Male and transgender sex workers in South Africa are at particularly high risk of HIV infection and have significant unmet prevention needs, according to results of a large multi-site study presented last month at the Southern African HIV Clinicians Society conference in Cape Town.
Male sex workers were found to be 2.9 times (AOR, 95%CI=1.6-5.3, p<0.001) more likely, and transgender sex workers 2.4 times (AOR, 95%CI 1.1-4.9, P=0.021) more likely, than female sex workers to have unprotected sex, according to the multivariate analysis of a study examining the characteristics and sexual behaviour of sex workers in South Africa. The study also aimed to assess the risk factors for unprotected penetrative sexual intercourse of female, male and transgender sex workers.
Across four site, 1799 self-identified female, male and transgender sex workers were interviewed by trained sex worker research assistants during May to September 2010. The research sites included two urban centres and one semi-rural site adjacent to a mine and were purposively selected, based on the presence of sex worker advocacy groups and peer education work. Although the three cities were selected to obtain data on diverse sex work settings, these findings may not apply to other sex work areas in South Africa.
There is no estimation of sex worker numbers in South Africa. Little is known about the features and health needs of sex workers in South Africa. This is partly because it is a criminalised occupation. No public health services exist for sex workers specifically and sex workers are often discriminated against by healthcare workers when they access health services. A handful of NGO-driven health interventions exist for sex workers in South Africa.
Sex workers in the three study sites where no sex work-specific clinic and mobile outreach clinical services for sex workers existed were significantly more likely to engage in unprotected sex than those situated within the site where these services do exist. At this site, a cadre of sex work peer educators disseminate information and condoms within hotels and clubs from where sex workers operate, while a male community health worker provides HIV and STI education and referrals to clients within bars and nightclubs.
“This model should be duplicated in other areas of sex work concentration in South Africa,” said Marlise Richter, a study researcher of the International Centre for Reproductive Health, Ghent University, and African Centre for Migration and Society of the University of Witwatersrand.
Alcohol use was found to be a major risk factor for unprotected sex. Participants who reported daily or weekly binge drinking were 2.1 times more likely to have unprotected sex (95%CI 1.2-3.7, p=0.011) compared to those who never binge drink. About a fifth of females, a third of transgender people and over 40% of males reported daily binge drinking. More than 40% of females were drunk during sex with last client in comparison to 59.7% of males and 66.1% of transgender people.
Of all participants, 27.0% had unprotected sex when engaged in anal intercourse with their last client. “This is the most risky sex act for acquiring HIV and other STIs. Public health interventions with female, male and transgender sex workers and their clients should emphasise the risks associated with anal sex and ensure that condoms and lubrication are accessible and freely available within the sex industry,” said Richter.
Of female participants 44.3% (446 of 1006) had used a female condom at some point. Of these, 28% reported to “like” female condoms and 45% stated they “liked them a lot”. Among those female participants who did not use female condoms and provided reasons for non-use, 17.7% noted that they had never been given female condoms, 19.8% did not know how to use them and 23% reported to “not like” female condoms.
Female condoms are one of few female-controlled HIV prevention technologies available, with some female sex workers even using them without clients’ knowledge. South African sex work activists have advocated for the greater availability of female condoms in sex work settings, with little success.
Sex work was the major livelihood strategy adopted by the study populations. More than 40% had been in the industry for more than five years. Approximately two thirds were full-time sex workers, while over a third had no other work experience prior to entering sex work.
When comparing full-time sex workers’ income with data from Statistics South Africa on monthly earnings by occupation, sex workers in this study were earning more than clerks or people working in sales and services or crafts and related trades, and up to six times more than domestic workers.
“This is pertinent [information] for some ideology-based health and social interventions aiming to rehabilitate sex workers or focused solely on exit programmes,” said Richter.
Richter M Characteristics, sexual behaviour and risk factors of female, male and transgender sex workers in South Africa. First Southern African HIV Clinicians Society Conference, Cape Town, 2012.