The median age of participants was 30 (interquartile range [IQR] 26 – 33 years) and they reported a median of two (IQR 1 – 5) years of sex work. Twenty five (83%) of the women were widowed or divorced. Participants reported a median of three pregnancies (IQR 1 – 3) and two (IQR 1 – 3) live births. Twenty (67%) women worked in bars, whereas the remainder worked in night clubs, brothels, or at home. Women on ART had been on treatment for a median of 13 months (IQR 11.7 – 23.6).
Common themes detailed in the following sections demonstrate complex relationships between factors such as sexual partnership duration and HIV risk. Notably, antiretroviral use was not routinely mentioned as either an explicit barrier or facilitator of safer sex practices.
KNOWLEDGE OF HIV AND AIDS
All participants had some understanding of HIV disease; seropositive women had more in-depth knowledge of the relationships among viral load, CD4 count, and impaired immunity. Many had developed their own explanations of the natural history and transmission of HIV. A number of HIV-positive women discussed being “filled up with the virus” or having virus “added” to their own through unprotected sex with an infected partner. Two women described antiretrovirals’ therapeutic mechanism as making the virus leave the blood and enter the skin thus, in their belief, inactivating it.
PERCEPTIONS OF HIV IN RELATION TO ANTIRETROVIRAL AVAILABILITY
Despite universal awareness of the availability of medications to treat HIV, both HIV-positive and -negative women continued to perceive HIV as a serious threat. Two primary reasons were given. First, almost half of the women mentioned that HIV remained a concern because the medications are not curative. One HIV-positive ART-naïve woman stated:
There is cause to worry because you know this HIV has no cure…so you cannot say you will stop using condoms because the medicine is available. We are told that this thing [the medicines] (are) just to suppress those guys not to be too many so you have to protect yourself. (35 year-old)
An HIV-negative woman similarly stated:
No, I cannot say let me get it [HIV] and go use those drugs…no, because the drugs don’t cure it just adds some little time. What kind of drug is that? You are better off protecting yourself. (44 year-old)
Many women used analogies of not choosing to hurt oneself simply because of the ability to receive assistance later. One HIV-negative woman stated:
Eh, as you can see a ditch and go jump inside? Because even if you fell you will be pulled out? You cannot see a ditch and jump in it, no one likes to be sick. (34 year-old participant)
Women reported that HIV is associated with illicit sex, which contributes to discrimination and social isolation of those affected. Many considered a diagnosis of HIV to be shameful or embarrassing, even in the context of available treatment. An HIV-negative woman stated:
No. I don’t want [HIV], eh, that is an embarrassing disease. It’s embarrassing. Ah ah, how can you cut yourself? It’s like telling me to take a knife and cut myself. Even if you give me medicine for my cut the scar will remain. (26 year-old)
Additional concerns expressed by HIV-seropositive women on ART included the need to take medications “for life” and concerns over long-term drug availability.
FACTORS INFLUENCING SEXUAL RISK BEHAVIOUR
Availability of ART did not substantially change women’s perceptions of the seriousness of HIV. None of the women reported an increase in sexual risk behavior linked to ART availability. In fact, there appeared to be the opposite effect, with HIV-positive women reporting that they engaged in safer sex after ART initiation because of perceived personal benefits. These included avoiding acquiring “more” virus or resistant virus, supporting their health, and extending the durability of their response to ART.
