Bargaining with the body: the lived experiences of gay Zimbabwean migrants navigating survival and social integration in Cape Town

Sex workers in Sub-Saharan Africa are vulnerable to a range of factors that dispose them to poor health outcomes. In particular, they are at high risk of violence, injury, rape, discrimination and a spectrum of human rights abuses. Their vulnerability to HIV and other STIs are many fold greater than the non-sex worker population of the same age. Health care systems world-wide, and particularly in Africa, are not adequately responsive to the needs of sex workers. As a result, many sex workers do not receive adequate health services, education or HIV prevention tools. While the literature on female sex work in Africa is fairly robust, troubling research gaps are evident on male and transgender sex work, as well as on the intersections of migration and sex work. Mega-sport events have been associated with increased anxiety about sex work and human trafficking, with few studies tracking the impact of such events on local sex work industries over time. These fears were prominent during the 2010 FIFA Soccer World Cup. This PhD project consisted of three research projects based in South Africa and Kenya. It aimed to evaluate the impact of social and behavioural factors on the health of sex workers. To achieve this objective, it examined the effects of sex worker characteristics, migration status, and their relationships with commercial and non-commercial partners on sexual behaviour and access to services. Such information may assist in designing more effective health policies in addition to providing insights into the structural factors that affect sex work settings and heighten sex worker vulnerability to ill-health. The first research project consisted of face-to-face surveys with 1799 male, female and transgender sex workers in Johannesburg, Rustenburg and Cape Town. The second research project involved telephonic interviews in three waves with 663 female sex workers who advertised online or in newspapers in South Africa. The third component was a prospective cohort of 400 female sex workers in Mombasa, Kenya. The research findings indicate the diversity of the sex industry and the people who work in it. Sex work is an important livelihood strategy that provides an income for sex workers and their extended network of dependents. Migration is a vital component for exploring and understanding how many sex worker lives and work are structured in South Africa. Sex workers are subject to violence from their non-commercial partners as well as from police, while unprotected sex with non-commercial partners emerges as an important risk factor for HIV. The PhD research detected little significant changes in the sex industry due to the 2010 Soccer World Cup, and documents how strategic opportunities were lost to alter some of the structural conditions of sex work during a time of heightened sex work awareness, funding and scrutiny. Moreover, this thesis highlights the shortcomings of health care services in responding to the needs of sex workers. It recommends the rolling-out of specialised, sex work-specific health care services in areas of sex work concentration, and sex work-friendly services in mainstream health care facilities in areas of lower sex work concentration. Non-judgemental and empathetic health workers are a key component of responsive services. Lastly and perhaps most importantly, it underscores the importance of decriminalising sex work in order to safeguard sex worker rights and to protect individual and public health.

As of 2016, women make up the majority of people living with HIV globally, and especially in sub-Saharan Africa where women and girls make up 59% of all people living with HIV. Female sex workers (FSWs) are at even higher risk of acquiring HIV, given vulnerabilities in criminalization of their work and challenges in negotiating safer sex. HIV prevalence among FSWs in South Africa is higher than any other sub-population, with a recent study recording a prevalence of up to 72% in the greater Johannesburg area, and 40% and 54% prevalence in Cape Town and Durban respectively. To date, female-initiated HIV prevention options have been limited, with most interventions focused on male condom use. However, in the last few years, oral pre-exposure prophylaxis (PrEP) has been shown to be highly efficacious in preventing HIV infection among men and women, if taken consistently. To examine whether women, especially those who are considered part of key populations, will take up and use PrEP outside of clinical trials, many demonstration or pilot studies are underway around the world. This thesis explores the real-world applicability and acceptability of oral PrEP in order to inform intervention design, implementation, and product use for female sex workers in South Africa. A range of methods were used to answer this overarching aim including: an adapted meta-ethnography to explore and understand previous research regarding motivations and barriers to uptake and use of female-initiated HIV prevention technologies that could be used by women in sub-Saharan Africa; formative research in South Africa, using a grounded approach to examine the practical and contextual factors that might influence successful delivery of a PrEP intervention with the aim of designing an intervention; focus group discussions with FSWs to examine community-level acceptability of PrEP with potential end users (the final activity in the formative research); demographic and behaviour surveys conducted during the Treatment And Prevention for Sex workers (TAPS) Demonstration Project to identify key characteristics of FSWs who took up and used PrEP within the context of TAPS; and, in the individual perspectives and lived experiences of PrEP users in TAPS are explored through analysis of in-depth face-to-face interviews with FSW. The overall findings of this thesis point to the multi-dimensional aspects of individual needs, community perceptions and beliefs, clinic delivery platform and feasibility, as well as societal norms and environmental context which determine the ability of FSWs to successfully use PrEP. Recommendations for including and acknowledging these dimensions, as well as how to leverage them to develop more effective programmes are included.

