Review of HIV and AIDS programming with female sex workers in sub Saharan Africa

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Fairly often I am asked to do literature reviews of various areas of HIV and AIDS programming.  They are often conducted for a specific purpose – for instance, training of staff of HIV and AIDS agencies, presentation at conferences, or as background for planning exercises.  What this means is that once they have been used they don’t necessarily get taken any further, because it was never intended for them to be published – and indeed the time and investment is such that they often don’t get to publishable standard…

However, I always think it is a shame to lose them altogether – if only because they often contain very complete bibliographies.  I’ve started asking various clients to allow me to release elements of this work to share here, so that they don’t disappear altogether.

The attached report has been lopped out of a larger review I conducted in June 2009 of HIV programming with “at risk” or “key” populations in sub-saharan Africa.  I haven’t had time to do a proper edit or major update, but the references are good and although the conclusions are brutally reductionist I think they broadly summarise the sorts of things HIV programmes with sex workers should be addressing.  I’d like at some point to turn it into something more substantial that goes into the practicalities of setting up services, training practitioners and so on because I think this is more useful to implementers than the quick and dirty intervention descriptions that are provided in journal articles.

Feel free to read, pick at, use the references and so on.  Please get in touch if you would like to actually cite this document or want any further information – because although I have been authorised to share it I would need to check again with the client about any further usage.

Syphilis somewhere else

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The “facebook causes syphilis” story (a great summary here http://bit.ly/df3Ez2) has reminded me of another syphilis storm that I was following a few years ago, in Madagascar.  

“Syphilis emergency in Madagascar”

http://news.bbc.co.uk/1/hi/world/africa/6905625.stm

Health scares – and particularly sexual health ones – are of course often used as a weapon in other battles.  This story about an explosion of syphilis – and a consequent declaration of a “state of emergency” – in Fort Dauphin in the south of Madagascar is a very good example.  Syphilis prevalence has been very high in the region for a long time, though nothing like as high as 30%.  On the other hand Fort Dauphin is one of the most marginalised regions in the country in terms of health promotion and health care.  Nonetheless the politics were such that the government presented a figure from a very small sample as being representative, then blamed it on sex workers and on foreign migrant workers.  And decided to take action because “there are fears the condition could provide an entry route for HIV/Aids”…  So you ignore a massive syphilis epidemic – and all manner of other sexual and reproductive health problems – until you can tag it to foreign workers and HIV?

I’m going to try to write more about Madagascar, where I helped run an HIV and sexual health programme for 3 years.  But this is just a taster of the sorts of challenges we faced in getting stuff done, in particular as we were working with some of the most stigmatised groups – including a fantastically dynamic sex worker collective in Fort Dauphin.

Fort Dauphin also happens to be – in my opinion – one of the most stunning places in the world, so I think that deserves a pretty picture.

 

40,000 new sex workers for the South Africa world cup? Really? Anatomy of a number

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David Bayever of South Africa’s Central Drug Authority’s announcement that the World Cup in South Africa would lead to 40,000 foreign sex workers being brought to South Africa (“many… from Eastern Europe”) has received blanket coverage in the press (http://tinyurl.com/ygpz8wp; http://tinyurl.com/ya35p3k; http://tinyurl.com/yfwfluh).  The only hint of a source for this very high figure is the “event organisers” (in the Telegraph article). 

  But it looks like this particular figure wasn’t made up on the hoof by anyone in South Africa.  Try googling “40,000, world cup, prostitute, germany” and you’ll see that exactly the same figure was being given in the run up to the Germany World Cup in 2006 (http://bit.ly/clc6dN; http://bit.ly/c44hgv;  http://bit.ly/aLuhoM), amid accusations that the German government, having legalised prostitution in 2002, was facilitating trafficking and coercion. 

While the organisers of the South Africa World Cup seem to have got their figure from the Germany World Cup – right down to the emphasis on sex workers coming “mostly from Eastern Europe” – it looks like there was no robust source for the original figure.  And the assumption that the situation in South Africa – another time, another country, another continent – will be analagous to the situation in Germany, seems sketchy at best. It’s also too bad that whoever proposed the 40,000 figure for South Africa wasn’t aware of or ignored the fact that the figure was serially debunked after the 2006 World Cup, in the Lancet (http://tinyurl.com/ydaq278), by the Council of Europe (http://tinyurl.com/ye8h9ms), and by the International Organisation for Migration (http://tinyurl.com/y9a48hz).   According to the Council of Europe report:

 
    “…there was no confirmation of the reports sometimes made prior to the 2006 World Cup in which it was claimed that the expected additional demand for prostitutes would be covered by women forced into prostitution and perhaps brought to Germany for this purpose. There was no sign whatsoever of the alleged 40,000 prostitutes/forced prostitutes – a figure repeatedly reported, also in international media – who were to be brought to Germany for the 2006 World Cup.)”

 

UPDATE: 11 March 2010.  A quick scan of the press reveals that many, many more outlets have reported the 40,000 figure.  By now it is folklore.  To list a few:

NY Daily news http://bit.ly/aXW7Pp

Iafrica.com http://bit.ly/9W6MP9

Times of India http://bit.ly/dtGXlt

News24.com http://bit.ly/cuqXoW

UK Guardian: http://bit.ly/91toJm

etc etc etc…

 

Epi…dream…iology. How HIV prevention programmes are sometimes based on made up stuff.

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In my view, one of the strengths of many HIV and AIDS programmes is that they emphasise community participation, involving the people affected in analysing the issues they face and developing strategies to overcome them.  It can work really well, when it is well facilitated and based in reality.  But in the absence of good data on HIV vulnerability and risk – which is the case in many low income countries – everyone becomes an expert, and there can be a fair amount of people sitting around trying to conjure up the most worst scenarios to respond to.  And as a result, HIV prevention strategies often reflect prejudices and moral panic.  You often end up with long lists of stuff that could, conceivably happen, but no sense of whether it actually does.

