Addressing the “Demand” Side of Sex Work: The Need for Male-focused Interventions to Reduce the Spread of HIV/AIDS in Botswana Gabrielle O’Malley, PhD International Training and Education Center for HIV, University of Washington

Context Botswana’s national strategic framework for the prevention of HIV infection, 2003–2009—Goal 1: Strengthen prevention programs that target commercial female sex workers in collaboration with development partners, NGOs, etc.

Botswana’s national strategic framework for the prevention of HIV infection, 2003–2009—Goal 1:

Strengthen prevention programs that target commercial female sex workers in collaboration with development partners, NGOs, etc.

Exploratory/Diagnostic Study Objectives: To understand sex work in Botswana To identify suitable programmatic interventions to reduce HIV/AIDS transmission among: Women in sex work Their clients

Objectives:

To understand sex work in Botswana

To identify suitable programmatic interventions to reduce HIV/AIDS transmission among:

Women in sex work

Their clients

Botswana: Overview Population ~1.8 million Size of Texas or France Fairly ethnically homogenous “ Middle income” country Diamond industry drives economy Stable democracy Literacy ~82%

Population ~1.8 million

Size of Texas or France

Fairly ethnically homogenous

“ Middle income” country

Diamond industry drives economy

Stable democracy

Literacy ~82%

Source: UNAIDS/WHO, 2008; available from: http://www.who.int/globalatlas/predefinedReports/EFS2008/full/EFS2008_BW.pdf Estimated Adult* HIV Prevalence, 1990–2007 * “Adult”= ages 15–49

Study Sites in Botswana Kasane Ghanzi Letlhakane Francistown Gaborone Selebi-Phikwe

Kasane

CSW Intervention Focus Program Theories : Lack of HIV knowledge/understanding Lack of skill in negotiation Lack of self-efficacy Lack of income alternatives Lack of medical attention and care Targets : Women involved in commercial sex work or at risk for CSW

Program Theories :

Lack of HIV knowledge/understanding

Lack of skill in negotiation

Lack of self-efficacy

Lack of income alternatives

Lack of medical attention and care

Investigation Map HIV risk in sex work FSW Customers NGOs (peer HIV education; economic opportunity [skills training]) Traditional healers Formal medical community

Study Methods (1) In-depth interviews: 17 health care workers (HCWs) 16 traditional/faith healers 13 NGOs 30 FSW 22 citizens 8 non-citizens

In-depth interviews:

17 health care workers (HCWs)

16 traditional/faith healers

13 NGOs

30 FSW

22 citizens

8 non-citizens

Study Methods (2) Focus group discussions: 6 groups of 3–4 young men from target communities (n = 20) Informally, with representatives of the Men’s Sector Data analysis: Comparative phenomenological analysis Comparison within and across interview types and focus groups

Focus group discussions:

6 groups of 3–4 young men from target communities (n = 20)

Informally, with representatives of the Men’s Sector

Data analysis:

Comparative phenomenological analysis

Comparison within and across interview types and focus groups

Study Limitations Did not include male, transgendered, and underage sex workers Selection bias Not representative sample

Did not include male, transgendered, and underage sex workers

Selection bias

Not representative sample

Qualitative Research Main tasks: To explore the ways people in particular settings understand, account for, take action, talk about and manage particular activities Gain holistic (systemic, encompassing) understanding of the context under study, its logic, its arrangements, its explicit and implicit rules

Main tasks:

To explore the ways people in particular settings understand, account for, take action, talk about and manage particular activities

Gain holistic (systemic, encompassing) understanding of the context under study, its logic, its arrangements, its explicit and implicit rules

Areas of Inquiry for Women Knowledge of risk Risk behaviors Self-efficacy Reasons for entry into sex work Desire for exit Social and medical support

Knowledge of risk

Risk behaviors

Self-efficacy

Reasons for entry into sex work

Desire for exit

Social and medical support

Areas of Inquiry for Men Perceptions of FSW Perceptions of risky behaviors involving FSW Normative descriptions of men’s relationships with FSW

Perceptions of FSW

Perceptions of risky behaviors involving FSW

Normative descriptions of men’s relationships with FSW

Demographics of Women N=30 Ages ranged from 18–42 years old (mean = 27) 15 came from poor families, 14 from middle-class families, and 1 from a rich family 1/3 had income source in addition to CSW 2/3 had regular partners in addition to clients 10 provided unsolicited information of being infected with HIV

Ages ranged from 18–42 years old (mean = 27)

15 came from poor families, 14 from middle-class families, and 1 from a rich family

