STUDIES OF FEMALE SEX WORKERS IN PORT MORESBY,

PAPUA NEW GUINEA

EUNICE ADJOA KWANSEMAH BRUCE

A THESIS SUBMITTED FOR THE DEGREE OF DOCTOR OF PHILOSOPHY

FACULTY OF MEDICINE, DENTISTRY & HEALTH SCIENCES SCHOOL OF POPULATION HEALTH MELBOURNE SEXUAL HEALTH CENTRE THE UNIVERSITY OF MELBOURNE

FEBRUARY 2010

PRODUCED ON ARCHIVAL QUALITY PAPER DECLARATION

This is to certify that:

i. the thesis comprises only my original work toward the PhD except where indicated;

ii. due acknowledgement has been made in the text to all material used;

iii. the thesis is less than 100,000 words in length, exclusive of tables, maps, bibliographies and appendices.

Eunice Adjoa Bruce

Date 26/02/2010

i ACKNOWLEDGEMENTS

The work described in this thesis was funded by United Nations Population Fund (UNFPA), through United Nations Joint Programme on HIV/AIDS (UNAIDS) under the Regional Unified Budget and Work plan (UBW) grant to the budget of “Comprehensive models of STI/HIV/AIDS prevention for sex workers and their clients in Asia Pacific”: a regional project number RAS/02/P0. United Nations Population Fund (UNFPA) Asia Pacific Division (APD) and World Vision International (WVI) were the executing agencies. Technical assistance and overall coordination was provided by UNFPA Country Support Team (CST) in Bangkok. World Vision International (WVI) Asia and Pacific Regional Office provided regional technical backstopping and regional administrative support to the implementing WVI Country offices in Nepal (WVIN), Vietnam (WVIV) and Papua New Guinea (WVIPNG). These organisations deserve my special thanks; without them this work would have been impossible.

In preparation and completion of this work, I must acknowledge the efforts of the following individuals: the success of this work is directly attributable to the benevolence of Professor Christopher K. Fairley (Kit), Professor of Sexual Health and the Director of the Melbourne Sexual Health Centre. Thank you for welcoming me to the centre, giving me the opportunity to develop this experience here and challenging me every day to make me a better student. I acknowledge with heartfelt thanks your endless inspiration to walk me through one of the most difficult steps of my career. Your writing skills and diligence in the correction of my manuscripts helped relieve my many episodes of writer’s block. Kit is proof that kindness and determination can be united in one person. I am also immensely thankful to Dr Louise Keogh of the School of Population Health, Centre for Women’s Health, Gender and Society, for giving me space in her mighty heart to document this work. I really have to thank you because this work would not have been complete without your input. Thank you for the constant cheering, interest and enthusiasm that allowed me to push through the difficult times of my study. The

ii ample time you spent contributing so graciously to this work greatly enhanced it. I am fortunate enough to have had the support of Professor John Kaldor, Professor of Epidemiology and Deputy Director, National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Australia: you left your mark on this work for which I would like to say thank you . To all my supervisors, I greatly appreciate your advice, valuable review, comments and suggestions during the finalisation of this document.

The project in Port Moresby was a collaborative effort that required commitment, willpower and energy from a team of professionals, the target population and a number of organisations locally and abroad. Among those who supported the project with significant contributions and therefore merit my gratitude include: School of Medicine and Health Sciences, University of Papua New Guinea, Central Public Health Laboratory, National Department of Health (NDOH) — the HIV/STI; Research, Monitoring and Evaluation; and Health Promotion branches, AusAID National HIV/AIDS/STI Support Project, European Union Sexual Health Project, National AIDS Council Secretariat, Provincial AIDS Committee, PNG Institute of Medical Research, National Broadcasting Corporation, NCD Health Services, Stop AIDS, Hope Worldwide, ICRAF, YWCA, the sex workers, their clients and regular sexual partners.

The following persons deserve my special appreciation: Mr Duah Owusu-Sarfo, Professor Mathias Sapuri, Dr Andrew Masta, Professor A.B. Amoa, Dr Nii Plange, Dr Sri Chander, Dr Chaiyos Kunanusont, Dr N. Moiya, Dr Glen Mola, Dr Diro Babona, Dr Greg Law, Dr Doani P. Esorom, Dr Gilbert Hiawalyer, Dr Chris Hudson, Dr J. Pantumari, Dr J. Millan, Mr Tony Lupiwa, Mr William Yeka, Mrs Miriam Midirie, Mr Wilfred Peters, Mr Joseph Annang, Dr Richard Eves, Mr Renato Gordon, Mr Paul Martell, Mrs Frieda Kana, Mr Rava Win, Ms Dilsy Arbunte, Ms Kuniko Yoshida, Mrs Ludwina Bauai, Ms Rachael Pokesy and Mr Thomas Hanjupari.

I dedicate this work to the late Mabel Ruth Afua Bogya Tandoh (Mummy) and the late Mr. Thomas Kwamenah Nyarko Bruce (Daddy) who did not live long enough to enjoy the fruits of their labour — this is for you!

iii TABLE OF CONTENTS

DECLARATION...... 1

ACKNOWLEDGEMENTS...... ii

LIST OF TABLES...... viii

LIST OF FIGURES ...... x

LIST OF ACRONYMS ...... xiii

GLOSSARY OF TERMS ...... xvi

PNG LOCAL TERMINOLOGIES...... xviii

PUBLICATIONS...... xix

CONFERENCE PRESENTATIONS AND PRIZES ...... xxi

CONFERENCE PRESENTATIONS: ABSTRACTS...... xxiv

SUMMARY ...... xxxiii

CHAPTER 1 ...... - 1 -

PAPUA NEW GUINEA, HIV, THE SEX INDUSTRY AND FEMALE SEX WORKERS: AN OVERVIEW...... - 1 -

1.1 Papua New Guinea: The country ...... - 2 - 1.2 Papua New Guinea: The HIV situation...... - 13 - 1.3 The sex industry, female sex workers and HIV/AIDS...... - 24 - 1.4 Justification for targeting sex workers ...... - 48 - 1.5 Government of PNG perspective...... - 49 - 1.6 The way forward for FSWs in PNG — based on UNAIDS recommendations ..- 52 - 1.7 The many “faces” of prostitution: “sex work” ...... - 78 -

CHAPTER 2 ...... - 86 -

A SYSTEMATIC REVIEW OF STUDIES ASSESSING RISKS OF SEXUALLY ACQUIRED HIV AMONG FEMALE SEX WORKERS IN PAPUA NEW GUINEA SINCE 1980:...... - 86 -

iv A LITERATURE REVIEW...... - 86 -

2.1 Co-authors and citation ...... - 87 - 2.2 Abstract...... - 87 - 2.3 Introduction ...... - 88 - 2.4 Methods ...... - 88 - 2.5 Results...... - 89 - 2.6 Discussion ...... - 95 - 2.7 Weaknesses ...... - 98 - 2.8 Strengths ...... - 98 - 2.9 Conclusion and recommendations ...... - 99 -

CHAPTER 3 ...... - 100 -

THE LOCATIONS AND SIZE ESTIMATION OF THE FEMALE SEX WORKER POPULATION IN PORT MORESBY, PAPUA NEW GUINEA ...... - 100 -

3.1 Co-authors and citation ...... - 101 - 3.2 Abstract...... - 101 - 3.3 Introduction ...... - 102 - 3.4 Methods ...... - 103 - 3.5 Results...... - 106 - 3.6 Discussion ...... - 112 - 3.7 Limitations...... - 114 - 3.8 Strengths ...... - 114 - 3.9 Conclusion and recommendations ...... - 114 -

CHAPTER 4 ...... - 115 -

KNOWLEDGE, ATTITUDES, PRACTICES AND BEHAVIOUR OF FEMALE SEX WORKERS IN PORT MORESBY, PAPUA NEW GUINEA ...... - 115 -

4.1 Co-authors and citation ...... - 116 - 4.2 Abstract...... - 116 - 4.3 Introduction ...... - 117 - 4.4 Methods ...... - 118 - 4.5 Result...... - 119 -

v 4.6 Discussion ...... - 127 - 4.7 Weaknesses ...... - 130 - 4.8 Strengths, conclusion and recommendations ...... - 130 -

CHAPTER 5 ...... - 131 -

A CROSS SECTIONAL STUDY OF REPORTED SYMPTOMS FOR SEXUALLY TRANSMITTED INFECTIONS...... - 131 -

5.1 Co-authors and citation ...... - 132 - 5.2 Abstract...... - 132 - 5.3 Introduction ...... - 133 - 5.4 Methods ...... - 134 - 5.5 Results...... - 136 - 5.6 Discussion ...... - 143 - 5.7 Weaknesses ...... - 144 - 5.8 Strengths, conclusion and recommendations ...... - 145 -

CHAPTER 6 ...... - 146 -

PERIODIC PRESUMPTIVE TREATMENT (PPT) OF COMMON CURABLE SEXUALLY

TRANSMITTED INFECTIONS (STI S) AMONG FEMALE SEX WORKERS IN PORT MORESBY: MEASURING STI INCIDENCE AND PPT EFFECTS...... - 146 -

6.1 Co-authors and Citation...... - 147 - 6.2 Abstract...... - 147 - 6.3 Introduction ...... - 148 - 6.4 Methods ...... - 149 - 6.5 Results...... - 152 - 6.6 Discussion ...... - 154 - 6.7 Weaknesses ...... - 155 - 6.8 Strengths, conclusion and recommendations ...... - 156 -

CHAPTER 7 ...... - 159 -

KNOWLEDGE OF HIV RISK AND SAFER SEX PRACTICES AMONG FEMALE SEX WORKERS IN PORT MORESBY, PAPUA NEW GUINEA...... - 159 -

vi 7.1 Co-authors and citation ...... - 160 - 7.2 Abstract...... - 160 - 7.3 Introduction ...... - 161 - 7.4 Methods ...... - 162 - 7.5 Results...... - 163 - 7.6 Discussion ...... - 166 - 7.7 Weaknesses ...... - 168 - 7.8 Strengths ...... - 169 - 7.9 Conclusion and recommendations ...... - 169 -

CHAPTER 8 ...... - 171 -

CONCLUSIONS...... - 171 -

8.1 Literature review ...... - 172 - 8.2 Mapping and size estimation of FSWs in Port Moresby...... - 172 - 8.3 Knowledge, attitudes, practices and behaviours (KAPB) survey ...... - 173 - 8.4 Reported symptoms associated with laboratory confirmed STIs ...... - 173 - 8.5 Periodic presumptive treatment (PPT) of common curable STIs ...... - 174 - 8.6 HIV risk perceptions and safer sex practices ...... - 174 -

Bibliography...... - 177 -

Appendix A: Rapid Formative Research — Mapping and Size Estimation Tool...... - 199 -

Appendix B: HIV/AIDS/STI Behavioural Surveillance Survey (BSS) for Female Sex Workers Papua New Guinea - June–July 2003 (FHI Adopted).....- 212 -

Appendix C: Rapid Risk Assessment (to determine HIV risk and when exposure to risk occurred)...... - 239 -

Appendix D: Explanatory Statement: Periodic Presumptive Treatment (PPT) ...... - 242 -

Appendix E: Legal and Ethical Considerations ...... - 244 -

Appendix F: Rapid Formative Research — English FGD Guide...... - 247 -

vii LIST OF TABLES

Table 1.1. New and cumulative HIV infections detected in Papua New Guinea, 1987–2006...... - 15 -

Table 1.2. Estimated HIV prevalence, 1993–2012...... - 16 -

Table 1.3. HIV infections reported in Papua New Guinea, 1987–2006, by mode of transmission...... - 18 -

Table 1.4. Available measurements of HIV prevalence data ...... - 20 -

Table 1.5. Prevalence of sexually transmitted infections, from surveys, 1998 ...- 21 -

Table 1.6. Prevalence of STIs among female sex workers in three towns of Eastern Highlands Province (EHP) ...... - 43 -

Table 2.1. Summary of studies on female sex workers in Papua New Guinea — key HIV risks...... - 91 -

Table 2.2. Measurements of consistent condom use among female sex workers over time across several locations in PNG ...... - 93 -

Table 3.1. Estimation of female sex workers by key informants, observation and nomination methods in fourteen locations in POM...... - 108 -

Table 4.1. Demographic characteristics of female sex workers in Port Moresby...... - 120 -

Table 4.2. Knowledge, attitudes, practices and behaviour of female sex workers ...... - 121 -

in Port Moresby with STIs ⁿ ٭ Table 5.1. Number and proportion of FSWs and HIV ...... - 136 -

Table 5.2. Analysis of symptoms reported via questionnaires by female sex workers (FSWs) diagnosed with and without Chlamydia trachomatis (Ct), Neisseria gonorrhea (Ng), Trichomonas vaginalis (Tv) and (Ct, Ng and/or Tv) in Port Moresby CI, confidence interval; OR, odds ratio...... - 138 -

Table 5.3. Sensitivity 1, Specificity 2, Positive Predictive value (PPV) 3 and proportion screened for specific symptoms and leukocyte esterase urine test to detect any of Chlamydia trachomatis (Ct), Neisseria

viii gonorrhea (Ng), Trichomonas vaginalis (Tv) and (Ct, Ng and/or Tv) ...... - 141 -

Table 6.1. STIs and reported condom use at first (T=0 months) 2003 and final (T=10 months) 2004 visits ...... - 152 -

Table 6.2. Comparison of the characteristics of STIs prevalence, reported symptoms and condom use among 71 FSWs (follow-up) and 58 FSWs (dropouts) at first (T=0) 2003 visit ...... - 153 -

Table 6.3. HIV Prevention Program Budget…………………………………...-157-

Table 7.1. Demographic characteristics of female sex workers in Port Moresby...... - 164 -

ix LIST OF FIGURES

Figure 1.1. Map and pictures of PNG...... - 3 -

Figure 1.2. People of PNG, diverse range of culture and traditions ...... - 4 -

Figure 1.3. PGK notes...... - 7 -

Figure 1.4. Children in primary school in PNG...... - 9 -

Figure 1.5. New and cumulative annually reported HIV infections in Papua New Guinea, 1987–2006 ...... - 14 -

Figure 1.8. Women selling betel nut for an income...... - 26 -

Figure 1.9. Dilapidated housing conditions at Vadavada settlement, outskirts of POM ...... - 27 -

Figure 1.10. Female sex workers at a training workshop in Port Moresby ...... - 30 -

Figure 1.11. Waterfront sex worker site — Dig and Dump in Port Moresby...... - 31 -

Figure 1.12. Two Kina bus meri in Port Moresby...... - 32 -

Figure 1.13. Disco meris at peer education training in Port Moresby ...... - 33 -

Figure 1.14. Female sex workers in Port Moresby — the young and old ...... - 35 -

Figure 1.15. Female sex workers and their regular sexual partners at a meeting with the national director of WVI in Port Moresby...... - 37 -

Figure 1.16. Women selling betel nut at a market in the Highlands...... - 46 -

Figure 1.17. UNFPA/WVI Project: signing of a MOU with the dean, School of Medicine and Health Science (UPNG) for research partnership ...- 53 -

Figure 1.18. UNFPA/WVI Project: synergy with ICRAF — the advocacy group for social, legal and human rights representation of SWs in POM ...... - 55 -

Figure 1.19. UNFPA/WVI Project: partnerships and multisectoral approaches among civil societies in POM...... - 56 -

Figure 1.20. Peaceful protest march addressing violence against women involving FSWs & civil societies in Port Moresby...... - 57 -

x Figure 1.21. WVI staff members, FSWs, clients and regular sexual partners working together in POM...... - 60 -

Figure 1.22. Selected FSWs and RSPs attending peer education training in POM ...... - 61 -

Figure 1.23. UNFPA/WVI Project: partnersip with Stop AIDS Inc. for training and graduation of FSWs and RSPs in peer education ...... - 61 -

Figure 1.24. UNFPA/WVI Project: partnership with YWCA for training and graduation of FSWs in income generation and life skill activities.....- 62 -

Figure 1.25. A health extension officer of WVI disseminating STI information via outreach...... - 68 -

Figure 1.26. FSWs attending life skills, grooming and self esteem building workshop in Port Moresby ...... - 70 -

Figure 1.27. UNFPA/WVI Project: Clients being screened and administered presumptive treatment via DOT for STIs during the Periodic Presumptive Treatment PPT Study by a health extension officer...... - 71 -

Figure 1.28. UNFPA/WVI Project: signing of a MOU with the local health sector (NCD Health Service) for partnership and outreach service coordination...... - 72 -

Figure 2.1. Inclusion criteria used in selecting papers on female sex workers in Papua New Guinea ...... - 90 -

Figure 2.2. Search method used in selecting papers on female sex workers in Papua New Guinea ...... - 90 -

Figure 2.3. Consistent condom use among female sex workers with their clients in Papua New Guinea...... - 93 -

Figure 2.4. Consistent condom use among female sex workers with their regular sexual partners...... - 94 -

Figure 2.5. STI rates in female sex workers over time in PNG ...... - 94 -

Figure 2.6. HIV rates in female sex workers over time in PNG...... - 95 -

Figure 2.7. Condom use rate in female sex workers (FSWs) in PNG with their clients & RSPs compared to FSWs in countries with similar gross domestic product ...... - 97 -

Figure 3.1. Sex worker locations the study team visited across Port Moresby...- 110 -

Figure 3.2. Selected locations for the estimation of the female sex worker population in Port Moresby...... - 111 -

xi Figure 4.1. Socio-demographic characteristics of female sex workers in Port Moresby...... - 125 -

Figure 4.2. Sexual practices and other risky behaviours of female sex workers in Port Moresby ...... - 125 -

Figure 4.3. HIV/STI knowledge of female sex workers in Port Moresby...... - 126 -

Figure 4.4. Health-seeking behaviours of female sex workers in Port Moresby...... - 126 -

Figure 4.5. HIV risk perception of female sex workers in Port Moresby...... - 127 -

Figure 8.1. Final review meeting UNFPA-WVI collaboration: Comprehensive models of HIV/STI prevention for FSWs and their clients in Asia Pacific – Key note speaker, UNFPA Asia Pacific Regional Representative...... - 175 -

Figure 8.2. UNFPA-WVI collaboration interim meeting in Malaysia 2003 ...... - 176 -

Figure 8.3. UNFPA-WVI collaboration final review meeting in Bangkok 2004 ...... - 176 -

xii LIST OF ACRONYMS

ABC Abstinence, Be faithful, Use a Condom Model APD UNFPA Asia Pacific Division AIDS Acquired Immunodeficiency Syndrome ARV Antiretroviral AusAID Australian Agency for International Development BSS Behavioural Surveillance Survey CBO Community Based Organisations CST Country Support Team CSW Commercial Sex Worker EU European Union EUSHP European Union Sexual Health Project FHI Family Health International FSWs Female Sex Workers HIV Human Immunodeficiency Virus GoPNG Go Papua New Guinea ICRAF Individual & Community Rights Advocacy Forum ICRW International Community of Women Living with HIV/AIDS IPPF International Planned Parenthood Federation IEC Information, Education and Communication INGO International Non-Governmental Organisation IPPF International Planned Parenthood Federation KAPB Knowledge, Attitude, Practices and Behaviour MOU Memorandum of Understanding

xiii MSHC Melbourne Sexual Health Centre MSM Men Who Have Sex with Men MTCT Mother to Child Transmission MTP Medium Term Plan NACs National AIDS Council Secretariat NCD National Capital District NCW National Council of Women NDOH National Department of Health NGOs Non-Government Organisations NHASP National HIV/AIDS Support Project OVIs Objectively Verifiable Indicators PAC Provincial AIDS Council PE Peer Educator PLA Participatory Learning & Action PLWHA People Living With HIV/AIDS PMGMH Port Moresby General Medical Hospital PNG Papua New Guinea PNGIMR Papua New Guinea Institute of Medical Research POM Port Moresby PPT Periodic Presumptive Treatment RH Reproductive Health RTIs Reproductive Tract Infections SPSS Statistical Package for the Social Sciences STP Short Term Plan STDs Sexually Transmitted Diseases STIs Sexually Transmitted Infections SW Sex Worker UBW Unified Budget and Work plan USAID United States Agency for International Development

xiv UNAIDS United Nations Joint Programme on HIV/AIDS UNDAF United Nations Development Assistance Framework UNFPA United Nations Population Fund UNGASS United Nations General Assembly Special Session on HIV/AIDS UNICEF United Nations Children’s Fund UPNG University of Papua New Guinea VCT Voluntary Counselling and Testing WHO World Health Organization WVI World Vision International WVIN World Vision International Nepal WVIPNG World Vision International Papua New Guinea WVIV World Vision International Vietnam YWCA Young Women’s Christian Association

xv GLOSSARY OF TERMS

‘At-Risk’ Populations : Groups of people who are currently at high risk of contracting and transmitting HIV/AIDS as a result of their behaviour.

Census of sex workers: A complete enumeration of the different types of sex workers by establishment and/or by specific working location. The enumeration includes the exact number and other associated characteristics of the sex workers.

Client of sex worker: An individual who exchanges money, gifts or good and services for sexual activity.

Five Kina house: A house where the owner lends a room for a few hours for sexual activity for a fee of five Kina.

Mapping of sex workers: The process of identifying the areas, establishments and specific locations where sex workers are found

Nomination Technique: Nomination is a type of a “systematic estimation technique” and refers to a sampling method that collects data on hidden populations using a visible fraction of the subgroup to identify and contact other members. If the purpose of the research is only to estimate population size, a nomination technique may be the most efficient study design.

Peer education: Training individuals in health education and counselling techniques so that they can educate others in their peer group e.g. training of sex workers to become peer educators on STIs and HIV.

Periodic presumptive treatment (PPT), also known as mass treatment: STI treatment of individuals presumed to be infected with one or more STIs, without attempting to make an individual diagnosis. PPT can be targeted to persons with known high-risk behaviours for example, sex workers. It is done by administering 1 g Azithromycine as PPT to a core group of people at certain intervals, with the presumption that many are infected with STIs. Alternatively, mass treatment can be provided to the general population, without attempting to target those who may be at increased risk.

Policy of 100 percent condom use in sex work: An intervention that seeks to reduce transmission of HIV and other STIs to and by sex workers by ensuring that condoms are used for every act of intercourse.

xvi Sex Worker: Female, male and transgender adults and young people who receive money or goods in exchange for sexual services, either regularly or occasionally, and who may or may not consciously define those activities as income-generating” (UNAIDS, June 2002).

Syndromic management: Treating a patient for all likely causes of a symptom or sign of an STI, rather than on the basis of a specific diagnosis (etiological management).

Vulnerable People: People who could be potentially at risk as per their behaviours

xvii PNG LOCAL TERMINOLOGIES

Pamuk: A generic term for prostitute or a female with multiple sexual partners

Paseniia meri: Literally means “transient” or mobile female

Opis meri: “Office women”, working females who sell sex occasionally

Raun meri: Occasional female sex worker

Two kina bus meri: A female sex worker who charges 2K per sex act in the bushes

Disco meri: A middle class female sex worker

Haiwei meri: A female sex worker along the highway

Paul meri: A foul female sex worker

K-pap/pamuk man: A man who buys/pays for sex

Lewa (liver or heart): A regular customer very well known to the female sex worker/Pren/Pap

Sip-sip (sheep): A sex worker

Paul badi: (Foul body) a derogatory term

Boskru: Guard for a female sex worker

Wasman: Guard/watchman for a female sex worker

xviii PUBLICATIONS

1. Eunice A. Bruce 1, Mathias Sapuri 2, Louise A. Keogh 3, John M. Kaldor 4,

Christopher K. Fairley 1. A systematic review of studies assessing risks of HIV among female sex workers in Papua New Guinea since 1980. Submitted to Asia Pacific

Journal of Public Health - 20/11/09.

2. Bruce E 1,6 , Bauai L 2, Sapuri M 3, Keogh L 4, Kaldor J 5 and Fairley CK 1 .The locations and size of the female sex workers population in the national capital district,

Port Moresby, Papua New Guinea. Submitted to Global Public Health - 24/12/09.

3. Bruce E 1,7 , Bauai L 2, Yeka W 3, Sapuri M 4, Keogh L 5, Kaldor J 6 and Fairley CK 1

.Knowledge, attitudes, practices and behaviour of female sex workers in Port Moresby,

Papua New Guinea. Sexual Health 2010 Feb;7(1):85-86.

4. Bruce E 1,7 , Bauai L 2, Masta A 3, Rooney PJ 3, Paniu M 3, Sapuri M 4, Keogh L 5,

Kaldor J 6, Fairley CK 1 .A cross sectional study of reported symptoms for sexually transmitted infections among female sex workers in Papua New Guinea. Sexual Health

2010 Feb;7(1):71-76.

5. E. Bruce 1, L. Bauai 2, A Masta 3, P.J. Rooney 3, M. Paniu 3, M. Sapuri 4, L. Keogh 5,

J. Kaldor6 and C.K. Fairley 1. Periodic presumptive treatment (PPT) of common curable sexually transmitted infections (STIs) among female sex workers in Port Moresby,

xix Papua New Guinea: measuring STI incidence and PPT effects. Submitted to

Australian and New Zealand Journal of Public Health - 05/02/2010.

6. EA Bruce 1, L Bauai 2, M Sapuri 3, JM. Kaldor 5, CK. Fairley 1, LA. Keogh 4.

Knowledge of HIV Risk and Safer Sex Practices among Female Sex Workers in Port

Moresby, Papua New Guinea. Submitted to Asia Pacific Journal of Public Health -

28/08/09.

xx CONFERENCE PRESENTATIONS AND PRIZES

2008

1. E.A. Bruce *, L. Bauai, A. Masta, P.J. Rooney, M. Paniu, M. Sapuri, L.A.

Keogh, J.M. Kaldor, C.K. Fairley. Periodic presumptive treatment (PPT) of

common curable sexually transmitted infections (STIs) among female sex

workers in Port Moresby, Papua New Guinea: Measuring STI incidence and

PPT effects. Australasian Sexual Health Conference, Perth, Australia: 15

September 2008 (Accepted as an Oral Presentation ).

2. E.A. Bruce *, L. Bauai, M. Sapuri, L.A. Keogh, J.M. Kaldor, C.K. Fairley. The

Locations and Size of the Female Sex Workers’ Population in the National

Capital District, Port Moresby, Papua New Guinea. Australasian Sexual Health

Conference, Perth, Australia: 15 September 2008 (Accepted as a Poster).

3. E.A. Bruce *, L. Bauai, M. Sapuri, L.A. Keogh, J.M. Kaldor, C.K. Fairley.

Knowledge of HIV Risk and Safer Sex Practices among Female Sex Workers in

Port Moresby, Papua New Guinea. Australasian Sexual Health Conference,

Perth, Australia: 15 September 2008 (Accepted as a Poster ).

2009

1. E.A. Bruce *, L.A. Keogh, J.M. Kaldor, C.K. Fairley. A systematic review of

studies assessing risks of HIV among female sex workers in Papua New Guinea

xxi since 1980. Australasian Sexual Health Conference, Brisbane: 7 September 2009

(Accepted as an Oral Presentation ); Interviewed by Sean Dorney (Australia

Network) for the Australia Network as part of the news bulletin on Wednesday

at 5pm directed at the Pacific.

2. E.A. Bruce *, L. Bauai, W. Yeka, M. Sapuri, L.A. Keogh, J.M. Kaldor, C.K.

Fairley. Knowledge, attitude, practices and behaviour of female sex workers in

Port Moresby, Papua New Guinea. Australasian Sexual Health Conference,

Brisbane: 7 September 2009 (Accepted as an Oral Presentation ); Interviewed by

Sean Dorney (Australia Network) for the Australia Network as part of the news

bulletin on Wednesday at 5pm directed at the Pacific.

xxii PRIZES

E.A. Bruce *, L. Bauai, M. Sapuri, L.A. Keogh, J.M. Kaldor, C.K. Fairley.

Knowledge of HIV risk and safer sex practices among female sex workers in

Port Moresby, Papua New Guinea. A presentation at the Australasian Sexual

Health Conference, Perth, Australia: 15 September 2008. Awarded the prize for the best poster presentation on social science research by the Sexual Health

Society of Victoria in 2008.

xxiii CONFERENCE PRESENTATIONS: ABSTRACTS

2008

1. Periodic presumptive treatment (PPT) of common curable sexually

transmitted infections (STIs) among female sex workers in Port Moresby,

Papua New Guinea: Measuring STI incidence and PPT effects.

Bruce E 1, Bauai L 2, Masta A 3, Rooney PJ 3, Paniu M 3, Sapuri M 4, Keogh L 5,

Kaldor J 6, Fairley CK 1

1Melbourne Sexual Health Centre, School of Population Health, The University of

Melbourne, VIC, Australia; 2Pacific Adventist University, Port Moresby, Papua

New Guinea; 3School of Medicine and Health Sciences, University of Papua New

Guinea, NDC Papua New Guinea; 4Pacific International Hospital, 4 Mile. P.O

Box 6103 Stores Road, Boroko, Port Moresby, National Capital District, Papua

New Guinea; 5Key Centre for Women’s, Health in Society, Department of Public

Health, The University of Melbourne Vic, Australia; 6 National Centre in HIV

Epidemiology and Clinical Research, University of New South Wales, Australia.