BackgroundRobust population size estimates of female sex workers and other key populations in South Africa face multiple methodological limitations, including inconsistencies in surveillance and programmatic indicators. This has, consequently, challenged the appropriate allocation of resources and benchmark-setting necessary to an effective HIV response. A 2013-2014 integrated biological and behavioral surveillance (IBBS) survey from South Africa showed alarmingly high HIV prevalence among female sex workers in South Africa’s three largest cities of Johannesburg (71.8%), Cape Town (39.7%), and eThekwini (53.5%). The survey also included several multiplier-based population size estimation methods.ObjectiveThe objective of our study was to present the selected population size estimation methods used in an IBBS survey and the subsequent participatory process used to estimate the number of female sex workers in three South African cities.MethodsIn 2013-2014, we used respondent-driven sampling to recruit independent samples of female sex workers for IBBS surveys in Johannesburg, Cape Town, and eThekwini. We embedded multiple multiplier-based population size estimation methods into the survey, from which investigators calculated weighted estimates and ranges of population size estimates for each city’s female sex worker population. Following data analysis, investigators consulted civil society stakeholders to present survey results and size estimates and facilitated stakeholder vetting of individual estimates to arrive at consensus point estimates with upper and lower plausibility bounds.ResultsIn total, 764, 650, and 766 female sex workers participated in the survey in Johannesburg, Cape Town, and eThekwini, respectively. For size estimation, investigators calculated preliminary point estimates as the median of the multiple estimation methods embedded in the IBBS survey and presented these to a civil society-convened stakeholder group. Stakeholders vetted all estimates in light of other data points, including programmatic experience, ensuring inclusion only of plausible point estimates in median calculation. After vetting, stakeholders adopted three consensus point estimates with plausible ranges: Johannesburg 7697 (5000-10,895); Cape Town 6500 (4579-9000); eThekwini 9323 (4000-10,000).ConclusionsUsing several population size estimates methods embedded in an IBBS survey and a participatory stakeholder consensus process, the South Africa Health Monitoring Survey produced female sex worker size estimates representing approximately 0.48%, 0.49%, and 0.77% of the adult female population in Johannesburg, Cape Town, and eThekwini, respectively. In data-sparse environments, stakeholder engagement and consensus is critical to vetting of multiple empirically based size estimates procedures to ensure adoption and utilization of data-informed size estimates for coordinated national and subnational benchmarking. It also has the potential to increase coherence in national and key population-specific HIV responses and to decrease the likelihood of duplicative and wasteful resource allocation. We recommend building cooperative and productive academic-civil society partnerships around estimates and other strategic information dissemination and sharing to facilitate the incorporation of additional data as it becomes available, as these additional data points may minimize the impact of the known and unknown biases inherent in any single, investigator-calculated method.

‘Business’ is the going professional terminology for sex work in South Africa. Often times it also doubles as a covert term due to the criminalised nature of sex work, on judicial and moral grounds, in South Africa. Yet sex work is a livelihood for bodies that have been placed outside the margins of the mainstream political economy; such bodies reside along margins of differentiation of race, gender, class and sexuality, produced through histories of disposition rooted in colonisation and apartheid in South Africa. Although this is a predominantly heterosexual and cis-gendered industry, what then does it mean to ‘do business’ for gender queer sex workers? How do they navigate a heavily heterosexist and violent political economy that alienates African-ness from same-sex/gender intimacies, and does not foreground sexual pleasure? This article will centre the narratives and lived experiences of gender queer sex workers in Cape Town, based on an ethnography with sex workers carried out over a period of three and a half years. Working within the framework of performance as research – a curatorial methodology and praxis – I will offer some insight on gender queer sex workers as bodies out of place. I argue street-based sex workers’ narratives proliferate as a cascade of space invaders by ‘un/doing business’ both within a heavily criminalised, heterosexist frame and political economy in Cape Town, to contribute to the GDP as well as centre sexual pleasure. In addition, the curatorial praxis deployed as a cascade of space invasion works towards humanising sex workers by foregrounding their everyday lives as well as contributing to the collective agenda of decriminalisation and destigmatisation of sex work in South Africa.

