Hawa Abdallah works in a brothel in Tanzania's largest city, where
a third of sex workers are infected with HIV.
Photo by Mia Collis/The Global
Fund
The world needs more prostitutes like Hawa Abdallah. At least that’s what many public health officials believe.
There’s something about the 25-year-old the harsh angle of her eyebrows, the way her red lipstick contrasts with the dirty walls, the cold stare she directs at passing men -- that says she’s in control. Abdallah has sex with as many as 20 men every day in a brothel in Dar es Salaam, Tanzania's largest city, where 1 in 20 residents and 1 in 3 sex workers are infected with the virus that causes AIDS.
But a series of simple steps have kept Abdallah healthy until
now: She knows how HIV spreads. She is tested regularly. And she’s confident
enough to insist that her customers use condoms every time. Just as
importantly, she’s managed to avoid the assault, arbitrary arrest and extortion
that plague the profession. Health officials say that unless more prostitutes
start fitting a similar profile, the world doesn’t stand a chance at beating
back the virus.
It’s not just sex workers, of course. The same applies to
injecting drug users, men who have sex with men, inmates and other groups in
which HIV rates have moved against the global trend, and continue to rise.
Which is why experts with organizations as diverse as the World Health
Organization and Human Rights Watch agree that government officials must do
more to support these “key populations” - no matter how illegal their
activities may be - if they want to see an AIDS-free generation within their
borders anytime soon.
Halting the spread of HIV among these key populations comes down
to a series of calculated risks for both governments and the individuals
themselves. Abdallah’s calculations started several years ago.
She never intended to spend her nights negotiating in the dark
with a never-ending stream of drunks. She wanted to be a hair stylist. But the
young woman quickly discovered that no matter how busy her beauty salon became,
no matter how many hours she put in cutting and braiding hair, she rarely
earned more than $20 per day -- not nearly enough to support her two young
children and a long-term boyfriend who scrapes by as a motorcycle taxi driver.
Her first night in the brothel, she made close to $60 -- triple
the amount in a fraction of the hours. Her boyfriend discovered what she was
doing and tried to make her to stop. “I have refused,” she said. “It’s
worth the risk.”
Among the most immediate of those risks: It’s illegal. Tanzanian
law states clearly that men and women caught “loitering for the purposes of
prostitution” can be locked up for three months. Male sex workers can be charged
with “carnal knowledge against the order of nature” and punished with a minimum
of 30 years and a maximum lifetime sentence. Officials consider both
prostitution and homosexuality to be threats to the social order.
But of course, those same officials have also been preoccupied
with a far more serious societal threat in recent years. When HIV began
ravaging Africa, making its population the most-infected on the planet in the
last decades of the 20th century, the virus struck Tanzania particularly hard.
By the mid-90s, close to 1 in 10 Tanzanians were dying; a generation of
children were orphaned; local economies buckled. And for years, the Tanzanian
government lacked the resources to respond in force.
The situation changed to some extent in the early 2000s when the
newly formed Global Fund to Fight AIDS, Tuberculosis and Malaria and the U.S.
President’s Emergency Plan for AIDS Relief, among other groups, began funneling
billions toward the cause. At long last, Tanzanian officials -- like many of
their neighbors in sub-Saharan Africa -- had both bragging rights and the
numbers to back them up. Treatment coverage jumped from 3.5 percent in 2005 to
55 percent in 2011. The number of health facilities providing HIV care and
treatment services rose from a few dozen in 2004 to about 1,200 in 2012.
Mother-to-child transmission of the virus plummeted. People started living
longer.
With similar results coming in from around the world -- including
one from UNAIDS showing a 50 percent drop in new infections in more than 25
low- and middle-income countries over the previous decade -- former Secretary
of State Hillary Clinton stood before a crowd in Washington in 2012 and
declared that “as we continue to drive down the number of new infections and
drive up the number of people on treatment, we will get ahead of the pandemic,
and an AIDS-free generation will be in sight.”
But optimism wasn’t running quite so high in the back alleys and
brothels of the world --including Abdallah’s. While HIV prevalence among the
general population has decreased to 5 percent in Tanzania, it’s on the upswing
globally among “key populations” at the greatest risk for contracting and
passing HIV, according to an August 2013 report from the Foundation for AIDS
Research, or amfAR.