ABSTRACT

Background: Sexually transmitted infections (STIs) are common in female sex

workers (FSWs). Our aim was to determine if 3 monthly periodic presumptive

treatments (PPT) would reduce the incidence of STIs in FSWs in Port Moresby.

xxiv Methods: This was a cohort study conducted in between November 2003 –

September 2004. FSWs were provided information about the study and informed consent was obtained. FSWs were counselled and interviewed using a questionnaire. Testing by PCR for Chlamydia trachomatis ( Ct ), Neisseria gonorrhea (Ng) , Trichomonas vaginalis ( Tv) and serology for syphilis and HIV were carried out at baseline and at 10 months. Each participant was given 3 monthly (3 months, 6 months and 9 months) oral doses of 2g amoxicillin, 1g probenecid, 625mg X 2 augmentin and 1g Azithromycin via direct observed therapy. We administered “once only” 2g Tinadazole per day over three days at the 9 month visit. Results: The cohort consisted of 129 FSWs at baseline and

71FSWs (55.1%) at 10 months. There was a significant decline in the proportion with Ct from 38 to 15.5% ( P = 0.001), syphilis from 45.1 to 19.7 % ( P = 0.000),

Tv from 62 to29.6% ( P = 0.000), Ng from 56.3 to 22.5% ( (P = 0.000) between baseline and the 10 month visit. Of the 71 FSW who were seen at both visits, 11 were HIV positive at T=0 and 15 were HIV positive at T=10. Conclusions: The

PPT strategy was statistically effective in reducing STIs in the short term but STI rates rebounded rapidly and even with three monthly PPT a significant number of

HIV infections occurred. If PPT is to be very effective in FSWs where the force of infection is so high then 100% condom use with clients and very high rates of partner notification or 100% condom use would be required if a very low incidence and prevalence of STI were to be achievable.

Keywords: Cohort Study, Periodic Presumptive Treatment, HIV, STIs, Female Sex

Workers, Port Moresby, Papua New Guinea

xxv 2. The Locations and Size of the Female Sex Workers Population in the

National Capital District, Port Moresby, Papua New Guinea.

Louise A. Keogh 3†, John ,٭ Eunice A. Bruce *, Ludwina Bauai¥, Mathias Sapuri

M. Kaldor ɪ and Christopher K. Fairley*

*Melbourne Sexual Health Centre, School of Population Health, The University

of Melbourne, VIC, Australia; ¥ Pacific Adventist University, Port Moresby,

Pacific International Hospital, 4 Mile. P.O Box 6103 Stores٭ ;Papua New Guinea

Road, Boroko, Port Moresby, National Capital District, Papua New Guinea; †Key

Centre for Women’s, Health in Society, Department of Public Health, The

University of Melbourne Vic, Australia; ɪNational Centre in HIV Epidemiology

and Clinical Research, University of New South Wales, Australia .

ABSTRACT

Background: Accurate data on the size of the female sex worker (FSW)

population is a key piece of information required to effectively implement

prevention programs. Our aim was to identify the locations where sex work takes

place and estimate the size of the FSW population in Port Moresby where no local

data exist. Objective: To identify the locations where sex workers operate and

estimate the size of female sex worker (FSW) population within these locations

across Port Moresby, Papua New Guinea (PNG). Methods: We used key

informant (KI), mapping, observation and nomination methods. We interviewed

stakeholders and FSWs (recruited as fieldworkers) and obtained the names of the

xxvi locations. We visited the locations and interviewed additional local informants who participated in the study. Field workers were given coupons to nominate other FSWs they identified as FSWs. The identities of FSWs who returned coupons were checked, registered, counted and given coupons to repeat the process. Other FSWs who were observed but did not return coupons were also counted. We used strategies to minimise double counting and aggregated the data from the selected locations . Results: 51 local informants, 36 stakeholders and 12

FSWs participated in KI interviews. We obtained the names of 42 locations of which 22 were visited, 14 selected for the study and 28 excluded. The locations were settlements, peri urban villages, wharf, guest houses and bars. At the 42 locations, a range of 2,500-4,000 FSWs were estimated by KI. Of the selected 14 locations, 338 were estimated through observation whereas 212 were estimated through nomination. Identified FSWs comprised of (69%) street based and common in settlements and (31%) fixed establishment based who operate around the inner city and the wharf area. Conclusions: The method is challenging but simple and rapid. For systematic estimation of FSWs to better inform HIV policy, the method should be replicated in PNG.

Keywords: Female sex workers; Size estimation; Mapping; Observation;

Nomination; Key informants; Field workers; Port Moresby; Papua New Guinea.

xxvii 3. Knowledge of HIV Risk and Safer Sex Practices among Female Sex Workers

in Port Moresby, Papua New Guinea

.Louise A ,٭ Eunice A. Bruce *, Ludwina Bauai ¥, Anna Irumai , Mathias Sapuri

3 Keogh †, John M. Kaldor ɪ, Christopher K. Fairley*

*Melbourne Sexual Health Centre, School of Population Health, The University

of Melbourne, VIC, Australia; ¥ Pacific Adventist University, Port Moresby,

Papua New Guinea; The National Department of Health-Monitoring and Research

.Pacific International Hospital, 4 Mile٭ ;Branch, Port Moresby, Papua New Guinea

P.O Box 6103 Stores Road, Boroko, Port Moresby, National Capital District,

Papua New Guinea; †Key Centre for Women’s, Health in Society, Department of

Public Health, The University of Melbourne Vic, Australia; ɪNational Centre in

HIV Epidemiology and Clinical Research, University of New South Wales,

Australia.

ABSTRACT

Background: Safer sex practice reduces the risk for contracting and transmitting

human immunodeficiency virus (HIV). This study explored perceptions of HIV

risk and the practical barriers to safer sex practices among female sex workers

(FSWs) in Port Moresby, Papua New Guinea (PNG). We engaged local

stakeholders to identify and recruit FSWs in 19 sites in Port Moresby. Participants

could choose to take part in either a focus group discussion or a face-to-face in-

depth interview. 174 FSWs took part in 32 interviews and 16 focus groups. We

xxviii identified recurring themes in the data. The average FSW demonstrated good

basic HIV knowledge and her perception of HIV risk was high. She knew condom

use prevented transmission but her practice of safe sex was poor. (79%; 95% CI

33-47 sometimes used condoms, only 6%; 95% CI 3-11 used condoms at all times

and 15%; 95% CI 10-21 never used it). These findings demonstrate that adequate

knowledge of HIV risk does not necessarily translate into safer sex practices. We

identified a number of structural and environmental barriers to the adoption of

safer sex practices (poverty, gender inequality, cultural norms). We argue that

HIV policies and program interventions must address these barriers.

Keywords : HIV risk perception; Safer sex practices; Condoms use; Female sex

workers; Clients; Regular sexual partners; Port Moresby, Papua New Guinea

2009

4. A systematic review of studies assessing risks of HIV among female sex

workers in Papua New Guinea since 1980

Bruce E 1, Keogh L 2, Kaldor J 3, Fairley CK 1

1Melbourne Sexual Health Centre, School of Population Health, The University of

Melbourne, VIC, Australia; 2Key Centre for Women’s, Health in Society,

Department of Public Health, The University of Melbourne Vic, Australia;

xxix 3National Centre in HIV Epidemiology and Clinical Research, University of New

South Wales, Australia.

ABSTRACT

Background : Sex work plays an important role in the heterosexual transmission of human immunodeficiency virus (HIV). Female sex workers (FSWs) in Papua

New Guinea (PNG) are therefore considered a high-risk group for acquiring and transmitting HIV including sexually transmitted infections (STIs). Our aim was to review published and unpublished studies of the risks for sexually acquired HIV among FSWs in PNG to determine if risks for HIV have decreased and condom use has improved overtime. Methods : We searched “All databases in the ISI

Web of Knowledge” electronic database in March 2009 for studies published in between 1980-2008 using the keywords: sex workers and PNG. We also searched for unpublished studies from International Aid Agencies that operate in Port

Moresby with FSWs. Results : Seven studies met the inclusion criteria- 5 were published and 2 were not. Risks for acquiring HIV among FSWs included inconsistent condom use with clients (range: 0-63%) and regular sexual partners

(range: 0-34%) and high rates of STIs. The four most common STIs included;

Trichomonas (range: 21-56%), Neisseria gonorrhea (range: 20-39.4%), Syphilis

(range: 16-33.7%) and Chlamydia (range: 14-32.8%). The rates of HIV ranged from 0–21%. Conclusions : The measurements of condom use varied across different studies. Some improvement in the rate of condom use has occurred overtime however, their use remains suboptimal. In contrast, the rate of STIs remains high and did not appear to change overtime with most STIs present in

xxx 20% or more FSWs. Disturbingly, the proportion with HIV was higher in the

more recent studies and present 21% in 2004. The suboptimal condom use, high

rates of STIs and suggestion of rising HIV prevalence in FSWs are a great

concern and demands urgent actions.

Keywords : Systematic review; HIV; STIs, Condom use; Female sex workers;

Clients; Regular sexual partners; Papua New Guinea

5. Knowledge, attitude, practices and behaviour of female sex workers in Port

Moresby Papua New Guinea

Bruce E 1, Bauai L 2, Yeka W 3, Sapuri M 4, Keogh L 5, Kaldor J 6 and Fairley CK 1

1Melbourne Sexual Health Centre, School of Population Health, The University of

Melbourne, VIC, Australia; 2Pacific Adventist University, Port Moresby, Papua

New Guinea; 3 Papua New Guinea Institute of Medical Research, Goroka Papua

New Guinea; 4Pacific International Hospital, 4 Mile. P.O Box 6103 Stores Road,

Boroko, Port Moresby, National Capital District, Papua New Guinea; 5Key Centre

for Women’s, Health in Society, Department of Public Health, The University of

Melbourne Vic, Australia; 6National Centre in HIV Epidemiology and Clinical

Research, University of New South Wales, Australia.

xxxi ABSTRACT

Background: Female sex workers (FSWs) are considered a high risk group for human immunodeficiency virus. We therefore aimed to study the characteristics that render FSW vulnerable to HIV and track risky behaviours through a knowledge, attitude, behaviour and practice (KAPB) survey. Methods: We recruited FSWs through a convenience sampling and collected behavioural data using a structured questionnaire between June and July 2003. The data were double entered into FoxPro 2.6 database, converted and analyzed using Stata 7.0

(Stata Corporation). Results: We surveyed 79 FSW. The average FSW was 25 years old (range: 14-47), have 5 years of formal education (range: 0-11) and had first non paying sex at 16 years old (range: 12-23) and first paying sex at 19 years old (range: 13-32). They had an average of 3 (range: 0-7) sexual partners per day of which 2 (range: 0-4) were clients and 1 (range: 0-2) was a regular sexual partner. Condom use was (32%; 95% CI 22-43) with clients and (15%; 95% CI 6-

29) regular sexual partners. For 50, (63%; 95% CI 52-74) sex work was their only source of income. Seventy nine (100%; 95% CI 95-100) have heard of the male condom but only 53 (67%; 95% CI 56-77) thought it prevents HIV. Seventy eight

(99; 95% CI 93-100) thought one could catch HIV through sex but 38 (48%; 95%

CI 37-60) thought one could catch it from mosquito bite whilst 12 (15; 95% CI 8-

25) thought they have no chance of catching it. Twenty eight (36%; 95% CI 25-47) have had the HIV test. Other risky behaviours included alcohol 43 (54%; 95% CI

43-46) and marijuana 35 (44%; 95% CI 33-56) use. Conclusions : The findings identify areas for improved actions targeting sex workers based on the characteristics identified in this survey.

xxxii SUMMARY

This thesis contains eight chapters, seven of which form the basis of six studies that I undertook in Papua New Guinea while I was employed as the HIV advisor by World Vision International in collaboration with UNFPA. My role in these studies was to assess the HIV situation in PNG, work with populations most at risk, develop evidence- based strategies to reduce HIV transmission and vulnerability, and contribute to national policy. Specifically, my core responsibilities required that I identify gaps in HIV research and prevention programs concerning female sex workers, their clients and regular sexual partners and to propose constructive study concepts that are “intervention-linked” in nature to address the gaps in the context of PNG. Essentially, I was involved in all aspects of the studies from conception to completion.

To begin with, I identified, consulted and brought on board relevant “scientific advisers” to work collaboratively with on the conception, design, development and implementation of the intervention-linked studies. These included academic and research institutions and other organisations that provided:

• technical help and advice • writing assistance • training assistance • department chair for general support • resource/material support and • programmatic directions

A. Study design, data acquisition, management and analysis:

In all the studies presented in the thesis:

• I also completed a literature search and, based on the findings, formulated the original concept of the studies for dissemination, discussion and critical revisions.

xxxiii • I was involved in refining the research concepts that lead to creating the various study designs’ “research proposals”. • I contributed to the research protocols in defining precise methods, procedures, tools/instrument selection, resources, timeframes, treatment regimens, funding, etc. • I was involved in identifying and contextualising the questionnaires used in the studies. • I was directly involved in the organisation and coordination of the data collection processes. • I assisted in recruiting the study participants and mobilised research material/resources. • I participated in the collection of some biological specimens and measurements, and interview data including their analysis and interpretation. • I was responsible for the acquisition of funding for the studies.

B. Research proposal preparation:

• Furthermore, I played a substantial role in the drafting, preparation, revision and the write-up of the research proposals.

• I was involved in revising the final versions of the proposal for approval and submission.

C. Expertise:

• In effect, I played substantial roles in the selection of data analysis mechanisms and performing data analysis. • I was part of the team that ensured that the final versions of research protocols, design and proposals met the national and international guidelines and donor requirements for funding. • I wrote the grant proposal and acquired funding for the studies. • I brought to the studies and the research team advisory and technical support. • I was present and directly involved with the studies at the various study sites and facilitated the performance and support of the study team and volunteers. • I made significant contributions to the planning and execution of the research. • I was directly involved in the hiring, training and supervision of the study team. • I supervised the study performance and ensured that the study team adhered to devised instructions, research protocols, etc.

The studies were part of a large research project that was funded by United Nations Population Fund (UNFPA), through United Nations Joint Programme on HIV/AIDS

xxxiv (UNAIDS) under the Regional Unified Budget and Work plan (UBW) grant to the budget of “ Comprehensive models of STI/HIV/AIDS prevention for sex workers and their clients in Asia Pacific”: a regional project number RAS/02/P0. United Nations Population Fund (UNFPA) Asia Pacific Division (APD) and World Vision International (WVI) were the executing agencies. Technical assistance and overall coordination was provided by UNFPA Country Support Team (CST) in Bangkok. World Vision International (WVI) Asia and Pacific Regional Office provided regional technical backstopping and regional administrative support to the implementing WVI Country offices in Papua New Guinea (WVIPNG), and also Nepal (WVIN) and Vietnam (WVIV). Preliminary formative research, orientation meetings, strategic planning activities, field-based interventions and final evaluation took place at the beginning of March 2003 through to the end of September 2004. Permission was granted in 2008 by Mr Duah Owusu-Sarfo, former UNFPA Country Representative – Papua New Guinea, to document the research findings into a thesis.

The research project, “Comprehensive models of STI/HIV/AIDS prevention for sex workers and their clients in Asia Pacific”, was a trial demonstration of innovative prevention intervention models that address the important issue of HIV in female sex workers (FSWs). This is because epidemiological studies continue to show that FSWs in developing countries experience higher rates of HIV infection than in most. The overall goal of the research project was to reduce HIV/AIDS transmission, vulnerability and impact with the purpose to have contributed to achieving agreed goals and targets resulted in the UNGASS and United Nations System Strategic Objectives.

The aim of this thesis is to document the work that was undertaken as part of the UNFPA project above. This project involved a series of studies and conclusions that form the basis of my thesis which is divided up into seven chapters. In addition, the thesis includes a chapter that summarises the HIV situation and sex work in PNG with a touch of global views on sex work.

Chapter one of the thesis describes an overview of the HIV situation, the sex industry and female sex workers in Papua New Guinea. Available literature shows that the overall HIV situation is worsening in PNG and female sex workers are most affected.

xxxv This chapter also includes different views on sex work; the diversity and distinctions of which may help communicate the best way forward for FSWs in specific contexts.

Chapter two deals with a systematic review of studies assessing the risks of sexually acquired HIV in FSWs in PNG. The review included published and unpublished studies since 1980. The purpose was to document the major risks and determine if there have been any improvements at all in the “indicators” for sexually acquired HIV over time so as to evaluate if prevention efforts are having the desired impacts. In March 2009, “all databases in the ISI web of knowledge” were searched electronically for studies published between 1980 and 2008 using the keywords: “sex workers” and “PNG”. In addition, unpublished studies were searched from International Aid Agencies. In total , seven studies, five published and two unpublished, met the inclusion criteria and were selected. Risks for acquiring HIV in FSWs included inconsistent condom use with clients (range: 0–63%) and regular sexual partners (range: 0–34%) and high sexually transmitted infections (STIs). The prevalence of the four most common STIs were Trichomonas (range: 21–56%), Gonorrhea (range: 20–39%), Syphilis (range: 16–34%), Chlamydia (range: 14–33%). HIV prevalence ranged between 0–21%. Condom use has risen but rates of STI remained high. These data indicate that despite condom use rising, the rate of STIs remained high and did not appear to change over time, but the proportion with HIV rose. The suboptimal condom use, high rates of STIs and rising rates of HIV indicate currently there are inadequate control measures.

Chapter three deals with a study describing the locations where sex work takes place and estimating the FSW population size within these locations across Port Moresby. The purpose was to generate accurate data on the size of the FSW population which is a key element to implementing cost effective prevention programs. This information was not available at the time of the study. In this study, the information collection methods included key informant (KI), mapping, nomination and observations. Key informants, some of whom were sex workers, were interviewed to obtain the names of the locations of sex work in Port Moresby. The locations were visited and additional local key informants were identified, interviewed and were invited to participate in the study. Field workers were given coupons to give to other FSWs who they identified as sex workers. The identities of FSWs who returned coupons were checked, registered,

xxxvi counted and given coupons to repeat the process. The identities of FSWs who did not return coupons were confirmed by field workers and local KI and were counted. Strategies were used to minimise double counting and data from the selected locations were then aggregated.

A total of 52 local KI, 36 stakeholders and 12 FSWs (recruited as fieldworkers) participated in KI interviews. The names of 42 locations were obtained, of which 20 were considered too risky and were excluded. Twenty-two locations were visited, eight more were excluded because they were deemed unsafe to carry out research activities by the local key informants at the time of the study. Overall, 14 locations that were deemed safe were selected for the study. The locations were settlements, urban villages, peri urban slums, wharfs/waterfront, guest houses and bars. KI interviews estimated the FSW population at the 42 locations to be 2500–4000. Nomination and observation methods estimated the population at the 14 locations to be approximately 550, of which 212 were through nomination and 338 through observation. The FSWs comprised of two main categories: (69%) street-based and common in settlements, and (31%) fixed- establishment-based that operate around the inner city and the wharf area.

However, if the mapping was to extend to the 28 locations that were excluded, and they had on average the same number of FSWs, then the total population would be about 1700 FSWs across 42 locations. The method was rapid and simple, but challenging due to the illegal nature of sex work. That said, our study showed that with sensitivity, the so-called “hidden populations” can be reached in settings where reliable estimates are not available. The method can be applied in other parts of PNG. The data obtained can be used as a baseline for future research and better informed HIV policy. More research is required to obtain an accurate estimation of FSWs in PNG.

Chapter four deals with a study that describes the knowledge, attitudes, practices, and behaviours (KAPB) in relation to HIV risk. Since FSWs are considered to be at high risk of HIV, the purpose of the study was to identify areas where swift prevention efforts and effective programming decisions were required to reduce vulnerability in this group. A sample of 79 FSWs was recruited between June and July 2003 and administered a structured questionnaire. The average of the 79 FSWs was: 25 years old

xxxvii (range: 14–47), five years of formal education (range: 0–11), they had their first non- paying sex at 16 years old (range: 12–23), and first paying sex at 19 years old (range: 13–32). They had an average of three (range: 0–7) sexual partners per day of which two (range: 0–4) were clients, and one (range: 0–2) a regular sexual partner. Condoms were used for 32% (95% CI: 22–43) of clients and 15% (95% CI: 6–29) of regular sexual partners. For 63%, sex work was their only source of income. All FSWs (100%) (95% CI: 95–100) had heard of condoms, but only 67% (95% CI: 56–77) thought it prevented HIV. About 99% (95% CI: 93–100) thought one could catch HIV through sex, but 48% (95% CI: 37–60) thought one could catch it from a mosquito bite, whilst 15% (95% CI: 8–25) thought they had no chance of catching it; only 36% (95% CI: 25–47) have had the HIV test. Other risky behaviours included alcohol 54% (95% CI: 43–46) and marijuana 44% (95% CI: 33–56) use. The findings identify areas for improved actions targeting sex workers based on the characteristics identified in this survey. If HIV is to be successfully prevented among FSWs in PNG, condom use will need to rise towards 100%. For this to happen, considerable resources will need to be invested in preventive programs that address the high risk practices among FSWs and their clients, including a major focus on their regular sexual partners.

Chapter five deals with a study that assessed the sensitivity and specificity of reported symptoms obtained via a questionnaire augmented with a leukocyte esterase (LE) urine dipstick test for the detection of Chlamydia trachomatis ( Ct ), Neisseria gonorrhea (Ng ) and Trichomonas vaginalis ( Tv ), detected using polymerase chain reaction (PCR). The purpose was to identify other feasible STI screening tools for FSWs in resource constrained settings. In November 2003, a cohort of FSWs was screened for STIs and completed a questionnaire. A total of 129 FSWs (90% participation rate) were enrolled, of whom 48 (37%), 30 (23%) and 53 (41%) were diagnosed with Ng, Ct and Tv respectively by PCR. Of those diagnosed with any of these infections, 78% reported anogenital symptoms and of those without infections, 28% reported symptoms. Anogenital symptoms were present in over 50% of FSWs. Genital odour (present in 26%), lower abdominal pain (present in 29%) and dysuria (present in 19%) had a sensitivity around (50%), specificity (>80%), and all were significantly associated with positive PCR results for individual organisms; however, the sensitivity of these

xxxviii symptoms to detect the presence of any positive PCR result (Ct and/or Ng and/or Tv) was low ( <50%). When a LE urine dipstick test of greater than one was combined with the presence of three reported symptoms, the sensitivity was 86%, specificity of 73% and a positive predictive value (PPV) of 72% — a better predictor of infections. The findings suggest that the use of reported symptoms to predict STIs in FSWs is of limited use. However, an approach that incorporates a LE urine dipstick test result greater than one, and multiple symptoms, may be useful for screening infections and a feasible option among FSWs in resource constrained settings.

Chapter six deals with a study that was aimed to determine if periodic presumptive treatments (PPT) would reduce the incidence of STIs in FSWs in Port Moresby. This was a cohort study conducted between November 2003 and September 2004. Female sex workers were provided with information about the study and informed consent was obtained. They were counseled and interviewed using a questionnaire. Testing by PCR for Chlamydia trachomatis (Ct ), Neisseria gonorrhea (Ng) , Trichomonas vaginalis (Tv) and serology for HIV were carried out at baseline and at 10 months. Each participant was given four, three-monthly (0 month, 3 months, 6 months and 9 months) oral doses of 2g amoxicillin, 1g probenecid, 625mg X 2 augmentin and 1g Azithromycin via direct observed therapy. Every FSW was administered “once only” 2g Tinadazole per day over three days at the nine-month visit. The cohort consisted of 129 FSWs at baseline, and 71 FSWs (55.1%) completed the follow-up at 10 months. Among the 71 there was a significant decline in the proportion with Ct from 38% to 16% ( P = 0.001), Ng from 56% to 23% (P = 0.000) and Tv from 62% to 29.6% ( P = 0.000) between baseline and the 10-month visit. Of the 71 FSWs who were seen at both visits, 11 were HIV positive at T=0, and 15 were HIV positive at T=10. The PPT strategy was statistically effective in reducing STIs in the short-term, but STI rates rebounded rapidly, and even with three-monthly PPT a significant number of HIV infections occurred. If PPT is to be very effective in FSWs where the force of infection is so high, then 100% condom use with clients, and very high rates of partner notification, or 100% condom use, would be required if a very low incidence and prevalence of STI were to be achievable.

Chapter seven deals with a study that explored perceptions of HIV risk and barriers to safer sex practices among female sex workers (FSWs) in Port Moresby. One-hundred-

xxxix and-seventy-four FSWs were recruited to participate in 16 focus group discussions and 32 individual interviews. The average FSW demonstrated adequate knowledge of HIV risk but her practice of safe sex was poor. The average FSW was aware that condom use prevented HIV transmission but only 6% (95% CI: 3–11) used condoms at all times, 79% (95% CI: 33–47) used it sometimes and 15% (95% CI: 10–21) never used it. The findings demonstrated that adequate knowledge of HIV risk does not ensure safer sex practices. A number of structural and environmental factors such as poverty, gender inequity and cultural norms were identified as important barriers to safer sex practices. In this paper, it is strongly argued that HIV policies and public health interventions must address these barriers if HIV is to be addressed effectively in this group.

Chapter eight, the final chapter of the thesis, has my concluding comments about the significance of the findings and how these findings may assist in the future planning of effective HIV prevention interventions in female sex workers in Papua New Guinea.

xl CHAPTER 1

PAPUA NEW GUINEA, HIV, THE SEX INDUSTRY AND FEMALE SEX WORKERS: AN OVERVIEW

- 1 - 1.1 Papua New Guinea: The country

Papua New Guinea (PNG) occupies the eastern half of the island of New Guinea, an area about the size of Thailand. It is a country of approximately 6.2 million people and the capital is Port Moresby (POM) [1, 2]. Except for a few areas, the population density is considered low with people sparsely scattered all over the landscape. Numerous remote islands and a rugged central mountain spine are some of the major geographical features which contribute to a very beautiful [2, 3], but extremely difficult, terrain with regard to communications and transportation (Figure 1.1). It consists of approximately 85% rural residents whose main income is through subsistence farming and 15% urban residents [1, 2, 4]. Mines and industries such as palm oil, coffee and sugar plantation contribute to the wage earning capacities of individuals, mostly men [5].

The country differs considerably from other nations in the Asia Pacific region. Culturally, it is distinctive and grouped only with the other Island Melanesian societies. It has about 900 distinctive but mostly unwritten languages; a sixth of the world's total. About one-third of the population is literate in English or Melanesian Pidgin, the lingua franca [1, 2, 6-9] . Papua New Guineans, especially those in the interior, were isolated from the outside world for many thousands of years. This allowed for a proliferation of unique cultural forms and a diverse range of traditions and customs that come with several practices, attitudes, beliefs and expressions (Figure 1.2), including those of a religious and sexual nature [1, 10]. The most prominent social safety net in PNG society is the wantok 1 system, derived from the traditional kinship system through which relatives in need can expect assistance, support and favours from their village kin who are better off economically and socially. The nation is a highly masculinised one, has a polygamous culture and heavily populated with young people [1, 10-12].

1 Wantok is a pidgin word that means “one who speaks the same language”. PNG has many ethnic groups each with their own particular language or dialect.

- 2 - Figure 1.1. Map and pictures of PNG

The flag of PNG

The map of PNG, showing some of the major infrastr uctures

PNG showing mountains & rugged terrains The National Capital District of PNG – Port Moresby

- 3 - Figure 1.2. People of PNG, diverse range of culture and traditions

- 4 - A Papua New Guinea — signs of a fragile nation

Like most developing countries, PNG exhibits similar characteristics that put the nation at risk of HIV. Over the past years, PNG has been experiencing significant socio- economic and political changes; this includes PNG democratic governance undergoing a delicate transition to attain a market economy [13], a transition that has not been an easy process. In addition to this are a series of political hiccups since independence in 1975, which have also provoked a number of major political, social and economic challenges [2, 7, 8]. A classic example is the Bougainville crisis that brought a huge influx of Papuans across to POM in 1989, sparking the explosion of settlements with unskilled settlers. Several tribal fights, in the Highlands in particular, also added to the influx of poor and unskilled Highlanders to the settlements in POM, sparking mega explosions of joblessness, lawlessness and prostitution [14-16].

B Political situation — an overview

Papua New Guinea has the largest and most politically significant population in the pacific. After discovery by the Europeans, Papua New Guinea was colonised by the Germans, British and Australians, while the western half of the island went to the Dutch, followed by the Indonesians [241]. Independence was granted to Papua New Guinea in 1975, just a century after its peoples' first exposure to tools and institutions such as metal, cars, writing, the state, money economy and guns [1, 241].

The events after independence showed that democratic transition would be longer and more difficult than it was previously thought, and thus came with it several changes: the economic transition from a centralised and collective economy to a free-market one [2, 4, 17]; uncontrolled free movement of population bringing demographic changes and increasing the predomination of an urban society [2, 4, 7, 8, 17]; and a societal shift from complete isolation to openness. At the same time, governance was gradually weakening coupled with a destructive economy and depletion of the resource base [2, 4, 7, 8, 17]. The central government became and remained distant from the majority (85%) of the rural poor population. The road towards integration into a world economy and family of nations brought with it problems of cultural incompatibilities, despite

- 5 - extraordinary efforts on the part of Papua New Guineans to reach out for modern lifestyles [1]. This pattern of changes complicated the process of political transition that was fraught with problems. Despite these crises, PNG took decisive steps to be disassociated from the past. Today, PNG has an independent judiciary or an advanced legislation, a democratic system, an active Parliament and a free press media that is fuelling a diverse public opinion [1].

C Social and economic conditions

Papua New Guinea is considered the largest economically significant nation with a transition to a more developed free-market economy that has had a profound impact on the population compared to any other nation in the whole of the Pacific [1, 2, 4, 17]. The official currency of PNG is the Kina (Figure 1.3) expressed as PGK , divided into 100 toea and introduced in 1975, replacing the Australian dollar. After independence through most of the 1980s, economic indicators of PNG showed considerable improvement. However, after the crisis of Bougainville in 1989, including the closure of the most important foreign exchange earner — the Panguna mine, a continuing and increasingly threatening financial crisis developed [2, 4, 17]. Despite a rich natural resource base, the social indicators of PNG showed the lowest in the Pacific and it was classified as a low-income country (similar to those of Cambodia) among Asian nations [2, 13, 17]. Per capita gross domestic product (GDP) officially dropped from USD 930 in 1997 to USD 765 in 2000, and 740 in 2002 [18], with a per capita average annual growth rate of 1.6% and current per capita GDP of USD 2543 [19]. The transportation infrastructure deteriorated and access to services drastically declined. The Asian economic crisis brought greater economic deterioration from which recovery has been difficult [1, 17].

