Marlise Richter marlise.richter@gmail.com International Centre for Reproductive Health, Ghent University

1. Sex worker characteristics and risk factors for STIs and ill-health Marlise Richtermarlise.richter@gmail.comInternational Centre for Reproductive Health, Ghent University

3. Face-to-Face study(South Africa) • Repeat cross-sectional study design • Three periods: • pre-World Cup (May-early June 2010); • during the World Cup (mid June - mid July 2010); and • post-World Cup (September 2010). • Self-identified female, male and transgender sex workers in Hillbrow, Sandton, Rustenburg and Cape Town were interviewed by trained sex worker fieldworkers. • University-based researchers collaborated with two non-governmental organisations – SWEAT and Sisonke Sex Worker Movement.

4. Face-to-Face study(South Africa) • SWEAT and Sisonke introduced the researchers to sex worker peer educators known to them • 45 peer educators trained as fieldworkers • During each research phase, fieldworkers administered a 43-item semi-structured questionnaire to 20 sex workers.

5. Key Findings a.) Sex work is a key livelihood strategy for participants in the South African studies. • Sex work was a full-time profession for two-thirds of sex workers in the face-to-face survey • A substantial number reported never having had a job before sex work. • Around two-thirds of all sex workers received no income aside from sex work.

6. Key Findings a.) Sex work is a key livelihood strategy for participants in the South African studies. • Study participants in South Africa were responsible for a number of dependants:

7. Key Findings a.) Sex work is a key livelihood strategy for participants in the South African studies. • Sex worker earnings are relatively high • six times more than the typical earnings of a domestic worker (Statistics South Africa, 2010). • Sex work will therefore remain a pragmatic livelihood strategy for many in South Africa for a number of factors: • South Africa’s high unemployment rates, • the fact the entering sex work requires no formal qualifications, • the pressing need to provide for dependents – often without the support of spouse, and • the relatively robust earnings that could be secured by sex workers.

8. Key Findings b.) High proportion of sex workers in South Africa were migrants • Just over 85% (1396/1636) of FSWs in the face-to-face survey had migrated from their place of birth: • 39.0% (638/1636) were internal migrants • 46.3% (758/1636) were cross-border migrants.

9. Key Findings c.) Cross-border sex workers may be more tenacious in negotiating the sex industry, but access to health care is low • Cross-border female migrants in South Africa had higher education levels, predominately worked part-time and mainly at indoor venues, and earned more per client than internal or non-migrants • Cross-border migrants were also responsible for more dependants;

10. Key Findings c.) Cross-border sex workers may be more tenacious in negotiating the sex industry, but access to health care is low • A quarter of cross-border participants (152/626) were sex workers before leaving their place of birth • compared to only about 10 % of internal migrants (58/539, P<0.001) • These data, together with recent studies (Oliviera, 2011, Nyangairy, 2010, Flak, 2011), resist popular assumptions that maintain that foreign-born sex workers in South Africa are necessarily victims of human trafficking and sexual exploitation (Gould, 2011).

11. Key Findings c.) Cross-border sex workers may be more tenacious in negotiating the sex industry, but access to health care is low • It is of concern that cross-border FSWs in the face-to-face study had marginally lower health service contact than internal or non-migrants. • Studies have documented that recent immigrants are often healthier than the host population because of positive self-selection or the “healthy migrant effect” (Razum et al., 1998, Deane et al., 2010, Malmusi et al., 2010).

12. Key Findings c.) Cross-border sex workers may be more tenacious in negotiating the sex industry, but access to health care is low • Could be postulated that cross-border sex workers did not actively seek health services as they may have no need for them. • Alternatively, it may reflect on cross-border migrants’ unwillingness to access health facilities because of poor previous experiences, or fear of arrest or discrimination (Vearey, 2012, Scorgie et al., 2012, Human Rights Watch, 2009, Scorgie et al., 2013). • Yet, in either case, peer education and outreach services need to access this group regularly; the data indicates that this has not happened.

