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F I N A L R E P O R T "I expect to be abused and I have fear": Sex workers' experiences of human rights violations and barriers to accessing healthcare in four African countries Study team: Acknowledgements
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... ''Decriminalisation of sex work is a matter that has been a subject of debate and society should continue to deliberate on the matter until final resolution''-National Strategic Plan on HIV, STIs and TB 2012Á2016 launched by the South African government, 1 December 2011(SANAC, 2011d. ...
... Something must be done. Yet the Government has changed the final draft of the National Strategic Plan to remove any trace of a commitment to end the criminalisation of sex workers and their clients'' -Mickey Meji, Leader: SANAC Sex Work Sector, 1 December 2011(SWEAT, 2011 In May 2007, sex workers had a victory. The new South African AIDS Plan 2007Á 2011 was passed by Cabinet, and not only acknowledged the existence of sex workers in South Africa, but contained a number of progressive provisions on sex work. ...
... Little further research has been done on HIV prevalence amongst sex workers in South Africa -an indication of the marginalisation of this group even within the research community. Studies in South Africa have documented substantial levels of direct violence against sex workers from clients, non-paying partners and the police (Campbell, 2000: Pettifor et al, 2000Gould and Fick, 2008;Vetten and Dladla, 2000) as well as structural violence against sex workers (CORMSA, 2011;Vearey et al, 2011;Scorgie et al, 2011b;Scorgie et al, 2011a). The unequal power relations between sex workers and their sexual partners limit sex workers' ability to insist on the use of condoms during sex, thus increasing their risk of contracting HIV and other STIs (Pauw and Brener, 2003;Varga, 1997;Varga, 2001). ...
Sex work is highly stigmatised in South Africa. All aspects of sex work are currently a criminal offence. Sex workers’ stigmatised position in society, and the nature of their work-multiple, concurrent sexual partnerships, working within dangerous and violent spaces, and lack of services and legal protection-render them particularly vulnerable to HIV and other Sexually Transmitted Infections (STIs). No recent data on sex worker HIV prevalence in South Africa exists, but it ranged from 45%–69% in 1998.
Sex work often occupies a much maligned – and often sensationalised or lurid – space in contemporary thinking and social change activism on feminism, health matters, policy-formation and human rights in Africa. Few individuals or institutions treat sex work or sex workers with seriousness or respect. Indeed, in areas of policy-formation, programme design or law reform, sex workers are often either overlooked, paid lip-service to, or they are let down during power-broking. South Africa's AIDS response has been no exception. This Briefing explores South Africa's 2007 and 2012 AIDS Plans and the South African National AIDS Council (SANAC) processes during 2007–2011 as a case study of sex work marginalisation at a critical time where their interests and demands should have been heeded: not only as it would recognise sex worker health, human rights and dignity, but as it would have significant public health effects.
... Munyewende et al. (2011, p. 5) also chronicle challenges such as "confusion about eligibility for treatment and negative, unfriendly attitudes from facility staff. " Rumors of unpleasant previous experiences (Scorgie et al., 2011;Vearey, 2012) are said to travel fast among the migrant community, which leads to migrant women developing a strong suspicion of the South African public healthcare system (Crush and Tawodzera, 2014; Chekero and Ross, 2018;Vearey et al., 2018). ...
Background
Studies on the barriers migrant women face when trying to access healthcare services in South Africa have emphasized economic factors, fear of deportation, lack of documentation, language barriers, xenophobia, and discrimination in society and in healthcare institutions as factors explaining migrants’ reluctance to seek healthcare. Our study aims to visualize some of the outcome effects of these barriers by analyzing data on maternal death and comparing the local population and black African migrant women from the South African Development Countries (SADC) living in South Africa. The heightened maternal mortality of black migrant women in South Africa can be associated with the hidden costs of barriers migrants face, including xenophobic attitudes experienced at public healthcare institutions.
