HIV Needs Assessment of Female Sex Workers in Major Towns, Mining Towns, and Along Major Roads in Botswana

Background

I-TECH conducted this formative assessment in collaboration with Matshelo Community Development Association (MCDA) to inform HIV prevention strategies for female sex workers (FSW) and their male partners. The assessment focused on the following field sites: Francistown, Gaborone, Ghanzi, Kasane, Letlhakane, and Selebi-Phikwe.

The assessment aimed to:

• Compile a list of partners best positioned to help reduce the risk of HIV and AIDS for and by FSW.
• Describe the current nature of high-risk behaviors and situations for FSW in Botswana (locations, motivations for behaviors, risk recognition for HIV, constraints and cultural supports for their practices in FSWs' daily lives, type of sexual practices and characteristics of sexual partners from FSWs' and males' perspectives).
• Describe the current state of clinical and social services available to and used by FSW.
• Provide timely information to make recommendations to the government, donors, and implementers for future clinical and social programs targeted at FSW, men potentially at risk of HIV acquisition from FSW, and high-risk situations as appropriate.
  

Methods

In-depth interviews (IDI) were conducted in 6 towns across Botswana (as noted above) with 17 health care providers, 16 traditional/faith healers, 13 non-governmental organizations, and 30 FSW. Focus group discussions were also held with 6 groups of 3 to 4 men (n=20 total). FSW were identified via observations on roadsides, in bars and hotels, or via key persons, such as hotel employees and other sex workers. Constant comparative and phenomenological approaches were used to analyze data.

Findings

Stigmatization, group organization, and HIV and AIDS risk for FSW varied by town. For example, high stigma, low visibility, small FSW networks, and high-risk behaviors characterized FSW groups and behaviors in Ghanzi, while medium stigma, high visibility, large FSW networks with peer leaders, and lower risk behaviors typified those found in Francistown. Among FSW, there is extensive individual variation in working hours, location, condom use, and self-defense strategies—all of which put FSW at variable risk for HIV. Participants commonly attributed entry into sex work to perceived failure of male partners to adequately provide for them, as well as lack of female earning power. Women described sex work as a means for financial and personal autonomy. Most hid their work from their families. Some used alcohol daily to ease their transition into sex work while others refrained to remain alert when working. FSW accessed free condoms, STI treatment, and VCT services at public health clinics but never revealed their risk for STIs and/or HIV. FSW who were not citizens of Botswana perceived a threat in the new requirement for identification, usually their passports, when accessing health care. Most FSW feared disclosure, entrapment, theft, physical violence, rape, pregnancy, and STIs and/or HIV. Though most FSW wanted to leave sex work, very few saved from their monthly earnings (≈US$160–1,000/month) or used it to gain vocational or professional skills.

In focus group discussions with men, it was reported that some men sought sex with unknown women due to their inability to meet the increasing material demands from wives or girlfriends. Instead, they used their small budgets to find sexual relief using FSW. Most of the study's male informants believed that men indulged in casual sex due to use of alcohol, sexual abstinence, a wish for excitement and adventure, and to appear as men of means. Some male participants reported using condoms (though not consistently), while others reported a willingness to pay more for unprotected sex and the accompanying increase in sexual pleasure, as well as the thrill of risking the danger of STIs and/or HIV.

Men wanted women to take more responsibility for condom use if they were sexually available for money and had multiple partners. Male informants also suggested that HIV and AIDS campaigns "make a big mistake by targeting women only and not targeting men" because the campaigns need to look at both sides of the market. "There is demand and supply." Men offered suggestions based on best practices for health promotion and culturally embedded consultative processes. In general, they felt health promotion needed to be more innovative and participatory to reach the people.

Health care services were accessed and appreciated by both men and women. However, women did not reveal their risk for STIs and/or HIV to providers of those services. Men did not test for HIV, preferring to infer their results from those of their intimate partners. Health care workers prided themselves on providing equitable health care to all their patients, yet conceded that FSW might not be receiving appropriate counseling and treatment because of nondisclosure. However, they were not able to articulate how the needs of FSW might differ from those of other women. Only one traditional healer specifically served women in sex work, to address the conditions peculiar to their work.

Very few organizations directly targeted FSW to offer assistance. One exception was the Matshelo Community Development Association (MCDA), a network organization working in 16 places (including in partnership with Nkaikela in Tlokweng) to reach sex workers largely through funds provided by the Norwegian and Swedish Embassies through the Project Support Group (PSG) Basket Fund. FSW in the networks received health promotion and HIV prevention information, safety tips, support for appropriate care seeking, linkages to designated STI clinics, and vocational training to help with exit from sex work through peers. Other organizations did not directly engage with sex workers, partly because of the existing legal frameworks on sex work. Instead, for example, they promoted condoms among young women in bars with the hope that they were reaching some sex workers. Others offered vocational training in usually female dominated fields, such as cookery.

Overall, participants felt that the government needed to revisit policies on education, employment, minimum wage, and sex work to address the legal, social, and health care needs of women. While some grassroots organizations had taken initiative and strove to address issues of gender, poverty, and HIV, the not-for-profit sector (non-governmental and community- and faith-based organizations [abbreviated as NGO, CBO, and FBO, respectively])—with a few remarkable exceptions—was largely weak and needed strengthening. 

Recommendations

Geographical and individual variations in sex work preclude a single intervention for reducing the risks of HIV and AIDS transmission for FSW in Botswana. Addressing gender inequities through community consultative gender discussions and vocational/professional training for academically challenged girls may reduce women's entry into sex work. Harm reduction could include group formation, psychological and substance abuse counseling, self-defense, access to appropriate counseling for STI and/or HIV prevention through discrete clinics, saving schemes or microfinancing projects, and health promotion interventions that target FSW and their clients. To reduce the demand for FSW services, including unprotected sex, current initiatives focusing on men need to be strengthened. Interventions that provide men with alternative perspectives on desirable sexual behavior and modified gender expectations may reduce the demand for unsafe sex by generating cultural support for safer sexual practices.

There is much that can be done for FSW and their clients without requiring the government or NGOs, CBOs, or FBOs to change their positions or take a stand on sex work. These efforts can be directed at preventing entry into sex work, harm reduction in sex work, and facilitating exit for those women who want to stop engaging in sex work.