Inner-city female sex workers in Durban, South Africa : a qualitative inquiry.

Abstract

Background: Female sex workers (FSWs) in sub-Saharan Africa and South Africa are classified as a most-at-risk-population with regards to HIV acquisition and transmission. This is due to the nature of their work, which involves multiple partnerships and risky sexual behaviour. In order to fight against HIV and AIDS and to reduce the rate of new infections among FSWs, their clients and the broader population, it is vital that FSWs are exposed to effective HIV-related health promotion interventions. Objectives: Due to the criminalised and stigmatised nature of sex work in South Africa, FSWs are a hidden population. This makes it difficult to design and implement appropriate HIV-related interventions for this group. Using the ecological systems theory as a framework, the objective of this study was to characterise Durban inner-city FSWs by providing a detailed and current understanding of this vulnerable group, pertaining to who they are, where they work, the challenges they face in the sex trade as well as the type of health-care services they need. This will aid in informing the design, adaptation and implementation of more effective targeted HIV-related health-promotion interventions. Methods: This qualitative-descriptive case study was conducted among 39 participants recruited through snowballing. The majority of study participants were black South African isiZulu-speaking street-based FSWs. This study made use of the constructivist paradigm, which enabled the researcher to understand the world of sex workers from their Individual-lived experiences. Data were collected through participant observations, focus-group discussions and key informant interviews. Data analysis was conducted using a framework analysis. Results: The majority of FSWs trading in Durban inner city are born in KwaZulu-Natal, with some coming from neighbouring provinces and other African countries as well as China and Thailand. Most participants were street-based and sex occurred in unsafe environments such as the veld or abandoned buildings. These venues expose FSWs to violence especially from clients who demand unprotected sex which increases their risk of HIV. Due to the criminalised nature of sex work in South Africa, FSWs are often victims of crime and suffer extortion from the police in the form of bribes to avoid arrest. Support organisations such as Lifeline and TB/HIV Care provide HIV counselling and testing (HCT), and peer education to FSWs and refer FSWs for further care. However, FSWs prefer receiving health care directly v from these support organisations because of long waiting times at public health facilities, as well as the perceived stigma and discrimination from health care providers. Conclusion: The challenges faced by Durban inner-city FSWs are similar to challenges faced by FSWs trading in other parts of South Africa and sub-Saharan Africa. Structural challenges such as the criminalisation of sex work make it difficult for FSWs to report the violent sexual crimes they experience at the hands of their clients. The police use condom possession as proof of engagement in sex work and go as far as confiscating condoms from FSWs. All these factors exacerbate FSWs exposure to HIV. Furthermore, HIV awareness among FSWs has not necessarily translated into behavioural change, especially when faced with the challenge of providing unprotected sex for more money. Health-promotion interventions need to strive to bridge the gap between knowledge and behavioural change. Even though this group has access to HCT, condoms and peer education, accessing follow-up care after being referred is a challenge due to time constraints and issues of perceived and internalised stigma. Effective health-care response for FSWs needs to be immediate and comprehensive to minimise the need for referral. Support organisations can work closely with sex worker sensitised clinics on site to provide health care. A sex worker clinic similar to the one in Hillbrow, Johannesburg or drop in centres would be beneficial for this group of sex workers. The government should also fast-track the provision of Pre-exposure prophylaxis (PrEP), test and treat as well as access to self-test kits to FSWs through health-support organisations.