It is estimated that nearly half of the population is illiterate, malnutrition rates are high and about 40% of the population lives below the poverty line with rural communities worst affected [2, 7, 8, 17]. Generally, living standards are worsening, the resource base of PNG is depleting, income-earning opportunities are decreasing and the population is rapidly increasing [4, 7, 8, 13, 17]. In addition, government support is very scant and social security is non-existent. Therefore, economic migration to urban areas has

- 6 - increased as individuals seek better financial prospects after a lull during the early 1990s, prior to which urban growth averaged 15–17% per year [2, 4, 7, 8, 20].

Figure 1.3. PGK notes

While some services may be better accessed in urban areas, the cost of living is very high relative to incomes [17, 21], thus driving an increasingly worsening law and order problem [14, 15]. Without meaningful experiences and skills to secure jobs in the normal employment sector, land for subsistence farming in the urban areas, jobs and coherent cultural controls, hundreds of thousands of vulnerable individuals have no option but to end up in squatted settlements that are rife with prostitution and violent crime [14-16, 20]. It is at this fragile state of increasing economic and social changes that HIV has reached PNG and is spreading rapidly [22-26].

Continuous efforts have been made in PNG to stabilise the macroeconomic indicators, but the economic growth has yet to have a substantial impact on the lives of Papua New

- 7 - Guineans [8, 17, 21]. This is partly due to insufficient large-scale investments, a shortage of skilled labour and a lack of coordinated national policies on employment and inefficient labour market institutions [1, 2, 8, 13, 17, 21]. The official unemployment rate remains high, but higher among young people [2, 7, 8, 16, 21, 24, 27]. In the 1990s, the national statistics show that formal employment constituted only 9.2% of the total economic activities of the labour force [7, 8]. It must be stressed that the unemployed and families living in desperate economic conditions are not the only vulnerable groups in the country. Papua New Guinea is increasingly growing towards a critical masses situation of at-risk populations. These include children (out of school children, orphans, street children and those involved in steeling, begging, etc.) [28], women (domestically abused, unemployed, sex workers, etc.) [16, 28-30], the disabled, abandoned people, handicapped and the youth (drug and alcohol users, unemployed, school quitters, young people involved in criminal activity) [16, 22-24, 27-29]. The education, health, legal and law enforcement systems are insufficient to fully address the needs of the emerging vulnerable people [14].

D Education indicators

Contemporary PNG has no free basic education system. The central government expenditure allocated to education is 18% [2, 8]. According to UNESCO, the total adult literacy rate is 74%. The net primary school enrolment for both sexes from 1997–1999 stood at 85% [8, 9, 31, 32], with net primary school attendance of 32% for males and 31% for females. At the national level, only 60% of children who enter first grade primary school (Figure 1.4) eventually reach grade five level [8, 31]. This translates to a significant proportion of primary school age children missing out on a basic primary school education. During the same period, the net secondary school enrolment stood at 18% for females and 26% for males whilst gross tertiary school enrolment was 2% [8, 9, 31, 32]. In the subsequent years the secondary school level enrolment ratio for females dropped from 31% to 11% compared to 32% to 17% for males [9, 31, 32]. In 2002 the total adult literacy rate stood at 77%: 59% for females and 72% for males [9].

Initially, PNG had a free education system. After independence, the education system faced numerous problems. These included inadequate curricula, teaching methods and

- 8 - financial resources including human resource management [13, 17]. These burdens eventually become the responsibilities of parents who were hit with high school fees and academic expenses [21]. Hence, children from low income homes began to drop out of school at different grades and those in the rural areas were worst affected. The fact that only a few youth make it to secondary school due to declining education opportunities is perceived to fuel massive emigration and migration activities and

Figure 1.4. Children in primary school in PNG

affect future job prospects [2, 13, 34]. It is doubly problematic for the under-funded education system to also respond to the needs of newly migrated populations who end up in the urban centres [14, 15, 34].

E Health situation and trend

Public health in PNG faces both inherited and new problems. The country’s health status is the lowest in the Pacific Region [19, 35]. Life expectancy at birth of an average Papua New Guinean is estimated to be 59 years old [2, 13]; 59 for females and 57 years

- 9 - for males [13]. Communicable diseases including pneumonia, malaria, tuberculosis, diarrhoeal diseases, meningitis and HIV/AIDS remain the major causes of morbidity and mortality in all groups and account for 50% of all mortality [35]. In addition, vaccine-preventable diseases are a concern due to suboptimal immunisation coverage. For instance, of 898 suspected measles cases reported in 2008, only 48 were adequately investigated [35]. Malaria is endemic across the country, the leading cause of all outpatient visits and the third highest leading cause of hospital admissions and deaths [35]. An average of 1.5–1.8 cases of malaria are seen at health facilities annually with the mortality rate for 2007 estimated to be 8.4 per 100,000 [35]. According to WHO estimates, in 2007 PNG has an estimated tuberculosis (TB) prevalence rate of 430/100, 000; TB death rate of 60/100,000 per year; and a total of 15,002 cases for all types of TB [35].

Maternal and child morbidity and mortality rates are high. Maternal mortality estimates vary with rates of 300 per 100,000 live births in 2000 according to the World Health Report [19]; 930 per 100,000 live births in 2002 according to the UN [13]; and 733 per 100,000 live births in 2006 according to the WHO [35]. The causes of maternal mortality include postpartum haemorrhage, puerperal sepsis, eclampsia and anaemia. About 53% of pregnant women are cared for by trained health personnel [13, 35] and 52% of births take place in health facilities with contraceptive prevalence of 24.3% [33].

Perinatal conditions account for 10% of all recorded deaths. Under-five mortality ranks thirty-ninth highest among 187 nations. The annual number of births is 149,000 [8], and the infant mortality rate per 1000 live births varies and ranges from 62 between 2000 and 2005 [13] to 58 in 2006 [33], compared to 82 in 1991 and 72 from the 1981 National Census [8]. Under-five mortality rate per 1000 live births varies and ranges from 85 [8] in the years preceding 1997, 113 in 2000 [13], to 93 in 2004 [19]. Infants born with low birth weight is estimated to be 23% [8]. According to the health indicators, approximately 91% of children under one year old are fully immunised against TB, 81% against polio, 79% against diphtheria, 57% against measles and 14% of pregnant women are immunised against tetanus [8]. Overall, about 30% of children

- 10 - are considered to be malnourished and 31% aged 0–5 years old are stunted in growth [35].

Total population using an improved drinking water source is estimated to be 42%: 88% in urban centres and 32% in the rural areas [2, 13]. Total population who have access to adequate sanitation facilities is 82%: 92% in urban centres and 80% in rural areas [2, 13].

More recently, health authorities expressed concerns about the growing incidence of HIV/AIDS, sexually transmitted infections (STIs), malaria, diarrhoea, anaemia, deterioration in living conditions, inadequate health service structures, low quality of service delivery and lack of capacities in health management and insufficient specialists [8, 14, 33, 35, 36]. The National Department of Health figures show that there are six doctors for every 100,000 population; 77 nursing officers per 100,000; and 89 aid post staff per 100,000 people [8]. Above all, the most fundamental problem for the health sector is lack of financial resources to provide adequate care. Current total government expenditure allocated to health as a share of GDP is 3.2% [35], of which 80% recurrent provincial health budget was allocated to salaries. Health services have to tackle new problems for which there is minimal experience such as sexually transmitted infections, sexual violence and drug abuse [14, 36]. Health services are provided by government and church groups (both of which are financed primarily from the private sector); enterprise-based services (e.g. mines); modern private sector; and traditional healers [35].

F Migration and emigration

Emigration and migration are a common practice in PNG. The majority are men particularly in their reproductive years. Internal migration has been one of the most dramatic features of the PNG transition [1]. Most migration occurs from villages in the remote areas to the central urban areas in search of work [2, 4, 7, 8, 17, 20, 21]. These internal migratory movements rapidly added to the increased numbers of urban unskilled populations and numerous rural settlers [14-16, 34, 37, 38]. This mode of migration, usually spontaneous, uncontrolled and unplanned, contributed significantly

- 11 - to most of the serious economic [17, 21] and social problems [22-24]. The overwhelming migration has played a damaging role in the urban and environmental equilibrium [14, 15, 20, 22-24, 27, 37]. Not only has the migration contributed to the explosion of urban slums and settlements densely populated with unskilled settlers and the jobless, but also increased the level of conflicts, crimes and prostitution in the urban centres.

G History with illicit drug use

Over recent years the production and trafficking of drugs, mainly marijuana and other locally made stimulants, has increased dramatically in PNG [1]. The increase is explained by a number of factors which include poverty, high unemployment, easy movements across borders, the desire to make big money, and lack of survival opportunities for young people [1, 7, 8].

Papua New Guinea is recognised as a country that produces one of the most potent forms of cannabis. Cultivation of cannabis is mainly concentrated in the highlands region of PNG but is also found in all parts of the country [1]. The ratio of male to female drug use is almost 1:1. The main reasons for drug use are mainly curiosity and the desire to feel high [14, 16, 20, 39]. The main route of administration is smoking and orally. There are no reliable data related to the morbidity and mortality related to drug use in PNG and there is no history of injecting drug use in the country to date [1, 14]. The anti-drug unit of the police force is responsible for arresting drug users and traffickers.

H History of sex work

Sex work in Papua New Guinean society is by no means a new phenomenon [16, 29]; it has existed for decades. Compared to males, females are generally economically disadvantaged, with only a few owning their business and land [6, 16, 29, 40]. In PNG, sex work began with the first wave of poverty and economic deprivation [29, 41]. The country’s economic situation and lack of a rapid recovery encouraged economic migration [2, 17, 21]. Economic factors are the most important reasons behind population movement. Main motives for emigration include higher wages to help family

- 12 - members, job opportunities, better working conditions, better living standards and better education possibilities [20, 21]. It is at this fragile state of increasing economic and social changes that HIV has reached PNG and is spreading rapidly [14, 21, 22, 24, 25, 29, 34, 36, 42].

1.2 Papua New Guinea: The HIV situation

Papua New Guinea is reported to have one of the most serious HIV epidemics in the Asia Pacific subregion [43]. Human Immunodeficiency Virus (HIV) was first reported in Papua New Guinea in 1987 and according to UNAIDS and other reports, HIV cases have since been increasing at a rate of 30% annually since 1997 [36, 44, 45]. Table 1.1 and Figure 1.5 show data viewed as increments over time; a measure of the rapid rise in detected cases.

A Trend in reported HIV infections over time

Since HIV was first reported in PNG, the trend in reported infections shows an exponential growth with a prevalence rate that is increasing steadily (Figure 1.5) [46]. In 2000, the number of people infected with HIV was estimated to range between 5500 and 22,000, while at the same time the First National Consensus Workshop estimated this to be 10,000–15,000 [47]. However from 2002 onwards, at least 2000 new infections were reported annually and by then, the prevalence of HIV among antenatal women in the Port Moresby General Hospital had passed 1% [36, 47]. By this time also, a total of 6469 people had been reported to have the HIV infection in a national population that year of around 5.4 million people. Since this time, AIDS had become the leading cause of death at the Goroka Hospital, while at the Port Moresby General Hospital 60% of the medical wards were occupied by AIDS patients and 20% of in- patients with tuberculosis (TB) were HIV positive [46]. Hence in 2002, PNG declared a generalised HIV epidemic and became the fourth country after Thailand, Cambodia and Myanmar, to have a generalised HIV epidemic in the Asia Pacific Region [45].

In 2004, it was estimated that there were between 25,000 and 69,000 people infected with HIV in the country with a median estimate of 47,000, thus translating to a median adult prevalence of 1.7% [48]. But by the turn of 2005, the prevalence of HIV in PNG

- 13 - was the highest (1.3%) in the Asia Pacific Region [49]. In 2006 alone, Papua New Guinea had 4017 new confirmed cases of HIV, a 30% increase from 2005 [46]. By the end of 2006, a total of 18,484 people had been diagnosed with HIV. Of these infections, 46% were in males, 48% in females, and 6% in individuals whose sex was not reported [50]. By this time, the national HIV prevalence was estimated to be 1.28% among youth and adults aged 15–49, with an estimated 46,275 people living with HIV [46, 50].

Figure 1.5. New and cumulative annually reported HIV infections in Papua New Guinea, 1987–2006

Source: NDOH and NACS.

At the same time, a working group estimated the HIV prevalence to range between 0.8– 3.2% with an estimated 57,000 of the total population infected and a median prevalence of 2%. However, according to UNAIDS, the adult population estimated to be infected with HIV by the end of 2006 was 1.3%; a prevalence rate significantly lower than the 2005 estimate of 1.8% reported by UNAIDS [51]. A more recent report puts the HIV prevalance rate at 1.5% [52]. The reduced prevalence rate is considered a reflection of

- 14 - improvements in surveillance rather than a shrinking epidemic. According to UNAIDS, Papua New Guinea accounts for 70% of the subregion's HIV cases [43].

Table 1.1 shows the reported number of HIV infections to the end of December 2006, statistics taken from the December 2006 Quarterly Report [50] with the total number of people diagnosed with HIV reaching 18,484. Figure 1.5 above indicates the new and cumulative annually reported HIV infections.

Table 1.1. New and cumulative HIV infections detected in Papua New Guinea, 1987–2006

Year of Male Female Unknown Total HIV Cumulative HIV Diagnosis Infections by year Infections 1987 2 4 0 6 6 1988 8 5 0 13 19 1989 11 7 0 18 37 1990 24 12 0 36 73 1991 17 16 2 35 108 1992 12 18 0 30 138 1993 19 21 0 40 178 1994 42 31 1 74 252 1995 68 57 1 126 378 1996 94 96 2 192 570 1997 173 174 1 348 918 1998 331 307 23 661 1579 1999 418 335 37 790 2369 2000 598 448 27 1073 3442 2001 642 615 56 1313 4755 2002 840 796 78 1714 6469 2003 1058 1137 121 2316 8785 2004 1152 1193 284 2629 11414 2005 1310 1587 156 3053 14467 2006 1711 1965 341 4017 18484 Total 8530 8824 1130 18484

Source: December 2006 Quarterly Report (NACS and NDOH, 2006).

- 15 - B New estimates: the new trend of the epidemic

As per available historical data from both urban and rural areas, key HIV indicators and the high increasing trend of the epidemic in PNG, a projection exercise in 2007 predicted that HIV prevalence among the rural population will become higher than in

Table 1.2. Estimated HIV prevalence, 1993–2012

NATIONAL URBAN RURAL

%HIV+ Num %HIV+ Num %HIV+ Num HIV+ HIV+ HIV+ 1993 0.05 1,310 0.1 438 0.04 871

1994 0.06 1,771 0.14 597 0.05 1,175

1995 0.08 2,387 0.18 807 0.07 1,580

1996 0.11 3,204 0.24 1,081 0.09 2,122

1997 0.15 4,282 0.31 1,433 0.11 2,848

1998 0.19 5,694 0.4 1,875 0.15 3,819

1999 0.24 7,530 0.5 2,412 0.2 5,118

2000 0.31 9,898 0.62 3,043 0.26 6,855

2001 0.4 12,931 0.75 3,754 0.34 9,176

2002 0.51 16,796 0.88 4,521 0.44 12,275

2003 0.64 21,714 1.01 5,308 0.57 16,405

2004 0.81 27,978 1.13 6,076 0.75 21,902

2005 1.02 35,988 1.24 6,787 0.98 29,200

2006 1.28 46,275 1.32 7,415 1.27 38,860

2007 1.61 59,537 1.38 7,943 1.65 51,594

2008 2.03 76,665 1.43 8,369 2.14 68,297

2009 2.56 98,757 1.45 8,698 2.76 90,059

2010 3.22 127,121 1.46 8,942 3.55 118,179

2011 4.05 163,245 1.46 9,119 4.53 154,126

2012 5.07 208,714 1.44 9,244 5.74 199,471

Source: NDOH and NACS, 2007.

- 16 - urban areas [53]. Table 1.2 details the estimations of HIV prevalence from 1993 with projections to 2012 at urban, rural and country levels. As of December 2006, the national prevalence stood at 1.28% and the number of people living with HIV was estimated to be 46,275. By that time, the urban prevalence was 1.32% with an estimated 7415 people living with HIV; while the rural prevalence was 1.27% with 38,860 people estimated to be living with HIV in 2006 [46, 50]. Although the trend of the epidemic in rural areas shows a late epidemic, it also shows a rapid increase. Based on the prevalence alone, the estimates show that as of 2007, the HIV epidemic is expected to become more rural where 85% of the PNG population resides [46]. Given the high percentage of the rural population, it can be said that the trend of the rural epidemic is almost close to the trend of the national epidemic.

The graph below (Figure 1.6) shows the estimated and projected trends of the epidemic in PNG. The trend of the national epidemic is very close to the trend of the rural epidemic given the high percentage of the rural population. This means that the numbers of people that will require treatment will increase, many people will die of AIDS, the

Figure 1.6. Urban, rural and national trends in the HIV Epidemic in PNG

Source: NDOH and NACS, 2007.

- 17 - number of orphans due to AIDS will increase and the overall impact on children, youth and the nation will be great. The graph above shows a rural trend that is sharply increasing with a rural epidemic that is strongly determining the national trend [46]. Based on these estimates, it can be concluded that the HIV epidemic in PNG has now shifted to rural areas.

C Mode of Transmission

Heterosexual contact is the most common mode of HIV transmission and unprotected sex is the major risk factor (Table 1.3). Most cases occur among people aged 20 to 40 followed by perinatal transmission, according to a 2006 report by the National AIDS Council Secretariat and National Department of Health [50].

Based on the data presented in Table 1.3, the predominant mode of transmission is unprotected heterosexual intercourse. Given the fact that heterosexual unprotected sex is the major risk factor, female sex workers have therefore been linked with the epidemic and, as a result, received a considerable amount of debate [16].

Table 1.3. HIV infections reported in Papua New Guinea, 1987–2006, by mode of transmission

Mode of Transmission Male Female Sex not stated Total %

Heterosexual 2712 3386 194 6292 34.04

Homosexual 18 8 0 26 0.14

Perinatal 118 97 4 219 1.18

Blood transfusion 0 0 0 0 0.00

Contaminated needle 0 0 0 0 0.00

Mode not recorded 5682 5333 932 11947 64.63

Total 8530 8824 1130 18484 100.00

Source: NACS and NDOH, 2006.

- 18 - D Distribution of HIV infection by age and sex

For males, the most common age at diagnosis is in the 25–29 and 30–34 year age groups. From available data, almost 60% of these infections are diagnosed among those below the age of 35 [46, 50]. For females, the most common age at diagnosis is in the 20–24 and 25–29 year age groups with infections occurring in females below the age of 29 years [46, 50]. The ratio of HIV infected women to men is about one to one. However, from the data available, there are higher numbers of infections detected in younger women (Figure 1.7) [46, 50].

Figure 1.7. HIV infections detected in Papua New Guinea by age, 1987–2006

E Available HIV surveillance

Surveillance conducted in PNG shows rapid rising HIV infection among patients at STI clinics in Port Moresby, where HIV prevalence more than doubled during 1998–99, from 3% to 7% [54]. In four other locations it increased from 0.7% to 1.2% from 1997 to 1999. In healthy blood donors, HIV prevalence increased from 0.09% to 0.25% between 1998 and 1999, and among women attending Port Moresby General Hospital Antenatal Clinic HIV prevalence doubled from 1998 to 1999 [54]. HIV prevalence among female sex workers in Port Moresby and Lae in 1998 were 17% and 3%

- 19 - respectively. Based on available sentinel surveillance data and special studies, the prevalence data below (Table 1.4) are known and show that FSWs are mostly affected. As per the data also, it seems the infection is more concentrated in the capital cities with a rapid increase in all surveyed groups, especially those in Port Moresby, since 1999 [54].

Table 1.4. Available measurements of HIV prevalence data

Sites (Urban) Year Collected Percent %

Port Moresby: STD 1999 7

Port Moresby: Antenatal 1999, 2002 0.32, 0.95

Port Moresby: Blood Donor 1999 0.25

Port Moresby: FSWs 1998 17

Lae: FSWs 1998 3

Other STD clinics in 4 locations 1999 1.2

Whole Country: Defence Force 1999 0.4

Source: WHO (2000): Dr. Amoa, PMGH, personal communication.

F Papua New Guinea: sexually transmitted infections

In Papua New Guinea, sexually transmitted diseases are widespread [41, 55-61] and estimated to be among the highest in the Asia Pacific Region [36, 45, 62]. Over the last decade, Syphilis, Gonorrhea and Chlamydia are the most prevalent but are also under- diagnosed, under-reported and less well documented [8, 23, 36, 56]. In PNG, STI prevalence data are mostly gathered among people who present to STI clinics and these are only a small proportion of the people with STIs [54]. A high prevalence of STIs in the population significantly increases the risk of HIV transmission and indicates a high degree of unprotected sex [24, 39, 63, 64]. Sexually transmitted infections are a matter of concern because HIV transmission through STIs is becoming more prevalent in PNG [65]. This is true of low and high risk populations across all age groups including children [44, 47, 57, 59, 66, 67].

- 20 - According to the PNG statistics, Chlamydia is present in more than 30%, Gonorrhea in 12% and Syphilis in 4% of the entire population [36, 62]. A population-based random sample survey of village women in the Eastern Highlands found prevalence levels similar for Chlamydia (26%), but lower for Syphilis (4%), and Gonorrhea (15%) [61]. Further Studies conducted in Goroka showed that Congenital Syphilis, a completely preventable disease, was responsible for 5.5% of neonatal admissions, and 22% of neonatal deaths [68].

A case control study by Amoa et al. concluded that approximately 10% of all stillbirths at the Port Moresby General Hospital were attributed to Syphilis [65]. Further studies conducted in five STI clinics (Port Moresby, Goroka, Lae, Rabaul and Daru) in 1989 and 1990 detected the presence of Herpes Simplex virus type 2 in genital ulcers [56]. Trichomoniasis was found in 45–50% of both the low and high risk populations [14, 55, 58, 61]. The World Health Organization estimated that in PNG more than one million new cases of STI occur every year, two-thirds of which are Chlamydial infections [62].

Table 1.5. Prevalence of sexually transmitted infections, from surveys, 1998

High Risk Populations Low Risk populations

Sex Workers Ante-natal women Highland villagers

STIs % % %

Gonorrhea 36 - 15

Chlamydia 31 - 26

Syphilis 32 4 (unknown year) 4

*Trichomoniasis 45 - 50

*Lae 44

*Port Moresby 21

Source : WHO, National AIDS Council and Department of Health (2000).

Community-based studies conducted by the PNG Institute of Medical Research of asymptomatic people in 10 provinces showed that of the total 3288 people tested, 40% (1315) were infected with at least one STI. Of those infected, the prevalence of

- 21 - Chlamydia was 13.2% (434), Syphilis was 15.0% (493), Gonorrhea 11.5% (378) and Trichomoniasis 19.7% (648) [63]. The presence of an STI greatly increases one’s risk of contracting and transmitting HIV [65, 69]. The prevalence of HIV from these studies was 3.4% in urban areas and 1.3% in rural areas, with an overall prevalence of 2.4% [63]. Females showed higher levels of HIV infection in both rural and urban areas [63].

Statistics from the provinces show evidence of the increasing prevalence of Syphilis, and current data from the STI clinics in Port Moresby, Lae and the Highlands provinces indicate an increasing prevalence of genital herpes and genital warts [46]. As Herpes and Syphilis are both ulcerative STIs, there is increased chance of HIV transmission during unprotected sexual contact. A recent national mapping study by the PNG Institute of Medical Research showed that there was 2.5 times more chance of being infected by HIV if Syphilis was a co-infection [63].

Given that females have showed higher levels of HIV infection in PNG [46, 63, 65, 69], it is expected that those most at risk will include FSWs (Tables 1.4 & 1.5). It also implies that clients and regular sexual partners of FSWs, including the wives or spouses of these men, would equally be at risk. Like other developing countries, the spread of HIV has typically occurred along transportation routes of the Highlands Highway and is known to exist in areas surrounding mining, plantations and logging sites where female sex workers commonly solicit their clients [46].

G Condom conundrum

Over the years, condom promotion and its use in PNG is growing irrespective of the fact that it is perceived to encourage promiscuity [70, 71]. The first ever national study on condom acceptability showed that ordinary people expressed little resistance, but overall, many people at the time of the study had little knowledge, experience and access to condoms [70].

The acceptability study was conducted in 1995 and supported by UNFPA [70]. The study did not only show that female condoms had a role to play in the prevention of HIV, but concluded that there was no doubt that the female condom once tried, would

- 22 - be an acceptable method in urban PNG [70]. Overall, 43% (or 194) of 450 persons interviewed indicated they manage to use the female condom and, of these, 95% reported they would continue to use it [70]. Based on this report, UNFPA ordered 30,000 female condoms for distribution through selected urban outlets in Port Moresby, Lae and Goroka in March 1997 to test the potential use. Distribution was monitored between November 1997 and November 1998 and a recorded total of 5300 female condoms were distributed to 574 women on 803 separate occasions [72].

Most of the women (87%) were recruited through a project aimed at FSWs and (12%) at family planning clinics with STD clinics (1%) accounting for the rest [72]. One-quarter of the women returned at least once to obtain further supplies of female condoms. Two- thirds of the women recruited said they were sex workers and were more than twice as likely as other women to become repeat users [72]. Of the women recruited to the study, 29% stated that they wanted the female condom for STD prevention [72]. Almost all women who became repeat users said that they liked using the female condom, and three-quarters of them also reported that their partners liked the idea of the female condoms [72]. Although a small number of women had problems with the condoms, nearly all women expressed satisfaction [72]. The monitoring study recommended that the female condom should continue to be available to women, particularly FSWs, through peer education programs and be formally included in the National Department of Health family planning and reproductive health programs [72]. Contrary to what might be expected in a society where women are relatively powerless, the female condom may potentially pave the way to empower women [73] to protect themselves from HIV and other STls and must be encouraged in future programs [64, 74-78].

A demographic and health survey undertaken in 1996 showed that only 2% of all women in the country had ever used a male condom, whilst at the same time a staggering 73% felt they were at no risk of acquiring HIV [8]. Between 1993 and 2000, millions of free condoms were distributed to at-risk populations via numerous avenues including HIV related programs, though occasional supply hiccups had occurred [79].

In 2002, a 100% condom use policy was adopted by the National AIDS Council Secretariat (NACS) with the aim to ensure that condoms (Karamap brand) were always

- 23 - available to all in need [44]. While few studies have examined the use of condoms closely it appears that many people, including “at risk” populations such as FSWs, are using condoms, but consistency remains very low to date [14, 16, 39, 55, 58, 79-81]. The reasons for inconsistent and low condom use must be examined at the national and local level if HIV is to be effectively addressed [73, 76].

1.3 The sex industry, female sex workers and HIV/AIDS

The links between sex work and HIV vulnerability have been recognised since the earliest days of the epidemic however, studies continue to confirm that in many developing countries, sex workers experience higher rates of HIV infection than in most [58, 82-85]. This is unacceptable. Like most developing countries, FSWs in PNG have accounted for some of the highest HIV prevalence of the total infected adult population [58]. In medical, epidemiological and social research arenas, FSWs are referred to as a “high risk group” for the acquisition and transmission of HIV including STIs. The evidence supporting such assertion, persisting into the present era, is the reported high rates of HIV and STIs in FSWs [78, 82, 84]. For instance, in 1998 the HIV prevalence among FSWs in Port Moresby was 17% [58] and rose to 21% in 2004 [86]. The estimates illustrate a situation worsening rather than improving, which also indicates that FSWs are witnessing a dramatic increase in HIV infection rates. The rising HIV rate is a great cause of concern. It is not surprising that the sex industry is associated with the HIV epidemic and women in the industry are labelled as “vectors of diseases” [85] and considered a significant threat to public health due to their sexual behaviour [84].

In most developing countries where heterosexual contact is the most common mode of human immunodeficiency virus (HIV) transmission, women in sex work are often the first group to become infected [82, 84]. In PNG, a study in 1998 found an HIV prevalence of 17% among 207 FSWs in Port Moresby [58], while at the same time the prevalence was 0.34% among the adult population in Port Moresby, 0.37% in pregnant women and 0.19% among the adult population in the rest of the country [45]. In 2004, the prevalence of the infection in pregnant women nearly quadrupled to 1.4% [51]. However, more recent data indicate that the prevalence of infection within the general

- 24 - population has risen by nearly seven-fold to 1.5% [52]. Furthermore, PNG has a number of features that suggest that HIV transmission is likely to continue, particularly among FSWs. These include a poor working environment of sex workers [16, 74], extreme poverty [16, 29, 30, 74], a high rate of partner change [58], high rates of STIs [55, 58, 86], inconsistent use of condoms [16, 55, 58, 80, 86-88], poor HIV knowledge [16, 80, 87, 88], marijuana and alcohol use [16, 55, 58, 87] and poor health-seeking behaviours [16, 55, 80, 87].

A Factors influencing sex work

In PNG, women are generally poor and are affected by poverty in several ways by several factors. Few women own any land or can inherit any [40], and very few own profitable businesses [6, 16]. Most women spend more time providing unpaid care- giving services within their families and communities [6, 16]. Others can barely survive on the income of a working spouse whilst some spouses may be unemployed [16]. Women without skills, those raising children and family members by themselves, and those divorced or separated who have limited resources to support themselves and their children, are particularly vulnerable [16, 29, 76, 89]. With scant employment opportunities in addition to lack of social support services for disadvantaged families, especially in the areas of health care, child care, education and housing, women face multiple barriers to economic security (Figure 1.8) [16, 76].

In an environment that offers very few options for economic gain, economic migration becomes a viable option particularly for individuals seeking economic betterment. In rural PNG, economic migration to urban areas has become an increasingly significant phenomenon and reported to be one of the driving forces behind the booming sex industry [15, 16, 22, 23, 29]. More often than not, rural migrants arrive in the urban centres without adequate skills and expertise to qualify for work in the normal employment sector [7, 8]. In addition to low education statuses of many, rural migrants are faced with limited employment opportunities [7, 8, 17, 21].