Two HIV-positive women reported that transmission risk behavior may initially increase in response to receiving an HIV diagnosis. One recalled her own behavior for a limited period, acknowledging that she felt she “must take my followers with me.” She described later coming to terms with her diagnosis and reducing her risk behaviors to protect herself from HIV superinfection. Another woman described observing a similar reaction in a colleague who discovered that she was HIV-positive. Many of the women interviewed imputed this type of behavior to men. The phenomenon was frequently described in terms of someone spreading the disease because they do not want to “die alone.” Similar phrases and behaviors have been reported in Uganda (King et al., 2009
HIV testing was described by seronegative and seropositive women as a turning point after their initial entry into sex work, often following divorce, widowhood, or a violent partnership. Many reported higher risk behaviors during this earlier period when their serostatus was unknown. Women who tested negative reported that the test served as a powerful motivator to practice safer sex. Those who tested positive generally transitioned to lower risk behavior, adaptation to living with HIV and, for some, ART treatment. A natural history of risk behaviors corresponding to stages of HIV infection has been outlined (Eaton & Kalichman, 2009
) pointing out the need to tailor risk reduction support over the course of infection.
Women reported several barriers to safer sex including economic pressures, sexual partnership changes (e.g., a partner who was initially a new client subsequently demanding ‘intimacy’ without condoms), physical violence, concurrent partnerships, and alcohol use (). Women also reported a number of facilitators of safer sex, including individualized strategies for mitigating risk (). Facilitators included HIV testing, a desire to avoid superinfection, belief that men who do not want to use condoms must be infected, and avoidance of long-term partners, who often want to give up condom use when a partnership has become “regular.” Women reported they are the primary promoters of condom use within their sexual relationships.
Barriers to safer sex after antiretroviral rollout, interviews with female Kenyan sex workers 2006
Facilitators and strategies of safer sex after antiretroviral rollout, interviews with female Kenyan sex workers 2006
The need for resources to support themselves and their children was an important barrier to women’s ability to practice safer sex. An HIV-negative woman described her dilemma:
I don’t have money in the house. Yesterday I had a guy, he refused to give me money because I told him to use a condom. Today also, I get a guy he doesn’t want to use a condom…what am I going to do and I don’t have money in the house? Let me try without [a condom]…because I don’t have money. (33 year-old)
Despite this, some women reported resisting men who do not want to use condoms even if it meant giving up income. One HIV-positive woman stated:
If you are greedy you will see the money you can go with a man with a condom, then he tells you, “I had told you I would give you 500 (Kenyan shillings), now I will give you 1,000 if I eat (have sex) without.” If you are a fool, and not thinking of your life, you will accept the one without and get 1000. But if you are clever you will say let me leave with my 500…(you are looking at) your future life. (34 year-old)
Partner type strongly influenced women’s ability to negotiate condom use. Condom use was easier to negotiate with one-time or short-term clients. Negotiating safer sex became more difficult with long-term partners (paid or unpaid). Women routinely mentioned the difficulty of bringing up condom use with regular partners. An HIV-positive woman on ART explained:
that “one only” [the regular partner] is the one who will refuse to use a condom completely and finish me. I cannot have a man for more than 4 months and continue using a condom. He will refuse and call you his…and him I cannot trust and then I will not use a condom and then my immunity will start reducing. (25 year-old)
Many of the women, particularly those who are HIV-positive, discussed avoiding or leaving regular or long-term sexual partnerships to avoid this problem. An HIV-positive woman on ART explained:
He will use a condom for a short while. I have seen many men someone comes and tells you he likes you then you use a condom a short while. After like a month he starts saying now he trusts you, he doesn’t want to use a condom with you anymore, now he wants to have a child and get married, and he is just trying to get a way to sleep with you without a condom. And yet you don’t know him and he doesn’t know you so when someone starts that I get a reason to leave him completely. (35 year-old participant)
Among HIV-positive women, 17 (85%) reported a concern over the potential for “adding on more virus” (superinfection) as a result of unprotected sex. An HIV-positive woman stated:
It weakens when you move around carelessly [have sex without a condom] because I could say today I have the virus and want to infect you and maybe he has more than mine so he will add onto mine. (42 year-old)
HIV-negative women also seemed aware of the potential for superinfection:
Those too [HIV-positive women] need to protect themselves so that they don’t get reinfected with the virus. They just stay with what they already have because if they have the virus and still move out with someone with the virus they multiply. (40 year-old)