Addressing HIV/STI Risk Among Female Sex Workers A Group Model Approach Presentation at the 1st African Conference on Key Populations in the HIV Epidemic Dar es Salaam, Tanzania August 19-21, 2013 By Kushatha Mosienyane & Erin Smith RTI MARPs PROJECT Agenda • • • • • • • Problem statement Project information: Botswana HIV MARPs project Background: risk reduction model Project design Lessons learned Benefits of the group model Conclusion Problem Statement The 2012 Biological Behavioral Surveillance Survey of high risk sub-populations revealed a 61.9% HIV prevalence rate among sex workers (SW) in Botswana. • In a program review, only 16% of program respondents reported using condoms “often” and 80% said they regularly had unprotected sex with clients. Problem Statement • Program respondents reported clients preference for dryness during intercourse. To achieve this, drying agents are used prior to work. Condoms are not used, or often break. • Of problems in the past year, customer and partner violence ranked #1, with 82% of participants reporting having experienced incidents of gender based violence (GBV). Problem Statement • High HIV prevalence, a preference for dry sex, and high incidence of GBV all propel the continuation of the HIV epidemic in Botswana, but sex workers face multiple challenges to sustained risk reduction: • Fractured, highly mobile populations with little or no sense of community • Exposed to physical and sexual abuse with little opportunity for recourse due to the illegality of sex work in Botswana • A large percentage have a history of severe psychological shocks ( rape, physical and emotional abuse, abandonment, political conflict, etc.) • All program participants reported regular use of alcohol during working hours Project Information • Botswana HIV-MARPs: a 5-year USAID project run by RTI International. • Targets: female sex workers ; male clients of sex workers; men who have sex with men. • Program Objectives: • Develop and implement behavior change communication (BCC) strategies that move beyond abstinence and fidelity to motivate sustained behavior changes for risk reduction • • • Bring services, such as voluntary HIV testing and counseling (HTC), closer to the target populations through outreach mechanisms • • Reduce barriers to access to care, and engage clients and providers in defining and monitoring service quality • Background: Risk Reduction Model • Project staff identified a need to develop a different kind of intervention to increase risk reduction activities among FSW in Botswana. • Based on multiple studies which show increasing solidarity and a sense of community among FSW has been effective in improving condom use, project staff reached out to the University of Botswana’s Dr. Tirelo Modie-Moroka, an expert in psycho-social and group counseling among sex workers. • Together, this model was piloted, and rolled out to all project areas. Risk Reduction Model Group Model Program Objective: • Empower target populations to reduce their risk of encountering violence and of becoming infected or infecting others with HIV • Build on multiple research reports showing that developing group solidarity is one of the most effective risk reduction techniques among sex workers • Increase enrollment and adherence of ART Project Design • Technical officers of CSO’s working with key populations were trained in: • • • • • • • Group counseling methods HIV risk reduction Substance abuse Gender based violence Poverty alleviation Sex workers rights Effective referrals for services Project Design • From 2011 to 2013, a total of 100 women aged 22 – 45 years were enrolled for the group counseling model across three districts • Groups met twice a month, guided by facilitators with mentorship from the HIV-MARPs project specialist • Discussion was open forum, allowing women to talk about whatever they wanted within the guidelines of the group objectives Lessons Learned • In the group settings, women found a sense of community and support that they had not previously received • Women participating in the group model reported feeling groups were a safe environment to discuss matters that cannot be explored through more conventional models • Groups offered a true peer experience where women were free to discuss their common daily problems such as, • Causal factors influencing engagement in sex work, • Realities of gender based violence • Challenges behind leaving sex work for alternate employment • Money struggles • Relationship problems Benefits of the Group Model • The group setting allowed women to: • Build relationships among themselves • Create a safety net effect on the job which supported decreased risk taking • Improve self esteem • Improve sense of community • Improve access to care and treatment services • Increase enrollment into ART and improve adherence • Develop protection strategies to decrease gender based violence • Set common prices and insist on condom use during sex (refusing to accept more money for condom free sex) Conclusion • The group psychosocial counseling model for SWs in Botswana has yielded positive results: • Offering a safe environment for sharing experiences • Allowing SWs to build a network of trust among their peers • Supporting positive choices towards risk reduction • Accessing health services • Increasing adherence, and in some cases • Exiting sex work