- 25 - Figure 1.8. Women selling betel nut for an income

Without income, most migrants are unable to afford rental housing [7, 16, 21]. They have no option but to live in settlements which are frequently overcrowded, filled with dilapidated housing conditions (Figure 1.9), lack basic amenities and are usually rife with high crime and prostitution [14-16, 22-24]. These factors further disrupt the lives of many rural migrants and young women are particularly vulnerable [16, 28, 90].

While some may freely choose to engage in sex work, in most instances many females are compelled to enter sex work; a viable option for economic survival [16, 29, 30, 63, 74] due to poor socioeconomic indicators [2, 7, 17, 21]. Sex work provides an alternative to earn a living to provide and cater for self and other family members [16, 29, 76].

- 26 - Figure 1.9. Dilapidated housing conditions at Vadavada settlement, outskirts of POM

While this reflects deplorable economic conditions and not in any way involves direct coercion and/or deceit by another, the desire to enter sex work for most females across the world stems from a combination of socio-cultural factors including individual circumstances such as: poverty, gender issues, low levels of education, lack of employment opportunities, lack of access to disposable income, spousal separation, family neglect, disintegration of the social safety net, social isolation, debt and sometimes death [16, 76]. In PNG, available literature points to these as part of the contributing factors fuelling sex work and explains the reasons why the sex industry is expanding at a fast pace [16, 29].

B The nature and features of the sex industry in PNG

The HIV epidemic in relation to sex workers, including the sex industry in PNG, is hardly documented. There is limited research conducted to explore the extent of the sex industry. Moreso, there have been very few scientific publications on the HIV epidemic and female sex workers in PNG. However available literature suggests that sex work

- 27 - has long existed in Papua New Guinea [16, 29], but is believed to have grown substantially over the last decades and become more recognised in the large cities [16, 29, 58].

C The size of the sex industry

The exact size of the sex industry in PNG is not yet known. To date, there have been three studies that have attempted to estimate the size of the FSW population. In 1992, a national study conducted in rural and peri urban areas concluded that about half of all women investigated revealed they exchanged sex for money or gifts [64]. Also, an ethnographic study was undertaken 15 years earlier in 1993 and described sex workers in two major cities and a small town in PNG [16, 39]. The study used a population survey and concluded that of a total population of the 315,000 subjects they surveyed, there was an estimated 15,000 women working independently as FSWs in Port Moresby, Lae and Goroka, but no separate estimate was provided for POM [16, 39]. Anecdotally, there is an estimated 10,000–12,000 freelance FSWs who work from the streets, the “bushes” and other informal settings in Port Moresby alone [14]. Literature also suggests that a greater proportion of the sex industry remains underground due to the legal, political and social conditions surrounding it [16]. Another study in 2003, through extrapolation, estimated the number of FSWs in Port Moresby to be approximately 1700 [91]. The same study used the nomination method and estimated the number of FSWs in fourteen locations across Port Moresby to be 212, whilst a more recent study undertaken in 2005 used respondent-driven sampling and estimated the FSW population in Port Moresby to be 245 [88].

D Special features of the sex industry

The sex industry in Papua New Guinea PNG is complex and unique compared to the sex industries in other parts of the world. The industry is unique in the sense that firstly, it is not defined in terms of sex worker popular “hot spot” or “red light districts” [16]; Jenkins asserts that the legal, political and social parameters surrounding sex work hinder the establishment of such “sex worker” zones [16]. Secondly, the sex industry is neither established into brothels nor regulated by a national legislation. Sex workers are

- 28 - therefore not registered or regulated as found in other countries [6, 16]. Thirdly, the industry is independent of the so called “gatekeepers”, commonly referred to as “pimps” or “madams”, hence FSWs in this part of the world are generally in control of their own income and lives [16]. Fourthly, the industry is not sanctioned by PNG law [6, 16]; in spite of this, sex work is common, visible and widely practiced across the country [16, 242, 243].

Furthermore, the industry is predominantly “freelance”: FSWs are therefore more visible around bars, discos, on the streets and such vicinities with little or no cover [16]. In fact, ethnographers maintain that sex may be negotiated for and performed almost anywhere in vicinities such as the wharfs, trucking depots, cannery factories, mines, sugar plantations, oil fields, dam sites, gas installations and logging operation sites [16, 55, 58, 69, 242, 243]. Other fixed venues include the bushes, beaches, clubs, discos, residential houses and offices [16, 58]. Across the entire country, sex work is more commonly noted along the transport routes and truck stops along the Highland Highway [16]. Hotel-based sex work and the like are rare for mainstream sex work in PNG; this is because it is relatively expensive [16].

In PNG, the majority of the industry is operational during the day; sex work at night is relatively rare [16]. The level of violence somewhat determines the time sex work takes place; street violence by gangs is common at night [16]. This is partly the reason why the sex industry in PNG is busier during the day than at night. For instance, female sex workers who reside in the settlements usually leave in the morning for popular day time sex venues such as the post office, markets, grassy fields, guest houses, public parks and wharfs to solicit clients for sex until late afternoon, and then return home in the evenings [16]. Another distinctive feature of the sex industry is that FSWs exhibit no distinguishable features or characteristics that single them out; they rarely wear makeup, short skirts and tights pants as observed among sex workers in other parts of the world. In short, they blend in with everyday society (Figure 1.10).

- 29 - Figure 1.10. Female sex workers at a training workshop in Port Moresby

E The composition of the sex industry

The sex industry comprises of females and males, but female sex workers far outnumber their male counterparts [16]. Both female and male sex workers are common in the major cities, but more females are found in the villages and rural areas [16]. According to Jenkins and Law, some villages in various regions of the country are well-known for the fact that the entire adult female population is available for sex work [6, 16]. Female sex workers in these areas are a lot more organised into vicinities such as village drinking bars established along major highway arteries, shores of the coasts and major rivers (Figure 1.11). Compared to FSWs, to date very little documentation exists about male sex workers including their roles and involvement in the sex industry in PNG. Information available shows that this group is either bisexual or homosexual; traditionally known as logohu and also referred to as “gerlie-gerlie” [16, 92].

- 30 - Figure 1.11. Waterfront sex worker site — Dig and Dump in Port Moresby

F Classification of the sex industry — sex workers and the class system

Analysis of the sex industry in PNG suggests that a hierarchical stratification exists among FSWs. The hierarchical stratification is unique, clearly depicts the “class system” and exists in three distinctive levels [16]. The sex industry is stratified into low, middle and high class categories [16]. In local terms, Jenkins refers to the low class sex workers as “2 Kina Bus Meri”, the middle class as “Disco Meri” and the high class as “Escorts” as described below.

F.1 “Two Kina bus meri”:

This category is comprised of the least paid FSWs who may earn between K2–K20 per sex act (PNG K=US$ 0.25), and is by far the largest group. Sex workers of this category mainly work outdoors such as the on the roads and streets (Figure 1.12). They are also popularly known to have sex in the bushes and weedy areas, hence the name.

- 31 - Figure 1.12. Two Kina bus meri in Port Moresby

“Two Kina bus meri” ( a female who has sex in the bushes for payment of two Kina). These women mostly work during the daytime and have approximately 300 to 900 partners per year [16]. Their clients are usually men earning a low income and street vendors. These women are the least educated with only 0–5 years of formal education [16].

F.2 “Disco meri”:

Female sex workers of this category are usually paid more in cash, food and drinks, and may earn K20–K50 per sex act and have fewer partners [16]. These women mostly work indoors and around the clock (night and day) from vicinities including offices, homes of clients, discos, small guest houses, bars, in cars and sometimes in hotels. Unless women of this category are desperate for money, they usually demand set

- 32 - Figure 1.13. Disco meris at peer education training in Port Moresby

prices for various sex acts [16]. The peak times for clients for these women include lunch times, late afternoons, during holidays and paydays. If rooms are rented for sexual activities, usually it is the responsibility of the clients to pay for them [16]. These women are generally better educated, usually up to secondary school level (Figure 1.13) [16].

F.3 “Escorts/High Class”:

Women of this category may not necessarily be highly educated or bourgeois, but are often among the better educated women in PNG. They are less dependent on sex work for basic economic needs because they work for a salary [16]. Females of this category attract better paying clients because they are fashionable, hygienic, have high self esteem and are also eloquent in English. They are well-known local women who may act as recruiters for better paying clients including politicians, big businessmen or high- ranking civil servants, who more often than not are married [16].

- 33 - In Port Moresby, these women reside in expensive homes in upper class areas. The homes usually have a manager and several security men who act as boskru but are not involved in arranging business for them [16] . All sex negotiations are made between individual sex workers and their clients. They are independent working women, rented out on an hourly basis, operate at a much higher price and have fewer partners [16]. The sexual activities of these women tend to be more adventurous and, as a result, they are able to demand up to100-fold higher payments per sex act [16]. The managers and the security guards in turn receive a portion of the payment for ensuring their safe return home [16].

The work of these women goes beyond Port Moresby and sometimes outside the country. This category is apparently well organised, funded by high ranking officials and, at times, advertised. Women working in government offices and businesses are the common players of this category so some sex takes place in the offices [16]. Evidence indicates that these women are more likely to use condoms [16]. According to Jenkins, competition among these women is very great thus sexual blackmail is a common occurrence. Housing, promotions, opportunities for overseas education, overseas trips, cars, weekend holidays and cash are just a few of the rewards FSWs of this category enjoy [16].

G Sex workers, demographics and their clients

In PNG, most FSWs are poorly educated and their years of formal education range between an average of three to seven years [16, 55, 58, 80, 87, 88]. The rate of illiteracy ranges between 26%–36% of FSWs [16, 55, 58, 80, 87, 88]. A considerable number of females who engage in sex work do so for a living [16, 29]. It appears as though, occasionally, some women may have sex just for the fun of it without any sort of remuneration [16]. The contemporary rural scene includes young women who expect to be paid, others who accept cash “to be nice”, and others who accept gifts such as beer, food, clothes and do not expect cash [16]. In small towns, women who define themselves as sex workers openly negotiate price [16, 242]. In larger urban centres, many women are nearly totally dependent on the sale of sex for their income and may support several other family members from this income as well [16]. Of the FSWs, there

- 34 - are full-timers who sell sex for a living and work around the clock, and casual-timers who exchange sex for favours and extra cash when the need arises [16]. It must be noted however that most casual sex workers may not always perceive themselves as sex workers [6, 16].

The age of FSWs is reported to range from 10–59 years old with an average age of 25– 28 years old [16, 55, 58, 80, 81, 87]. Most young females between the ages of 14 and 18 years old usually require the money for school fees and daily expenses [6, 16]. Among poorest families, young girls between the ages of 10–14 years old are reported to be readily offered to any paying clients [6, 16]. Female sex workers 18 years old and over had mostly never been married [16, 55, 58, 80, 87], sometimes deserted [6, 16] and also have children between the ages of one and five to support [16, 55, 87] .

Figure 1.14. Female sex workers in Port Moresby — the young and old

- 35 -

The number of clients for self-defined full time urban FSWs per year has been reported to be as high as 300–900 [16]. While the highest number of clients per FSW in a week recorded is as high as 30, in some areas of Port Moresby and Lae, the ratio appeared to be one FSW per 15 clients [16]. One report indicated that there was a sudden increase in the number of clients from three to an average of six per week among FSWs in Port Moresby between 1996 and 1998, the period of massive economic decline [14]. In another study, the number of clients per FSW ranged between one and eight per week, with one FSW having an average of three clients per week [55]. The overall average range is about two to eight clients per week [55, 58, 80, 81, 87]. Main clientele for FSWs in Port Moresby include government workers and businessmen, whereas in Lae sailors and truckers also form a significant proportion of their clients [16, 55, 58]. Besides clients, most FSWs also have steady sexual and casual partners (Figure 1.15) [16, 55, 58, 80, 81, 87].

- 36 - Figure 1.15. Female sex workers and their regular sexual partners at a meeting with the national director of WVI in Port Moresby

H Factors influencing fee charged per client

In general, FSWs of the high class category, including younger, good-looking ones who have positive self-esteem and are known to be skilled at their work, are more likely to attract better clients and also be able to negotiate proper fees amounting to Kina 50– Kina 100 per sex act [16]. Since 2000, the fee paid per sexual act ranged between 2K– 30K (US $0.50–$8.00) [55]; however the very young and inexperienced are unable to assert or demand such fees from their clients [16, 29, 30]. Also, FSWs of the low class, the destitute, the least educated including those who live under deplorable economic circumstances, are unlikely to demand such fees and more likely to provide inexpensive sex for as little as K2–K5 per sex act [16, 29, 30]. This is a major problem [27, 30].

Sex workers who partake in group sex usually attract higher payment from each man involved in the sex act; those who perform specialised sex acts charge set prices while others charge one set price for a combination of many sex acts [16]. More fees are demanded if clothes are to be taken off; this is because so much sex takes place

- 37 - outdoors that undressing for sex is not the norm [16]. Set charges are demanded for vaginal intercourse, a slightly higher fee for anal intercourse and a higher price yet for oral sex [16]. Expatriates are charged more than local clients because apparently they demand several sex acts [16]. Sometimes, known neighbours, security guards and other individuals such as the police may go without a fee [16]. Fees charged per regular clients are discounted from time to time as rapport develops and they eventually become valued clients. Young clients are generally not preferred because they often negotiate sex for free or demand inexpensive sex [16, 39].

I Legal framework of sex work and the powers at play

Sex work or sex in exchange for money, gifts or other goods is not an offence per se in Papua New Guinea [6]. However, according to the constitution, activities surrounding sex work are criminalised [6]. In spite of this the sex industry is thriving and expanding across the country [16]. The National Court infers to the Summary Offences Act to apply an offence of living on the earnings of prostitution to the sex worker herself [6]. The main criminal laws dealing with sex work is Section 218 of the Criminal Code, which prohibits living off the earnings of prostitution, keeping a brothel 2, or buying 3 sex [6]. More recently though, the legislation deems sex work illegal, and few women have been prosecuted and imprisoned for it [6].

I.1 The Police:

Under normal circumstances, the sex industry itself is left untouched. However, Section 218 is commonly applied in PNG and accounts for almost all prostitution-related offences reported by the law enforcement agency [6, 16]. The one salient power broker of the constitution is the police force who ensures that the anti-prostitution laws are enforced [6, 16]. Section 218 is interpreted to accord a degree of authority to the law enforcement agency to reprimand those who breach it. This makes the sex industry an

2 Summary Offences Act (Chapter 264) Part VII.

3 Criminal Code Section 218.

- 38 - easy target and, with hard fist rules, the police exert their authority to exercise full control over it [16]. As the activities of sex workers are deemed illegal, for this reason they risk being picked up by authorities. Also labelled as law offenders, they are often the easy targets for intimidation, harassment, exploitation, violence and abuse [6, 14, 16].

According to Jenkins, FSWs are subject to physical and sexual violence, often “pack raped” and thrown into cells without a charge or protection from the legal environment [16]. She asserts that FSWs in PNG live in fear of their lives, often at the mercy of the police, and are rendered powerless by society. Critiques have often criticised the code that is perceived to focus solely on controlling prostitution rather than providing safety for the sex workers [6, 16]. While the code has not been found to avert or abolish sex work, Jenkins asserts that the law has potentially driven a proportion of the sex industry underground [16, 29, 30, 93]. Knowing that clandestine sex work does foster an ambience that can increase the risks of HIV, violence and other human rights abuses, this is a real public health concern [37, 74, 94].

I.2 Gatekeepers:

Most FSWs in PNG are independent of pimps or madams [16]. However, a few operate through pimp-like individuals who may connect FSWs with clients or serve as messengers or “sex couriers” to relay information between FSWs and clients [16]. Primarily they serve as guards or procurers in return for money, food, etc. as a way of payment for their services, but some urban FSWs are totally independent of them [16]. Locally, the guard is referred to as boskru or wasman and may be a close relative or a friend, but seldom in control of their income [16]. However if the sex worker is under eighteen or very young, and the wasman is the sex worker’s husband, brother or father, then he may control her income [6, 16].

Depending on the time of business, sex work in PNG can be quite dangerous [16]. Under this circumstance, the wasman specifically guards the area where sex work is taking place, keeps intruders out and helps the sex worker collect her money amicably. He also ensures that the people on the periphery of the trade are paid by the sex worker

- 39 - either in money or in kind, but refrains from exerting violent power over the sex worker as found in sex work cultures elsewhere [16].

J Sex workers and stigma

Traditional PNG is a conservative society [1], hence sex work and issues related to sexuality pose a major challenge [10, 93]. Due to this reason, sex work is socially, morally and culturally demonised [6, 16]. Female sex workers are therefore a highly stigmatised group of people and as a result a sizable proportion remains hidden [16]. The very existence of sex workers threatens traditional family values and sexual moral standards found in most conservative societies. These are intertwined into taboos and traditional beliefs surrounding matters related to sex and sexual orientation [1, 10, 93]. Furthermore, a high proportion of Papua New Guineans are Christians; this religion has stringent religious doctrines and moral stands related to sex work [1].

To escape the social stigma and societal perception, coupled with the illegal nature accorded sex work, most FSWs hide their work from families, neighbours and community members [16]. Some simply work away from home where they even stand a better chance of finding better paying clients outside the poorer areas where they live [16]. Others choose to go “under cover” by maintaining they sell market produce elsewhere [16, 29]. Exposure to stigma and working underground means that real barriers exist to target sex workers, thus making them a difficult group to reach for preventative services and research [76, 95]. It also means that FSWs are less likely to report physical and sexual abuses by perpetrators [16, 96]. This presents serious ramifications for effective planning and implementation of public health interventions [76, 94, 95].

However in the current economic and social contexts, it appears that contemporary values, perceptions and rigid opinions of sex work are gradually softening across PNG [6]. Although on the whole societal attitude remains negative, it appears as though sex work is no longer entirely “demonised” based on the current poor economic indicators, the sheer magnitude of limited job opportunities and lack of social support services available. Based on these reasons it is perceived that, to an extent, FSWs are accorded a

- 40 - degree of sympathy and protection by community members, especially that of close families who view sex work as an inevitable means of survival and therefore justified [6, 14]. This is particularly so when women in sex work share their earnings with family members and friends. Under these conditions, sex work is less stigmatised and individuals including husbands, brothers and other male family members may set women up in the sex trade [6, 14, 16].

According to Jenkins, family-driven sex work is certainly not new in PNG. Husband and wife sex traders have been documented earlier in Port Moresby, and men from villages in the Highlands were seen to take a few “sisters” to the major lowlands truck stops to procure a number of male clients for them [16]. Anecdotally, such family- driven sex work appears to be increasing in urban areas with residences occupied by numerous women available for sex becoming known [14, 16].

K Sex workers and HIV rates

Lessons learned from various countries have showed that the potential acquisition and transmission of HIV through sex work is great [82, 84]. In PNG, previous and current studies in FSWs show a similar pattern to rates of infection that remain high and increasing over time [58, 86]. A 1998 study by Mgone et al. found a HIV rate of 17% among FSWs in Port Moresby and 3% among those in Lae [58], with the study concluding that ignorance about the epidemic remains pervasive among FSWs and their clients [58]. The same study further reiterates that most FSWs lack the skills and the resources to control and protect themselves from the virus [58]. A more recent study reported a much higher HIV rate of 21%, indicating an infection that is not decreasing but increasing [86].

L Sex workers and STI rates

To date, three studies have measured the prevalence of STIs including HIV in FSWs and were undertaken in 1998, 2001 and 2003 [55, 58, 86]. The proportion of FSWs with: Trichomonas vaginalis ranged from 21–56%, Neisseria gonorrhea ranged from 20–39.4%, Syphilis ranged from 16–33.7% and Chlamydia trachomatis ranged from 14–32.8% [55, 58, 86]. A 1998 study among 407 FSWs in Port Moresby and Lae found

- 41 - high levels of Chlamydia trachomatis of 31%, Syphilis of 32% and Neisseria gonorrhea of 36% [58]. Mgone et al. reported that the infections were not only common, but in many cases they were present as multiple infections with 74% of the FSWs having at least one of the STIs that were tested for [58]. The study also reported that double and triple infections were present in 63.5% and 14.1% of the FSWs respectively, and at least 1% had all four curable STIs that were tested for [58].

In another 2001 study among 211 FSWs in three different locations in the Eastern Highlands Province, 20.8% were positive for Neisseria gonorrhea, 19.4% for Chlamydia trachomatis , 51.2% for Trichomonas vaginalis and 24.2% for Syphilis [55]. In this study, Neisseria gonorrhea and Chlamydia trachomatis were more common in FSWs with a mean age of 22.3 and 23.3 years respectively, and were significantly associated with each other (Odds ratio, 11.32 CI, 4.88; 26.60 and p <0.01) [55]. Gare et al. reported that Neisseria gonorrhea, Chlamydia trachomatis and Trichomonas vaginalis were the most common STIs and concurrent triple infections detected in the FSWs [55]. In 2001, of the FSWs whose results were available and analysed, 74% were positive for at least one of the four pathogens that were detected [55]. Mixed infections with these STIs were observed to be common. Among the 176 FSWs for whom complete results of all STIs were available, 72% (126) were infected, of whom 43% (54 of 126) had more than one STI [55]. Double infections accounted for 63% (34 of 54); 33% (18 of 54) had triple infections; whereas 4% (2 of 54) had all of the four detected STIs [55]. None was seropositve for HIV [55]. Table 1.6 shows the distribution of these STIs in the three major centres.

In a more recent study in 2003, Chlamydia trachomatis was found to be 23.3%, Trichomonas vaginalis 41.0%, Neisseria gonorrhea 37.2% and Syphilis 33.3% among 129 FSWs in Port Moresby [86]. Mixed infections with these STIs were observed to be common. Among the 129 FSWs for whom complete results of all STIs were available, 79% (103) were infected, of whom 34% (45 of 129) had one STI, whereas 40% (52 of 129) had double or more of the infections that were detected [86].

- 42 - Table 1.6. Prevalence of STIs among female sex workers in three towns of Eastern Highlands Province (EHP)

District Province

STIs Goroka Kainantu & Yonki Total (EHP) (n =162) (n = 49) (n =211) Neisseria gonorrhea 34 (21%) 10 (20%) 44 (21%) Chlamydia trachomatis 34 (21%) 7 (14%) 41 (19%) Trichomonas vaginalis 91 (56%) 17 (35% 108 (51%) Treponema pallidum 34 (26%)* 8 (16%) 42 (24%)† HIV 0 (0%) 0 (0%) 0 (0%)

T. pallidum, n =129* and †176, respectively. Source Gare 1998.

M STI history, recognition of symptoms and treatment-seeking behaviours of FSWs

In an ethnographic study in 1993, Jenkins reported that nearly half of the 85 FSWs interviewed stated they had at some time experienced an STI at least once; most knew very little about these sicknesses and claimed not to have ever had symptoms [16].

In a 1998 study, Mgone et al. reported that of the 346 of 408 FSWs whose test results for five STIs were available, 45% reported symptoms associated with STIs at the time of the study [58]. Among those with symptoms, 51% had vaginal discharge and 44% had dysuria. Of these, only 20% of FSWs with symptoms had sought treatment in the last past six months and overall only 15% had ever done so [58].

A KAPB study conducted in 1999 reported that of the 190 FSWs interviewed, 41%, 37%, 25%, 8% and 3% correctly identified vaginal discharge, dysuria, genital odours, pain with intercourse and genital sores respectively as signs and symptoms of an STI [80]. Questions related to treatment-seeking behaviour revealed that 74% of these FSWs stated they had sought treatment from an STD clinic, but 32% had done so from traditional treatment [80]. Further questions revealed that 11% had sought self-treatment from remedies, whilst others claimed to have done nothing [80].

- 43 - A subsequent study in 2001 among 211 FSWs reported that 96% of the women reported experiencing an STI and/or associated signs and symptoms at the time of the study [55]. Lower abdominal pain and vaginal discharge were reported by 81% and 68%, respectively, whilst dysuria and genital sores were reported by 37% and 3% respectively [55]. Questions related to whether the women were infected in the past revealed that 71% (149 of 211) gave a history of having had STI symptoms at one time, 25% answered “no”, and 5% were either not sure or did not know [55]. Questions related to treatment-seeking behaviours revealed that 70% had ever been treated for an STI; this ranged between one and nine times [55]. From data that were available for 94 FSWs, 88% (83 of 94) reported to have sought treatment in the last three months [55]. Almost 90% of those who reported to have sought treatment in the past had presented to either an STI clinic (58%) or urban clinics (30%), whilst 9% had done so through “off-the- shelf” treatment and the remaining 3% through other avenues, including self-remedies and traditional healers [55].

In a more recent study conducted in 2005, 28–43% of FSWs in Port Moresby and Goroka reported to have experienced a vaginal discharge, whilst 12–21% reported sores in/around the vagina in the past twelve months [88].

Jenkins is of the assertion that FSWs, especially the least educated and the very young by virtue of their work, coupled with societal stigma, refrain from seeking medical and preventive services [16, 74]. Their poor economic conditions mean that only a few are able to afford regular check-ups from private clinics that are too costly [16, 74]. Consequently, they seek inadequate treatment alternatives. In her ethnographic study, Jenkins reported that FSWs in urban areas frequently resort to Dettol or ordinary Washing Powder for treatment of genital sores [16]. The study further reported that other treatment behaviours included self-medication with antibiotics, “off the-shelf” treatment and local herbal remedies, whilst others seek no medical care at all [16]. Jenkins partly attributed this to the fact that FSWs who access public clinics complained of being screamed at by health workers and were sometimes refused treatment unless they brought in their sexual partners [16].

- 44 - N Sex workers and HIV/STI knowledge

Available data show that most FSWs generally have limited levels of knowledge about HIV and STIs especially, and therefore are not fully aware of their own vulnerabilities [16, 55, 58, 80, 81, 87]. In 1993 an ethnographic study reported that of all the FSWs interviewed, the levels of knowledge about both STIs and HIV were very low [16]. The study concluded that although most FSWs have heard of AIDS and knew it was incurable, very few gave little thought to their own vulnerability and, more importantly, HIV risk perception was very poor [16].

In 1999, another study found that of the 190 FSWs interviewed, 24% knew no transmission route, 44% had prevention knowledge through condom use, and only 3% knew that genital sores might be due to an STI infection [80]. At the same time, 71% felt they were of low or no risk of acquiring HIV [80]. In a more recent study conducted in 2005, about 37% of FSWs in Port Moresby and 31% of FSWs in Goroka thought mosquitoes could transmit HIV [81].

O Sex workers and risk taking behaviours

Researchers in PNG stress that general risk taking behaviours such as unsafe sex, inconsistent condom use and substance abuse remain pervasive in FSWs, rendering these women and their sexual partners even more susceptible to the virus [15, 16, 22, 24, 29, 30, 39, 55, 58, 63, 79-81]. And for the majority, the use of heavy alcohol, marijuana, locally brewed stimulants and violent personal relationships as well as ambient violence within their communities, counter HIV prevention efforts including those at personal development levels [16, 55, 71, 87, 94].

P Risky sexual behaviours

A report on prevalence of sexual behaviour among FSWs in the Eastern Highlands indicated that 63% of those interviewed admitted to have had regular anal-penile penetrative sex and 67% oral-penile sex [55]. Approximately 21% (45 of 210) admitted to have been “pack-raped” at least once in the course of selling sex, commonly known as “line-up” in PNG; 67% stated to have been raped while under the influence of

- 45 - alcohol; 2% while under the influence of marijuana; and 27% while under the influence of both alcohol and marijuana, while others confirmed that other substance use among them was also common [55].

Q Sex workers and cheap unsafe sex on the Highway

Sex work is reported to be prevalent at most truck stops along the Highlands Highway, which are open and lack indoor facilities as found in certain parts of the world [16, 39]. Truck drivers, including other men, frequent these truck stops to buy sex from the highway FSWs locally known as haiwei meri [16, 39]. Additionally, at several market places along the Highlands Highway, females also exchange sex for accommodation and/or betel nut from the local young men including teenage boys [16, 39]. More often than not, this is accompanied by group sex, lainap, where one female agrees to have sex with approximately four males for a stalk of betel nut at a price of about K6 per stalk, which is to be sold for ten-fold later. At these truck stops the availability and use of condoms is virtually non-existent [16, 39].

Figure 1.16. Women selling betel nut at a market in the Highlands

- 46 - R Sex workers and condom use

To date, very few studies have examined the use of condoms involving FSWs. Previous studies in PNG show that condom use in FSWs is low and inconsistent [16, 39, 55, 58, 80]. In 1993, an ethnographic study by Jenkins [16] found that 5% of 88 FSWs reported consistent condom use with their clients. In 1998, another study by Mgone et al. found that 25% of 207 FSWs in Port Moresby and 5% of 200 FSWs in Lae reported consistent condom use with their clients [58]. Only 45% indicated they use it for every sex act, but 34% stated they never use condoms at all [58]. The same study found that 9% of 407 FSWs reported consistent condom use with their regular sexual partners [58]. In 1999, Morof et al. found that 7% of 190 FSWs reported consistent condom use with their clients, whilst only 3% did so with their regular sexual partners [80].

In 2001 Gare et al. found that none of the 211 FSWs in their study reported consistent condom use with either their clients or regular sexual partners [55]. Nearly three- quarters stated to have not used a condom with their clients during their previous sexual encounter just before the study [55]. During this time, the mean sexual acts per week among FSWs was four; condom use was only during one in four of these sexual encounters [55]. Only 42% admitted ever using a condom with their non-paying steady partners in their entire lives [55]. Eighty per cent stated the main reason for not using condoms was availability, while 75% indicated clients’ refusal and 33% attributed it to their own failure to negotiate for condom use due to being under the influence of alcohol or marijuana [55]. In a more recent study in 2005, Yeka et al. found that 63% of 245 FSWs in Port Moresby and 31% of 249 FSWs in Goroka reported consistent condom use with their clients, whilst 34% and 16% in POM and Goroka respectively reported doing so with their regular sexual partners [81]. While this indicates some improvement, it is believed condom use is yet to reach the required level to protect female sex workers from the human immunodeficiency virus.

