about HIV/AIDS by evangelists. 39.3% (68/173) reported that no activity had taken place, while 9.2% (16/173) said they could not attend because they couldn't read and write. One sex worker said: "I cannot go there (to the HIV/AIDS seminars) because I do not know how to read or write" (23 year old sex worker).
Sex workers were asked what they had learnt from these activities. 40.2% (35/87) said they had learnt how to use condom, 37.9% (33/87) said they had learnt how to avoid being infected by HIV/AIDS, 19.5 % (17/87) had learnt to change their sexual behavior, 16.1% (14/87) had learnt facts about HIV/AIDS, 8% (7/87) had learnt how to counsel others, and 5.7% (5/87) had learnt that AIDS is bad. Sex workers who participated in focus group discussions emphasized the lessons they had learnt form AIDS seminars:
· "To reduce risky sexual practices and look for a job" (31 year old sex worker).
· "That behavior change is possible. Condom use is necessary for prevention of AIDS" (18 year old sex worker).
· "To use condom and have one sex partner but for me (sic) I have my problems" (25 year old sex worker).
· "How to use a condom and a lot about behavior change. I have learnt to keep on using a condom" (20 year old sex worker).
· "How to avoid AIDS and STDs but I have my problems. I can't care about it" (20 year old sex worker).
3.8.2 Proposals for Interventions among Sex Workers
Sex workers made proposals for strategies that could be done to prevent further spread of HIV/AIDS in their community. Most of them suggested promotion of condom use 35.6% (64/179), followed by those who suggested teaching everybody about AIDS 34.6% (62/179) and promoting faithfulness 12.3% (22/179). Other suggestions included creating job opportunities 2.8% (5/179), teaching about salvation 1.7% (3/179) and putting a clinic in the area to provide free drugs and condoms. 11.7% (21/179) said nothing could be done to prevent HIV/AIDS among sex workers. Sex workers who participated in focus groups discussions gave their views:
· "Create jobs. But this will help to a less extent because prostitutes are lazy, they don't want to work. But even these women who work can also come back and go into prostitution. So this can only help to a less extent" (35 year old sex worker).
· "Educate people how to use condoms and give them freely" (27 year old sex worker).
· "Bring so many projects where everybody can get a job and get enough money" (18 year old sex worker).
Those who thought nothing could be done also had their views:
· "Never! There is no way you can stop people from engaging in sex, unless the world ends" (30 year old sex worker).
· "Nothing can be done because men and women sleep around quite a lot. Only God can save Katanga" (22 year old sex worker).
Finally, in order to explore potential areas involving sex workers in intervention activities among themselves, they were asked how they could contribute in preventing the spread of HIV/AIDS.
Most of them 37.7% (60/159) said they could participate in teaching and counseling people in the community, 13.8% (22/159) said through behavior change, 13.2% (21/159) through condom use, 11.9% (19/1159) through participation in seminars, while 23.3% (37/159) said they had nothing to do in prevention activities. Sex workers made some comments in qualitative interviews:
· "To teach my friends and partners" (20 year old sex worker).
· "To teach people how to use condoms house to house" (30 year old sex worker).
Those who said they had nothing to do also gave their views:
· "I am not trained, I haven't much to do" (24 year old sex worker).
· "I don't think I have much to do, people here are independent" (18 year old sex worker).
