Kenya sex worker study looks for answers to the HIV menace
A female sex worker stands in the door to a room she rents at a "sex den" in Kisii
133 675. That, according to new data presented in April 2014 by the Kenyan Ministry of Health, is the number of women who routinely engage in sex work from the shores of Lake Victoria in the country's west, to the coastal communities around the second city of Mombasa and to the capital Nairobi.
Reaching these women, and reducing their HIV infection rate from its current estimated level of 23%, is one of the central planks of the country's national strategic plan (NSP) going forward for 2015 -- and for Kenya’s country dialogue and the development of its concept note to access an allocation of $337.3 million from the Global Fund for 2014-2016.
Targeted programming for sex workers has drawn some $3.4 million from a Round 10 Global Fund disbursement of $40 million to the Kenya Red Cross Society (KRCS), to expand an existing complement of prevention, diagnosis and counseling and other targeted services by 25% over the period 2011-2016.
The challenge, however, is actually finding women who are willing to self-identify as sex workers, according to outreach workers interviewed by Aidspan in Kisumu and Kisii in western Kenya, and in Nairobi. Community-level derision and stigma, coupled with the illegal nature of sex work in Kenya despite its widespread practice, mean that women stay in the shadows, unaware of their status and unaware of how to protect themselves.
To get a better estimate of the population, and a better understanding of who, exactly, these women are so that targeted activities are more effective, the Global Fund has contributed around $100,000 to a landmark study currently under way to develop a balanced portrait of the key populations in Kenya: commercial sex workers, for one, as well as men who have sex with men and people who inject drugs. The results, expected before the end of 2014, will provide evidence for the NSP and, by extension, work to develop the concept note for the Global Fund.
"This study is the only behavioral outcome measurement study to measure key population outcomes in the country," said Helgar Musyoki, program manager for key populations at the National AIDS and STI Control Program (NASCOP).
Some 2,000 women, who self-identified as sex workers, have consented to participate in the survey. They were chosen from one of seven sites nationwide including Nairobi and Kisumu. Curiously, however, there was no effort to penetrate any of the border communities where infections are rife due to their location along East Africa's inland transport corridor.
An 18 year old female sex worker sits in a VCT clinic in Kisii
Interviews followed the completion of a polling booth survey, Musyoki explained, in order to try and draw out the most accurate self-reporting of behavior possible.
"Accurate reporting of sexual behaviour is heavily influenced by personal and contextual barriers, such as predisposition to self-disclosure, poor recall, perceptions of confidentiality and social desirability bias, among others," she told Aidspan in an email. So by using a polling booth survey, NASCOP was trying to "overcome sexual behaviour reporting biases associated with face to face interviews and self-administered questionnaires”.
But because participation is voluntary, the survey is unlikely to provide much insight into two of the most vulnerable -- and thus most under-represented -- groups of sex workers: migrants and minors.
"When they see us coming, they run"
Constrained by a lack of identity papers, some of them unable to communicate either in English or in the East African lingua franca, Kiswahili, and always on the run from the police, migrant sex workers are most often beyond the reach of even the most community-based, discreet outreach interventions.
"Somali and Sudanese sex workers are afraid to talk and disclose their identities," explained Mary Mwangi, an HIV advocacy officer with the Bar Hostess Empowerment and Support Program, a Global Fund sub-recipient under the KRCS grant. "They fear to be expelled or jailed. Plus, we don't have any interpreter, so it's very often impossible to communicate with them."
One study conducted in 2010 by the International Organization for Migration developed a portrait of what a migrant sex worker is likely to look like: young, single and probably from a Muslim family, with only basic literacy and numeracy. She is unlikely to know her status -- and even less likely to know that she has options to protect herself from risk. The difficulty in reaching these young women remains one of the central frustrations for the KRCS, as they are unknowingly the most likely vectors for transmission of HIV.
"The Somali women wear [their veils] in the street but underneath they are in tight jeans, miniskirts and sexy tops," said Florence Mueni, AIDS program manager for the Makadara district. "They remove the veil when they are with their client, but in the street they look like any young Muslim woman. It makes it very difficult to identify them."
A mobile clinic that circulates in some of the densely populated ethnic minority neighborhoods in Nairobi has been one of the more successful community interventions carried out with the Global Fund grant. The clinic's movements have, however, been curtailed due to rising insecurity, particularly in the predominantly Somali neighborhood of Eastleigh, where the Somali sex workers attract clients from all over the city.
People attend a mobile clinic run by the Kenya Red Cross in Nairobi
There are different, but no more surmountable, obstacles when trying to reach the teenagers involved in sex work in urban and rural communities. National laws require an adult to accompany any minor to a state-run voluntary counseling and testing center (VCT), which undermines any hope of confidentiality for a young person.
Still, some inroads are being made, with other programs supported by the Global Fund. The Impact Research and Development Organization (IRDO) center in Kisii is working with roughly 100 girls aged 15-17, half of whom are HIV positive and all of whom live in abject poverty, having turned to sex work when there were no other options.
For them, says Silvia, a former sex worker who now works as a volunteer counselor, the choice is a stark one: "If HIV is not going to kill them tomorrow, hunger will".
Photos by Phil Moore