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In South Africa, HIV Prevention Starts With Sex Workers

A government rollout of antiretroviral treatment PrEP puts the power of prevention into women’s hands in a country once called the ‘world’s rape capital.’ One of the first groups to get the free pills is also one of the most vulnerable: prostitutes.

Written by Hannah McNeish Published on Read time Approx. 4 minutes
In this photo taken on April 9, 2009, an unidentified girl hangs around in the shadows near Musina truck stops along with other older prostitutes, in South Africa. AP/Tsvangirayi Mukwazhi

DURBAN, South Africa – A condom or a coffin. That is the real choice a woman faces when she decides between a man paying 40 to 400 South African rand (around $3 to $30) for sex while wearing a condom, and one paying 1,000 to 1,500 rand (around $75 to $110) for unprotected sex, explains sex worker Emily.

In the city of Durban, where 53 percent of sex workers have HIV, peer educators like Emily (not her real name) walk the streets with condoms and wooden dildos looking to show women how to put them on properly, and warning against men who will pay more not to use them. “For men, it’s so easy to just give out the money and spread whatever infections they have to sex workers, because they think [the women] are that easy because they need the money” or have to take it to pay off pimps, she says.

But Emily and many other women in South Africa, once dubbed “the world’s rape capital” by media, know too well that the decision to have unprotected sex is often out of their control. So as well as educating prostitutes on how to have safer sex, since June 1, Emily and other peer educators working with the charity TB/HIV Care Association have been trying to convince women to take a daily combination pill of antiretrovirals (ARVs), or Pre-exposure Prophylaxis (PrEP). If taken properly, PrEP is 90 percent effective at preventing the contraction of HIV, putting the power of protection entirely into the women’s hands.

Emily’s path to sex work began with a loss of power. She ran away from home in her teens after being raped by an uncle. She bore his child when she was 16 and turned to sex work when her supermarket job couldn’t support them both. In the first few days of taking to Durban’s streets, she was picked up by a policeman who took her not to a station, but to his police lodgings, where he raped her in the parking lot.

“You’re out there in the cold and you know what you left behind at home, maybe you left starving kids. You come out in the street looking for money and you’re taken advantage of by a client who came by you for fun,” she says.

Emily can’t stop the attacks or the unprotected sex on Durban’s streets. But by giving HIV-negative sex workers access to PrEP, she is contributing to South Africa’s latest move to fight an epidemic that has already infected 7 million of its people.

In the first phase of a government rollout, certain NGOs in a few areas are giving out free PrEP to women at risk of contracting HIV. The project is starting slowly, because people are suspicious of anyone trying to get them to take free medication. Harry Hauser, who runs the TB/HIV Care Association in Durban, says that the charity has already put 43 women on PrEP and is screening for more candidates among the 3,800 sex workers that peer educators have registered over the past four years.

“The availability now of PrEP for sex workers is revolutionary. It’s a very exciting time that we now have another option to provide good protection for sex workers to protect their own health, as well as protect the health of the broader population,” says Hauser.

Across South Africa, home to the largest number of people living with HIV in the world, 20 percent of new infections come from sex workers or their clients. “Whoever is negative must stay negative to stop spreading the virus, and PrEP is helping a lot,” says Emily.

While some women were wary of her at first, assuming that she was making a commission by putting them on pills, the government’s endorsement of PrEP combined with word of mouth is increasing the popularity of the prevention method.

“Most of the ladies are saying it’s perfect,” says Emily. “There’s no side effects like other medications, it’s just maybe those few headaches for one to two days, and then it’s gone.” She says only one of the 44 women TB/HIV Care has put on PrEP stopped taking it due to nausea.

Thuli Xhosa, a representative for South Africa’s sex workers union SISONKE, says that “since the rollout of PrEP started in June, there’s been a lot of uptake” by many women too scared to even carry condoms, because police often use condoms as evidence to arrest sex workers.

But the pills are not without controversy. Trials by the Wits Reproductive Health and HIV Institute, one of South Africa’s leading research institutes, found that some sex workers didn’t want to carry PrEP pills as they might be taken for ARVs and lead to stigma, says clinician Michelle Moorehouse. “We have some sex workers who live under bridges or live in the bush, so what we do for them is that the pharmacist at the site just gives them a non-descriptive packet,” she says.

Many experts in South Africa have high hopes for the benefits PrEP can bring to the country. “PrEP is one of the biggest breakthroughs we’ve had in more than a decade” to reduce “the 300 new infections in young women and girls we see in this country every single day,” says Linda-Gail Bekker, incoming president of the International Aids Society.

For Emily, PrEP came too late. She is HIV-positive and takes ARVs to help her live longer and prevent her from transmitting the virus to rough customers who break condoms or refuse to wear them.

“What I’ve experienced, I’ve got that knowledge now to give out to sex workers,” she says.

And for many women, that means a condom or a coffin are no longer their only choices.

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