Methods
Our analysis is based on data on reported causes of death (COD) from the South African Department of Home Affairs (DHA). Statistics South Africa (Stats SA) processed the data further and coded the cause of death (COD) according to the WHO classification of disease, ICD10. The dataset is available on the StatsSA website ( http://nesstar.statssa.gov.za:8282/webview/ ) for research and statistical purposes. The entire dataset consists of over 10 million records and about 50 variables of registered deaths that occurred in the country between 1997 and 2018. For our analysis, we have used data from 2002 to 2015, the years for which information on citizenship is reliably included on the death certificate. Corresponding benchmark data, in which nationality is recorded, exists only for a 10% sample from the population and housing census of 2011. Mid-year population estimates (MYPE) also exist but are not disaggregated by nationality. For this reason, certain estimates of death proportions by nationality will be relative and will not correspond to crude death rates.
Results
The total number of female deaths recorded from the years 2002 to 2015 in the country was 3740.761. Of these, 99.09% ( n = 3,707,003) were deaths of South Africans and 0.91% ( n = 33,758) were deaths of SADC women citizens. For maternal mortality, we considered the total number of deaths recorded for women between the ages of 15 and 49 years of age and were 1,530,495 deaths. Of these, deaths due to pregnancy-related causes contributed to approximately 1% of deaths. South African women contributed to 17,228 maternal deaths and SADC women to 467 maternal deaths during the period under study. The odds ratio for this comparison was 2.02. In other words, our findings show the odds of a black migrant woman from a SADC country dying of a maternal death were more than twice that of a South African woman. This result is statistically significant as this odds ratio, 2.02, falls within the 95% confidence interval (1.82–2.22).
Conclusion
The study is the first to examine and compare maternal death among two groups of women, women from SADC countries and South Africa, based on Stats SA data available for the years 2002–2015. This analysis allows for a better understanding of the differential impact that social determinants of health have on mortality among black migrant women in South Africa and considers access to healthcare as a determinant of health. As we examined maternal death, we inferred that the heightened mortality among black migrant women in South Africa was associated with various determinants of health, such as xenophobic attitudes of healthcare workers toward foreigners during the study period. The negative attitudes of healthcare workers toward migrants have been reported in the literature and the media. Yet, until now, its long-term impact on the health of the foreign population has not been gaged. While a direct association between the heightened death of migrant populations and xenophobia cannot be established in this study, we hope to offer evidence that supports the need to focus on the heightened vulnerability of black migrant women in South Africa. As we argued here, the heightened maternal mortality among migrant women can be considered hidden barriers in which health inequality and the pervasive effects of xenophobia perpetuate the health disparity of SADC migrants in South Africa.
... In sub-Saharan Africa, female sex workers represent a marginalized and hard-to-reach population (Scorgie et al., 2012). They face numerous challenges, including social stigma, discrimination, gender-based violence, and human rights violations due to the nature and criminalisation of their work Scorgie et al., 2011;Shannon et al., 2018;UNAIDS, 2022). At the same time, female sex workers are disproportionately affected by HIV. ...
Introduction
In sub-Saharan Africa, accurate estimates of the HIV epidemic in female sex workers are crucial for effective prevention and care strategies. These estimates are typically derived from mathematical models that assume certain demographic and behavioural characteristics like age and duration of sex work to remain constant over time. We reviewed this assumption for female sex workers in South Africa.
Methods
We reviewed studies that reported estimates on either the age or the duration of sex work among female sex workers in South Africa. We used Bayesian hierarchical models to synthesize reported estimates and to study time trends. In a simulation exercise, we also investigated the potential impact of the "constant age and sex work duration"-assumption on estimates of HIV incidence.
Results
We included 24 different studies, conducted between 1996 and 2019, contributing 42 estimates on female sex worker age and 27 estimates on sex work duration. There was evidence suggesting an increase in both the duration of sex work and the age of female sex workers over time. According to the fitted models, over each decade the expected duration of sex work increased by 55.6% (95%-credible interval [CrI]: 23.5%–93.9%) and the expected age of female sex workers increased by 14.3% (95%-CrI: 9.1%–19.1%). Over the 23-year period, the predicted mean duration of sex work increased from 2.7 years in 1996 to 7.4 years in 2019, while the predicted mean age increased from 26.4 years to 32.3 years. Allowing for these time trends in the simulation exercise resulted in a notable decline in estimated HIV incidence rate among sex workers over time. This decline was significantly more pronounced than when assuming a constant age and duration of sex work.