1/3 had income source in addition to CSW

2/3 had regular partners in addition to clients

10 provided unsolicited information of being infected with HIV

Earnings from FSW

Years as FSW Years as a FSW Std. dev = 2.98 Mean = 4.0 N = 30.00

Customers per Day Average number of customers per day Std. dev = 2.10 Mean = 3.9 N = 30.00

FSWs’ Perspective - Economic Women’s language clearly indicates CSW as business Pricing depends on: rounds (male orgasm) time commitment FSW cash flow perceived status of client discomfort of requested position market demand level market value of a particular woman risk to own health

Women’s language clearly indicates CSW as business

Pricing depends on:

rounds (male orgasm)

time commitment

FSW cash flow

perceived status of client

discomfort of requested position

market demand level

market value of a particular woman

risk to own health

“ You are spreading the disease because some [clients] are not using the condom. How many else are they going to sleep with? The risk is so high!” Awareness of HIV Risk

“ You are spreading the disease because some [clients] are not using the condom. How many else are they going to sleep with? The risk is so high!”

“ I look at the health; if he looks sick, then it is risky and then the charges are high at 250-300BWP. He may not be willing for the higher price, but if he does at least you will not risk for nothing.” “ He does not want to use a condom to enjoy sex. For 250 BWP spreading AIDS to me [disparagingly]. But if he offers, 500 BWP, I will do it.” Cost (Risk)-Benefit Analysis

“ I look at the health; if he looks sick, then it is risky and then the charges are high at 250-300BWP. He may not be willing for the higher price, but if he does at least you will not risk for nothing.”

“ He does not want to use a condom to enjoy sex. For 250 BWP spreading AIDS to me [disparagingly]. But if he offers, 500 BWP, I will do it.”

Cost (Risk)-Benefit Analysis “ You have to tell the man you are HIV positive. Even if I tell, they refuse [to use a condom]. ... But I do it anyway because I am desperate, I need money. Even though you know that you are killing yourself. After doing this, you can put vegetables/healthy food in you to keep the body fit.”

“ You have to tell the man you are HIV positive. Even if I tell, they refuse [to use a condom]. ... But I do it anyway because I am desperate, I need money. Even though you know that you are killing yourself. After doing this, you can put vegetables/healthy food in you to keep the body fit.”

Comparative Risk Analysis “ They [rough customers] take you, after, they can leave you there in the bush, especially if you refuse sex without a condom. They just leave you there. Some stay far and if you refuse a condom, they chase you away without giving you any money or providing transport.”

“ They [rough customers] take you, after, they can leave you there in the bush, especially if you refuse sex without a condom. They just leave you there. Some stay far and if you refuse a condom, they chase you away without giving you any money or providing transport.”

Comparative Risk Analysis “ I stayed for a long time without working. My parents are not helping me. The father of my child was not taking care then. I decided to go into the business and say ‘money first’ and it improved my life. I am able to take care of my child. … I sometimes think of getting infected but I don’t have a choice because clients don’t listen and I need money. … There are risks in sex work. You can get HIV because you are not protecting sex. Men can kill you. You can be caught with a married man and get arrested.”

“ I stayed for a long time without working. My parents are not helping me. The father of my child was not taking care then. I decided to go into the business and say ‘money first’ and it improved my life. I am able to take care of my child. … I sometimes think of getting infected but I don’t have a choice because clients don’t listen and I need money. … There are risks in sex work. You can get HIV because you are not protecting sex. Men can kill you. You can be caught with a married man and get arrested.”

Limited Alternative Opportunities “ When I was 20 years old, I had sugar daddies with whom I would have sex once in a while. I began full time 5 years ago because I was unemployed and I had an abusive boyfriend. Every month’s end would come and he would give me no money. He would beat me and verbally abuse me. That’s why I decided to stay clear….That way, there is no commitment or anyone to say this and that.”

“ When I was 20 years old, I had sugar daddies with whom I would have sex once in a while. I began full time 5 years ago because I was unemployed and I had an abusive boyfriend. Every month’s end would come and he would give me no money. He would beat me and verbally abuse me. That’s why I decided to stay clear….That way, there is no commitment or anyone to say this and that.”

Limited Alternative Opportunities “ When I started, it was hard. Because of the situation, I had to do it. I didn’t look good. Even my child was sick. So, I went out. I went with a man for 2 months thinking I would get something at month’s end. I got nothing. I went back to the bar. There I met a …man. He said that he loved me. I said I cannot go in love because people are cheating me. He agreed to give me 100 BWP. I thought he was cheating me, but as soon as the door opened, he gave me 100 BPW.”