BackgroundGlobally, female sex workers (FSWs) are considered a key population group due to the high HIV prevalence. Studies show that there are various factors in some contexts that render FSWs marginalised, which limits their access to sexual reproductive health (SRH) services. Access to SRH services are particularly challenging in countries where sex work is criminalised such as is the case in South Africa. Evidently, there are alternative ways in which FSWs in this context receive non-stigmatising SRH care through non-governmental organisations. The aim of this study was to understand the functioning of these non-governmental health care services as well as to document the experiences of FSWs utilising these services.MethodsEleven focus group discussions were held with 91 FSWs. In addition, 21 in-depth individual interviews with researchers, stakeholders and FSWs were conducted. Interview guides were utilised for data collection. Informed consent was obtained from all participants. Data were analysed thematically.ResultsThe FSWs expressed challenges related to SRH care access at public health facilities. The majority felt that they could not consult for SRH-related services because of stigma. The non-governmental health and advocacy organisations providing SRH services to FSWs through their mobile facilities utilising the peer approach, have done so in a way that promotes trust between FSWs and mobile health care providers. FSWs have access to tailored services, prevention materials as well as health information. This has resulted in the normalising of HIV testing as well as SRH seeking behaviours.ConclusionThis study has established that health and advocacy organisations have attempted to fill the gap in responding to SRH care needs of FSWs amidst intersecting vulnerabilities. FSWs’ engagement with these organisations has encouraged their willingness to test for HIV. However, it is important to note that these organisations operate in urban areas, thus FSWs operating outside these areas are most likely exposed to compounding health risks and lack access to tailored services.

In South Africa, information on sex workers' characteristics, sexual behaviour and health needs is limited. Current social, legal and institutional factors impede a safe working environment for sex workers and their clients. To describe characteristics and sexual behaviour of female, male and transgender sex workers, and assess their risk factors for unprotected sex. Repeat cross-sectional surveys among sex workers were conducted in Hillbrow, Sandton, Rustenburg and Cape Town in 2010. Sex workers were interviewed once; any re-interviews were excluded from analysis. Unprotected sex was defined as any unprotected penetrative vaginal or anal sex with last two clients. Trained sex workers interviewed 1 799 sex workers. Sex work was a full-time profession for most participants. About 8% (126/1 594) of women, 33% (22/75) of men, and 25% (12/50) of transgender people had unprotected sex. A quarter of anal sex was unprotected. Unprotected sex was 2.1 times (adjusted odds ratio (AOR), 95% CI 1.2 - 3.7; p=0.011) more likely in participants reporting daily or weekly binge drinking than non-binge drinkers. Male sex workers were 2.9 times (AOR, 95%CI 1.6 - 5.3; p<0.001) more likely, and transgender people 2.4 times (AOR, 95% CI 1.1 - 4.9; p=0.021) more likely, than females to have unprotected sex. Sex workers in Hillbrow, where the only sex work-specific clinic was operational, were less likely to have unprotected sex than those in other sites. Tailored sex work interventions should explicitly include male and transgender sex workers, sex work-specific clinics, focus on the risks of unprotected anal sex, and include interventions to reduce alcohol harm.

BackgroundPeople who use drugs including people who inject drugs (PWUD/ID), sex workers (SWs) and men who have sex with men (MSM) are at increased risk of HIV and viral hepatitis infection. Limited epidemiological data on the infections exists in key populations (KPs) in South Africa. We investigated the prevalence of hepatitis B (HBV), hepatitis C (HCV) and HIV and selected risk factors among these KPs to inform effective responses.MethodsWe used convenience sampling to recruit a targeted 3500 KPs accessing HIV-related health services across Cape Town (SWs, MSM, PWUD/ID), Durban (SWs, PWUD/ID), Pietermaritzburg (SWs), Mthatha (SWs), Port Elizabeth (SWs), Johannesburg (MSM) and Pretoria (MSM and PWUD/ID) into a cross-sectional survey. An interviewer questionnaire to assess socio-demographic characteristics, drug use and sexual risk practices, was administered. HBV surface antigen (HBsAg); HCV antibody, viral load and genotype, and HIV antibody, was tested.ResultsAmong the 3439 people included in the study (1528 SWs, 746 MSM, 1165 PWUD/ID) the median age was 29 years, most participants were black African (60%), and 24% reported homelessness. 82% reported substance use in the last month, including alcohol (46%) and heroin (33%). 75% were sexually active in the previous month, with condom use at last sex at 74%. HIV prevalence was 37% (highest among SWs at 47%), HBsAg prevalence 4% (similar across KPs) and HCV prevalence was 16% (highest among PWUD/ID at 46%).ConclusionsHBV, HCV and HIV pose a health burden for KPs in South Africa. While HIV is key for all included KPs, HCV is of particular importance to PWUD/ID. For KPs, HBV vaccination and behavioural change interventions that support consistent condom and lubricant access and use are needed. Coverage of opioid substitution therapy and needle and syringe services, and access to HCV treatment for PWUD/ID need to be expanded.