In fact, HIV prevalence is 22 times higher among people who inject
drugs. In low- and middle-income countries, men who have sex with men and
female sex workers are 19 and 13.5 times more likely, respectively, to have HIV
than their peers. Many researchers have long downplayed the rates in key
populations, believing they represent only a “modest share of the epidemic
globally” and represent a major concern only in countries with low-level
epidemics. But amfAR contends that members of these groups are critical because
they are often part of “dense, high HIV-prevalence social and sexual networks”
that help the disease spread rapidly from one population to another.
Consider 22-year-old Abdul Rashid. After stumbling into a
community resource center several miles from Abdallah’s brothel in Dar es
Salaam, Rashid -- still strung out on marijuana and cocaine -- was tested for
HIV. The results came back quickly: Positive. And he wasn’t a bit surprised.
Rashid enjoys having sex with female prostitutes at a brothel near
his drug den. But the premium he pays for sex without a condom, combined with
the high price of drugs, long ago left him in such a financial bind that he
started having sex with men for cash. To top it off, police also recently
arrested him for selling drugs and threw him in one of the local jails --
notorious places for sex among inmates. Within the last few months alone,
Rashid may have spread the disease widely within all four of the primary “key
populations” in Tanzania. If those individuals then have sex with their partners
-- who are often not a part of the high-risk groups -- the virus then spills
into the general population.
Sitting in a filthy orange T-shirt on the floor of the drug
center, Rashid seemed too dazed to care. “I have no option to change my status,
so I must say, ‘OK, if that’s the case now, I have nothing to do,’” he said.
Of course, this situation isn’t unique to Tanzania. Key
populations and their sex partners account for as much as 51 percent of new
infections in Nigeria, 33 percent in Kenya, 80 percent in Morocco and 47
percent in the Dominican Republic. And according to some estimates, men who
have sex with men alone could make up more than half of all new infections in
Asia by 2020, amfAR reports.
"Sex workers do
not have a place to speak against injustices done to them ... If they go to the
police, the police just become their customers for that night."
“Unless effective strategies are put in place to mitigate the HIV
burden in key populations, the global epidemic will worsen over time,
preventing the world from realizing the dream of an AIDS-free generation,” the
group warned in its August report.
That brings us back to Tanzania’s dilemma -- similar to the one
faced by most countries where prostitution is illegal. Should officials enforce
the law of the land or facilitate safer testing and treatment for prostitutes
in the name of public health?
When drafting their “Strategic Framework on HIV and AIDS” several
years ago, the government decided to take a calculated risk and “acknowledge
the vulnerability of sex workers and men who have sex with men.” The document
advocated for their access to HIV prevention information and services and,
surprisingly, “for decriminalization of their activities.” Despite the worries
of some that it would come across as a tacit endorsement of illegal activities,
the officials decided to push ahead with this approach because the potential
gains in the HIV fight could be huge.
And it’s worked, to a limited extent. A report published in June
by Human Rights Watch found that “a few state hospitals and some
nongovernmental organizations throughout the country” have succeeded in providing
friendly services to the “most at-risk populations.” Through its health
agencies, the government has also supported the outreach efforts by local
governments and nonprofits. Even so, this limited success is “systematically
undermined” by police officers who abuse their authority and often make things
worse, the report concludes.
“The Tanzanian government has committed on paper to reduce the
stigma for at-risk groups, but that commitment is meaningless if the police
regularly rape, assault, and arrest them,” concluded Neela Ghoshal, the author
of the Human Rights Watch paper. “The government’s HIV policy can’t succeed if
police are driving away the very people the public health programs most need to
reach.”
A survey by the country’s National AIDS Control Program in 2010
found that a full third of sex workers in Dar es Salaam reported being beaten
by their customers, but few felt comfortable reporting the crimes to police.
When Human Rights Watch interviewed 66 men, women and children who were current
or former prostitutes, at least 23 said the police had forced them into sex --
often in exchange for release from custody. Some of those police officers
refused to use condoms, “making the police possible conduits for transmission
of HIV and other STIs.”
As a public health worker in the city of Mwanza told the group,
“Sex workers do not have a place to speak against injustices done to them ...
If they go to the police, the police just become their customers for that
night.”