13. Key Findings d.) Female sex workers are more likely to practice safer sex than transgender or male sex workers • In the face-to-face study, more women had penetrative sex with last clientthan malesor transgender people

14. Key Findings d.) Female sex workers are more likely to practice safer sex than transgender or male sex workers • Yet, FSWs were more likely to have protected sex with last clients:

15. Key Findings e.) Levels of daily binge drinking are high • High levels of binge drinking among participants in South Africa: • Close to a fifth of females, • more than 40.0% of males • and a third of transgender sex workers reported daily binge drinking.

16. Key Findings e.) Levels of daily binge drinking are high • Drunk at last paid sex

17. Key Findings e.) Levels of daily binge drinking are high • Unprotected sex was 2.1 times (adjusted odds ratio (AOR), 95% CI 1.2 - 3.7; P=0.011) more likely in participants reporting daily or weekly binge drinking than non-binge drinkers.

18. Key Findings f.) Access to health care services and condom-use are higher among sex workers working near a sex work-specific health clinic • Sex workers in Hillbrow - where the only sex work-specific clinic was operational - were less likely to have unprotected sex than those in other sites in South Africa in the face-to-face survey • Programmes in other settings that are tailored to sex workers’ needs and include sex worker consultation, peer education and empowerment initiatives have been shown to be successful in reducing the risk of acquiring HIV (Basu et al., 2004, Jana et al., 2004, Vuylsteke et al., 2009, Laga and Vuylsteke, 2011).

19. Key Findings g.) Low use of female condoms by FSWs, but high acceptability • Male and female condoms are currently the only barrier methods available that reduce the risk of HIV (UNFPA et al., 2009). • The face-to-face survey data showed that just under half of FSWs (446/1 006) ever had used a female condom • Of participants who had used female condoms, acceptability was high

20. Key Findings a.) Condom-use with non-commercial partners of FSWs is low • The total number of unprotected sex acts per week was 5-6 times higher with non-commercial partners than with regular or casual clients in Mombasa • Almost two thirds of respondents noted that they did not use condoms with their non-commercial partners because of “trust” in them.

21. Key Findings a.) Condom-use with non-commercial partners of FSWs is low • Close to 80% of the FSWs in Mombasa who saw themselves at “moderate” to “great” risk of contracting HIV, noted that their risk was attributable to their clients’ behaviour. • This could be related to the “the ideological barrier”: • It may be necessary for sex workers to construct a dichotomy between risky, impersonal and therefore protected sex with clients on the one hand, and sex in a safe and personal environment with non-commercial partners where condoms are deemed unnecessary or inappropriate, on the other.

22. Key Findings a.) Condom-use with non-commercial partners of FSWs is low • Paradoxically, many respondents were not in personal relationships that could be deemed safe or harmless. • Sexual and/or physical violence by a non-commercial partner was experienced by over half (202/367) of FSWs over the 12-month study period • Close to a quarter (79/367) of respondents had experienced rape in the preceding year, of which 22% (17/79) had been raped by their non-commercial partner.

23. Key Findings a.) Condom-use with non-commercial partners of FSWs is low • HIV-prevalence of non-commercial partners of sex workers in SSA are generally higher than among clients (Scorgie et al., 2012). • FSWs have low control over relationships • a third of participants (108/293) perceived themselves to have low control over their relationships with their non-commercial partners • Regardless of whether the FSWs who participated believe in maintaining an ideological barrier between commercial and non-commercial partners, it might be difficult for them to insist on consistent protected sex with non-commercial partners because of power imbalances. .

24. References • M. Richter, Chersich MF, Temmerman M, Luchters S (2013) "Characteristics, sexual behaviour and risk factors of female, male and transgender sex workers in South Africa" South African Medical Journal 103(4):246-251. • M. Richter, Chersich MF, Vearey J, Sartorius B, Temmerman M, Luchters S. (2012) "Migration status, work conditions and female sex work in three South African cities.' Journal of Immigrant and Minority Health Dec 13. • S Luchters*, Richter M*, Bosire W, Nelson G, King'ola N, Zhang X, Temmerman M, Chersich, MF (in press) "The contribution of emotional partners to sexual risk taking and violence among female sex workers in Mombasa, Kenya: a cohort study" PLoSOne