HIV and AIDS: The Global Inter-Connection

CLIENTS AND COMMERCIAL SEX WORK

 By Dr. Eka Esu-Williams

An accurate assessment of the scope and intensity of the HIV epidemic in Nigeria continues to be elusive, retarding the evolution of rational decisions and appropriate actions by health policy makers and other interested parties. The low numbers reported to date reinforce the officially sanctioned notion of Nigeria as a low HIV prevalence country. This in turn reinforces the already pervasive apathy among the population, who believe that there is no significant present or future threat.

Recent surveillance studies offer a potentially more accurate signal of Nigeria's precarious position, documenting seroprevalence rates of up to 36 per cent among women working in the commercial sex industry, up to 5.8 per cent in antenatal clinic attenders, up to 4 per cent among blood donors.

Among those who work as commercial sex workers in the city of Lagos, a baseline HIV prevalence reported at 3 per cent in 1987 rose to 17 per cent in 1992, and among blood donors in Maiduguri City, it rose from 0 per cent in 1987 to over 4 per cent in 1992. Although this difference may be attributable to more intensive and regular testing, it is likely that new infections account for most of the dramatic increase.

These figures represent an exponential increase in infection rates and suggest that HIV infection is entrenched in the population and is assuming epidemic proportions. Unfortunately, current attitudes and competing demands for scarce resources leave the Nigerian population vulnerable to a rapid spread of HIV infection and subsequently to AIDS.

The Cross River State (CRS) of Nigeria, one of the country's twenty-one states with a population of about 2 million out of a total of 106 million, provides a prototype for targeted interventions. The results and experiences of an HIV prevention programme for commercial sex workers and their clients started in 1987. The formulation and execution of the programme activities have involved key members of the target group such as hotel owners and managers, chairladies (head sex workers), sex workers, and clients. To indicate the programme's scope to date, more than 1,500 low income full-time resident sex workers and clients have been reached.

Commercial sex work is not culturally sanctioned in Nigeria, and it is seldom a preferred choice of vocation. Women are commonly coerced into it for a variety of reasons, including involuntary divorce, widowhood, joblessness and, in some cases, infertility. The CRS programme found no women for whom sex work was a choice and not a necessity, and 95 per cent of them were prepared to abandon this occupation if alternative employment with comparable, or even slightly lower, income could be found.

Because sex work is illegal and highly stigmatized, female sex workers in Nigeria become part of a vicious cycle of exploitation and harassment by their clients, hotel owners, and managers, as well as law-enforcement agents. The latter have traditionally viewed them as easy targets for extortion. According to the women, one of the many unwritten rules is that the client is always right. This is rigidly enforced by hotel owners and managers to encourage a steady flow of clients, which in turn ensures that sex workers pay their bills. Because the clients often determine the price, may claim dissatisfaction and seek a refund, or later request compensation for treatment of a sexually transmitted infection (STI) without offering proof of infection, there is seldom an opportunity for the women to save money. Given these conditions and the fact that the price for their services has remained the same for over a decade, despite spiraling inflation, the women are compelled to seek and accept a high number of clients.

The inability to negotiate fairly with clients, hotel owners, managers and law-enforcement agents, coupled with societal stigmatization of sex work, leads to and perpetuates very low self- and group-esteem among the women. They commonly referred to one another as "ashawo," a derogatory local name for a commerical sex worker and to their children as "ashawo pikin." They are also reluctant to deal with decisions and transitions that affect their lives, particularly those involving persons in positions of authority.

The new, younger sex workers do not, however, abandon their desire for children. With little access to family planning and health information, these young women are at considerable risk of contracting HIV. They are also at risk of becoming pregnant, leading inevitably to an upsurge in the number of infants with HIV infection and pediatric AIDS cases.

Exploitation, extortion, negative self-perception and societal condemnation ultimately disable many women working in the sex work industry. Often these attitudes render them incapable of saving substantial income or reintegrating into society should they choose to disengage from the business, let alone seeking and adopting the health-promoting behaviours necessary for HIV prevention.