Conclusions
In South Africa, age and duration of sex work in female sex workers increased over time. While this trend might be influenced by factors like expanding community mobilization and improved rights advocacy, the ongoing criminalisation, stigmatisation of sex work and lack of alternative employment opportunities could also be contributing. It is important to account for these changes when estimating HIV indicators in female sex workers.
... The above-mentioned findings raise concern, since they down-play the empowerment that could be derived from using a condom without the need to negotiate its use, which is possible only with the use of a female condom. The findings show frequent reporting from FSWs of clients refusing to use condoms, experiences of violence, physical abuse, and being overpowered by clients with the FSWs ending up having condomless sex as was cited in other studies [24][25][26][27][28][29][30]. However, the data revealed that some of the FSWs were quite confident in their condom use strategies and stood their ground in the face of their clients by refusing to have unprotected sex. ...
Introduction:
female sex workers (FSWs) are the key vulnerable populations since they carry the high burden of HIV and sexually transmitted infections (STIs). However, the vulnerability of street-based FSWs to HIV/STIs is much higher than that of the establishment-based FSWs. The study aimed to explore street-based FSWs' condom negotiation skills, barriers to condom use as well as the challenges and predicaments they face on a daily basis.
Methods:
an exploratory qualitative approach using focus group discussions was conducted among FSWs working in a major provincial road in a district of Gauteng Province. Thematic content analysis using NVivo version 10 software was conducted.
Results:
the age range of the FSWs was 19 to 44 years. The themes that emerged from the data on challenges to negotiation and condom use among FSWs revealed the ways condoms are used in early sex work and over time, ways of enforcing condom used, preferred types of condoms and the predicaments to working in the sex trade. FSWs gained experience of negotiating condom use over time in their work. Both female and male condoms were available and accurate insertion of condoms was reported. Male condom was preferred. Condom use strategies included direct request; using health-information messages; charging more for condomless sex; and refusing condomless sex. The FSW reported the risks of violent attacks of unregulated street-based environment.
Conclusion:
condom negotiation strategies illustrated that peer-education and sharing experiences among themselves were beneficial for protective sexual behaviours. Peer-education benefits and peer-interactions yielded assertive attitudes and behaviours of demanding and/or enforcing condom use.
... Furthermore, many migrant FSWs have not been able to easily access HIV testing and treatment. This group is therefore one of the main risk populations for HIV incidence and transmission Scorgie et al., 2011). Risk behaviors at the individual level drive HIV infections, including injectable drug use, high numbers of sexual partners, and inconsistent condom use. ...
This study aimed to investigate HIV risks among female sex workers (FSWs) who were from the Shan ethnic group, and how they relate to complex relationships with inconsistent condom use. The study was conducted using in-depth interviews with 17 Shan FSWs (aged 18–45 years old) in Chiang Mai. Intimate relationships between participants and regular clients/steady partners were found to facilitate inconsistent condom use. Participating Shan FSWs sustained intimacy with regular clients not only for economic ends but also for emotional support. Gender norms and male power dominated condom use decision making. Some participants lacked proper HIV preventive knowledge regarding condom breakage and HIV risks. Effective intervention and proper HIV preventive practices should address these intimate contexts. Capacity building among women would assist FSWs to make choices that protect them from HIV/STDs infections. Couples-based HIV interventions addressing emotional intimacy is an urgent need for HIV communication and service delivery in Thailand.
... Marginalisation and stigmatisation of young lesbian, gay, bisexual, transgender and intersex (LGBTI) people, sex workers and injecting drug users (IDUs) are often a fundamental barrier to these YKPs accessing health services where attitudes towards them are discriminatory and where the care provided is inappropriate or unresponsive to these young people's specifi c SRH needs. Sex workers, for example, have been found not to disclose their work to health professionals or to misrepresent their health problems or even to avoid care entirely because of their fears of discrimination (Scorgie et al., 2011;Lafort et al., 2016;Mwashita, 2017). ...