- 47 - 1.4 Justification for targeting sex workers

Studies indicate that the sexual behaviour of FSWs places them at risk of acquiring HIV and STIs [58, 64, 84, 85, 97-100]. In one study conducted among young FSWs in rural, per urban and urban areas of the Eastern Highlands, (n=42) reported a high sexual partner exchange rate with the mean number of different partners the previous year being 4.05–14.9, but they took no money for sex, compared with those who accepted cash and/or gifts (n=35) — their mean number of sexual partners was 18.35–26.05 [64]; whereas the number of partners in the past for self-defined full time urban FSWs is more in the order of 500 to 2000 [16]. Thus, sex in exchange for money or gifts is widespread across the country, particularly in areas where economic developmental activities have created the market for sex work [14, 16]. Secondly, the levels of STIs in FSWs are higher than reported in the general population of which a proportion comprises of the steady clients of sex workers [55, 58, 86]. An ethnographic study among FSWs in PNG indicated that a considerable number of men, mostly married, buy sex from sex workers at some stage of their lives and therefore constitute an important bridging population [16]. This implies that there is a great potential for HIV to spread from FSWs to their bridging populations and therefore to community members at large [16, 76, 85].

Considering the evidence of the recent rising rate of HIV in the adult population, and among FSWs in particular, in addition to inconsistent condom use, high rates of STIs, poor health-seeking behaviours and lack of social support, indeed the added risk of acquiring and transmitting HIV in FSWs is perceived to be great, and potentially so among their sexual networks. While condom use is becoming more acceptable for FSWs [70], its use has not yet reached the required levels that would protect FSWs and their bridging populations from the potential spread of HIV. More rigorous, targeted interventions for FSWs, including their clients and regular sexual partners, are important [76]. Given the high rates of HIV and STIs in this group and inconsistent condom use, implementation of a behaviour change program with a focus on improving condom use for FSWs and their sexual partners is paramount, whilst at the same time improving strategies for STI management and health-seeking behaviours in FSWs [76].

- 48 - More importantly, interventions must include empowerment approaches that create economic capacities and enable FSWs to take control of their lives [101, 102].

1.5 Government of PNG perspective

In 1986, the National Department of Health (NDOH) set up a National AIDS Surveillance Committee and in 1988 adopted the first national policy on AIDS control [103]. Both short-term and medium-term plans were developed by the NDOH with the support of the World Health Organization (WHO), but their implementation was handicapped by financial and human resources constraints [103]. However since the first HIV case was reported in PNG in1987, the PNG government has demonstrated a strong political commitment to addressing HIV. The first response was the establishment of the National AIDS Council by an Act of Parliament in 1997 (No.30 of 1997) which moved to the Prime Minister’s Department in 2005, followed by the National Medium Term Plan (1998–2002) based on a broad multi-sectoral approach that led to the establishment of HIV control committees in every province around the country [103]. Also in 2000, Papua New Guinea was one of the 189 member states that adopted the Millennium Declaration and, in doing so, committed itself to the achievement of the Millennium Development Goals (MDGs) 4. The aspirations that underscore the MDGs are consistent with the development values enshrined in the Constitution of Papua New Guinea [104].

The mid-term review of PNG’s national response to HIV/AIDS by UNAIDS/USAID team in December 2002 highlighted a number of areas that required urgent attention. These included a focus on populations at risk such as FSWs and their sexual partners. This, in addition to collaborative efforts among the National AIDS Council Secretariat (NACS) and UN agencies at the national level, serves as a positive step to responding to

4 A set of eight goals and associated targets to achieve poverty alleviation, fighting disease epidemics such as AIDS, and developing a global partnership for development by 2015, which found their origin in the United Nations Millennium Summit. http://www.un.org/millenniumgoals/bkgd.shtml

- 49 - the epidemic [46, 103-105]. Furthermore, the Parliament approved the HIV/AIDS management and a more recent concrete strategic plan, the Prevention Act in 2003, prohibiting discrimination on the basis of HIV infection, and the key guiding document, the National Strategic Plan on HIV/AIDS (2006–2010) [46, 103-105].

The Medium Term Plan (MTP) provided the following priority program areas:

• Transmission prevention and improvement of sexual health status • Reduction of impact through treatment, care and support • Creation of a supportive legal and ethical environment in which human rights are upheld • Minimisation of social and economic consequences • Strengthening of national capacity to respond to the epidemic.

While there are limitations with the HIV/AIDS National Medium Term Plan, overall it showed that the PNG government acknowledges HIV/AIDS as a crucial public health issue [46]. The National AIDS Council (NAC) has since taken the lead in responding to the HIV epidemic [46]. In addition, the NDOH has also implemented sexual health and HIV/AIDS prevention projects in selected areas of the entire country [46, 103-105]. The Australian Agency for International Development (AusAID) — the Australian government overseas aid program — continues to provide technical assistance to the NDOH through several HIV support projects. The European Union has committed some US 3.5 million dollars towards HIV activities over a number of years [46, 103-105]. The Papua New Guinea Institute of Medical Research (PNGIMR) continues to undertake a number of operational research in HIV [46, 103-105]. The Provincial AIDS Committees (PAC) is mandated to take the lead in HIV program implementation in the provinces [46]. The National AIDS Council Secretariat (NACS) has a resource centre filled with documents and information, education and communication (IEC) materials accessible to the public [46]. The Health Promotion Section of the NDOH also has produced a large amount of IEC materials relevant to HIV/AIDS [46, 103-105].

- 50 - A Challenges and opportunities

Though some progress has been made, to some extent HIV remains stigmatised and few persons disclose their status [46, 47]. Political will has intensified but budgetary issues remain a problem [46, 47]. That said, the MTP adds strength to government agencies at national and provincial levels [46]. The PNG IMR, a statutory body under the Ministry of Health, serves a strong operational research unit. With the new leadership of NACS and agreement from the NDOH, massive opportunities exist to build up civil society actors [46, 47]. This model of government and non-government agency collaboration has reportedly been successful in countries as diverse as Cambodia, Thailand, India and Uganda [47].

Currently, the environmental movement all over the country has created an active presence of several NGOs, demonstrating that such social development can occur [46, 47]. Whilst prevention strategies appeared to be directed at the population at large, the MTP in December 2002 has clearly identified FSWs as a priority area that requires urgent attention. This means that opportunity exists to intensify prevention activities involving this group. Lessons learned and programmatic experiences have demonstrated that through successful government and non-government agency collaborated programs, the feasibility of reducing HIV vulnerability, transmission and impacts in FSWs is more likely [76, 78].

Evidence also indicates that in settings where FSWs are able to assert control over their working environments, insist on safer sex practices and have access to testing and treatment services, HIV risk and vulnerability can be averted or reduced [76, 78]. Some examples of such successful HIV prevention programs for FSWs include: AVAHAN (India), Clinque de Confiance (Cote d’Ivoire), CONASIDA (Mexico), DAVIDA (Brazil), Durjoy Nari Shango (Bangladesh), EMPOWER (Thailand), FIMIZORE (Madagascar), Durbar Mahila Samanwaya Committee (India), SWING (Thailand) and TAMPEP (Europe) [78]. These sex work programs and settings have served as excellent venues for HIV prevention programs. While in PNG one similar program occurred many years ago (Transex project) [74], FSWs will benefit from more programs with a

- 51 - focus on sustaining safer sex practices, improving access to STI services, addressing societal stigma and working with the sexual networks of this group [76].

1.6 The way forward for FSWs in PNG — based on UNAIDS recommendations

The following section is based on UNAIDS and does not represent my original thought; however, it is important for the context of this thesis. Whilst contextualisation and learning from successful programs are important, effective HIV policies, ample operational research and evidence-based program interventions are needed to reduce HIV vulnerability in FSWs; without which the opportunity to address HIV adequately would be missed [76, 106]. Although it is important to focus on the so called “obvious” needs of FSWs, which primarily entails access to and promotion of condoms, national policies and program interventions must begin to address contextual factors that contribute to the demand for paid sex, barriers to safer sex practices and barriers to adequate HIV/STI service access [38, 76, 78, 106-109]. Of the utmost importance, sound evidence-based measures that address HIV in the context of sex work in PNG must form an integral component of the response which also underpins the overall national HIV control. Based on the available data on FSWs and HIV vulnerability, effective response must rest on three main areas which include: (1) the creation of supportive environments and partnerships that facilitate access to needed services, including life choices and occupational alternatives to sex work [76, 78]; (2) access to HIV prevention, adequate STI management and other support services [76, 78]; and (3) actions that address contextual factors or structural issues that increase HIV vulnerability and sex work [76, 78, 110].

A Area 1. Build supportive environments, strengthen partnerships & expand choices

Lessons learned from around the world show that in enabling environments that have non-judgmental attitudes towards sex work and have user friendly policies and legislations, FSWs have more control over their lives and, as a result, HIV incidence is relatively low [78, 100, 111, 112]. This means the PNG government, HIV stakeholders and all relevant community members (Figure 1.17) must work together towards

- 52 - addressing the underlying prejudices and inequalities that exist within the society toward FSWs [76]. An attitude of tolerance towards FSWs will help create a supportive and enabling environment shown to significantly reduce HIV incidence in this group [74, 78].

Figure 1.17. UNFPA/WVI Project: signing of a MOU with the dean, School of Medicine and Health Science (UPNG) for research partnership

Recommendations — Area 1:

A.1 Stigma and discrimination

Sex work is highly stigmatised in PNG and, as a result, most FSWs face a degree of stigma and discrimination [6, 16, 74]. As legitimate citizens, all FSWs must have the rights to participate equally in economic, cultural, political or social aspects and aspirations of life without fear, discrimination or marginalisation [76]. Promoting a

- 53 - supportive environment and strengthening partnerships across all relevant stakeholders including community members at large can help reduce the stigma and discrimination that FSWs face (Figure 1.18) [113]. Appropriate national policies must spearhead the process with HIV programs playing crucial roles in helping communities to identify and change stigmatising attitudes towards sex work [76]. Significant impacts can be achieved through targeted interventions on social inclusion, attitude of tolerance and capacity-building on sensitisation [76, 78]. Groups including health care providers, law enforcement agencies, the judiciary, social welfare agencies, women’s groups and community/opinion/religious leaders and the like must be specifically targeted [114- 116].

A.2 Partnerships and coordination

Effective HIV programming entails several components that require several stakeholders at different levels with different targeted interventions. This shows that inter-organisational partnerships at national, provincial and local levels is crucial and forms an integral part of the effective response to the HIV epidemic associated with sex work [76, 78]. This means that partnerships across all relevant stakeholders at the national, provincial and local levels, including all coordinating structures between the law enforcement, health, other government sectors, civil societies, community groups and FSWs themselves, must be strengthened (Figure 1.18) [78, 117]. In doing so, the partnership is able to work together towards removing barriers that exist to service access and program participation [74, 76, 113]. Such efforts can also drive and reinforce the implementation of supportive policies, laws and programs tailored to the needs of FSWs [78].

- 54 - Figure 1.18. UNFPA/WVI Project: synergy with ICRAF — the advocacy group for social, legal and human rights representation of SWs in POM

However to increase support for and the success of HIV interventions directed at FSWs, greater impact would be made if education efforts and advocacy roles that are culturally sensitive are developed and directed towards groups such as opinion leaders, religious leaders, law enforcement agencies and other relevant groups at the community level [74, 78, 113].

- 55 - Figure 1.19. UNFPA/WVI Project: partnerships and multisectoral approaches among civil societies in POM

WVI and YWCA signing a MOU for SWs project participa tion WVI and ICRAF signing a MOU for SWs project partici pation

WVI and Hope Worldwide signing a MOU for SWs project participation WVI and NCD Health Service signing a MOU for SWs project participation

- 56 - A.3 Supportive environments

Environments that support wellbeing goals created through concrete community actions in setting priorities, making decisions, planning and implementing strategies, yield sustainable outcomes [76]. At the heart of this process are the full consultation, participation and empowerment with the aim of the target population taking ownership and control of their own endeavours [74, 78, 102, 118]. This means that to attain sustainable outcomes with FSWs in PNG, the environment must be conducive to encourage full service access, participation and ownership through removing contextual barriers including stigma and discriminatory practices (Figure 1.20) [113].

Figure 1.20. Peaceful protest march addressing violence against women involving FSWs & civil societies in Port Moresby

- 57 -

- 58 -

- 59 - It also means that national policy and HIV interventions must be developed to empower FSWs to take control of their own development [76, 78, 108, 109, 119, 120]. All FSW related programs must incorporate the full participation of FSWs in the designing, implementation, monitoring and evaluation processes based on the fact that HIV efforts will be ineffective without the active participation of this group (Figure 1.21) [74, 76, 78].

Capacity-building of FSWs, the fundamental commitment and cornerstone of empowerment, cannot be disregarded [76]. Female sex workers must be adequately trained and equipped with specific expertise such as peer education skills so as to

Figure 1.21. WVI staff members, FSWs, clients and regular sexual partners working together in POM.

communicate and share good practices effectively with their peers, stakeholders and community members including the government (Figure 1.22) [76, 78]. This is because trained FSWs, together with civil societies working with sex workers (Figure 1.23), can play a crucial role in providing support for FSWs who may be difficult for mainstream

- 60 - providers to reach, including those working underground and those in informal sex work settings [109].

Figure 1.22. Selected FSWs and RSPs attending peer education training in POM

Figure 1.23. UNFPA/WVI Project: partnersip with Stop AIDS Inc. for training and graduation of FSWs and RSPs in peer education

- 61 - A.4 Expanding choices

All adult FSWs must have the right to determine whether to remain in or leave the sex industry [76]. This means that national policies and programs must be designed to support FSWs to acquire life, education, vocational skills and training they require to have alternative choices to sex work and make informed decisions [101, 102, 108, 109, 121, 122]. Programs working with FSWs must have in place a comprehensive package of services to facilitate expanding choices that include:

Meaningful alternative employment and livelihood opportunities through avenues such as income generation activities (IGA), microfinance and assistance in obtaining economic empowerment as a means to reducing unsafe sex [101, 102, 120]. Education for life, including literacy classes, vocational and life skills training [78, 101, 102, 120].

Figure 1.24. UNFPA/WVI Project: partnership with YWCA for training and graduation of FSWs in income generation and life skill activities

- 62 -

- 63 -

- 64 -

- 65 - Partnerships between local authorities, civil societies and HIV programs can help FSWs tap into micro-credit and microfinance schemes available that focus on providing economic opportunities to alleviate poverty (Figure 1.24) among girls and women [84, 101, 102, 106, 108, 109, 114, 121-124].

B Area 2. Improve access to adequate HIV prevention, STI management and support services

The provision of adequate HIV/STI prevention, treatment and ongoing support for FSWs has been shown to be cost effective in a number of programs [76, 110, 244]. This means that these services must be scaled up, made user friendly and tailored to the needs of FSWs in PNG. In addition, lessons learned from around the world have shown that in programs where FSWs have sufficiently demonstrated their willingness to participate and become active players, such programs are very successful [74, 78, 125- 127]. This means that the provision of these services in PNG must engage the full participation of FSWs. Furthermore, where health and social services adapted to the local contexts are provided and FSWs have actively engaged in these efforts, HIV incidence has declined significantly [125, 128]. Programs focused on FSWs in PNG must learn and adopt such models.

Actions must include:

Actions that address structural/contextual barriers including policies, legislation and cultural practices that prevent adequate access and utilisation of HIV/STI prevention and treatment services [106]; Policies and programs that effectively address social stigma and discrimination [113]; Improved access to HIV/STI prevention and treatment services [76, 78, 113, 126]; Improved service coverage through such means as mobile clinics, health patrol teams, health outreach workers, trained peer educators and the like [74, 78, 126]; Integrated prevention services across all relevant stakeholders including sexual and reproductive health services, alcohol and drug-related harm reduction programs and social/legal support mechanisms [76]; Encouraging full participation of FSWs for whom HIV/STI prevention, treatment and support programs are planned — this is critical for program impact [78, 125].

- 66 - Effective delivery of these services requires concerted and coordinated efforts by a range of stakeholders who operate at different levels. This means that a central body is required to convene and facilitate the collaboration of all relevant players to ensure the delivery of these coordinated actions and services. The central body must promote and strengthen the planning and delivery of these activities on the scale required to achieve adequate access and support of FSWs.

Recommendations — Area 2:

B.1 Removing structural/contextual barriers to access

In PNG, FSWs face barriers to accessing HIV/STI prevention and treatment support services partly because sex work is illegal and socially unacceptable [6, 16]. Ensuring that FSWs have adequate access to these essential services requires concerted efforts and a shift in societal attitudes to overcoming structural/contextual factors that impede access and participation [106, 108, 109, 119, 129]. This means that social stigma and discrimination must be swiftly addressed and barriers to participation assessed [38, 106, 113, 130]. It must be acknowledged however that achieving changes in this area is less likely to occur in the short-term, yet it is essential to implement reforms required now in order to achieve long-term sustainable outcomes [106, 108].

B.2 Information and education

Female sex workers in PNG are poorly educated and, in addition, not all FSWs are adequately informed about HIV, particularly STIs [16, 80, 106, 114, 131]. This means that efforts must be made to improve access to ongoing HIV/STI information to this group in a range of environments, bearing mind that FSWs solicit their clients at formal and informal sex work settings [16, 46, 55, 58, 107]. It also means that the information and education programs must not only focus on the basics about HIV risk and prevention, but also cover a range of STIs (Figure 1.25), sexual health and treatment, human rights, self esteem building, obligations, responsibilities and mutual decision making, mutual negotiated safety and collective action (Figure 1.26)

- 67 - Figure 1.25. A health extension officer of WVI disseminating STI information via outreach

[76, 78]. Effective approaches therefore require coordinated use of diverse methods and must include a combination of peer outreach and education, facility-based counselling, print materials and mass media activities that are age-specific, gender-responsive, scientifically accurate, locally sensitive and culturally appropriate [76, 78]. These approaches can greatly improve and sustain the knowledge base of FSWs.

B.3 Adequate/effective services

All HIV/STI prevention, treatment, testing (Figure 1.27) and relevant related social services must be available and acceptable at locations and hours that will encourage full participation of FSWs. This means that integrated services must be in place to increase the number of entry points and expand coverage [76]. These services must not only address the needs of FSWs but must also correspond to the specific needs of their clients and regular sexual partners, who are often overlooked under most circumstances [73, 76, 107, 132-134]. It also means that the overall service and standard of care must be adequate and reflect virtues such as respect for and confidentiality of FSWs [76].

- 68 - To increase participation of FSWs, the provision of services must be sufficiently flexible and also address the diverse needs of FSWs, taking into consideration the physical, social, legal and local context in which sex is sold [76]. It is common knowledge that not all women who sell sex would like to identify themselves openly as sex workers to avoid judgmental attitudes of service providers and community members alike [16, 135]. This means that desensitisation strategies are crucial across all relevant stakeholders if HIV is to be effectively addressed in FSWs [76]. Female sex workers who are also drug users will require additional support including access to drug- and harm-reduction programs [78, 113, 130, 132]. Service providers must incorporate a range of referral protocols to assist those who might require these services.

B.4 Preventive commodities

Condoms are the single most effective available means to reduce the sexual transmission of HIV and other sexually transmitted infections [73, 128, 136]. Female sex workers in Port Moresby do not lack condoms, but it must come with femidoms and water-based lubricants and the knowledge to use them correctly. More importantly, condoms and lubricants must actively reach clients, regular sexual partners and fixed- base establishments where sex workers operate [73, 78, 107, 132]. This means that, as programs aimed at reducing HIV transmission associated with sex work continue to promote condom use among FSWs, they should maximise successful promotion of condom use through risk minimisation strategies for clients and the regular sexual partners of FSWs [73, 78, 107, 132]. It also means prevention approaches must address condom use and negotiated safety equally for FSWs (Figure 1.26), their clients and regular sexual partners. For FSWs, the promotion of condom use and negotiated safety must come hand in hand with empowerment and self-efficacy strategies [106, 108, 114]. Drug and alcohol use, violence, harassment, abuse and extreme poverty, among other factors, have been reported to reduce the ability of FSWs to negotiate condom use [16, 123]. HIV policies and program interventions must address these issues to maximise the impact of condom use [108, 113].

- 69 - Figure 1.26. FSWs attending life skills, grooming and self esteem building workshop in Port Moresby

- 70 - Figure 1.27. UNFPA /WVI Project: Clients being screened and administered presumptive treatment via DOT for STIs during the Periodic Presumptive Treatment PPT Study by a health extension officer

- 71 - B.5 Linking and integrating services

Integration of HIV, sexual and reproductive health programs and allied health services can significantly reduce HIV infection [102]. This means that health care workers, including those in primary health care settings, STI public clinics, youth-focused services including programs that prevent mother-to-child HIV transmission, and community health workers must all be aware of and responsive to the specific health needs of FSWs. It also means that service linkages and integration must encompass aspects of sexual and reproductive health including STI management services (Figure 1.28) [76]. The hours of the service delivery should be flexible to improve the participation rate.

Figure 1.28. UNFPA/WVI Project: signing of a MOU with the local health sector (NCD Health Service) for partnership and outreach service coordination

B.6 Elimination of violence against female sex workers

Female sex workers can be victims of violence which is sometimes perpetrated by their clients, regular sexual partners, law enforcement agencies or ordinary members of the community [114, 116]. Violence has been documented to be associated with unprotected sex and heightens the risk of HIV transmission [116, 137]. This means a

- 72 - policy framework that protects all FSWs from violence and other forms of abuse is imperative in HIV control [76]. Experience shows that violence towards FSWs can be reduced when law enforcement agencies, the judiciary, health services, community women’s groups and other arms of government are engaged and cooperate fully with FSWs and other civil society groups to address the matter (Figure 1.20) [74, 108, 114- 116, 130].

B.7 Clients and regular sexual partners

Clients and regular sexual partners of FSWs reflect a cross-section of the population [16, 107]. The fact that they are not easily visible but form a potential bridge to transmitting HIV to the general community and are often overlooked in prevention programs presents a serious problem [107, 134, 138]. This means that HIV programs must endeavour to identify these men and involve them in prevention activities. It is crucial that HIV information and other relevant services are accessible to them as well. Like FSWs, specific education campaigns and behaviour change strategies must be developed with and for these men, some of whom can be reached at sex work settings, at certain occupational sites and through specific “men-focused” organisations within the community [46, 76, 107, 134, 138]. In PNG, prevention interventions for clients and regular sexual partners can start with those in the transport industries, seafarers, street vendors, farmers, and men in mining and infrastructure projects including those separated from their families for long periods, and those in law enforcement agencies as indicated by FSWs [16, 39, 46, 55, 58].

In developing strategies to reach these men by program planners, FSWs must be engaged as they can help identify settings where these men can be reached [107]. Programs can then reach them with messages about safer sex, condom use, service- seeking behaviours and risk reduction strategies as well as incorporating strategies that promote respect for FSWs, shared responsibility for protective behaviour and zero tolerance for abuse or intimidation [76, 78, 108, 113, 115, 116, 133]. Reaching the spouses and regular partners of these men can play an important role in effective HIV prevention. This means that prevention strategies must go a step further to reach these

- 73 - groups (spouses, wives, girlfriends, etc.) using entry points such as referral services for women and sexual and reproductive health services [76, 78, 133].

C Area 3. Address contextual factors and structural issues that increase vulnerability

Although evidence linking contextual factors to HIV vulnerability is limited, there is wide recognition of factors such as gender inequality, discrimination and social exclusion contributing to HIV vulnerability [16, 30, 75, 102]. And together with poverty and mobility, they have lead to increased sex work and HIV risk in several developing countries [20, 29, 123]. This shows that prevention efforts will not succeed in the long- term unless the underlying drivers of HIV are effectively addressed, and therefore must form a crucial component of a comprehensive strategy [108]. It means that national HIV policy must begin to address the underlying factors that heighten HIV vulnerability in FSWs [84, 106].

Actions must include: Policies and program interventions that address gender inequality, poverty, stigma and discrimination [108, 113, 139]; Efforts to invest in the education of females that is supported by policies mandating universal primary and secondary education for all women and girls [121]; Evidence-based programs that forge norms of gender equity with particular attention focused on men and boys [76]; Prioritising strategies that increase women’s economic independence and legal reforms that recognise and promote women’s rights [106, 114].

Many FSWs in PNG become involved in sex work while young [16, 93]. With the poorest FSWs in the rural areas with limited life choices or occupational alternatives, economic migration to the urban centres to assume responsibility for contributing to family income is common [16, 20]. Measures must be put in place to prevent children and young females compelled by deplorable conditions from entering into sex work [76]. The government must ensure that educational and occupational opportunities are available for this group whilst at the same time addressing issues that drive economic migration. While addressing contextual and structural determinants of HIV may seem

- 74 - inevitably challenging, all efforts that seek to address these factors and determinants must be promoted and encouraged [108]. Often it is argued that structural interventions can be time consuming and divert resources from immediate HIV control priorities to long-term ones [76]. While this may be true, it must be stressed however that the epidemic will not be averted, nor will progress on HIV be sustained unless comprehensive actions are taken to address all factors that increase HIV vulnerability [108] .

Recommendations — Area 3:

C.1 Gender equality, gender norms and relations

Gender inequality has been shown to be associated with many females entering into sex work and, in many settings, most sex workers are women or girls [131]. This is attributed to limited access to education, limited employment opportunities and in some cases, financial support outside marriage women and girls face [16, 29, 123, 131]. Without jobs and financial support, often women and girls see sex work as one of the few options available to them. Such economic pressures are compounded for females whose husbands have died or abandoned them, or otherwise bear the primary burden of supporting their families [16, 76]. Furthermore, denial, ignorance and taboos associated with sex, sexuality and sex work impede effective programming on HIV and sex work [16, 76, 84, 135].

This means that to minimise the harmful effects that societal norms about masculinity and gender often portray, effective and sustainable measures that forge norms of gender equity must be brought to scale [139]. Hence new programs must be implemented with particular attention directed on men and boys, with a focus on critical dialogue regarding gender inequalities concerning sexuality, relationships and cultural norms and harmful practices that place women in disadvantaged positions [108, 109, 139]. Specifically, the programs must address unequal access of women and girls to social, legal and political rights [76]. At the heart of this are structural measures such as national policy reform that address the norms and factors that increase paid sex and female-related vulnerability [108, 109, 119]. Religious leaders, educators, lobbyists,

- 75 - women’s groups and other community leaders can play crucial roles here and must be identified and mobilised to act as drivers for positive change (Figure 1.20) [76]. Such programs have been shown to significantly reduce the support for inequitable gender norms and practices, decrease sexual violence and increase condom use and reduce the rate of new HIV infections as reported in Thailand [76].

C.2 Address poverty and limited economic options

No human being should be compelled to enter into sex work as a result of insecurity, poverty or coercion, although this is a common observation in most resource constraint settings [76]. Since economic inequality is associated with HIV vulnerability, laws and policies that empower women and increase access to education are crucial [84, 108, 121, 124, 135]. This means strategies that expand educational, economic and social opportunities, especially for women and girls, are an urgent necessity [84, 108, 121, 124, 135]. More importantly, programs that extend access to livelihood skills, vocational training, micro-credit schemes and those that create local employment opportunities for women and girls are vital and must be funded [84, 106, 108, 123, 124]. The programs must be developed in areas where sex work is active.

Providing women and girls with opportunities for greater ownership and control over economic assets will empower them to make healthier choices about their future and mitigate economic factors that compel them to sell sex and do so under unsafe conditions [76, 78].

C.3 Promote education for all

Education is critical to HIV prevention, treatment, and support including mitigating the effects of HIV [121]. Education expands choices, reduces risky behaviours, diminishes stigma and discrimination and promotes self reliance and resilience [121, 122]. Education contributes to the reduction of poverty, elimination of gender inequalities and provides life opportunities apart from sex work [121, 122]. It also fosters economic independence and delayed marriage [121, 122]. While there has been steady progress towards the global goal of “education for all”, significant gaps remain in PNG with a significant number of girls not enrolled in formal education [2, 8, 9]. It is essential that

- 76 - educational opportunities are expanded to meet the needs of girls and females as ascribed in MDG that PNG is a state member [104].

Conclusion about way forward

Fundamental to reducing HIV risk and vulnerability is enhancing access to HIV/STI prevention, treatment, and support services [76]. Comprehensive programs on HIV and sex work are critical to the success of the HIV response [78]. Working in partnership with FSWs to identify their needs and to advocate for policies and programs that improve their health, safety and engagement in the HIV response is a proven strategy and an essential feature of a successful approach [76, 78].

Alongside the epidemic of HIV is the epidemic of stigma and discrimination, gender- based violence and other critical human rights violations such as unequal access to education and employment on the basis of gender in many resource constrained settings [113-116, 123, 130, 131]. Women’s rights are human rights, and progress for women is progress for all. Therefore, efforts that address these issues are essential to the success of approaches to HIV and sex work.

HIV and sex work is a complex issue and needs to be well understood. The delivery of effective services for FSWs often encounters barriers and resistance that reflect complex and longstanding cultural, structural and social factors [108, 140]. While these barriers will not be overcome overnight, or with ease, delaying action to address them will only continue to undermine the effective HIV response in PNG. Through honest dialogue and evidence-based interventions, sustained progress can be achieved [76, 106, 110, 135].