In an effort to redress some of these inequities, the CRS programme staff organized a programme involving security agents, hotel owners, managers and chairladies to secure an agreement to keep rents at current levels, while allowing the women to charge more money for sex. As a result of this collaboration, harassment and extortion by security agents has become rare and we have seen new expressions of self- and group-confidence among the women, including more assertive negotiation for condom use.

Targeting Clients

While commercial sex workers are readily identifiable, their clients often try to conceal their identity. The CRS programme gathered information about clients from managers, the commercial sex workers themselves and clients who volunteered. The men were primarily Nigerians and they represented a cross section of the population ranging from low-income artisans, traders and drivers to college students, members of the armed forces and government employees. Some of them were habitual clients, while others paid only occasional visits. Commonly, the men engaged in a high rate of partner exchange, placing both themselves and their sexual contacts at high risk of contracting HIV. Apart from contact with the sex workers, the clients, approximately 60 per cent of whom were unmarried, reported intercourse with wives, girlfriends, and casual acquaintances.

Despite substantial progress being made to increase the women's knowledge about HIV and STIs, their clients still exhibit apathy and denial of the epidemic. A disturbing finding was that seropositive clients consistently denied being infected and refused to seek counselling.

Assisting clients to educate themselves did not prove effective in the CRS programme. They remained unwilling to be identified or to assemble for education, and there were difficulties in finding a suitable forum and mode of communication. As a result, the programme's major strategy was to reinforce the initiatives and ingenuity of women who are commercial sex workers. For example, the women used a poster from a taxi billboard campaign which read "No AIDS please, the family needs you," as a pointed reminder to the clients of their obligation to protect their present and future families.

Condom Concerns

Consistent use of condoms has been considered the primary weapon for preventing HIV infection among sex workers, as well as for others in situations where there is risk. However, certain considerations need to be kept in mind when promoting condom use among the women and their clients, which have bearing on similar promotions among the rest of the population. The have many reservations regarding the use of condoms. Some fear they may retain the condoms in their vagina, while others will not use condoms because they want to become pregnant. Some of the women were ignorant of the existence or benefits of condoms. Among the older commercial sex workers, there is a belief that seminal fluid has nutritional value and contributes to good health when absorbed during intercourse. Men tend to regard the use of condoms as an alien practice that reduces sexual satisfaction and interferes with male control over sexual relationship. And both groups are suspicious of potential sexual partners who want to use condoms, believing that they may have an STI.

When condom interventions were implemented in the CRS programme, the health and economic benefits were promoted by the staff. Women were educated about HIV, its modes of transmission, and the savings they would realize from using condoms regularly instead of having to buy expensive antibiotics (54 per cent of the women reported taking antibiotics daily). Within the first year of intervention, the number of commercial sex workers who never used condoms fell from 25 per cent to 3 per cent. Because the men still seemed reluctant to initiate condom use, in nearly all instances the women reported that they had suggested use of and provided the condoms.

The lack of sufficient, affordable and reliable supplies of quality condoms represents the single most pressing concern of condom-based interventions. Although a high degree of condom use has been achieved, the programme has suffered major setbacks because of this problem. For example, the inadequate supply has made it impossible to meet more than one third of the condom needs for the city of Calabar alone. The shortage has also curtailed the expansion of the programme to four additional cities for another two years. When no alternatives were available, poor quality condoms were distributed for a three-month period in 1989. The frequent breakages severely discouraged condom users. Pursuing small supplies of condoms becomes a major programme task, redirecting valuable time and energy away from other activities and contributing to the high rate of burnout among field-workers.

Looking Ahead

To forestall an onslaught of HIV infection and AIDS cases, immediate action is required. Nigeria must institute a series of comprehensive, prioritized programmes taking into account lessons learned from the experiences of other African countries where the epidemic has produced devastating repercussions.

The recent decision by government to integrate HIV prevention activities within the primary health care (PHC) system is an important step. But the PHC system is still in its formative stages, and the time needed to effectively implement this approach is not available in the battle to check the spread of HIV infection. Additional strategies, specifically prevention initiatives that reach the entire population, are needed to supplement the longer-term PHC-implemented programmes. And since only about 20 per cent of transfused blood is being tested for HIV, action must be taken to improve the security of the blood supply.