BackgroundLate presentation combined with limited engagement in antenatal care (ANC) increases risk of vertical transmission among mothers living with HIV. Female sex workers (FSW) have more than four times greater burden of HIV than other women of reproductive age in South Africa and the majority of FSW are mothers. For mothers who sell sex and are at increased HIV acquisition risk, timely and routine ANC seeking is especially vital for prevention of vertical transmission. This study represents a mixed-methods study with FSW in Port Elizabeth, South Africa, to characterize factors influencing ANC seeking behaviors in a high HIV prevalence context.MethodsFSW (n = 410) were recruited into a cross-sectional study through respondent-driven sampling between October 2014 and April 2015 and tested for HIV and pregnancy. A sub-sample of pregnant and postpartum women (n = 30) were invited to participate in in-depth interviews (IDIs) to explore their current or most recent pregnancy experiences. IDIs were coded using a modified grounded theory approach and descriptive analyses assessed the frequency of themes explored in the qualitative analysis among the quantitative sample.ResultsIn the quantitative survey, 77% of FSW were mothers (313/410); of these, two-thirds were living with HIV (212/313) and 40% reported being on antiretroviral therapy (ART) (84/212). FSW in the qualitative sub-sample reported unintended pregnancies with clients due to inconsistent contraceptive use; many reported discovering their unintended pregnancies between 4 and 7 months of gestation. FSW attributed delayed ANC seeking and ART initiation in the second or third trimesters to late pregnancy detection. Other factors limiting engagement in ANC included substance and alcohol use and discontent with previous healthcare-related experiences.ConclusionsLate pregnancy discovery, primarily because pregnancies were unplanned, contributed to late ANC presentation and delayed ART initiation, increasing risks of vertical HIV transmission. Given limited ART coverage among participants, addressing the broader sexual and reproductive health and rights needs of mothers who sell sex has important implications for preventing vertical transmission of HIV. Integrating comprehensive family planning services into FSW programming, as well as providing active linkage to ANC services may reduce barriers to accessing timely ANC, decreasing risks of vertical transmission.

This study examined data collected from a sample of female sex workers (FSWs) during the first two years of a brief risk-reduction intervention for vulnerable populations that focused on substance use and HIV risk-related behaviours (2007–2009) as part of a rapid assessment and response evaluation study. In 2007, in collaboration with a local non-governmental organisation (NGO), an initiative was begun to roll out targeted harm reduction strategies for drug-using street based FSWs in Durban, South Africa. Data were collected on demographic characteristics, substance use and HIV risk behaviours to tailor these harm reduction strategies with participants. Over the first two years of the intervention, data were collected from 646 FSWs: 428 who reported being at low risk for HIV and 218 who reported being at high risk for HIV (defined as engaging in unprotected sex with sexual partners in the past 90 days). FSWs who had previously been diagnosed with HIV or a sexually transmitted disease (STD) were significantly less likely to report engaging in unprotected sex. Those who used over-the-counter or prescription (OTC/PRE) drugs reported engaging in unprotected sex significantly more often than FSWs who did not use these substances, while those who used heroin were less likely to report unprotected sex. The findings are encouraging in that those who are aware of their HIV status are less likely to engage in risky sexual behaviour, and therefore HIV testing and counselling is recommended. It indicates the need to identify strategies to encourage the likelihood of all FSWs, particularly those who are HIV-positive, to use condoms. It also encourages further research to investigate specific substances as possible predictors of high risk behaviours in high-risk populations of sex workers.

Sex workers are often perceived as possessing ‘deviant’ identities, contributing to their exclusion from health services. The literature on sex worker identities in relation to health has focused primarily on cisgender female sex workers as the ‘carriers of disease’, obscuring the experiences of cisgender male and transgender sex workers and the complexities their gender identities bring to understandings of stigma and exclusion. To address this gap, this study draws on 21 interviews with cisgender male and transgender female sex workers receiving services from the Sex Workers Education and Advocacy Taskforce in Cape Town, South Africa. Our findings suggest that the social identities imposed upon sex workers contribute to their exclusion from public, private, discursive and geographic spaces. While many transgender female sex workers described their identities using positive and empowered language, cisgender male sex workers frequently expressed shame and internalised stigma related to identities, which could be described as ‘less than masculine’. While many of those interviewed felt empowered by positive identities as transgender women, sex workers and sex worker-advocates, disempowerment and vulnerability were also linked to inappropriately masculinised and feminised identities. Understanding the links between gender identities and social exclusion is crucial to creating effective health interventions for both cisgender men and transgender women in sex work.