This book provides an overview of the current epidemiology of the HIV
epidemic among young people in Eastern and Southern Africa (ESA) and
examines the efforts to confront and reduce the high level of new HIV
infections among young people. Taking a multi-dimensional approach to prevention, the contributors discuss the many challenges facing these efforts, in view of the slow progress in curbing the incidence of HIV among young people, focusing particularly
on the structural and social drivers of HIV. Through an examination of
these issues, chapters in this book provide valuable insights on how to
mitigate HIV risk among young people and what can be regarded as the
catalysts to mounting credible policy and programmatic responses required
to achieve epidemic control in the region. The contributors draw on
examples from a range of primary and secondary data sources to illustrate
promising practices and challenges in HIV prevention, demonstrating links
between conceptual approaches to prevention and lessons learnt from
implementation projects in the region. Bringing together social scientists and public health experts who are actively engaged in finding effective solutions, the book discusses which interventions work, why they work and the limitations and gaps in our
knowledge to curb the epidemic among young people. As such it is an
important read for researchers focusing on HIV/AIDS and public health.
... Marginalisation and stigmatisation of young lesbian, gay, bisexual, transgender and intersex (LGBTI) people, sex workers and injecting drug users (IDUs) are often a fundamental barrier to these YKPs accessing health services where attitudes towards them are discriminatory and where the care provided is inappropriate or unresponsive to these young people's specific SRH needs. Young women who sell sex, for example, have been found not to disclose their work to health professionals or to misrepresent their health problems or even to avoid care entirely because of their fears of discrimination (Scorgie et al., 2011;Lafort et al., 2016;Mwashita, 2017). ...
... Poverty, food insecurity, precarious legal status, and lack of formal employment opportunities contribute to selling sex among refugee and displaced persons (Williams et al., 2018;Women's Refugee Commission, 2016). Refugee sex workers may experience language barriers, discrimination, and legal restrictions in their host country that reduce access to formal employment as well as health services (Ferguson et al., 2017;Rosenberg & Bakomeza, 2017;Scorgie et al., 2011;Women's Refugee Commission, 2016). Social and economic marginalization experienced by refugee sex workers contributes to poor sexual health outcomes (Women's Refugee Commission, 2016), including HIV and sexually transmitted infections (STI) exposure alongside sexual and reproductive health care barriers (Burton et al., 2010;Ferguson et al., 2017;Rosenberg & Bakomeza, 2017). ...
HIV prevention needs among urban refugee and displaced youth engaged in transactional sex are understudied. We examined associations between transactional sex and the HIV prevention cascade among urban refugee/displaced youth in Kampala, Uganda. We conducted a cross-sectional survey with a peer-driven sample of refugee/displaced adolescent girls and young women (n = 324) and adolescent boys and young men (n = 88) aged 16-24 living in Kampala's informal settlements. We conducted gender-disaggregated multivariable linear and logistic regressions to examine associations between past 12-month transactional sex and: lifetime HIV testing, condom self-efficacy, and recent [past 3-month] consistent condom use. Among the 27% of young women reporting transactional sex, 63% reported HIV testing. In multivariable analyses with young women, transactional sex was associated with higher condom self-efficacy, increased consistent condom use, but not HIV testing. Among the 48% of young men reporting transactional sex, 50% reported HIV testing. In multivariable analyses with young men, transactional sex was associated with lower HIV testing but not with condom self-efficacy or consistent condom use. Young men were 68% less likely to report HIV testing if transactional sex engaged. Findings point to urgent HIV testing gaps among transactional sex engaged urban refugee/displaced youth and a need for gender-tailored HIV prevention strategies. ARTICLE HISTORY
... Other programmes have noted the importance of the service delivery context for early use of new health technologies, such as family planning (Murphy, 2004). This is particularly true for marginalised populations for whom health services are often stigmatising and feared for potential harm to sex workers (Mtetwa et al., 2013;Nyblade et al., 2017;Scorgie et al., 2011;Wanyenze et al., 2017;Wong et al., 2011). FSW in South Africa also credited non-stigmatising, tailored services for encouraging PrEP use (Eakle et al., 2018). ...