The situation is not much better at government health centers. The
same Human Rights Watch report identified dozens of cases in which “health
workers turned away sex workers and other key populations from health
facilities, or publicly humiliated them.”
That includes a case where a drug addict went for treatment after
being attacked by a mob in Dar es Salaam and was denied anesthesia while the
staff stitched up his wound. “I asked for it, and the nurse said, ‘We don’t
need to. We are going to sew you without. We could inject you with poison rather
than with anesthesia.” In another example, a gay man in the semi-autonomous
region of Zanzibar asked to be treated for a sexually transmitted disease and
was told to leave. “You already have sex with men,” a staff member told him.
“Now you come here to bring us problems. Go away.”
Experiences like those create an atmosphere of fear and distrust
that pushes these key populations so far underground, they become almost
impossible to reach with HIV prevention messages, testing or treatment. “And
that’s woeful,” said Dr. Ade Fakoya, a senior advisor to the Global Fund to
Fight AIDS, Tuberculosis and Malaria. “Because it’s coverage of these very
basic, essential interventions which is key to the death of the epidemic.”Some organizations have managed to break through. As the sun sank a little lower one recent evening, some health workers partnering with the nonprofit Public Services International began setting up camp in the courtyard of Abdallah’s brothel.
She sat several feet away, watching as they erected an Army-green
burlap tent and pulled out tables, pamphlets, rubber gloves and HIV test kits.
Because it was still early, and because the truck drivers and
local drunks hadn’t started spilling from the nearby bars, many of the
prostitutes were relaxing on the stoops outside their rooms. Some had begun
drinking to brace for the hours ahead. Others played with their children.
About 150 women between the ages of 15 and 49 spend their nights
in this particular brothel - a small fraction of the 7,000 plying the streets
of Dar es Salaam - and most seemed to know the drill. When one emerged from
behind the green flaps of the tent, another stood and entered for her
check-up.
“We’re not afraid of these tests,” Abdallah said, unconvincingly.
“I’ve done this before. So have they.” To prove it, she clutched the sides of
her black floral purse -- embroidered with the word “Sweet” -- a little more
tightly and headed into the tent.Program Manager Shahada Kinyaga watched her from a distance. “It wasn’t this easy in the beginning,” she said. “When we first approached them, they were thinking maybe we were police officers looking to exploit them or that we wanted to publicize their activity to get them into trouble. They wouldn’t let us come near.”
To change that, the PSI workers took the time to speak with a
single sex worker, sharing health information and returning repeatedly.
Eventually, that sex worker started sharing bits of the knowledge with her
friends in the brothel -- how to get free condoms, for example, and how to tell
if a customer is infected with syphilis or herpes. In time, the women allowed
PSI to hold workshops on building “negotiation skills” to convince their
customers to wear condoms and to set up the HIV testing tent. Those diagnosed
as HIV-positive began listening to the health workers about follow-up care at
local clinics, and reported back about whether they were receiving the
appropriate treatment. Bottom line: It’s not that the women didn’t want help --
it was a matter of who to trust.
“So, more of them are doing this now,” Kinyaga said. “They are
testing more regularly. They are using condoms more. Some of them don’t do it
100 percent of the time, but it’s a step.”Inside the tent, Abdallah’s black-and-white striped pantsuit stood out starkly in the diffused light filtering through the burlap. She looked like a stylish prisoner in a war camp. She also looked worried.
These moments of dread -- of waiting for test results -- are part
of the calculated risk Abdallah accepted from the beginning. But she tries to
tell herself that if she plays the game well, if she insists that every one of
her customers uses a condom every single time, if she tests regularly and
receives follow-up treatment when needed, she stands a good chance of living to
see her two children grow old. Within a few years, she’ll also have enough
money in the bank to build a home and open her own beauty parlor. That endgame
is why she’s here in the first place -- why she says, “This is a good
environment for me.”
Within 30 minutes, her test results are ready. Her face is
stone-cold and will remain that way no matter the verdict. Abdallah knows that
as long as she works in this brothel, the uncertainty will linger. HIV-negative. For now.EDITOR'S NOTE: Jason Kane traveled to Tanzania with the Global Fund to Fight AIDS, Tuberculosis and Malaria. The international financing institution provides funding to countries to support evidence-based programs that prevent, treat and care for people living with the three diseases
PBS, Nov. 5, 2013.
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