Commercial sex workers and their clients hold important keys to successful HIV prevention efforts. From the workers we can learn what intervention activities appeal to clients, who in turn may be able to impart knowledge and positive attitudes to a larger base of men engaged in similar activities. We need to develop programmes for girls and women who are at an economic disadvantage that may predispose them to commence sex work. We must also target programmes at women who are already working in the sex industry as well as their clients.

Strategies for controlling HIV require careful thought and planning, and they must be sanctioned and supported by government as well as communities. This implies the recognition of the practice of sex work and the very existence of girls and women on the verge of adopting sex work as a means of livelihood.

In Nigeria, severe social and economic pressures have eroded cultural values and parental controls that normally would have a positive effect on HIV prevention. Not only are many parents unable to provide for and educate their daughters, but also they increasingly see the economic value of their sexuality as a potential source of support for the family.

Girls desperate to support themselves and assist their families often migrate to urban areas in search of employment opportunities and when that proves futile they turn to sex work. Successfully addressing the socioeconomic and cultural snares that offer young women no survival options besides sex work represents a major future challenge. Designing and implementing effective HIV-specific prevention programmes will become more complex because of the need to tailor efforts toward younger, inexperienced, and nonassertive commercial sex workers. These programmes will necessitate identifying very specific strategies for sustaining the women's involvement in prevention activities.

The vulnerability of girls and young men to partake in risky sexual behaviour is exacerbated by the absence of constructive sex education at home and in school. With roots in cultural systems where sex education was the work of aunts, grandparents, or other kin, many African parents still consider parental or school-based sex education a taboo. In urban settings, the traditionally appropriate relatives may not be available, yet teachers are not officially mandated to teach sex education in our schools. A culturally sensitive and appropriate sex-education curriculum needs to be developed and applied in schools, while parents and religious and community leaders must develop acceptable ways in which STI and HIV education can become an accepted theme for discussion.

Family-planning providers should orient their services toward birth and disease prevention to benefit those for whom unwanted pregnancies and STIs constitute major health risks. All women need to be empowered to initiate and adopt HIV-prevention efforts. They should be provided with health services, education, and training to ensure other employment options. The risk of HIV for full-time commercial sex workers with no other options for income is exceedingly high. Comfort, a twenty-eight-year-old woman who "always" uses condoms has recently become seropositive. She is a strong advocate of condom use among her peers and her infection underscores the point that economic considerations supersede health concerns. When talking about condom use at a recent target-group workshop, she said: "It is easier to get a client to use a condom for his sex act, but when a man comes to stay overnight, you cannot get the same man to use condoms for each of many sex acts." Because a woman can earn five to six times more money from an all-night client, in the absence of alternative income options the certainty of immediate monetary gain often takes priority over the potential risk of infection, even when the potentially deadly nature of the risks involved are known.

Prevention-centered programmes in Nigeria, as elsewhere in Africa, are in dire need of more effective male-centered approaches. Modifying male attitudes about HIV and sexual behaviour is one of the significant factors in controlling this epidemic, and this constitutes a great challenge. But in confronting this epidemic, men also have a responsibility to respond by developing and championing male-focused activities and programmes that reflect relevant issues and appeal to their sensitivities.

Male responsibilities extend beyond their sexuality. Men hold privileged positions in government, society, community, and family. They possess the power and resources needed to ensure that initiatives also benefit women and young people. Prevention programmes that are spearheaded and supported at the highest level possible are urgently required in Nigeria. Our future is at stake.

Biographical note

Dr. Eka Esu-Williams is a senior lecturer in the Department of Immunology at the University of Calabar. She is a founding member and the current president of the Society for Women and AIDS in Africa (SWAA), and is the AIDS Programme Coordinator for the Cross River State of Nigeria. She has extensive experience with HIV-prevention programmes addressing female commercial sex workers and their clients.