- 77 - 1.7 The many “faces” of prostitution: “sex work”

A fundamental part of identifying the pragmatic solutions to HIV transmission is the understanding of how sex work is perceived within specific communities. This section does not attempt to provide an in-depth critique or analysis of published literature on the different views of sex work. However, considering the integral context and reading of this thesis, I have provided a brief overview of sex work and thus formulated a series of ways that sex work can be perceived. The following references have contributed to these views and are explained below [141-143]. The views include:

• the radical feminist/abolitionist view • the commodification of women view • the libertarian feminist view • the romantic view • the materialist feminist view • the strain and stress view • the control view • the religious moralist view • an expression of patriarchal oppression view • the labelling view • the chauvinist view • the functionalist view • the violence against women view • the sex worker rights activist view • the harm reductionist view

Prostitution, commodified sexual relations or “sex work” as commonly referred to in the public health arena, is one of the most debated topics since the advent of the HIV pendemic.

Radical feminists demand the abolition of sex work,

Christians decry the moral degeneration it epitomises,

and civil libertarians say it is a free world "let 'em do what they want".

- 78 - Sex work is believed to be one of the “oldest professions” in the world dating back over thousands of years [141, 143]. It has neither been totally accepted nor condemned. Across different cultures today, the perception of the “oldest profession” varies widely. While some perceive sex work as a form of work and for some an inevitable means of economic survival, some perceive it as exploitation or degradation of women, while others perceive it as a social problem or social deviance [141-143]. Several theories have tried to analyse sex work; although there are no obvious distictions between them, they help bring a much broader perspective on the topic [141-143]. Perhaps understanding them may help contribute to pragmatic HIV programming decisions, thus leading to targeted responses in this group in specific contexts. Below, I have tried to bring to the fore some of the various views on sex work.

A Sex work: the radical feminist/abolitionist view

The radical feminists believe that sex work reinforces and perpetuates the objectification, subordination and exploitation of women which is necessary to maintain the patriarchy and therefore an oppression of women [141, 142]. From their point of view, sex work is nothing short of a sexual abuse and they advocate it must be eradicated by all means necessary. They go on to say that sex work is inherently violent, abusive, harmful and it violates women's human rights [141]. The radical feminists view women in sex work as "victims" and men as "abusers." More than any group, they have raised awareness about the perils of sex work, its link to trafficking, and the post- traumatic legacy that "survivors" often endure [141]. To this group, there is no reforming of the sex trade; it must be wiped out and they strongly advocate that women and girls must be "rescued" from the repugnant trade [141].

B Sex work: the commodification of women view

Here, sex work is viewed as the purchase of a woman’s body for sexual use and therefore commodification of women and their sexuality [142]. From this perspective, sex work produces nothing but a commodity which is the sexuality of the sex worker [142]. Sex work is viewed to steer sexual relations away from the sphere of mutual pleasure and into the domain of the market. It also fosters the notion that better sex can

- 79 - be bought for more money; an inclination that sex is a service which women provide for men either for favours, ongoing economic commitment or hard cash, thus transforming male sexual attitude in to one that views women as objects for sexual pleasure [142].

C Sex work: the libertarian feminist view

Libertarian feminists believe sex work epitomises individual autonomy, rights, liberty, independence and diversity [141-143]. They view sex work as a legitimate choice of work without any emotional attachment and advocate that women should be allowed to make money in whatever way they choose [141-143]. For this group, commodified sexual relations between two consenting adults is no crime and they believe policy makers must not interfere in the "private" realm of non-coercive sex [141-143].

D Sex work: the romantic view

The romantics believe in individual rights to sexual freedom and choices. They view sex work as a field in which women can express their aggressive or "transgressive" sexual feelings [143]. This group is all in favour of the actions and behaviours women demonstrate in their sexual choices, their strategies with men, and their stubborn refusal to abide by "polite" social conventions. From their point of view, men who purchase sex are dupes in the hands of savvy sex workers who manipulate male desires for their own financial gain [143]. Romantics use striking semantics such as "independent" women to wage war against what they call “petty” and helpless images perpetuated by abolitionists [143].

E Sex work: the materialist feminist view

The materialist feminists believe that the objective conditions in which women live define their oppression [142]. This group views sex work as a response to poverty and a particular exploitation of women analogous to the more general sex work of all who sell their labour [142]. They maintain sex work should be legal but heavily regulated.

- 80 - F Sex work: the strain and stress view

Those of the strain view believe that sex work is caused by stress [144]; stress in this sense is “poverty”. They strongly believe a sex worker feels this stress because she is poor; therefore, not satisfied with her own existence and is distraught because of the current state she finds herself in, and thus is compelled to improve upon her well-being. Because she is poverty-stricken and most likely uneducated, she feels she has no other way to sufficiently provide for herself and family other than succumbing to sex work [144]. The stress caused by extreme poverty gives her the power to excuse the feeling of deviance and immorality from her actions [144].

G Sex work: the control view

From the control view, sex work is common in today’s society because of the lack of opportunities that poverty stricken people have [144]. The group is of the view that if more jobs and more opportunities were available for the poor and lower class, sex work would be less evident in the world today. They fairly and squarely attribute sex work to lack of opportunities and insufficiency of employment to the point that some people have no other option than to give in to sex work so as to create a better life for themselves [144].

H Sex work: the religious moralist view

The religious moralists view sex work as sin, a pollution of one's body and an abuse of the "God-given gift" of sexuality [141, 143]. They argue that uncontrolled sexual expression — especially that of females — goes against God's design of sex within the bounds of marriage. They simply deem sex work an abomination to God [141, 143].

I Sex work: an expression of patriarchal oppression view

This theory believes patriarchal society was developed to serve the needs of capitalism by the appropriation of female labour for the sustenance of the male worker, and the passing of private property down through a male lineage [142, 143]. The maintenance of patriarchal society is thus fundamental in supporting capitalism. They are of the view that prostitution allows men to assert their power over women in a manner which is

- 81 - unacceptable in any other sphere [142]. Despite rising female power in many industries, the existence of an industry in which women are always subordinate reinforces the illusion of male privilege [142, 143]. The existence of prostitution oppresses women in a more general sense than the oppression and dominance asserted with each individual act — it sustains an attitude that women are sexual objects for sale or hire [142, 143].

Many common female insults imply the sale of sex, reinforcing the concept of prostitution as a threat to keep women in their place [142]. The patriarchal family is based on the notion of monogamy. The transfer of private property through the generations requires assured paternity, thus limiting the wife’s sexuality [142]. Prostitution, as opposed to consensual extra-martial affairs, ensures that the financial obligations to any offspring are negated, maintaining the “proper” transfer of property [142]. They promote the status quo, which places the burden of social stigma and legal vulnerability on female sex workers [142, 143]. Few explicitly claim that men deserve more rights than women, but their promotion of current legal standards reinforces a tradition of gender bias [142, 143].

J Sex work: the labelling view

This view argues that a person will simply accept who he or she is as determined by society, and continue on without refusal [144]. According to this view, the label one is given becomes part of ones concept, which then leads towards or steers one away from deviance [144]. Therefore, if a person is labelled as a sex worker by society, from a labelling theory point of view, she will consider herself as such because of the label society has given her [144].

K Sex work: the chauvinist view

The chauvinists argue that "boys will be boys”, that the male sexual urges are natural and inevitable, and that they need outlets for their passions, including sex work [143]. This view comes through from the so-called cultural traditionalists through the masculinist’s forms of popular culture. Cultural traditionalists place the responsibility of sexual moral integrity on females, relieving men of any responsibility for their sexual actions [143]. From this point of view, women are deemed the moral bedrock of the

- 82 - community, of morality, of domesticity and of family. Traditionalists leave women to face public shame and reproach while men are praised for going about their "natural" ways [143].

L Sex work: the functionalist view

This view argues that sex work flourishes because it satisfies sexual needs that are not able to be met elsewhere [144]. From this viewpoint, sex workers serve as an outlet for sexually frustrated men. Those of this perception believe that when a man is unable to find a secured sexual partner, he always holds the option of paying for sexual pleasure. Functionalists are of the view that sex workers provide a sexual outlet for men who have difficulty in establishing sexual relationships, cannot find long-term partners, have a broken relationship, want sexual gratification that is defined as immoral, desire quick sexual gratification without attachment, are curious, and/or are sexually dissatisfied in marriage [144]. They therefore argue that sex work serves as a form of social control over sexual behaviour and thus beneficial because it brings men with sexual desires away from unwilling partners to partners that are willing, but for a certain price. Sex workers meet the needs of men who otherwise do not have women always available to satisfy their sexual urges [144].

M Sex work: the violence against women view

From this point of view, sex workers are often perceived as victims of physical harm, violence, psychological and sexuality damage [141-143]. Those of this view go on to say that sex workers are by and large poor; they often opt for sex work as a career when other means of economic survival are eroded. They therefore believe sex work eroticises economic power, and the thrill of being able to purchase sex is a driver for many of those who use sex workers [141-144]. They argue that economic coercion to sell sex is a violation of women’s integrity and can only be understood within the continuing economic discrimination against women [141-144]. In PNG for instance, the average age of entry to sex work is 12 years old — and it is mainly driven by economic deprivation [16]. When those who are drawn in are children and those who wish to exit

- 83 - cannot, the deprivation of liberty and freedom is all too clear. Each contract is not a freely chosen pursuit but an expression of captivity [141-144].

N Sex work: the sex worker rights activist view

Sex worker rights activists believe that sex work should be decriminalised and reformed into a legitimate trade [141-143]. They are of the view that sex workers should be guaranteed adequate rights and protections [141-143]. These activists borrow metaphors from the trade union movement such as: women are to "organise" as sex "workers" in the sex "industry" and have women "represent" their needs to official structures [143]. From this perspective, sex workers ought to be able to count on the rule of law, legal protection, access to health care and be treated like any other labourer in a legal workforce [143].

O Sex work: the harm reductionist view

Harm reductionists take a pragmatic interest in the safety and health of sex workers. They believe that, given the general ineffectiveness of policing or regulation of sex work, society should guarantee that the women can at least operate without fear of harm, disease, abuse or treachery [143]. As many sectors of sex work expose women to high levels of violence and viral risk, the reductionists believe sex workers’ protection and empowerment is a crucial first step in addressing their needs including HIV/STI prevention [141, 143]. To the extent that societies recognise the vulnerability that sex workers face from clients, police, pimps and other locals, reductionists believe there is the need to at least keep sex workers safe from foreseeable harm. As these positions illustrate, feminist positions are far from stagnant positions, inflexibility and rigidity; however, they all recognise the vulnerability of the women in the trade. Their differences revolve around strategies for empowering them [143].

Conclusion

Considering the various viewpoints, some may argue that sex workers are victims of society while others may argue otherwise. Although this may be the case, one cannot help but sympathise with certain aspects of the viewpoints considering the sheer

- 84 - diversity of their descriptions, issues and contexts. Some caution must therefore be exercised in asserting one-size-fits-all recommendations for all sex workers. The sex industry is too diverse for one-size–fits-all solutions [143].

In Papua New Guinea, sex work is not illegal per se, however under the “Criminal Code” Section 218, it is a crime to live off the earnings of sex work, or to keep a brothel or to buy sex. Prostitution is dealt with under the Summary Offences Act passed by the National Court: the legislation that adjudicates sex work [6]. If convicted, the offences are imprisonable and few women have been prosecuted and imprisoned for it [6]. The police are the most outstanding power brokers who ensure that the legislation is enforced [6, 16].

Understanding the distinctions between the views and what is at stake in specific contexts can help programmers better communicate the best way forward. Perhaps a simple appreciation of the various viewpoints may allow decision makers to better determine whether to abolish, maintain, reform, decriminalise, regulate or embellish sex work [143].

- 85 -

CHAPTER 2

A SYSTEMATIC REVIEW OF STUDIES ASSESSING RISKS OF SEXUALLY ACQUIRED HIV AMONG FEMALE SEX WORKERS IN PAPUA NEW GUINEA SINCE 1980:

A LITERATURE REVIEW

- 86 - 2.1 Co-authors and citation

Mathias Sapuri, Louise A. Keogh, John M. Kaldor, Christopher K. Fairley. Submitted to Asia Pacific Journal of Public Health — 20/11/09

2.2 Abstract

Background: In resource constrained settings where heterosexual contact is the most common mode of human immunodeficiency virus (HIV) acquisition and transmission, often women in sex work are among those at greatest risk. Objective: This paper reviews published and unpublished studies of the risks for sexually acquired HIV among female sex workers (FSWs) in Papua New Guinea (PNG). Methods: We electronically searched “all databases in the ISI web of knowledge” in March 2009 for studies published between 1980 and 2008 using the keywords: “sex workers” and “PNG”. We also searched for unpublished studies from International Aid Agencies. Results: Seven studies, five published and two unpublished, met the inclusion criteria. Risks for acquiring HIV among FSWs included inconsistent condom use with clients (range: 0–63%) and regular sexual partners (range: 0–34%) and high rates of sexually transmitted infections (STIs). Condom use has increased over time. The four most common STIs in FSWs were Trichomonas (range: 21–56%), Neisseria gonorrhea (range: 20–39%), Syphilis (range: 16–34%) and Chlamydia (range: 14–33%) and HIV was found in 3–21% of FSWs. Rates of STI remained high over the period. Conclusions: These data indicate that despite condom use rising, the rate of STIs remained high and did not appear to change over time, but the proportion with HIV rose. The suboptimal condom use, high rates of STIs and rising HIV rates indicate currently there are inadequate control measures.

Keywords : Literature Review; Human Immunodeficiency Virus; Sexually Transmitted Infections; Risks;

Condom; Female Sex Workers; Clients; Regular Sexual Partners; Papua New Guinea .

- 87 - 2.3 Introduction

In most developing countries, sex work has played a significant role in the heterosexual transmission of the human immunodeficiency virus (HIV). In Papua New Guinea, heterosexual transmission is the primary mode of HIV infection [36]. Female sex workers (FSWs) may be at greater risk of acquiring HIV and therefore play a critical role in its transmission in PNG.

In 1998, a study by Mgone et al . found an HIV prevalence of 17% among 207 FSWs in Port Moresby [58], while at the same time the HIV prevalence was 0.34% among the adult population in Port Moresby, 0.37% in pregnant women and 0.19% among the adult population in the rest of the country [45]. In 2004 the prevalence of HIV nearly quadrupled in pregnant women to 1.4% [51]. More recent data indicate that the prevalence of HIV within the general population has risen nearly by seven-fold to 1.5% [52].

While documenting risks of HIV is critical for understanding the future transmission pattern in FSWs and the development of appropriate HIV intervention efforts, to date there has not been a systematic review of studies on HIV risks in FSWs. Given the critical role of FSWs in heterosexual transmission of HIV in PNG, we reviewed existing studies to document risks of HIV in FSWs to determine if some improvements in the “indicators” for sexually acquired HIV and condom use have occurred over time.

2.4 Methods

We searched “all databases in the ISI web of knowledge” electronic database in March 2009 for studies published between 1980 and 2008. We searched the database using the following key words: “sex workers” and “PNG”. We also consulted International Aid Agencies (IAA) in Port Moresby that work with FSWs and requested relevant published and unpublished studies. Of the studies we identified, we reviewed abstracts per against our inclusion criteria and included them if they were: (i) studies from Papua New Guinea; (ii) had a sample size of 50 FSWs or more; and (iii) the studies were in English (Figure 2.1). We further expanded our search by checking the references in the identified studies against our inclusion criteria.

- 88 - 2.5 Results

Using the search word “sex workers”, we identified 13,505 abstracts from “all databases in the ISI web of knowledge” and then added “Papua New Guinea”. Among these were 13 studies that contained “Papua New Guinea” that were reviewed. Of the 13 studies, five were published studies that included a sample size of FSWs more than 50, and were studies conducted in Papua New Guinea. We also identified two additional unpublished studies using a search through consultations with IAA that work with FSWs in Port Moresby (Figure 2.2). In all, seven studies (four qualitative and three quantitative) fulfilled the inclusion criteria and were selected. They were carried out between 1993 and 2005 (Table 2 .1).

In total there were 1600 FSWs from four different locations across PNG sampled between 1993 and 2005. The number of clients per FSW ranged from 1–30 per week. The rate of consistent condom use among FSWs ranged from 0–63% with clients and 0– 34% with regular sexual partners (Table 2.2), with the most recent study in 2005 reporting the highest condom use with clients at 63% and regular sexual partners at 34%. Three studies measured the prevalence of STIs including HIV in FSWs and were undertaken in 1994, 2001 and 2003. The proportion of FSWs with: Trichomonas ranged from 21–56%, N. Gonorrhea ranged from 20–39.4%, Syphilis ranged from 16–33.7% and Chlamydia ranged from 14–32.8%. The proportion of FSWs with STIs did not appear to change over time. The proportion of FSWs with HIV ranged from 0–21% with the most recent figure reaching 21% in 2004 (Table. 2.1).

- 89 - Figure 2.1. Inclusion criteria used in selecting papers on female sex workers in Papua New Guinea

Inclusion Criteria: i. Studies from Papua New Guinea

ii. Studies with a sample size of 50 FSWs or more

iii. Studies written in English

Figure 2.2. Search method used in selecting papers on female sex workers in Papua New Guinea

All databases search International aid agencies search

ISI web of knowledge in Port Moresby

“sex workers” “sex workers” n = 3 papers (unpublished ) n = 13,505 papers

Add “Papua New Guinea” Add “Papua New Guinea ”

n = 13 papers n = 2 papers

Papers with 50 or more FSWs Papers with 50 or more FSWs

between 1980–2008 between 1980–2008 n = 2 papers n = 5 papers

Papers obtained

n = 7

- 90 - Table 2.1. Summary of studies on female sex workers in Papua New Guinea — key HIV risks

Study Source Study location, dNo of Condom No Condom Condom use No Condom HIV Gonorrhea Syphilis Chlamydia Trichomonas & Date sample size & year clients/week use always use at all always with use at all positive positive positive positive positive study type & sampling or day with clients with clients RSP with RSP b Range or % % % % % % % % % Mean c

Jenkins 1994 Port Moresby, 30 /wk a5 ------(unpublished) Goroka & Lae Ethnographic/KAPB N=88 Community sampling 1993

Mgone et al. 2002 Port Moresby 3.5/wk 24.5 17 39.4 31.1 32.8 21.2 (published) N=207 & a85 a9=(15of 176) a71 Lae N=200 Quantitative Total N=407 3/wk 4.5 3 33.0 33.7 30.2 44.1 Peer mediated June1998- sampling Jan 1999

Morof et al. 2004 Goroka 0-5/wk b 7 93 3 99 - - - - - (published) N=190 KAPB Jan 1999- Peer mediated Oct 1999 sampling

Gare et al. 2005 Goroka a1-8b /wk a0 - a0 a42= 0 21 2 26 2 21 56 (published) N= 162 & (17of 40) Quantitative Kainantu N=49 a3/wk c 0 20 1 16 1 14 35 Peer mediated Total N=211 sampling Jan 2001- Aug 2002

- 91 - Study Source Study location, dNo of Condom No Condom Condom use No Condom HIV Gonorrhea Syphilis Chlamydia Trichomonas & Date sample size & year clients/week use always use at all always with use at all positive positive positive positive positive study type & sampling or day with clients with clients RSP with RSP b Range or % % % % % % % % % Mean c

Bruce et al .2009 Port Moresby 2/day c 32 - 15.2 ------(unpublished) N=79 KAPB June-July 2003 Convenience sampling

Bruce et al .2008 Port Moresby - 33.3 (pre) - 19.0 - 16.3 37.2 33.3 23.3 41.0 (published abstract) N=129 Cohort study Nov 2003 - Nomination Sept 2004 - sampling N=71 40.8(post) 30.9 21.1 22.5 19.7 15.5 29.6

Yeka et al. 2006 Port Moresby - 62.6 33.5 - - - - - (published) N=245 KAPB & Goroka N=249 31.3 16.0 Respondent Driven Total N= 494 sampling Feb – April 2005

a Combined figures for all study sites. b Range. c Mean. - =No data. d Number. N = Total sample size. RSP = Regular sexual partners. KAPB = Knowledge, attitudes, practices and behaviour.

- 92 - Table 2.2. Measurements of consistent condom use among female sex workers over time across several locations in PNG

Date Port Moresby Goroka Lae Kainantu

Clients RSP Clients RSP Clients RSP Clients RSP % % % %

1993 5a - 5a - 5a - - -

1998 24.5 5.8 - - 4.5 3.8 - -

1999 - - 7 3 - - - -

2001 - - 0 0 0 0 0 0

2003 32 15.2 ------

2003 33.3 19.0 ------

2004 40.8 30.9 ------

2005 62.6 33.5 31.3 16.0 - - - -

a Combined figures for all study sites. - No data. RSP = Regular sexual partner.

Figure 2.3. Consistent condom use among female sex workers with their clients in Papua New Guinea

Consistent condom use among FSWs with their clients in PNG 70 60

50 Port M oresby 40 Goroka Lae 30 Kainantu 20 10 0

19 19 19 20 20 20 20 20 20 20 93 98 99 00 01 02 03 03 04 05

Year and location of study

- 93 - Figure 2.4. Consistent condom use among female sex workers with their regular sexual partners

Consistent condom use among FSWs w ith their Regular Sexual Partners in PNG

40

30 Port M oresby Goroka 20 Lae Kainantu 10

0 1993 1998 1999 2000 2001 2002 2003 2003 2004 2005 Year and location of study

Figure 2.5. STI rates in female sex workers over time in PNG

STI rates FSWs in 4 locations

60

50

40 N Gonorrhea Syphilis 30 Chlamydia Trichomonas 20 & Percentatge STI 10

0 1998 POM 1998-Lae 2001-Goroka 2001-Kainantu 2003-POM Date and location of study

Three studies measured STIs and the four most common were:

Trichomonas (21-56%) N. Gonorrhea (20-39%) Syphilis (16-34%) Chlamydia (14-33%) *STI rates remain high and did not appear to change over time.

- 94 - Figure 2.6. HIV rates in female sex workers over time in PNG

HIV rates in FSWs in 4 locations

25

20

15 HIV 10

% Percentage HIV 5

0 1998 POM 1998-Lae 2001-Goroka 2001- 2003-POM 2004-POM Kainantu Date and location of study

Three studies measured HIV.

Two studies reported rates of HIV, one did not.

The proportion of FSWs with HIV ranged from 0-21%.

*HIV rate has increased over time.

2.6 Discussion

In the seven studies, we found increasing rates of consistent condom use among FSWs over the last 12 years, reaching 63% with clients and 34% with regular sexual partners in 2005 [81]. Although some improvement has occurred over time, consistent condom use remains suboptimal with both clients and regular sexual partners. We also found high rates of STIs that did not appear to change over time with most STIs present in 20% or more of FSWs. Disturbingly, the proportion of FSWs with HIV was higher in the more recent study (21% in 2004) [86]. The suboptimal condom use, high rates of STIs and suggestion of rising HIV prevalence in FSWs is of great concern and demands urgent action.

- 95 - In contrast, studies in Asian countries with gross domestic product (GDP) is similar to PNG have reported higher rates of consistent condom use among FSWs with their clients. This suggests that FSWs in Asia have lower rates of behavioural predictors of HIV compared to FSWs in PNG. For example, in Cambodia, a 1994 study by Prybyliski et al. found that 67% of 502 FSWs reported consistent condom use with their clients [145], whereas in Nepal, a 1995 study by Gurung et al. found this to be 93% [146]. Another 1997–99 study in the Philippines by Amadora-Nolasco et al. found consistent condom use to range from 37%–46% [147]. In Vietnam, a 2002 study by Trung et al. found consistent condom use at 62% [99]. In India, a more recent study by Dandona et al. 2003 found varying rates of consistent condom use at 46% of 5010 street-based FSWs, 70% of 1499 home-based FSWs and 87% of 139 brothel-based FSWs [148]. In Thailand, after the 100% condom use program was initiated [112], the rate of condom use is reported to have increased from 14% in 1989 to over 90% among FSWs according to the Ministry of Public Health, Thailand, 2000 [149].

However, studies in Africa have reported lower rates of consistent condom use among FSWs with their clients, an observation consistent with findings we identified in our review. This suggests that FSWs in Africa and PNG have similar and higher rates of behavioural predictors of HIV. For example, in 1991 a study in South Africa by Abdool-Karim et al. found that 15% of FSWs reported consistent condom use [150]. In Kinshasa, Zaire, Mann et al. found that only 2% of 377 FSWs (of which 27% were HIV positive) reported consistent condom use [151], whilst in Kenya, an intervention-linked study that was conducted between 1990 and 1993 by Fischbacher et al. found that 23% of 135 FSWs reported consistent condom use [152].

In addition, the overall patterns of condom use among FSWs with their regular sexual partners showed a different picture with nearly all studies in PNG, Asia and Africa by Mgone et al. ; Jenkins, Morof et al. ; Yeka et al. ; Gurung et al. ; Trung et al. ; Amadora- Nolasco et al. ; Dandona et al. ; Abdool-Karim et al. ; Mann et al. ; Fischbacher et al. ; and Wilson et al. for instance, reporting significantly lower rates [16, 58, 80, 81, 99, 134, 146-148, 150, 152]. Inconsistent condom use may suggest possible links to trust, together with the perception that regular sexual partners may be at low risk.

- 96 - Figure 2.7. Condom use rate in female sex workers (FSWs) in PNG with their clients & RSPs compared to FSWs in countries with similar gross domestic product

Comparison of condom use among FSWs in PNG and FSWs in countries with similar gross domestic product (GDP)

100 90 80 70

60 Minimum 50 Maximum

U s40 e 30 20 10

% Percentage0 Condom PNG condom use Sub S Africa SE Asia condom PNG condom use Sub S Africa SE Asia condom wth clients condom use with use wth clients RSP condom use RSP use RSP clients Locations

In relation to condom use in clients, Figure 2.7 illustrates that FSWs in PNG and Sub- Saharan Africa have similar and higher rates of behavioural predictors of HIV whilst their counterparts, South East Asia, have low rates of behavioural predictors of HIV. However, in relation to condom use in regular sexual partners, behavioural predictors of HIV remain similar for all FSWs.

Furthermore, nearly all studies in Asia conducted between 1991 and 2000 and in Africa between 1985 and 1999 reported high rates of STIs and were consistent with findings we identified in our review. In Asia, the proportion of FSWs with Trichomonas ranged from 5.4–14.5% in studies by Ryan et al. , Desai et al. and Ford et al. [153-155]; N. Gonorrhea ranged from 16.9–60.5%; Syphilis ranged from 10.9–22.7%; Chlamydia ranged from 8.5–41.3% in studies by Ryan et al. , Desai et al. , Ford et al. and Limpakarnjanarat et al. [153-156]; and HIV ranged from 40.6–47% in studies by Ryan et al. , Desai et al. and Limpakarnjanarat et al. [153, 155, 156]. In Africa, the proportion of FSWs with Trichomonas ranged from 23.0–41.3% in studies by Ramjee et al. , Lankoande et al. and Ghys et al. [157-159]; N. Gonorrhea ranged from 13–50%; Syphilis ranged from 4.6–42.1%; Chlamydia ranged from 4.5–25 %; and HIV ranged

- 97 - from 50.3–89 % in studies by Ramjee et al. , Lankoande et al. , Ghys et al. , Deceuninck et al. , Alary et al. , Steen et al. and Simonson et al. [97, 126, 157-161]. These results suggest the need for improved STI control in FSWs.

2.7 Weaknesses

This review had a number of weaknesses. Firstly, condom use was measured differently in different studies For example, some studies asked about condom use in the recent sex act: Bruce et al. , Bruce et al. [86, 87]; last sex act: Yeka et al. , Gare et al. [55, 81]; last few days: Mgone et al. , Morof et al. [58, 80]; and last week: Mgone et al, Morof et al. [58, 80]. In addition, the definition of the frequency of condom use also varied across different studies. For example some studies asked about condom use “always”: Mgone et al. , Jenkins, Morof et al. , Yeka et al. , Bruce et al. [16, 58, 80, 81, 87]; others asked about condom use “sometimes”: Morof et al. [80]; whilst others asked about condom use “never”: Mgone et al. , Morof et al. , Gare et al. [55, 58, 80]. Some studies reported condom use with clients and regular sexual partners separately: Mgone et al. , Morof et al. , Yeka et al. , Bruce et al. , Bruce et al. [58, 80, 81, 86, 87]; others pooled estimates: Mgone et al., Jenkins, Morof et al. , Gare et al. [16, 55, 58, 80]; others reported condom use for different locations: Mgone et al. , Yeka et al. [58, 81]; while others did not: Jenkins, Gare et al. [16, 55]. Secondly, only three studies tested FSWs for STIs and HIV: Mgone et al. , Gare et al. , Bruce et al. [55, 58, 86]; but in only two studies FSWs tested were positive for HIV: Mgone et al. , Bruce et al. [58, 86]. Finally, detailed methodology on sampling processes and participation rates were not always provided. Notwithstanding these weaknesses, it was possible to ascertain a number of substantial differences over time in the data including increasing condom use, relatively high rates of STIs and rising rates of HIV infection. It is unlikely that the large differences observed in these factors could be explained by the methodological differences in their measurement.

2.8 Strengths

This review had a number of strengths. Firstly, the review was able to draw on information from unpublished studies to get a much fuller picture of HIV risks among

- 98 - FSWs in PNG. Finally, the review highlights critical areas for improved policies and urgent programming decisions in this group, their clients and with more focus on regular sexual partners.

2.9 Conclusion and recommendations

What remains is a consensus as to the best way to measure and ensure correct and consistent use of condom use among FSWs. For a meaningful comparison over time, it is critical to establish a standardised and reliable measurement approach for future studies in PNG. Consistencies in methodologies, specific recommendations and guidelines may be useful to improve the accuracy of measurement and comparability of findings across different studies. This will help with adequate assessment and future patterns of HIV risks in this group. That said, more work is required to improve the use of condoms with clients and particularly with regular sexual partners, whilst at the same time improving access to STI service involving FSWs. It means if HIV is to be successfully prevented among FSWs in PNG, condom use will need to rise towards 100%. For this to happen, considerable resources will need to be invested in preventive programs that address the high risk practices among FSWs, including a focus on RSP.