Female sex workers (FSW) are prioritised for increased access to pre-exposure prophylaxis (PrEP), although rates of uptake remain sub-optimal, particularly across Southern Africa. In the first two years of its availability in Zimbabwe, 37.1% of FSW in trial sites initiated PrEP and received at least one re-supply. We conducted a qualitative study on perceptions of PrEP among 19 early users selected from sites with varying rates of PrEP initiation. Narrative interviews examined the pathways taken by FSW from hearing about PrEP, through their decision to start taking it, and early experiences. FSW appreciated PrEP’s introduction within familiar and trusted “friendly” services tailored for sex workers and valued positive encouragement from clinic staff and peers over negative influence from family members. They also found PrEP difficult to understand at first, and feared side effects and rare adverse complications described in information leaflets. While FSW identified individual strategies for remembering to take their medication, they also relied on structured peer adherence support, leading some FSW to actively promote the method to other FSW as “PrEP champions”. Information on how early users experience a new prevention technology such as PrEP can inform design of interventions that leverage existing support structures and target key barriers.
This qualitative study reports on female sex workers’ (FSWs) perceptions of the quality of antiretroviral therapy (ART) services they received as part of a community-based ART distribution intervention compared to services received by FSWs in the standard of care (SOC) arm. In-depth interviews were conducted with 24 participants to explore their perceptions of the quality of ART services. Data was analyzed using a quality-of-care framework that included but was not limited to, domains of accessibility, effective organization of care, package of services, and patient-centered care. Overall, FSWs in the intervention arm reported community-based ART services to be highly accessible, organized, and effective, and they highly valued the patient-centered care and high level of privacy. Community-based ART programs for FSWs can have high quality-of-care, which can have a positive effect on HIV treatment outcomes for FSWs.
In the framework of a research undertaken to study the role of clients of brothel prostitutes in the spread of HIV in Dakar, Senegal, prostitutes working in several sectors of prostitution (street, bar, hotels, etc.), provided information about their life and about how they became prostitutes through opened interviews. Information was also obtained by observation of the brothels during the fieldwork with clients. This paper describes some characteristics of prostitution in brothels and prostitutes in Dakar, Senegal. This research shows that young African women are vulnerable to HIV infection because sexual relations with men are an important means to achieve social and economic status, and for some women they are necessary for survival. These data show that Senegalese prostitutes, because of their high HIV prevalence, represent a reservoir of HIV infection and a core group for HIV transmission into Senegalese society. This suggests that in spite of information and free condoms, a number of prostitutes engage in unprotected sex. Clandestine and minor prostitutes are at major risk because they are not targeted for condom interventions. Pockets of non-utilization of condoms were found in some geographic areas (brothels) of Dakar and merit local interventions.
Sex work is receiving increased attention in southern Africa. In the context of South Africa's intense preparation for hosting the 2010 FIFA World Cup, anxiety over HIV transmission in the context of sex work has sparked debate on the most appropriate legal response to this industry.
Drawing on existing literature, the authors highlight the increased vulnerability of sex workers in the context of the HIV pandemic in southern Africa. They argue that laws that criminalise sex work not only compound sex workers' individual risk for HIV, but also compromise broader public health goals. International sporting events are thought to increase demand for paid sex and, particularly in countries with hyper-endemic HIV such as South Africa, likely to foster increased HIV transmission through unprotected sex.
The 2010 FIFA World Cup presents a strategic opportunity for South Africa to respond to the challenges that the sex industry poses in a strategic and rights-based manner. Public health goals and growing evidence on HIV prevention suggest that sex work is best approached in a context where it is decriminalised and where sex workers are empowered. In short, the authors argue for a moratorium on the enforcement of laws that persecute and victimise sex workers during the World Cup period.
This study examined cross-sectional data collected from substance-using female sex workers (FSW) and non-sex workers (non-SW) in Pretoria, South Africa, who entered a randomized controlled trial.
