Assessment of Utilization of the HIV Interventions by Sex Workers in Selected Brothels in Bangladesh

This 34-page study examines the strategy of peer education for reaching female sex workers (FSWs) with messages related to sexually transmitted infections (STI) and HIV and AIDS prevention in 4 large brothels in 4 different geographic sites in Bangladesh - in Tangail, Mymensingh, Faridpur, and Doulatdia.

As detailed here, since 2004, as part of the HIV/AIDS Prevention Project of the Government of Bangladesh, the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) joined with 3 non-governmental organisations - Bangladesh Women's Health Coalition (BWHC), Population Service and Training Center (PSTC), and Community Health Care Project (CHCP) - to together implement a comprehensive HIV/AIDS prevention programme in 8 selected brothels in Dhaka and Barisal divisions of Bangladesh. The programme is comprised of a clinic-based drop-in centre (DIC) along with a community-based intervention in selected areas that the NGOs reach. A team of counsellors, behaviour change communication (BCC) organisers, the medical team (paramedics and medical officers), and peer educators are working to make changes in FSWs' sexual behaviour (increase condom use) and healthcare-seeking behaviour (access to appropriate treatment for STIs). To accelerate these behaviours, the project emphasised influencing factors such as imparting knowledge and information, developing condom negotiation skills, and motivating FSWs to pursue STI treatment. Financially and technically managed by the United Nations Children's Fund (UNICEF), this project has, since late 2004, reached approximately 3,100 FSWs.

Data collection in the selected 4 (out of the 8) brothels took place during September-October 2008. Separate guidelines were developed for focus group discussions (FGDs)/in-depth interviews with FSWs, and key informant interviews with the healthcare providers and programme managers. FSWs were recruited in two categories: bonded and free. Two female field research officers (FROs) were recruited for data collection. Intensive training was provided through classroom lecture and practical visit to the brothels.

The study found that almost all peer educators were accepted and valued by the FSWs; the reason, as the managers mentioned, was that peer educators have physical and socio-cultural access to the FSWs in their natural environments without being conspicuous. Most of the FSWs were attracted to the condom demonstration session for peer education and, when asked about HIV prevention message, the condom-related message was mentioned first and spontaneously by almost all FSWs. Turnover in brothels is a common problem; therefore, researchers recommended continued training of both graduated peer educators and supervisory staff, as well as provision of new and attractive BCC materials to peer educators.

The FSWs and the Sordarnis (elderly, active FSWs who have a number of young girls working under them in the brothel), irrespective of their age and power structure, mentioned that they are accustomed to negotiating on condom use through educating the clients on AIDS and ways of its prevention. Although the self-reports of FSWs showed their high use of condoms, overall condom use was not consistent by type of young FSWs (bonded and free) or of their clients - regular clients ("Babu", often treated as fiance and custodian of an FSW in the belief that he is the only sex partner of the FSW) and irregular clients. Sordarnis and Babus have been identified as the two major obstacles to condom use.

Lack of sexual pleasure of clients was cited as one of the major causes for unprotected sex. In many instances of unprotected sex, FSWs took no further action to persuade clients in case of refusal after the first offer. The main reason was fear of losing clients; this is especially true for the elderly FSWs.

The reasons provided for FSWs' preference for the NGO clinics were: friendly services, close proximity of clinics to their brothel, availability of service during their more suitable hours, and targeted educational campaigns for sex workers. However, mobility of bonded FSWs was sometimes restricted and impossible without a trusted companion (e.g. either a peer educator or Sordarni). Fear on the part of Sordarnis about young FSWs running away from the brothel makes their mobility and access to healthcare service difficult.

One of the major criticisms of the NGO clinics was limited care. The universal demand of FSWs was comprehensive service provision from these clinics, especially for maternal and child health and menstrual regulation. The reason was that they were getting pregnant either knowingly or unknowingly because of their engagement in unprotected sex work. Another important constraint they mentioned was referral. For maternal and child health as well as severe STI cases, the healthcare providers needed to refer the FSWs to other secondary- and tertiary-level health facilities. So far, to key informants' knowledge, the FSWs tried to hide their identity to the care providers at the referral centres. The reason was that usually the care providers verbally abused the FSWs when they suspected them as being sex workers and used derogatory terms ("loose woman", "prostitute", etc.) to address them. This may be a cause of treatment non-compliance by the FSWs at the referral centres.

In summary, the peer educators were found to be acceptable and credible facilitators to the FSWs in brothels. However, the FSWs' high levels of knowledge of STIs/HIV/AIDS were not always supported by skills to negotiate with their clients. Therefore, it is recommended that more life skills training and role-playing exercises be integrated into FSW education. Beyond this, in order to increase FSWs' control over condom use and access to healthcare, the programme should evolve to include all the relevant individuals in the power structure, including Babus and stakeholders (such as the owner of the brothel, local police department, service providers at the referral centres, etc.) to motivate them to facilitate sex workers' need for protected sex.

Given the problem of stigmatisation of FSWs at the referral centres, it is suggested that training of care providers on human rights and interpersonal communication skills will improve FSWs acceptance of healthcare providers and, thus, increase the use of services at facilities.

Finally, to have a sustainable impact on STI control and HIV prevention, the researchers argue that this programme for FSWs should be seen as an integral component of the larger reproductive health efforts in the country.