- 99 -

CHAPTER 3

THE LOCATIONS AND SIZE ESTIMATION OF THE FEMALE SEX WORKER POPULATION IN PORT MORESBY, PAPUA NEW GUINEA

- 100 - 3.1 Co-authors and citation

L. Bauai, M. Sapuri, L. Keogh, J. Kaldor and C.K. Fairley. Submitted to Global Public Health — 24/12/09.

3.2 Abstract

Background: Accurate data on the size of the female sex worker (FSW) population is a key piece of information required to effectively implement prevention programs. Our aim was to identify the locations where sex work takes place and estimate the size of the FSW population within these locations across Port Moresby where no local data exist. Methods: We used key informant (KI), mapping, observation and nomination methods. We interviewed stakeholders and FSWs (recruited as fieldworkers) and obtained the names of the locations. We visited the locations and interviewed additional local informants, some of which participated in the study. Field workers used coupons to nominate other FSWs they identified as FSWs. The FSWs who returned coupons were identity-checked, counted, completed a short questionnaire and given coupons to repeat the process. Other FSWs who were observed but did not return coupons were also counted. We used strategies to minimise double-counting and aggregated data for the selected locations . Results: 51 local informants, 36 stakeholders and 12 FSWs participated in KI interviews. We obtained the names of 42 locations of which 22 were visited, 14 selected for the study and 28 excluded. The locations were settlements, peri urban villages, wharfs, guest houses and bars. At the 42 locations, a range of 2500–4000 FSWs were estimated by KI. Of the selected 14 locations, 212 were estimated through nomination and 338 through observation. Identified FSWs comprised of (69%) street- based and common in settlements/slums, and (31%) fixed-establishment–based and common in guest house/wharf area. Conclusions: The method is challenging but simple and robust. For systematic estimation of FSWs to better inform HIV policy, the method should be replicated in PNG.

Keywords: Female sex workers; Size estimation; Mapping; Observation; Nomination; Key informants;

Field workers; Port Moresby; Papua New Guinea.

- 101 - 3.3 Introduction

Female sex workers (FSWs) are reported to be at a particular risk of the acquisition and transmission of the human immunodeficiency virus (HIV) [76, 82, 84]. In most developing countries, FSWs are the first group to be observed with the epidemic and also disproportionately affected by the virus [82]. In 1998 in Papua New Guinea (PNG), a study of 407 FSWs in Port Moresby and Lae reported an HIV prevalence of 17% (34 of 205) among FSWs in Port Moresby [58], while at about the same time, the prevalence was estimated to be 0.34% among the adult population in Port Moresby [36], 0.37% among pregnant women and 0.15% among the adult population in the rest of the country [45]. A more recent report indicates that the adult HIV prevalence is 1.5%, indicating an epidemic rapidly increasing and supports increasing heterosexual transmission [52]; no estimates for sex workers were reported. For the above reasons, FSWs are regarded as an important group to involve in HIV prevention strategies [76, 78, 82, 133].

However, for adequate planning and implementation of preventive interventions and public health policies in FSWs [76], accurate data including an understanding of the size of this group are crucial [164]. In PNG, like many resource constrained settings, there is a dearth of this data including limited routinely collected data on the health and other characteristics of this group. Given that sex work is illegal in PNG [6], it is anticipated that efforts to obtaining reliable data on the number of females involved in this activity will be challenging. To date, very few studies have reported data on the female sex worker population in PNG. In 1993, an ethnographic study conducted across three different locations provided the first data on the number of FSWs in PNG, but no separate data for Port Moresby was reported [16, 39]. By the turn of 2003, no data on the number of FSWs in Port Moresby existed, reflecting an important information deficit. However in 2005, recent data on the female sex worker population in Port Moresby emerged from a study in which an innovative approach — the respondent driven sampling method (RDS) — was applied the in two locations across PNG [81].

In recent years, a number of innovative methods have been devised to estimate the numbers of people or groups in so called “hidden populations”. One of the underlying

- 102 - principles is the nomination method: a type of a “systematic estimation” or a sampling method that collects data on hidden populations using a visible fraction of the subgroup to identify and contact other members [164]. It is also emphasised that if the purpose of the research is “only” to estimate population size, then the nomination method may be the most efficient study design [166, 245]. Although the application of the nomination method has varied considerably across study sites, it has been reported to be effective to generate population estimates on hard to reach groups such as sex workers and drug users. For instance, the nomination method was applied effectively in a study in Kathmandu Valley in combination with mapping and actual counting via observation to produce data on the size of the FSW population from over 109 sites in a short space of time [162]. In another study in Slovenia, application of the nomination and key informants (KI) methods reported to produce data in a similar risk group where no other reliable sources of information existed [163].

We conducted a study to estimate the number of FSWs in Port Moresby using the nomination method as well as mapping, direct observation and key informant interviewing where no such data existed at the time of the study in 2003.

3.4 Methods

This study reported here was carried out as the first element of a program funded by an operational research grant from the United Nations Population Fund (UNFPA) [133]. The study was approved by the Research Committee of the School of Medicine & Health Sciences, Port Moresby, and the Medical Research Advisory Committee, National Department of Health, Papua New Guinea, and conducted in collaboration with the School of Medicine & Health Sciences, Port Moresby, which participates in research projects.

The study was carried out between May and June 2003. Firstly, the study team developed a list of stakeholders. These included female sex workers themselves, as well as persons or organisations with significant knowledge or program activity related to women involved in sex work. Organisations included United Nations (UN) agencies, Papua New Guinea government agencies (National Department of Health, National

- 103 - AIDS Council), HIV related donor and funding organisations, and academic institutions, as well as private sector organisations. Also included were bar and guest house owners, street vendors, clients of sex workers and “pimp-like” individuals who are locally known as boskru or wasman [16], and in general terms protect FSWs.

To initiate contact with these stakeholders, we organised a full-day workshop that was advertised in the local papers through targeted invitations and community radio announcements. Representatives from the stakeholder list and the general public attended. We provided information about the project and invited stakeholders to participate in KI interviews after the workshop.

All KIs were interviewed about the magnitude of sex work, the locations of sex work, the nature of the locations, the peak times of sex work activities and the types and number of women considered to be FSWs at each of the various locations. Interviews lasted about 40–50 minutes at locations convenient to the KI, and were semi-structured using open ended questions. Information was recorded verbatim in field notes and key themes were noted. The interviews were completed within a one-week period in May 2003. No payments were made. The data from the KI interviews provided initial estimates of the size of the FSW population.

At the same time we recruited FSWs to act as field workers in the second phase of the study. The field workers were women 18 years and older, who had received money for sex in the last month and intended to remain in Port Moresby during the period of the study. We aimed to recruit at least one field worker from each location in Port Moresby that was recognised as having a focus of sex work, based on the key informant interviews.

A Mapping and size estimation

In the second phase we conducted mapping and numerical estimation of sex workers. The mapping procedure involved first marking on a map of Port Moresby the locations obtained from the KI interviews and the field workers. The locations were defined as either fixed establishments or informal settings. The study team then visited the

- 104 - locations and identified additional local KIs who were perceived by the study team to have knowledge of local FSWs. The field workers approached these KIs and introduced the project and the study team. We confirmed the locations through interviews and sought advice on days and best times to commence numerical estimation. We invited some of the local KIs who were familiar with FSWs within their locations to participate later in the identification and numerical estimation of FSWs within their respective locations. After these visits, we excluded the locations that posed security risks to conduct field work, based on information from these informants. We selected the remaining locations to estimate the FSW population.

The numerical estimation involved firstly was counting by the nomination method [164] and counting by observation. Counting was undertaken each day. At every location, the field worker most familiar with the location took the lead. She was given five coupons to give to other women who she personally identified as sex workers working within that location. These women were asked to report to the study team for registration and complete a short questionnaire. The identities of these women were checked to ensure they had not previously presented that day by using a code that consisted of the initials of the first and last names, year of birth, location number and date and time they report to the study team. Women who presented with a coupon were in turn given five additional coupons to repeat the process on the same day. The study team continued the same process in all the selected locations. As compensation for the participant’s time, we provided HIV resources and a free grooming session where FSWs were given “hands on” lessons on improving personal hygiene and raising their self esteem.

Secondly, at each location the field workers were asked to count women whom they perceived to be FSWs. The field workers were familiar with the local community, considered that they were able to identify women who engaged in sex work within their respective communities, and were able to distinguish between those who had presented a coupon and those who did not. To minimise double-counting, the field workers helped created a tentative list of FSWs at each location in which those who returned coupons and those who were sighted or spoken to were noted. We then aggregated the data from each selected location to estimate the total number of the FSW population in the 14 locations.

- 105 - 3.5 Results

A total of 72 stakeholders participated in the workshop. Of these, 36 stakeholders and 12 FSWs participated in KI interviews. Twelve FSWs were recruited as field workers, representing 12 different locations across Port Moresby. Through the KI interviews we obtained the names of 42 locations of which 22 were visited, 14 were selected for the study and 28 locations that posed a security risk were excluded. The locations we visited were informal settings such as streets, markets and gambling areas in settlements, peri urban slums, waterfront/wharf areas and other fixed establishments including guest houses and bars. We assessed an average of three locations per day. At the 22 locations, we identified and consulted 51 local KI, including bar and guest house owners, FSW peer educators, street vendors, clients of sex workers and “pimp-like” individuals who are locally known as boskru or wasman . At each of the 14 locations we invited two local KI to participate in the numerical estimation process within their locations only.

The FSWs we identified were of two main categories: street and fixed-establishment- based sex workers, both of which were unevenly dispersed over the peri urban slums and settlements across Port Moresby. Of the two categories, the street-based FSWs were the most numerous and more common in settlements, while the fixed-based FSWs were more common in the peri urban slums and work in the inner city and around the wharf and waterfront areas.

The estimates of the number of FSWs made by KI at the 42 locations ranged between 2500 and 4000. The estimates made by local KI and field workers at the selected 14 locations ranged between 395–570 (Table 3.1). A total of 550 FSWs were estimated from the numerical estimation of the selected 14 locations (Table 3.1) of which 212 returned coupons through nomination (see below formula that takes account of the number of respondents at each round of referral). Of the 212 who returned coupons, 146 (69%) were street-based FSWs and 66 (31%) were fixed-establishment-based FSWs. A total of 338 FSWs were further identified through observation by the field workers at these locations, but did not return coupons.

- 106 - A Estimated size of FSW population at 14 locations

Total FSWs (initial seed) contacted (nominated) to provide contacts of five FSWs and after removing duplicates = 12 initial seed (1 st contacts) + five coupons = (60 of their contacts - 18 duplicates). Remaining 42 FSWs (2 nd contacts) + five coupons = (210 of their contacts - 52 duplicates). Total contacted (nominated) after removing duplicates = 12 + (60-18) + (210-52) = 12 + 42 + 158 = 212

Population Estimate Using Nomination = 212

If we were to extend the mapping to the 28 locations that were excluded and they had on average the same number of FSWs, then the total population would be about 2000 across the 42 locations.

- 107 - Table 3.1. Estimation of female sex workers by key informants, observation and nomination methods in fourteen locations in POM

Location Type of location The number of aFSWs Counting by direct Counting by nomination using coupons Number of FSWs counted estimated by b(KI) interviews observation by observation and prior to counting by excluding those nomination nomination & observation returning coupons

Maximum Minimum Total Street-based Fixed- Total Total FSWs establishment FSWs

Town Water front/Warf 40 35 23 4 12 16 39

Davara Peri urban slum 50 40 4 33 13 46 50

Dig & Dump Water front/Warf 20 15 11 2 5 07 18

Paga Hill Peri urban slum 30 20 0 19 11 30 30

June Valley Settlement 30 20 10 19 0 19 29

9 Mile Settlement 50 40 39 8 0 08 47

3 Mile Guest House Peri urban slum 20 15 7 3 9 12 19 /Hospital compound

Sabama Settlement 30 20 22 7 0 07 29

Talai Settlement 30 20 14 14 0 14 28

Morata 1 Settlement 50 40 43 5 0 05 48

Gerehu-Banana Settlement 20 15 8 11 0 11 19 settlement

Hanuabada Urban village built on stilts 80 30 63 6 9 15 78 over the sea

- 108 - Location Type of location The number of aFSWs Counting by direct Counting by nomination using coupons Number of FSWs counted estimated by b(KI) interviews observation by observation and prior to counting by excluding those nomination nomination & observation returning coupons

Bisini Oval Peri urban slum 20 15 6 5 7 12 18

6 Mile Bodiem 1& 2 Settlement 100 70 88 10 0 10 98

Total 570 395 338 146 (68.9%) 66 (31.1%) 212 550

a FSWs = Female sex workers. b KI= Key informant.

- 109 - Figure 3.1. Sex worker locations the study team visited across Port Moresby

- 110 - Figure 3.2. Selected locations for the estimation of the female sex worker population in Port Moresby

- 111 - 3.6 Discussion

In this study we identified 42 locations where FSWs operate across Port Moresby and through a variety of means estimate that the population of FSWs in this city to be about 2000. The identified FSWs in Port Moresby were of two main categories: street-based and fixed-establishment-based FSWs consistent with “2 Kina Bus Meri” who by description are (street-based, most numerous, least educated, common in settlements, have many sexual partners and least paid) and “Disco Meri” (fixed establishment/indoor-based, work around the clock, better educated, may have fewer sexual partners and better paid) as previously reported by Jenkins [16]. In this study we found the application of the nomination method challenging due to the illegal nature of sex work but overall, it was simple, cost effective, rapid and robust in producing numerical estimates of the FSW population in Port Moresby. This implies that with sensitivity, the so called “hidden populations” can be reached. In practice, the numerical estimate provides the basis to calculate the appropriate budget required for HIV programs and to allocate adequate resources to reach the appropriate 2000 FSWs in Port Moresby at any given time. The method is innovative and robust and provides future researchers a potentially viable tool to apply to estimate the size of populations at risk for HIV in the whole of PNG and similar settings.

Previous studies have reported applications of similar methods with similar findings in FSWs and similar risk groups. A study by Dangi to estimate the number of FSWs in Kathmandu Valley using mapping, nomination, actual counting and key informants, reported that the method was robust and cost effective in reaching a total of 5000 FSWs in 102 sites, 904 through nomination, 1473 through observation, and 2623 through a variety of other means [162]. Similar findings were reported by Nolimal by using key informant and the nomination methods to produce reliable estimates of a similar hidden population in Slovenia where there were no other reliable sources of information [163].

Other studies have applied a number of innovative methods and have reported similar findings. For instance, in Madagascar, Kruse [165] used the capture-recapture method among street-based sex workers whilst in Australia, Larson [166] used it among heroin users. In three Eastern European countries, two Vietnamese cities [167] and two urban

- 112 - cities in PNG [88], these three studies assessed and used the respondent driven method and reported accurate estimates of FSWs and similar risk groups. In Ethiopia, a study by Family Health International used census and enumeration [168] methods to produce similar estimates. In PNG [16, 39] and Pakistan [169], the studies used the population survey method. In two Chinese cities, the study used the multiplier method to produce similar estimates, but concluded that the method is feasible in settings where HIV behavioural surveillance has been established in hidden populations [170]. Another study applied and assessed a number of these methods and found their results comparable to those derived by other similar robust methods [171]. This was consistent with findings reported by Vandepitte [172]. The findings of our study can be compared with other studies that reported application of various robust methods in a range of settings [168, 171, 172].

In Papua New Guinea (PNG), there have been two studies that have estimated the size of the sex worker population; one an ethnographic study that was undertaken 15 years earlier in 1993 and used the population survey method [16, 39]; and a recent study that was undertaken in 2005 and used the respondent driven sampling (RDS) method [81]. The recent study described FSWs in two different locations and through the RDS method estimated a total of 494 FSWs in both locations, of which 245 is the estimate of FSWs in Port Moresby; a finding that is consistent with FSWs who returned coupons by the nomination method in our study. On the other hand, the 1993 study described sex workers in three different locations and concluded that there was an estimated 15,000 women working independently as FSWs in Port Moresby, Lae and Goroka, but no separate estimate was provided for Port Moresby [16, 39]. There are a number of possible explanations for the difference between the estimate from this study and ours. Firstly, they looked at three urban areas with a total population of 315,000 in contrast to our one which looked at one urban centre. In addition we could not get to all active sex worker locations in Port Moresby because some were deemed unsafe. The differences in the total population at the study locations may explain the vast differences in the FSW population estimates in both studies. Secondly, Jenkins [16, 39] spent four-and-a-half months in the field observing the study population in contrast to our study that was conducted over a period of approximately six to seven weeks. Finally, their study

- 113 - included all sex workers who reported sex work in exchange for money and goods compared to ours that used strict inclusion criteria, i.e. “women” who have sold sex in exchange for money or goods in the last month. This may have excluded women and young girls who do engage in sex work but may not have done so in the last month.

3.7 Limitations

Our study had a number of limitations. Firstly, our estimate includes an extrapolation of FSWs that may exist within all the 42 locations. There is the possibility that this figure may not reflect the true population size of FSWs in Port Moresby. Secondly, because FSWs are highly mobile and are known to move around the country for work, it is possible that we may have missed a number of women who were not present at the time of the study and therefore may have lead to an underestimation of FSWs. Thirdly, because sex work is illegal and socially unacceptable, it is possible we may have missed a number of FSWs who may have chosen to remain clandestine. At the time of the study, there were no local research estimates of FSWs in Port Moresby and because of this deficit we relied on estimates reported by local KI. It was therefore difficult to verify the accuracy of the reported figures to validate the estimates we obtained.

3.8 Strengths

The study has a number of strengths. It used a robust method that could be replicated to produce reliable estimates of the FSW population in Port Moresby as a whole, as well as monitor changes in the FSW population. We also were able to show an application of a method that is simple, convenient and rapid for obtaining estimates of the so called hidden population because it uses members of the sub-population to identify other members.

3.9 Conclusion and recommendations

However, for adequate information and systematic estimation of FSWs on which to base national HIV policy and programming decisions, we recommend that strategies to central information systems must improve.

- 114 -

CHAPTER 4

KNOWLEDGE, ATTITUDES, PRACTICES AND BEHAVIOUR OF FEMALE SEX WORKERS IN PORT MORESBY, PAPUA NEW GUINEA

- 115 - 4.1 Co-authors and citation

L. Bauai, W. Yeka, M. Sapuri, L. Keogh, J. Kaldor and C.K. Fairley — Sexual Health 2010; 7(1):85-6.

4.2 Abstract

Background: Female sex workers (FSWs) are considered at high risk of human immunodeficiency virus. Our aim was to describe the knowledge, attitudes, practices and behaviour (KAPB) of FSWs in relation to HIV risk. Methods: We recruited a convenience sample of FSWs between June–July 2003 and administered a structured questionnaire. Results: The average of the 79 FSWs was 25 years old (range: 14–47), they had five years of formal education (range: 0–11) and had their first non-paying sex at 16 years old (range: 12–23) and first paying sex at 19 years old (range: 13–32). They had an average of three (range: 0–7) sexual partners per day of which two (range: 0–4) were clients and one (range: 0–2) was a regular sexual partner. Condoms were used for 32% (95% CI: 22–43) of clients and 15% (95% CI: 6–29) of regular sexual partners. For 63%, sex work was their only source of income. All FSWs 100% (95% CI: 95–100) had heard of condoms but only 67% (95% CI: 56–77) thought it prevented HIV. About 99% (95% CI: 93–100) thought one could catch HIV through sex but 48% (95% CI: 37–60) thought one could catch it from a mosquito bite whilst 15% (95% CI: 8–25) thought they had no chance of catching it. Only 36% (95% CI: 25–47) have had the HIV test. Other risky behaviours included alcohol 54% (95% CI: 43–46) and marijuana 44% (95% CI: 33–56) use. Conclusions : The findings identify areas for improved actions targeting sex workers based on the characteristics identified in this survey.

Keywords: Female sex workers; Knowledge; Attitudes; Practices; Behaviour; Condoms; Regular sexual partners; Clients; Port Moresby; Papua New Guinea.

- 116 - 4.3 Introduction

In most developing countries where heterosexual contact is the most common mode of human immunodeficiency virus (HIV) transmission, women in sex work are often the first group to become infected [82, 84]. It is also recognised that in many settings worldwide, the epidemic has gained a stronghold among sex workers and is spreading to their clients and the general population [84]. Sex workers by virtue of their behaviour, such as f requent sexual contacts with a number of partners and inconsistent condom use, make them extremely vulnerable not only to HIV but to other sexually transmitted infections (STIs) [82, 84]. Sex workers therefore represent a potential source for rapid transmission of these infections throughout the general population.

In Papua New Guinea (PNG), a study in 1998 found an HIV prevalence of 17% among 207 FSWs in Port Moresby [58], while at the same time the prevalence was 0.34% among the adult population in Port Moresby [36] 0.37% in pregnant women and 0.19% among the adult population in the rest of the country [45]. In 2004, the prevalence of the infection nearly quadrupled in pregnant women to 1.4% [51]. However, more recent data indicate that the prevalence of infection within the general population has risen nearly by seven-fold to 1.5% [52]. Furthermore, PNG has a number of features that suggest that HIV transmission is likely to continue particularly among FSWs. These include the poor working environment of sex workers [16], extreme poverty [16, 29] , a high rate of partner change [16, 80], high prevalence of sexually transmitted infections (STIs) [55, 58], inconsistent condom use [16, 55, 58, 80], poor HIV knowledge [16, 55, 80], marijuana and alcohol use [16, 55, 80] and poor health-seeking behaviours [16, 55, 80].

Due to these observations, in recent years great interest and debate have been generated regarding their role in the spread of HIV, including STIs, and how to avert their transmission [16, 82]. However, in order to be effective in prevention programs, risky behaviours in this group and the reasons behind them must be understood. Documenting the risk factors for HIV vulnerability among FSWs is important for understanding future HIV transmission in this group. A knowledge, attitude, practices and behaviour (KAPB) survey is an important tool in identifying behavioural practices that place people at risk

- 117 - of the HIV infection and STIs, and in so doing providing the means to monitor changes in behaviour over time [76, 173].

Therefore, this project describes a study whose aim was to conduct a survey of the knowledge, attitudes, practices and behaviour (KAPB) of FSWs in the capital of PNG where the HIV epidemic is most advanced. The study attempts to understand the behaviours of this group and to gather data which is considered vital for program planners, health care workers and donors to support the development of appropriate and effective intervention programs. In addition, t his data should allow behavioural trends to be monitored and identify areas where change is needed.

4.4 Methods

This was a cross-sectional survey of FSWs in Port Moresby, the capital of Papua New Guinea. We carried out the survey between mid June and July 2003. We piloted a standard Behavioural Surveillance Survey (BSS) questionnaire that was adopted from Family Health International (FHI) [173]. This questionnaire was translated into pidgin and included information on socio-demographic characteristics, sexual history and practices, HIV/STI knowledge, health-seeking behaviours, risk perceptions and behaviour change.

We used a convenience sampling method to recruit FSWs from 12 of 14 locations where FSWs commonly worked across Port Moresby that were previously identified through a mapping and size estimation exercise [91]. Two locations were deemed unsafe to recruit from for this study. Examples of the locations were guest houses, wharfs/waterfront areas, markets, gambling and drinking areas.

Each day we visited each of the selected locations and approached FSWs and asked if they would like to participate in the survey. We explained the purpose of the survey to them and obtained informed consent by thumbprint. We administered the questionnaire face-to-face to the FSWs who satisfied the inclusion criteria. Each questionnaire took an average of about 45 minutes to complete. To be eligible for the survey, the FSWs had to

- 118 - be 14 years or older, had received money for sex in the last month, were not currently enrolled in a similar study, and intended to remain in Port Moresby during the survey.

The recruitment continued for six weeks. We provided every sex worker we interviewed with HIV resources. No money was offered.

The data were doubled entered into FoxPro 2.6 database (Microsoft Corporation, WA, USA). The database was then converted and analysed using Stata 7.0 (Stata Corporation, TX, USA). Missing values (blanks on a questionnaire) were left as blanks in the data entry process. The study was approved by the Research Committee of the School of Medicine & Health Sciences, Port Moresby, and the Medical Research Advisory Committee, National Department of Health, Papua New Guinea, and was conducted in collaboration with, and at, the School of Medicine & Health Sciences, Port Moresby, which participates in research projects.

4.5 Result

Seventy-nine FSWs from 12 locations participated in the survey. Table 4.1 shows the demographic characteristics of the 79 FSWs. The average FSW was predominantly young, poorly educated and had a limited source of income besides sex work.

- 119 - Table 4.1. Demographic characteristics of female sex workers in Port Moresby

Total number (N) = 79 N or mean (%) range

Age (mean) 25 years 14 - 47

Education:

Formal Education 70 (89) -

Years of education (mean) 5.3 years 0 - 11

Highest level – ( Primary) 60 (76) -

Place of birth and years lived the area:

Born in Port Moresby 49 (62) -

Years lived in Port Moresby (mean) 13 years 0 - 33

Marital status:

Ever married 57 (72) -

Single/divorced 34 (43) -

Currently married/defacto* 45 (57) -

Current boyfriends/regular sexual partners 46 (58)

Christian 64 (81) -

Source of income (sex work only) 50 (63) -

Other source of income besides sex work ! 29 (37)

Support anyone with income made from sex 53 (67) - work

Number (n) of people supporting (mean ) 5 people 1 - 9

*FSWs in defacto relationships stated their spouses or partners had other wives or sexual partners. ! All sell betel nut.

Table 4.2 shows the knowledge, attitudes, practices and behaviour of the 79 FSWs. The average FSW had a substantial number of clients and regular sexual partners, but condom use was uncommon.

- 120 - Table 4.2. Knowledge, attitudes, practices and behaviour of female sex workers

Total number (N) = 79 Mean or (%) 95% CI A or (range)

Age first had non-paying sex (mean) 16 years (12 – 23) Age first paid for sex (mean) 19 years (13 – 32)

Sexual partners/day(mean)

Number of paying clients/day (mean) 2 (0 – 4)

Number of regular sexual partners/day (mean) 1 (0 – 2)

Total number of sexual partners/day (mean) 3 (0 – 7)

Paying Clients

Number of sexual contacts the previous day 2 (0 – 6) (mean)

Condom (male) used at most recent sex 35 (44) 33 - 56

Condom (male) use suggested by FSWs 28 of 35 (80) 69 - 88

Condom use at all times 25 (32) 22 - 43

Reasons for not using condoms - Paying Clients

Did not think condom use was necessary 21 of 48(44) 29 - 59

Did not like condoms 16 of 48 (33) 20 - 48

FSW did not think it was necessary 11 of 48 (23) 12 - 37

Regular Sexual Partners

Number of sexual contacts the previous day 1 (1 – 2) (mean)

Condom (male) used at most recent sex 7 of 46 (15) 6 - 29

Condom use at all times 7 of 46 (15) 6 - 29

Reasons for not using condoms - Regular Sexual Partners

Did not think condom use was necessary 25 of 34 (73) 56 - 87

FSW did not think it was necessary 9 of 34 (27) 13 -44

Marijuana and alcohol use

- 121 - Total number (N) = 79 Mean or (%) 95% CI A or (range)

Marijuana use every day 43 (54) 43 - 66

Knowledge and condom use:

Heard of a male condom 79 (100) 95 - 100

Heard of a female condom 47 (70) 48 - 70

Ever used a male condom 60 (76) 65 - 85

Know where to get male condoms 75 (95) 86 - 99

Aware of free condoms available 64 (81) 71 - 89

Number of condoms in possession at all times 3 condoms (0 – 12) (mean)

STI knowledge and health-seeking behaviours:

Heard of sexually transmitted infections (STIs) 60 (76) 65 - 85

Recognition of STI symptoms in women

Lower abdominal pain 19 (24) 15 - 35

Vaginal discharge 11 (14) 7 - 26

Foul smelly discharge 10 (13) 6 - 22

Vaginal ulcers & sores 9 (11) 5 - 21

Pain on urination 9 (11) 5 - 21

Swelling in the vaginal area 8 (10) 4 - 19

Vaginal itch 8 (10) 4 - 19

Recognition of STI symptoms in men

Painful urination 24 (30) 2 - 42

Penile discharge 54 (68) 57 - 78

STI symptoms in the last 12 months

Vaginal discharge 28 (36) 25 - 47

Ulcer/sore/itch 23 (29) 19 - 40

Pain on passing urine 15 (19) 11 - 29

Health-seeking behaviours

- 122 - Total number (N) = 79 Mean or (%) 95% CI A or (range)

Ever had HIV test 28 (36) 25 - 47

Obtained test results 19 of 28 (67) 48 - 84

Preference for STI treatment

Self-medication 25 (31) 22 - 43

Friends 17 (22) 13 - 32

Health mobile teams 14 (18) 10 - 28

STD Clinics 13 (16) 12 - 31

Hospital 6 (8) 3 -16

Pharmacy – (over the counter) 4 (5) 1 -13

HIV/AIDS (knowledge, perceptions, opinions & attitudes):

Heard of HIV or AIDS 75 (95) 88 - 99

Know anyone infected with HIV or AIDS 68 (86) 76 - 93

Possible transmission modes

Sexual contacts 78 (99) 93 -100

Mosquito bites 38 (48) 37 - 60

Sharing a meal with infected person 28 (36) 25 - 47

Sharing infected needles 57 (72) 61 - 82

Breastfeeding 64 (81) 71 - 89

Pregnant mother to unborn child 71 (89) 81 - 96

Prevention strategies you have had heard of

Condom use 53 (67) 56 - 77

Have one faithful uninfected sexual partner 34 (43) 32 - 55

Abstinence 30 (38) 27 - 50

Prevent HIV from pregnant woman to unborn 35 (44) 33 - 56 child

Perceptions, opinions & attitudes

Aware HIV test in your community is 49 (62) 51 - 73

- 123 - Total number (N) = 79 Mean or (%) 95% CI A or (range)

confidential

Aware HIV test in your community is voluntary 56 (73) 60 - 81

Share a meal with an infected person 47 (60) 48 - 70

Associate with an infected person 58 (73) 62 - 87

Infected FSWs must continue sex work 39 (49) 38 - 60

Keep HIV positive status a secret and continue 46 (58) 47 - 69 sex work

Sell sex to HIV positive client if status is known 19 (24) 15 - 35

FSW must undergo (involuntary) HIV testing 53 (67) 56 - 77

FSW must undergo (voluntary) HIV testing 56 (71) 60 - 81

Risk perceptions and behaviour change:

Chance of Catching HIV

No Chance 12 (15) 8 - 25

Moderate Chance 25 (32) 22 - 43

Big Chance 23 (29) 19 - 40

Don’t know 19 (24) 15 - 35

HIV Status

Keep HIV positive status a secret 46 (58) 47 - 69

ACI = confidence interval.