“ When I started, it was hard. Because of the situation, I had to do it. I didn’t look good. Even my child was sick. So, I went out. I went with a man for 2 months thinking I would get something at month’s end. I got nothing. I went back to the bar. There I met a …man. He said that he loved me. I said I cannot go in love because people are cheating me. He agreed to give me 100 BWP. I thought he was cheating me, but as soon as the door opened, he gave me 100 BPW.”

Survival Sex and Beyond If sex work was legal, “No one would work as maids as it’s a small salary. Maids will leave and join us. Its hard work but better money. Even well-paid women would do it part-time. They are better looking than us so it would be to our disadvantage. They would be #1.”

If sex work was legal, “No one would work as maids as it’s a small salary. Maids will leave and join us. Its hard work but better money. Even well-paid women would do it part-time. They are better looking than us so it would be to our disadvantage. They would be #1.”

Survival Sex and Beyond “ The problem is that once you get used to this job, it is not easy to leave it just like that because you get used to getting money everyday. Even if the man is ready to certify [marry], I can just turn a corner and [gestures to show take off].”

“ The problem is that once you get used to this job, it is not easy to leave it just like that because you get used to getting money everyday. Even if the man is ready to certify [marry], I can just turn a corner and [gestures to show take off].”

Motivations of FSW Survival strategy and disposable income Sex work more reliable and lucrative than other income-earning possibilities and male relationships Sex work allows women to spread their financial and personal risk, rather than relying on one regular partner Autonomy

Survival strategy and disposable income

Sex work more reliable and lucrative than other income-earning possibilities and male relationships

Sex work allows women to spread their financial and personal risk, rather than relying on one regular partner

Autonomy

Male Perspectives

Male Perspectives

Masculinity and Sex “ Men find it exciting to have sex with different people. Some may stop because of fear of disease but for others, even if they see someone is having ARV, they will want to sleep without condoms, to take the risk, to see if this will infect them or not.”

“ Men find it exciting to have sex with different people. Some may stop because of fear of disease but for others, even if they see someone is having ARV, they will want to sleep without condoms, to take the risk, to see if this will infect them or not.”

Masculinity and Sex “In culture past, to realize that this is a man, he had a number of wives. A rich man had seven wives. It still exists today. To recognize that this is a dangerous guy, he must have all these women around him and we should be able to see that he can take anyone.”

“In culture past, to realize that this is a man, he had a number of wives. A rich man had seven wives. It still exists today. To recognize that this is a dangerous guy, he must have all these women around him and we should be able to see that he can take anyone.”

Masculinity and Sex “ During month end, most men, for example, myself, I like going to different places. Maybe my girlfriend is not there. I have left my girlfriend behind. Then around 3:00 in the morning, I have to sleep. I cannot sleep alone. All the blood has rushed to the waist. You have beer, money and then you must have sex. If you have money, you have everything” ----- “You are recognized at least for a time.”

“ During month end, most men, for example, myself, I like going to different places. Maybe my girlfriend is not there. I have left my girlfriend behind. Then around 3:00 in the morning, I have to sleep. I cannot sleep alone. All the blood has rushed to the waist. You have beer, money and then you must have sex. If you have money, you have everything”

----- “You are recognized at least for a time.”

Disempowered Men “ We actually want girlfriends, but they refuse, they want to sell.” “ You can’t just get it (sex) for free. Even if you have a girlfriend, you are paying. They demand money for this, for that. It gives you stress.”

“ We actually want girlfriends, but they refuse, they want to sell.”

“ You can’t just get it (sex) for free. Even if you have a girlfriend, you are paying. They demand money for this, for that. It gives you stress.”

Disempowered Men “ Female counterparts love money. They demand it even if they are earning more. They like expensive things/clothes. They are to be blamed. They are liking money. They are spreading diseases.” “ Men say ladies are too demanding and decide to go to the street. Going for 100-200 BWP every quarter is better than committing yourself to a woman.

“ Female counterparts love money. They demand it even if they are earning more. They like expensive things/clothes. They are to be blamed. They are liking money. They are spreading diseases.”

“ Men say ladies are too demanding and decide to go to the street. Going for 100-200 BWP every quarter is better than committing yourself to a woman.

Disempowered Men “ We have to change attitudes for ladies not to demand. Spouses should help each other. Women are abusive. They call you useless and then she goes away. That is why you go to a small girl.” “ Most women are sex workers. Even if you are living with her, she will love you/make love to you as long as you provide. That’s why I feel most are sex workers, especially those who are not working.”

