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Sex Workers (continued)

4 Reports by Jackie Powder

Antananarivo: Targeting Tiers

When Kirsten Stoebenau set out to understand the world of sex workers in Madagascar's capital, Antananarivo, she found a community defined by social divisions that shape the women's earning power, health and emotional well-being.

Stoebenau, PhD '06, who spent more than a year on the island nation off the southeast coast of Africa, uncovered a three-tiered social structure based on ethnic and racial differences. The local community loosely categorizes the women as "ambany," "antonony" and "ambony," designations that broadly translate as low, middle and high.

Sex workers in the low group typically live in poverty and are vulnerable to discrimination because of the assumption that they are descended from slaves.

Women in the middle group are associated with the "Merina," the majority ethnic group in Antananarivo, and identify as non-slave descendants. They attempt to conceal their activity by doing street-based work at night at a location removed from their home, putting them at greater risk of violence.

The women in the high group are often viewed by elite Merina as "cotier women" (from the coast). They tend to work in nightclubs and bars frequented by businessmen and tourists where they hope to find a foreign husband. They cultivate a glamorous, high-fashion image, and although they trade sex for money, many do not self-identify as sex workers. They're also less likely than women in the middle category to negotiate with clients upfront about condom use.

"The meaning of sex work is diverse and more complicated than what we understand when we think about the typical Western definition," says Stoebenau, noting that the differences have implications for HIV prevention and how protection messages are presented.

Women in the middle group, for instance, are more likely to insist on condom use because they view their client interactions as strictly business. Those in the low and high groups frequently hope for a shift to a long-term romantic relationship that offers economic support. Among these women, condom use is less likely.

The upshot for HIV prevention? Instead of efforts that emphasize condom use in commercial sex, focus on condom use in high-risk sexual relationships, which may not be commercial at all.

Karnataka: The Business of Prevention

In India's southern state of Karnataka, sex workers from a rural district attend monthly classes to learn basic economics and introductory HIV prevention. It's an odd pairing to be sure, but one that holds promise for helping the women.

"We know from hard data that HIV is spreading in rural areas. Addressing HIV prevention as part of a poverty alleviation and economic empowerment program may be beneficial," says Sudha Sivaram, DrPH '99, MPH, an assistant scientist in Epidemiology, who is conducting an evaluation of the program, which currently has 412 women enrolled in 24 groups.

A typical female sex worker in Karnataka is married and is likely the victim of domestic abuse, Sivaram notes. She may work in the region or go to a nearby town for clients and is often the breadwinner in the family.

The traditional microcredit model makes small loans so people can start a business. Instead, Sivaram says, this program helps sex workers save some money, which is then pooled in a group fund. Members decide collectively to approve loans to pay for immediate needs, like home repairs, children's education, or in one case, a wedding.

The inclusion of HIV and STD prevention information in group discussions is a way to help the women to be as safe as they can while earning a living as sex workers, she says.

"The program is not designed to get women out of sex work, as this is perceived as making a judgment ... where other alternatives for women in their situation are minimal to nonexistent," Sivaram says, adding that the economic component appeals to women who otherwise would not go to an HIV education seminar.

In general, Sivaram says, the women in the groups are talking more about HIV and clients' use of condoms—and some women have gone together to get HIV tests. "They're able to make friends, gain social support and discuss prevention," she says.

Over the next year, Sivaram plans to evaluate the pilot project. Longer term, she hopes to design a randomized study to compare two education groups for sex workers—one with the microcredit component, and one without—to determine which group fares better in HIV prevention knowledge.

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