Women who reported alcohol use and recently engaging in sex work or unprotected sex were recruited for a randomized study. The study sample (N = 506) comprised 335 FSW and 171 female non-SW from Pretoria and surrounding areas. Self-reported data about alcohol and other drug use as well as treatment needs and access were collected from participants before they entered a brief intervention.
As compared with female non-SW, FSW were found to have a greater likelihood of having a past year diagnosis of alcohol or other drug abuse or dependence, having a family member with a history of alcohol or other drug abuse, having been physically abused, having used alcohol before age 18, and having a history of marijuana use. In addition, the FSW were more likely to perceive that they had alcohol or other drug problems, and that they had a need for treatment and a desire to go for treatment. Less than 20% of participants in either group had any awareness of alcohol and drug treatment programs, with only 3% of the FSW and 2% of the non-SW reporting that they tried but were unable to enter treatment in the past year.
FSW need and want substance abuse treatment services but they often have difficulty accessing services. The study findings suggest that barriers within the South African treatment system need to be addressed to facilitate access for substance-using FSW. Ongoing research is needed to inform policy change that fosters widespread educational efforts and sustainable, accessible, woman-sensitive services to ultimately break the cycle for current and future generations of at-risk South African women.
Audio computer-assisted self-interview (ACASI) may elicit more frequent reporting of socially sensitive behaviours than face-to-face (FtF)-interview. However, no study compared responses to both methods in female and male sex workers (FSW; MSW) in Africa.
We sequentially enrolled adults recruited for an HIV-1 intervention trial into a comparative study of ACASI and FtF-interview, in a clinic near Mombasa, Kenya. Feasibility and acceptability of ACASI, and a comparative analysis of enrolment responses between ACASI and FtF on an identical risk assessment questionnaire were evaluated. In total, 139 women and 259 men, 81% of eligible cohort participants, completed both interviews. ACASI captured a higher median number of regular (2 vs. 1, p<0.001, both genders) and casual partners in the last week (3 vs. 2, p = 0.04 in women; 2 vs. 1, p<0.001 in men). Group sex (21.6 vs. 13.5%, p<0.001, in men), intravenous drug use (IDU; 10.8 vs. 2.3%, p<0.001 in men; 4.4 vs. 0%, p = 0.03 in women), and rape (8.9 vs. 3.9%, p = 0.002, in men) were reported more frequently in ACASI. A surprisingly high number of women reported in ACASI that they had paid for sex (49.3 vs. 5.8%, p<0.001). Behaviours for recruitment (i.e. anal sex, sex work, sex between males) were reported less frequently in ACASI. The majority of women (79.2%) and men (69.7%) felt that answers given in ACASI were more honest. Volunteers who were not able to take ACASI (84 men, and 37 women) mostly lacked reading skills.
About 1 in 5 cohort participants was not able to complete ACASI, mostly for lack of reading skills. Participants who completed ACASI were more likely to report IDU, rape, group sex, and payment for sex by women than when asked in FtF interview. ACASI appears to be a useful tool for high risk behaviour assessments in the African context.
The sex work industry in the Hillbrow area of Johannesburg is unique in southern Africa in that it exists in a high-density setting, where sex workers operate from hotels, flats and on the street. There is little information on the sex work trade in the city. Further, there have been few, if any, targeted health services for sex workers in this area. This study collected demographic data and information on sexual behaviour of women who identified themselves as sex workers. Female sex workers were recruited from the Hillbrow area by outreach workers. Screening included an interviewer-administered questionnaire and physical examination including HIV testing and diagnosis of current sexually transmitted infections. In total, 247 women were screened, of whom 46% had been operating as sex workers for less than one year. Almost half (45%) of the women were HIV positive. HIV status was significantly associated with condom use (P = 0.0003) and number of clients seen per day (P = 0.005). Duration of time as a sex worker was not found to be associated with HIV status; those working for three or more months showed similar levels of infection to those working for one year or more. The study confirmed that sex workers in Hillbrow exhibited the characteristics of a core transmitter group. Interventions are now addressing the issues of safer sex and health care of sex workers living and working in this area.