“ We have to change attitudes for ladies not to demand. Spouses should help each other. Women are abusive. They call you useless and then she goes away. That is why you go to a small girl.”

“ Most women are sex workers. Even if you are living with her, she will love you/make love to you as long as you provide. That’s why I feel most are sex workers, especially those who are not working.”

Lack of Male Self-efficacy “ Ladies follow men to the bar. They take sex to the men in the bar. Men can’t stay long without sex. These women who bring sex to the bar are very dangerous. …The only remedy is if men can ignore them. They are under pressure. If you don’t buy, she can’t sell. But if you are hungry, you will eat.”

“ Ladies follow men to the bar. They take sex to the men in the bar. Men can’t stay long without sex. These women who bring sex to the bar are very dangerous. …The only remedy is if men can ignore them. They are under pressure. If you don’t buy, she can’t sell. But if you are hungry, you will eat.”

Lack of Male Self-efficacy “ Women have power naturally as they give birth and nurture. Boys are kept stupid, oppressed. Men have 5 senses, women have a 6th, no fear. Even to have sex, it’s women who taught us. The problem of buying comes from women tormenting us. Men are denied conjugal rights.”

“ Women have power naturally as they give birth and nurture. Boys are kept stupid, oppressed. Men have 5 senses, women have a 6th, no fear. Even to have sex, it’s women who taught us. The problem of buying comes from women tormenting us. Men are denied conjugal rights.”

Blame and Responsibility “ Women are socially deviant. It’s women who are dragging men into this. Women are the judges in the love proposal because they have the power to say no. Men are deviant for going to sex workers, but they wouldn’t go if the women weren’t there. The women are vultures hovering over chicks.” “ Women are interested in money. I give choices. [You can] have this much without a condom. She is the one who [has to] say no. I want [no condom] because of my beliefs as a man that sex is enjoyable without a condom.”

“ Women are socially deviant. It’s women who are dragging men into this. Women are the judges in the love proposal because they have the power to say no. Men are deviant for going to sex workers, but they wouldn’t go if the women weren’t there. The women are vultures hovering over chicks.”

“ Women are interested in money. I give choices. [You can] have this much without a condom. She is the one who [has to] say no. I want [no condom] because of my beliefs as a man that sex is enjoyable without a condom.”

Men’s Perspectives Not about the market, about masculinity Male sexuality an overpowering force, beyond control Sex with many partners supports image of being a man of means Lack of alternatives Not responsible for risk reduction

Not about the market, about masculinity

Male sexuality an overpowering force, beyond control

Sex with many partners supports image of being a man of means

Lack of alternatives

Not responsible for risk reduction

Gender Construction as Backdrop FSW Market Mentality Cost Benefit Customer Satisfaction Male client Identify Assertion Being a Man Disempowerment/resentment Female Control/Responsibility Risky Sexual Behavior

FSW Market Mentality

Cost

Benefit

Customer Satisfaction

Male client Identify Assertion

Being a Man

Disempowerment/resentment

Female Control/Responsibility

Implication for Program Interventions HIV/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.”

HIV/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.”

Support for Male Focused or “Gender” Interventions 1994 Intl Conference on AIDS “There is an urgent need to target interventions to men clients of commercial sex workers” Ngugi et al. Supported by literature in anthropology, geography, sociology, African studies, social psychology, as well as public health Evaluations suggestive but inconclusive (Jewkes, BMJ,2008; Ross, AIDS, 2007) Receptivity to involving men mixed (Datta, JSAS, 2004)

1994 Intl Conference on AIDS “There is an urgent need to target interventions to men clients of commercial sex workers” Ngugi et al.

Supported by literature in anthropology, geography, sociology, African studies, social psychology, as well as public health

Evaluations suggestive but inconclusive (Jewkes, BMJ,2008; Ross, AIDS, 2007)

Receptivity to involving men mixed (Datta, JSAS, 2004)

Thank you! Acknowledgement of co-investigators Anjali Sharma (I-TECH, University of Washington); Selwana Fanyana (BOTUSA); Pedzi Motlhabane (Matshelo Community Development Association (MCDA); and project officer Marion Carter (BOTUSA).

Thank you!

Acknowledgement of co-investigators Anjali Sharma (I-TECH, University of Washington); Selwana Fanyana (BOTUSA); Pedzi Motlhabane (Matshelo Community Development Association (MCDA); and project officer Marion Carter (BOTUSA).