Journal Article Studying together, living apart: Emerging geographies of school attendance in post-apartheid Cape Town Get access Anthony Lemon, Anthony Lemon Search for other works by this author on: Oxford Academic Google Scholar Jane Battersby-Lennard Jane Battersby-Lennard * *Anthony Lemon (tony.lemon@mansfield.ox.ac.uk) is Emeritus Research Fellow in Geography, Oxford University, and Emeritus Fellow, Mansfield College. Jane Battersby-Lennard (jane.battersby.lennard@gmail.com) is Lecturer in Geography, University of Cape Town. Search for other works by this author on: Oxford Academic Google Scholar African Affairs, Volume 110, Issue 438, January 2011, Pages 97–120, https://doi.org/10.1093/afraf/adq062 Published: 18 November 2010

ABSTRACTPrevious research shows that interventions aimed at female sex workers (FSWs) can be successful in reducing HIV risk behavior. The current study evaluated a specific HIV prevention intervention for substance-using FSWs in Durban, South Africa by comparing such behaviors before and after the intervention. The intervention was provided by trained outreach workers by an organization that worked with FSWs, and consisted of community-based outreach, HIV and substance use education and information. Safer sex practices were also taught. The sample consisted of 457 substance-using FSWs, with findings indicating a significant decrease in the number of sexual partners (z = −16.05, p < 0.001), number of times they engaged in vaginal sex (z = −8.07, p < 0.001), and a significant decrease in all substances used with the exception of over-the-counter or prescription substances. The intervention therefore seemed to reduce certain risk behaviors among this group of FSWs. Future research should focus on the aspects of the substance use-sex risk intervention that were associated with decreased risk behavior, and include a randomized controlled trial to assess effectiveness of the intervention.

A second chance for microbicides

PrEP cycling among women is thought to be safe when there are distinct “seasons of risk.” However, cyclical PrEP use over short periods may be associated with increased risk of HIV acquisition. We aimed to characterize key social ecological factors contributing toward PrEP cycling among female sex workers (FSW) in the context of high HIV risk. Semi-structured, in-depth interviews were conducted with 36 FSW at risk for HIV acquisition and 12 key informant (KI) service providers in eThekwini (Durban), South Africa from January-October 2020. FSW identified key factors driving temporary discontinuation of PrEP including relocation, lack of information on or difficulty coping with side effects, and delays in accessing PrEP. In many cases, FSW were motivated to restart PrEP once barriers were overcome. In contrast, KIs emphasized the importance of individual adherence to PrEP and reliance on personal risk assessments when counselling FSW on cycling decisions. FSW and KI perspectives highlight a disconnect between providers’ recommendations on the potential for cyclical use of PrEP during periods of minimal risk and actual drivers among FSW causing temporary PrEP discontinuation. Further interventions supporting safe PrEP cycling are needed to ensure decisions around cycling are deliberate and guided by changes in HIV risk rather than external factors.

PrEP cycling among women is thought to be safe when there are distinct "seasons of risk." However, cyclical PrEP use over short periods may be associated with increased risk of HIV acquisition. We aimed to characterize key social ecological factors contributing toward PrEP cycling among female sex workers (FSW) in the context of high HIV risk. Semi-structured, in-depth interviews were conducted with 36 FSW at risk for HIV acquisition and 12 key informant (KI) service providers in eThekwini (Durban), South Africa from January-October 2020. FSW identified key factors driving temporary discontinuation of PrEP including relocation, lack of information on or difficulty coping with side effects, and delays in accessing PrEP. In many cases, FSW were motivated to restart PrEP once barriers were overcome. In contrast, KIs emphasized the importance of individual adherence to PrEP and reliance on personal risk assessments when counselling FSW on cycling decisions. FSW and KI perspectives highlight a disconnect between providers' recommendations on the potential for cyclical use of PrEP during periods of minimal risk and actual drivers among FSW causing temporary PrEP discontinuation. Further interventions supporting safe PrEP cycling are needed to ensure decisions around cycling are deliberate and guided by changes in HIV risk rather than external factors.