Healthy Brothel: The Context of Clinical Services for Sex Workers in Hillbrow, South Africa

Introduction

"The AIDS epidemic has reached alarming proportions in South Africa. By 2001 it was estimated that 4.7 million men and women between the ages of 15 and 49 were infected. By 2002 the number of those infected had risen to 5.3 million. According to antenatal HIV surveys conducted by the department of health, pregnant women infected with HIV had risen from 22.4% to 26.5% . South Africans experience similarly high levels of other sexually transmitted infections (STIs). Four million episodes of STIs occur each year in South Africa. These epidemics pose a massive challenge to the public health system in terms of prevention, treatment and care.

Although AIDS affects all South Africans, the rate of HIV infection amongst sex workers is a significant concern (See Wojciki & Malala; 2001:100) . In Hillbrow, sex workers face considerable danger of infection in their everyday working lives. In a survey in Hillbrow during 1997, 45% of 247 sex workers tested positive for HIV (Rees et al; 2000). Most disturbingly, those who had been working as sex workers for only three months displayed similar levels of infection to those who had been working for one year (Rees et al; 2000). The authors reported that ‘it is crucial that interventions address the issues of safe sex and access to good quality health care' in this population (Rees et al; 2000, P.284).

Unfortunately, sex workers tend not to seek care from public health services. This is mainly due to their negative experiences of care in these settings (Muyinda et al, 1997; Wojcicky and Malala, 2001; See also Lawless et al, 1996). Sex workers fear that they will be refused service and may experience public humiliation by health workers. The location of public health facilities and their hours of operation are also inconvenient for sex workers. Furthermore, although efforts have been made to professionalise the sex industry this has faced considerable barriers. Sex work was only de-criminalised recently in South Africa (See also Gysels et al; 2002).

This paper reports on an on -going intervention initiated by the Reproductive Health Research Unit (RHRU) that provided clinical services for sex workers in the inner city suburb of Hillbrow, Johannesburg. The intervention aimed to provide sex workers with quality sexual health services, to treat STIs and other reproductive health disorders, and provide AIDS education and counselling in the hotels in which they worked. Ultimately the intervention aimed to reduce the incidence of STIs and HIV in the sex worker population.

Internationally, positive outcomes are associated with improving access to STI services. Programmes combining outreach to commercial sex - workers with peer education and improved access to STI services have been described in Kinshasa (Laga, 1994), Nairobi and Zimbabwe (Ngugi et al, 1996), Nigeria (Esu-Williams ND), Tanzania (Mwizaruba et al, 1994) and elsewhere (Damiba, 1990; Bradbeer, 1988; Chipfakacha, 1993; Sanchez, 1998; Jana, 1994).

However, while clinical interventions promote impressive short term outcomes these are difficult to sustain. Public health interventions that address structural impediments to behaviour change are perhaps most effective; in Thailand a national campaign to promote and enforce condom use in brothels led to declines in STI incidence of more that 80% and reduced HIV incidence (Hanenberg et al, 1994; Nelson et al, 1996). Yet, as Evans and Lambert (1997) argue, interventions that ‘do not directly address the socio-economic context of women's lives may succeed in reducing levels of STIs, but they may have a questionable impact on improving women's health in the longer term' (p.1801). The structural factors that continue to place women's lives at risk remain.

Following the recent call for locating AIDS in its social and cultural context (Delius & Walker; 2001) we suggest that more attention needs to be placed on the contextual dynamics that place sex workers at risk. It is thus essential that we have a better understanding of sex workers as people, their interactions with their immediate context, and their divergent and varied reasons for entering sex work (Sedyaningsih-Mamahit, 1999:1113). Thus we argue that health seeking behaviour is a product of the complex interactions of histories, culture and political economy (See Evans and Lambert, 1997).

The paper begins by exploring the social organisation of sex work and an understanding of the risks that sex workers face in their everyday working lives. We argue that risk is shaped by both the locale of sex work and categories of sexual partner. Sex workers who operated from the hotels were generally at lower risk than those who worked the streets. However, women constantly drifted between these locales. Sexual partners were categorised as either romantic or paying partners.

Sex workers tended to exercise greater control and power over clients than with romantic partners, particularly with regard to condom use. The second part of the paper describes how sex workers responded to the intervention in the Hillbrow hotels. We suggest that women used the clinic as a resource that helped them to transform the way they saw their bodies, their relationships and the hotel environment. By so doing they reshaped their working environment into the image of the ‘healthy brothel'. In our conclusions we explore the potential for this model to be implemented in other settings with sex workers."

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