I recently came across some conclusions from a study carried out by a development NGO on risks of HIV in the NGO workplace, in a sub-saharan African country.  It is described as “baseline research” but the methodology is not clear.  I do know that some of the recommendations were developed at a workshop where the participants “decided that xxxxx was a risk factor”, which suggests that the conclusions were based on guesswork.

Here are a few excerpts from the study, relating to risk and vulnerability factors (translated from French, hence the oddness of some language).  As far as I can tell, the ultimate conclusion is that AIDS programmes cause AIDS.  Note the blind spot on same-sex relationships, and the fact that condoms aren’t mentioned anywhere. 

“The factors that negatively affect the fight against aids in institutional settings are as follows:

  • The planning of unnecessary overtime by employers and employees of different sexes
  • Placing managers’ offices in isolated or overly discrete (hidden?) places
  • Sending colleagues of different sexes together on missions lasting more than a day
  • Work with beneficiary communities can be tempting for employees especially girl beneficiaries (orphans) and women beneficiaries (widows)

In terms of employees, factors identified were:

  • long field visits away from partner
  • unnecessary overtime by managers and juniors of different sexes
  • the authority of the boss which can lead to more or less forced sex
  • seeking protection at work which can lead to sexual provocation (temptation?)
  • spending a long time in each other’s company (sharing the same office every day) which can lead to over-familiarity and can end in sex
  • participating in workshops lasting more than one day by colleagues of different sexes
  • work in the field that can lead to intimate relationships between employees and programme beneficiaries
  • Infidelity of the partners of employees because they are away so often.

Practices identifed at the level of beneficiary communities are field missions including participation in trainings and improving the lives of beneficaries for whom the new socioeconomic status opens the way to friends who let them satisfy their sexual needs… eg child headed househoulds and vulnerable women who got enough money to get boyfriends and took on other risk behaviours like polygamy, unmarried relationships and alcooholism.”

Does lots of health policy research and analysis get wasted?

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The recent article in the Lancet on “Fair trade” in public health data (http://bit.ly/96DZkU) got me thinking about my own work and the extent to which it does or does not get shared.

Quite often I am asked to research and write reviews on a specific topic related to HIV/AIDS programming.  Some are literature reviews, covering peer-reviewed research and grey literature, whereas others are “policy reviews” and are based on peer-reviewed research, interviews with experts or policy leaders, and written organisational policies.  A smaller number of papers are based on primary research.  My own papers are not of a type or standard that can be published in a peer reviewed journal, for various reasons: because I tend to do the research and data analysis on my own; because they can’t lay claim to be systematic reviews; they can be quite long and detailed; and because I am asked to provide conclusions based on my judgement and mine only.

When I do this type of research, it is often commissioned for a very specific purpose and audience.  Many of the papers I have written, for instance, were intended as background for meetings or discussions on a given policy or theme, or to help decision makers formulate programmes.  Once the meeting has happened or the programme has been designed, the paper in the form I submitted it has served its purpose.  Some clients will publish the paper on their website (like this one http://bit.ly/aRuzNC and this one http://bit.ly/9Wi6Lo) but many don’t.  There is some logic to this since in some cases they may go on to produce something better or more detailed based on the paper.  Alternatively they feel that the paper is so specific to the purpose it was written for, that it is unlikely to be of interest to a wider audience.  Another reason might be that they just don’t want to go to the effort of validating and publishing this sort of paper.  Unlike universities, neither my clients nor myself are evaluated on the number of publications we get into journals (or the number of glossy reports published).

Over the past four years, and for the purposes of this type of work, I have read and made notes on literally hundreds of documents, and I have compiled research on a number of topics.  For instance:

  • Epidemiological analysis of HIV risk in specific population groups
  • HIV programme evaluations
  • Global AIDS programming for men who have sex with men and transgenders
  • Policies of global health initiatives in relation to scaling up health, HIV and AIDS programmes
  • Human rights components of national AIDS programmes
  • Human rights of sex workers, and the sex worker rights movement’s evolution 
  • HIV and AIDS prevention programming with young people; sex workers; migrant workers; men who have sex with men
  • Economics and sex work
  • Integrating delivery of HIV prevention, care and treatment services
  • Community systems in HIV programming

Again, most of this is not primary research – it is research based on data that is already accessible.  But at the very worst, I have a number of fairly comprehensive thematic bibliographies, many of which have detailed annotations.  At best, I am sitting on at least a half dozen papers that include a passable compilation and analysis of data on these themes.  But I can’t really do much with them apart from use them myself – which is great for me but not much use in the grand scheme of things.  I do not “own” the rights to them, which is how it goes in freelance work (and anyway, I’ve been paid). 

So back to the Lancet article.  Another category of public health data that often fails to get shared is the “grey” literature of the type churned out on a regular basis by freelance consultants.  Most of it is secondary data, but there tends to be quite a lot of good stuff in these papers, if only because they compile large amounts of information on a given subject.  It is incredibly wasteful that this sort of work isn’t put somewhere where others can refer to it or use it.  I often ask, cajole, and pester clients to find some way of disseminating this work, and I’m happy to spend some of my own time adapting the documents.  But by the time I do this they’ve moved on, and the paper is long forgotten.

I’ll keep trying…  and if and when I am authorised I’ll post them on here, which is a modest start.

 

UPDATE 9th March 2010.  Hooray, well I just got permission to post up here a review I did of best practice in HIV and AIDS prevention programming in sub-saharan Africa with young people, sex workers, and migrant workers.  The report is quite long so I am going to break it up into each population group.  At some point in the next few months…