- 124 - Figure 4.1. Socio-demographic characteristics of female sex workers in Port Moresby

Socio-demographic characteristics of FSWs in POM (N=79)

100 Age (mean)

90 Formal Education Ever 80 Years of education 70 completed (mean) Ever Married 60 Single/Divorced 50 40 Currently married /defacto* 30 Curent Boyfriend/Reg Sex Partner Precentage % or mean 20 Sex Work Only Source of Income 10 Other Source of Income 0 Besides Sex Work Characteristics1

Figure 4.2. Sexual practices and other risky behaviours of female sex workers in Port Moresby

Sexual practices and other risky behaviours of FSWs in POM (N=79)

60 Age 1st sexual debut (mean) Age 1st paid for sex 50 (mean) Number of clients/day (mean) 40 Number of RSP/day (mean) Condom used with clients at most recent sex 30 Condom used with RSP at most recent sex Condom use with clients at 20 all times Condom use with RSP at

Percentage % or mean all times 10 Cannabis use previous day

Alcohol use previous day 0 Characteristic1

- 125 - Figure 4.3. HIV/STI knowledge of female sex workers in Port Moresby

HIV/STI knowledge of FSWs in POM (N=79) Heard of HIV or 120 AIDS

Transmission – 100 sexual contact

Transmission- mosquito bites 80 Heard of a male condom 60 Prevention – condom use

40 Number of

Percentage %or mean condoms on hand at all times (mean) 20 Heard of STIs

Vaginal discharge 0 as STI symptom Characteristics

Figure 4.4. Health-seeking behaviours of female sex workers in Port Moresby

Health seeking behaviours of FSWs in POM (N=79)

80 Ever had HIV test 70

60 Obtained test 50 results (19 of 28)

40 Preference for STI 30 treatment - clinic

Percentage % or mean 20 Preference for STI 10 treatment- self medicate 0 Characteristics1

- 126 - Figure 4.5. HIV risk perception of female sex workers in Port Moresby

HIV risk perception of FSWs in POM (N=79)

70 Chance of Catching HIV- No 60 Chance

50 Chance of Catching HIV- 40 Moderate Chance

30 Chance of Catching HIV-Big Chance 20 Percentage % or mean Keep HIV positive 10 status a secret

0 Characteristics1

4.6 Discussion

In this study, we found that FSWs in Port Moresby were predominantly young, poorly educated, unemployed and depended on sex work for economic survival. They initiated sex and engaged in sex work at a young age. They had substantial numbers of paying clients and non-paying sexual partners, and used condoms inconsistently. They frequently used marijuana and alcohol. They had basic HIV knowledge, limited understanding of STIs and infrequently sought treatment services. They had limited awareness of the risks of HIV and had concerns about HIV related stigma. These findings are similar to earlier studies in 1993 in PNG and suggest no significant improvements at the time of the survey. Some improvements were apparent in a 2005 study [81], however these are still suboptimal. While there have been some improvements over time with condom use, behaviours that protect against the virus remain suboptimal.

- 127 - Previous studies in PNG show that condom use in FSWs is low and inconsistent [16, 55, 58, 80, 81]. The findings suggest that FSWs in PNG have significantly high rates of behavioural predictors of HIV [84]. In 1993, an ethnographic study by Jenkins found that 5% of 88 FSWs reported consistent condom use with their clients [16]. In 1998, another study by Mgone et al. found that 25% of 207 FSWs in Port Moresby and 5% of 200 FSWs in Lae reported consistent condom use with their clients [58]. The same study found that 9% of 407 FSWs reported consistent condom use with their regular sexual partners [58]. In 1999, Morof et al. found that 7% of 190 FSWs reported consistent condom use with their clients whilst only 3% did so with their regular sexual partners [80]. In 2001, Gare et al . found that none of the 211 FSWs in their study reported consistent condom use with either their clients or regular sexual partners [55]. Our study found 32% of 79 FSWs reporting consistent condom use with their clients whilst 15% did so with their regular sexual partners. Compared to a subsequent study carried out in between 2003 and 2004, Bruce et al. found that 33% of 129 and 41% of 71 FSWs reported consistent condom use with their clients respectively, whilst 19% of 129 and 31% of 71 FSWs did so with their regular sexual partners in Port Moresby [86]. Moreso, in a more recent study in 2005, Yeka et al. found that 63% of 245 FSWs in Port Moresby and 31% of 249 FSWs in Goroka reported consistent condom use with their clients whilst 34% and 16% in POM and Goroka respectively reported doing so with their regular sexual partners [81]. While this indicates some improvement, we believe condom use is yet to reach the required level to protect female sex workers from the human immunodeficiency virus.

In contrast, studies in Asian countries with gross domestic products (GDP) similar to PNG have reported higher rates of consistent condom use in FSWs with their clients. This suggests that FSWs in Asia have lower rates of behavioural predictors of HIV compared to FSWs in PNG. For example, in Cambodia, a 1994 study by Prybyliski et al. found that 67% of 502 FSWs reported consistent condom use with clients [145], whereas in Nepal, a 1995 study by Gurung et al. found this to be 93% [146]. Another 1997–99 study in the Philippines by Amadora-Nolasco et al. found that 46% of 360 registered and 37% of 360 freelance FSWs reported consistent condom use [147]. In Vietnam, a 2002 study by Trung et al. found that 62% of 400 FSWs reported consistent

- 128 - condom use [99]. In India, a more recent study in 2003 by Dandone et al. found varying consistent condom use rate with 46% of 5010 reported among street-based, 70% of 1499 among home-based and 87% of 139 among brothel-based FSWs [148]. Possible explanations for this observation may reflect stages in HIV intervention efforts [174], a ripple effect of the 100% condom program in Thailand [111, 112] and perhaps the political and legal environment of sex work [76, 100].

However, studies in Africa have reported lower rates of consistent condom use in FSWs with their clients as reported in PNG. This suggests that FSWs in Africa and PNG have similar and higher rates of behavioural predictors of HIV. For example, in Harare, a 1989 study by Wilson et al. found that 53% of 98 FSWs reported consistent condom use, [134] a rate slightly higher than what is reported in PNG. In 1991, a study by Abdool Karim et al. found that 15% reported consistent condom use among South African FSWs [150]. In Kinshasa, Zaire, Mann et al. found that only 2% of FSWs reported consistent condom use [151], whilst in Kenya from 1990–93, an intervention study by Amadora-Nolasco et al. found that 23% of 135 FSWs reported consistent condom use [147]. There are a number possible reasons for this observation and it may reflect socio-economic factors in Papua New Guinea [16, 29, 42, 147] and in Africa [108, 150, 175, 176].

Disturbingly, the overall pattern of condom use in FSWs with their regular sexual partners showed a different picture with nearly all studies in PNG, Asia and Africa reporting significantly lower rates [16, 55, 58, 80, 99, 134, 146-148, 150-152]. This behaviour is besides the fact that FSWs in these studies, and our study, had sufficient knowledge regarding transmission through sexual contact (99% in our study) and prevention through condom use (67% in our study), but rarely translate this knowledge into protective behaviours where regular sexual partners are concerned. Inconsistent condom use observed across various countries may suggest possible associations with cultural factors [42, 176-178] and trust [179-181] surrounding the perception that regular sexual partners may be at low risk.

- 129 - 4.7 Weaknesses

Our study has a number of weaknesses. Firstly, this study was conducted a number of years ago, however the data obtained provides a baseline for future work. Secondly, the sample size was small, however the confidence intervals were reasonably tight. Thirdly, we used a convenience sample because other sampling methods were not possible in the environment at the time of the study. There is the possibility that this might limit the generalisability of the findings to represent all FSWs in Port Moresby, however other studies have reported consistent findings. Finally, we did not keep records of the actual number of the FSWs we asked to participate in the survey however, we believe about 80% agreed.

4.8 Strengths, conclusion and recommendations

Overall, the study has highlighted areas where change is needed in this group. We therefore recommend increased efforts in behaviour change through empowerment strategies targeting FSWs. More often than not, the clients and regular sexual partners of FSWs are often overlooked in intervention programs. We believe this is long overdue and recommend urgent behaviour change education programs targeting men.

- 130 -

CHAPTER 5

A CROSS SECTIONAL STUDY OF REPORTED SYMPTOMS FOR SEXUALLY TRANSMITTED INFECTIONS

- 131 - 5.1 Co-authors and citation

L. Bauai, A. Masta, P.J. Rooney, M. Paniu, M. Sapuri, L. Keogh, J. Kaldor, C.K. Fairley — Sexual Health 2010; 7(1):71-6.

5.2 Abstract

Background : Sexually transmitted infections (STIs) are common in female sex workers (FSWs), most of which are asymptomatic and therefore underreported. Our aim was to determine the sensitivity and specificity of reported symptoms obtained via questionnaire, augmented with a urine leukocyte esterase (LE) test for the detection of Chlamydia trachomatis ( Ct ), Neisseria gonorrhea (Ng ) and Trichomonas vaginalis ( Tv ) detected using polymerase chain reaction (PCR). Methods : In November 2003, a cohort of FSWs was screened for STIs and completed a questionnaire. Results : We enrolled 129 FSWs (90% participation rate) of whom 48 (37%), 30 (23%) and 53 (41%) were diagnosed with Ng, Ct and Tv respectively by PCR. Of those diagnosed with any of these infections, 78% reported anogenital symptoms and of those without infections, 28% reported symptoms. Anogenital symptoms were present in over 50% of FSWs. Genital odour (present in 26%), lower abdominal pain (present in 29%), dysuria (present in 19%) had a sensitivity around 50%, specificity >80%, and all were significantly associated with positive PCR results for individual organisms, however the sensitivity of these symptoms to detect the presence of any positive PCR result (Ct, and/or Ng and/or Tv) was low ( <50%). When a leukocyte esterase (LE) urine dipstick test of greater than one was combined with the presence of three reported symptoms the sensitivity was 86%, specificity of 73% and a positive predictive value (PPV) of 72%; a better predictor of infections. Conclusions: Our findings suggest that the use of reported symptoms to predict STIs in FSWs is of limited use. However, an approach that incorporates an LE urine dipstick result greater than one, and multiple symptoms, may be useful for screening infections and a feasible option among FSWs in resource constrained settings.

Keywords : Female sex workers; Sexually transmitted infections; Reported Symptoms, Leukocyte esterase test; Screening, Port Moresby; Papua New Guinea

- 132 - 5.3 Introduction

Sexually transmitted infections (STIs) have been reported to be common among female sex workers (FSWs) from countries with limited access to laboratory testing facilities, materials and health care [55, 58, 127, 182]. Despite several approaches to detect STIs in these settings, active case detection remains problematic [127]. Sex workers in particular have often reported low genital symptoms due to factors including the asymptomatic nature of many STIs [153]. In Papua New Guinea, STIs are widespread [41, 55-61] and estimated to be among the highest in the Asia Pacific Region [36, 45, 62]. Preventable and curable STIs are the most prevalent, but often under diagnosed, underreported, less well documented and therefore inadequately treated [8, 23, 36, 56]. Studies in PNG show that the proportion of FSWs with Trichomonas vaginalis ranges from 33–51%, Neisseria gonorrhea from 21–36%, Syphilis from 24–32% and Chlamydia trachomatis 19–31% [55, 58]. Over 74% of the FSWs had at least one STI and mixed infections were common in about 45% of the cases [55, 58]. Untreated and high rates of STIs increase disease burden and make HIV transmission far more efficient [63].

One approach that has been recommended by the World Health Organization (WHO) for countries with limited resources is to use the syndromic management approach through clinical algorithms to identify those at risk of STIs [183]. However, because the recognition of symptoms differs in different groups, and because some STIs may be present with few or rather vague symptoms [184-186], individuals may not recognise that they have them, and therefore do not access treatment services.

To date, no study has assessed the link between reported symptoms augmented with a leukocyte esterase urine test and Ng, Ct and Tv among FSWs in Port Moresby. The aim of our study was to assess the significance of reported symptoms augmented with leukocyte esterase urine test results greater that one for FSWs with laboratory confirmed Ng, Ct and Tv .

- 133 - 5.4 Methods

This was a cross-sectional survey undertaken in November 2003 among female sex workers in Port Moresby. Through existing program and peer contact, we invited FSWs from 12 sites, that had been previously identified as areas where FSWs solicit their clients, to participate in the survey. The survey was conducted at the School of Medicine and Health Sciences in Port Moresby. We provide free transport to this venue. Female sex workers were eligible to participate in the current survey if they were 18 years of age or older, had sold sex in the last month, not currently enrolled into similar study and operated within the 12 sites previously identified by a mapping study that was carried out earlier in May 2003 [91]. Informed consent was obtained from all FSWs by thumbprint.

The FSWs were interviewed by research assistants using a structured questionnaire about their past STI, current symptoms and sexual practices. The interviews were conducted at a private setting at the School of Medicine and Health Sciences to encourage responses to these sensitive questions. The interviews lasted approximately 35 minutes. A first-catch urine, a self-collected vaginal swab and blood samples were obtained. The urine samples were tested for white blood cell enzymes using the leukocyte esterase (LE) urine dipstick test (Qiagen, Melbourne, Australia). The blood samples were tested for Syphilis (VDRL and TPHA tests) and HIV (Serodia and Capillus tests). Self-collected vaginal samples were tested for Chlamydia trachomatis (Ct ), Neisseria gonorrhea (Ng) and Trichomonas vaginalis ( Tv ) using PCR. The specimens were processed as described below. FSWs were provided free presumptive treatment. All FSWs received HIV/STI information, condoms and lubricants but no payment was offered.

A Sample processing

The urine samples were analysed using a leukocyte esterase dipstick test (Qiagen, Melbourne, Australia). The dipstick changes colour depending on the concentration of white blood cell enzymes in the urine on a scale of negative, trace, 1+, 2+, 3+, thus indicating the likelihood of an infection. This was done in the laboratory at the School of Medicine and Health Sciences in Port Moresby.

- 134 - The vaginal and blood samples were directly placed in a cryovial and frozen at -80º Celsius at the School of Medicine and Health Science. Samples that required detection of STIs using primer-specific polymerase chain reaction (PCR) technique were later transported to the Papua New Guinea Institute of Medical Research in Goroka. Self- collected vaginal swabs were rinsed with 5ml of PBS buffer (Orgenics Ltd, Yvane, Israel) and DNA extracted using Pure DNA Extraction Kit (Bioman Scientific Co. Ltd, Taipei, Taiwan). The samples were then analysed for Chlamydia trachomatis ( Ct ), Neisseria gonorrhea (Ng ) and Trichomonas vaginalis ( Tv ) using Applied BioSystem GeneAmp PCR System 9700 (Geneworks, Adelaide, Australia). Cell suspensions from blood samples were centrifuged and DNA was extracted using lysis buffer solution with QIAmp-DNA Blood Mini Kit (Qiagen, Melbourne, Australia). They were analysed for Syphilis using Hexagon Syphilis Diagnostic Kits (Human, Weisebaden, Germany) with standard VDRL (Venereal Disease Research Laboratory) tests and confirmed using TPHA (Treponema Pallidum Haemagglutination) assayed according to the standard procedure (TPHA: Murex Biotech). Human immunodeficiency virus (HIV) was analysed using Hexagon HIV Diagnostic Kits (Human, Wiesbaden, Germany). All samples were re-screened using Serodia (Fujeribio, Japan). Repeat reactive samples were sent to the Central Public Health Laboratory (CPHL) in Port Moresby for confirmatory tests using Capillus (Human, Wiesbaden, Germany). Syphilis and HIV were analysed at the School of Medicine and Health Science in Port Moresby.

B Statistical analysis

We entered and analysed the data using the Statistical Package for the Social Sciences 15.0 for Windows (SPSS Inc., Chicago, IL, USA). For each of the infections, we used those who tested negative for each infection as a comparison group. We calculated odds ratios (OR) and 95% confidence intervals (CI) to determine the association between each infection and a range of reported symptoms and LE test results. Sensitivity and specificity were calculated for a range of symptoms, symptom groups and LE test results.

The study was approved by the Research Committee of the School of Medicine & Health Sciences, Port Moresby, and the Medical Research Advisory Committee,

- 135 - National Department of Health, Papua New Guinea, and conducted in collaboration with, and at, the School of Medicine & Health Sciences, Port Moresby, which participates in research projects.

5.5 Results

One-hundred-and-forty-three FSWs from 12 sites across Port Moresby were invited to participate in the survey. Of those invited, 129 (90% participation rate) agreed and participated in the survey. They ranged in age from 18 to 40 years (mean age = 23.2) and most (74.4%) were between 18–25 years of age.

The proportion of FSWs with STIs and HIV is shown in Table 5.1. The proportion of FSWs with HIV was 16.3%, with Syphilis was 33.3%, with Chlamydia trachomatis (Ct ) was 23.3% with Neisseria gonorrhea (Ng ) was 37.2% and with Trichomonas vaginalis (Tv ) was 41.0%.

in Port Moresby with STIs ⁿ ٭ Table 5.1. Number and proportion of FSWs and HIV

STIs Number (N=129) % 95% CI

HIV 21 16.3 10- 23

Syphilis 43 33.3 26-42

Chlamydia trachomatis 30 23.3 16-31

Trichomonas vaginalis 53 41.0 33-50

Neisseria gonorrhea 48 37.2 29-46

Ctª/Ng 51 39.5 31-48

Ct/Ng and/or Tvº 58 45.0 36-54

Any of (all) infections 103 79.1 73-87

ª Chlamydia trachomatis. Neisseria gonorrhoea. º Trichomonas vaginalis. .Female sex workers ٭ ⁿ Sexually transmitted infections.

- 136 - The reported symptoms of FSWs and the association between the symptoms and different STIs are shown in Table 5.2. Many symptoms were common and over 50% of FSWs had at least one symptom. Symptoms were significantly associated with one or more of C hlamydia trachomatis (Ct ), Neisseria gonorrhea (Ng ) or Trichomonas vaginalis ( Tv ), but itching or irritation was found 3.0 times likely to be associated with Trichomonas vaginalis (Tv ) compared to 7.9 with Chlamydia trachomatis (Ct ) and 3.8 times with Neisseria gonorrhea (Ng ). This suggests that itching or irritation is associated with all three STIs.

- 137 - Table 5.2. Analysis of symptoms reported via questionnaires by female sex workers (FSWs) diagnosed with and without Chlamydia trachomatis (Ct), Neisseria gonorrhea (Ng), Trichomonas vaginalis (Tv) and (Ct, Ng and/or Tv) in Port Moresby CI, confidence interval; OR, odds ratio

Reported symptoms Ct No Ct OR Ng No Ng OR Tv No Tv OR Ct, Ng or Tv No Ct, Ng or OR (n =30) (n=99) (95% CI) (n =48) (n=81) (95% CI) (n =53) (n=76) (95% CI) (n =58) Tv (n=71) (95% CI)

Anogenital discharge Yes 15 (50%) 19 (19%) 4.2 (1.8-10.1) 23 (48%) 11 (14%) 5.9 (2.5-13.7) 25 (47%) 9 (12%) 6.6 (2.8-16.0) 26 (45%) 8 (11%) 6.4 (2.6-15.5) No 15 (50%) 80 (81%) 25 (52%) 70 (86%) 28 (53 %) 67 (88%) 32 (55 %) 63 (89%)

Genital offensive odour Yes 16 (53%) 17 (17%) 5.5 (2.3-13.4) 27 (56%) 6 (7%) 16.1 (5.9-44.1) 27 (51%) 6 (8%) 12.1 (4.5-32.7) 27 (47%) 6 (9%) 9.4 (3.5-25.2) No 14 (47%) 82 (83%) 21 (44%) 75 (93%) 26 (49%) 70 (92 %) 31 (53%) 65 (91%)

Itching or irritation Yes 17 (57%) 14 (14%) 7.9 (3.2-19.9) 19 (40%) 12 (15%) 3.8 (1.6-8.8) 19 (36%) 12 (16%) 3.0 (1.3-6.9) 19 (33%) 12 (17%) 2.4 (1.0-5.5) No 13 (43%) 85 (86%) 29 (60%) 69 (85%) 34 (64%) 64 (84%) 39 (67%) 59 (83%)

Lower abdominal pain, pelvic tenderness Yes 17 (57%) 20 (20%) 5.2 (2.2-12.4) 24 (50%) 13 (16%) 5.2 (2.3-11.9) 24 (45%) 13 (17%) 4.0 (1.8-9.0) 24 (41%) 13 (18%) 3.1 (1.4-7.0) No 13 (43%) 79 (80%) 24 (50%) 58 (84%) 29 (55%) 63 (83%) 34 (59%) 58 (82%)

Dysuria Yes 16 (53%) 8 (8%) 13.0 (4.7-36.0) 16 (33%) 8 (10%) 4.6 (1.8-11.7) 16 (30%) 8 (10%) 3.7 (1.4 -9.4) 17 (29%) 7 (10%) 3.8 (1.4-9.9) No 14 (47%) 91 (92%) 32 (67%) 73 (90%) 37 (70%) 68 (90%) 41 (71%) 64 (90%)

Vaginal spotting/bleeding after intercourse Yes 9 (30%) (6%) 6.6 (2.1-20.7) 11 (23%) 4 (5%) 5.7 (1.7-19.2) 9 (17%) (8%) 2.4 (0.8-7.2) 11 (19%) 4 (6%) 3.9 (1.2-13.1) No 21 (70%) 93 (94%) 37 (77%) 77 (95%) 44 (83%) 70 (92%) 47 (81%) 67 (94%)

- 138 - Reported symptoms Ct No Ct OR Ng No Ng OR Tv No Tv OR Ct, Ng or Tv No Ct, Ng or OR (n =30) (n=99) (95% CI) (n =48) (n=81) (95% CI) (n =53) (n=76) (95% CI) (n =58) Tv (n=71) (95% CI)

Rashes in the genital or anal area Yes 4 (13%) 5 (5%) 2.9 (0.7-11.6 4 (8%) 5 (6%) 1.4 (0.4-5.4) 6 (11%) 3 (4%) 3.1 (0.7-13.0) 6 (10%) 3 (4%) 2.6 (0.6-10.6) No 26 (87%) 94 (95%) 44 (92%) 76 (94%) 47 (89%) 73 (96%) 52 (90%) 68 (96%)

Fever, fatigue, lack of energy Yes 7 (23%) 3 (3%) 9.7 (2.3-40.6) 9 (19%) 1(1%) 18.5 (2.3-151) 9 (17%) 1(1%) 15.3 (1.9-125) 9 (16%) 1 (1%) 12.9 (1.6-104.8) No 23 (77%) 96 (97%) 39 (81%) 80 (99%) 44 (83%) 75 (99%) 49 (84%) 70 (99%)

Genital ulcers/sores, lumps, blisters, warts Yes 2 (7%) 3 (3%) 2.3 (0.4-14.4) 6 (13%) 3 (4%) 3.7 (0.9-15.6) 4 (8%) 1 (1%) 6.1 (0.7-56.4) 5 (9%) 0 (0%) nc No 28 (93%) 96 (97%) 42 (87%) 78 (96%) 49 (92%) 75 (99%) 53 (91%) 71 (100%)

Dyspareunia Yes 1 (3%) 0 (0%) nc 1 (2%) 0 (0%) nc 1 (2%) 0 (0%) nc 1 (2%) 0 (0%) nc No 29 (97%) 99 47 (98%) 81 (100%) 52 (98%) 76 (100%) 57 (98%) 71 (100%) (100%)

Any symptoms Yes 27 (90%) 38 (38%) 14.4 (4.1-50.9) 44 (92%) 21 (26%) 31.5 (10.1- 98) 41 (72%) 24 (32%) 7.4 (3.3 -16.6) 45 (78%) 20 (28%) 8.8 (3.9-19.7) No 3 (10%) 61 (62%) 4 (8%) 60 (74%) 12 (28%) 52 (68%) 13 (22%) 51 (72%)

٭ Vaginal discharge syndrome Yes 24 (80%) 37 (37%) 6.7 (2.5-17.9) 39 (81%) 22 (27%) 11.6 (4.8-27.9) 41 (77%) 20 (26%) 9.6 (4.2 – 21.7) 42 (72%) 19 (27%) 7.2 (3.3-15.7) No 6 (20%) 62 (63%) 9 (19%) 59 (73%) 12 (23%) 56 (74%) 16 (28%) 52 (73%)

LE * Yes (++/+++) 3 (10%) 32 (32%) .2 (.07 - .82) 11 (23%) 24 (30%) 0.7 (0.3 -1.6) 25 (47%) 10 (13%) 5.9 (2.5-13.9) 25 (43%) 10 (14%) 4.6 (2.0-10.8) No ( Neg./trace/+) 27 (90%) 67 (67%) 37 (77%) 57 (70%) 28 (53%) 66 (87%) 33 (57%) 61 (86%)

.VDS is based on vaginal discharge, vaginal irritation, offensive odour and pain on intercourse ٭ .Leukocyte esterase. nc Not calculable *

- 139 - Table 5.3 shows the sensitivity, specificity, positive predictive vale and proportion of individuals who would be treated if a specific symptom was used to detect one of Chlamydia trachomatis (Ct ), Neisseria gonorrhea (Ng ) and/or Trichomonas vaginalis (Tv ). Only four clinical symptom groups detected over 50% of infections and required between 27% and 54% of individuals to be treated. The best performing symptom groups were any three symptoms and the presence of Trichomonas vaginalis (Tv ) that had a sensitivity of 92%, specificity 74% with a PPV 71% and LE test greater than +1 in the presence of CtNgTv that had a sensitivity of 86%, specificity of 73% with a PPV of 72%.

- 140 - Table 5.3. Sensitivity 1, Specificity 2, Positive Predictive value (PPV)3 and proportion screened for specific symptoms and leukocyte esterase urine test to detect any of Chlamydia trachomatis (Ct), Neisseria gonorrhea (Ng), Trichomonas vaginalis (Tv) and (Ct, Ng and/or Tv)

Reported symptoms, LE > +1 and Proportion Sensitivity Specificity PPV Sensitivity Specificity PPV Sensitivity Specificity PPV Sensitivity Specificity PPV symptom group treated % % Ct % Ct % % Ng % Ng % % Tv % Tv % % CtNgTv % CtNgTv %

Anogenital discharge 26 50 84 44 48 86 67 47 88 73 49 89 76

Genital offensive odour 26 53 83 48 56 93 69 51 92 81 47 91 81

Itching or irritation 24 57 86 55 40 85 61 36 84 62 33 83 61

Lower abdominal pain, pelvic 29 57 80 46 50 84 64 45 83 65 41 81 65 tenderness

Dysuria 19 53 91 66 33 90 66 30 89 66 29 90 70

Vaginal spotting or bleeding after 12 30 94 60 23 95 73 17 92 60 19 94 73 sexual intercourse

Rashes in the genital or anal area 7 13 95 44 8 95 44 11 96 66 10 95 66

Fever, fatigue, lack of energy 8 23 97 70 19 98 90 17 98 90 16 99 90

Genital ulcers/sores, lumps, blisters, 4 7 97 40 12 96 86 8 98 80 9 100 100 warts

Dyspareunia 1 3 100 100 2 100 100 2 100 100 2 100 100

LE > +1 (++/+++) 27 10 67 9 23 70 31 47 87 71 43 85 71

Any three symptoms statistically 47 77 62 38 81 73 59 77 74 67 72 73 68 associated with infections

Any five symptoms statistically 51 87 60 39 85 69 57 81 70 65 76 70 68 associated with infections

- 141 - Reported symptoms, LE > +1 and Proportion Sensitivity Specificity PPV Sensitivity Specificity PPV Sensitivity Specificity PPV Sensitivity Specificity PPV symptom group treated % % Ct % Ct % % Ng % Ng % % Tv % Tv % % CtNgTv % CtNgTv %

LE > +1 (++/+++) and any three 54 93 59 41 75 63 59 92 74 71 86 73 72 symptoms statistically ass ociated with infections

1Sensitivity = true positives/(true positives + false negatives) X 100. 2Specificity = true negative/(true negative + false positives) X 100. 3Positive predictive value = true positives/(true positives + false positives) X 100.

- 142 - 5.6 Discussion

In this study, anogenital symptoms were present in over 50% of FSWs and one of Ct , Ng or Tv was present in 45% of them. Almost one-quarter of individuals with one of these infections reported no symptoms. Most symptoms were significantly associated with infections, however their sensitivity to detect ( Ct, Ng and/or Tv ) was low ( <50%). This suggests that reported symptoms cannot be used to predict the presence of most of these infections, an observation that has been made previously. Based on vaginal discharge syndrome, about 28% of cases for ( Ct, Ng , and or Tv ) would have missed treatment and 27% would have been treated in the absence of infections [186, 187]. The LE urine dipstick result of greater than one in the presences of three or more reported symptoms was a good predictor of infections with sensitivity to detect ( Ct, Ng and/or Tv ) >80%, specificity >70% and PPV >70%. LE urine dipstick result greater than one in the presence of multiple reported symptoms could be useful to predict the presence of (Ct, Ng and/or Tv ), particularly Tv, and may be a feasible option for screening FSWs in resource constrained settings.

Previous studies have reported the presence of common STIs in an absence of symptoms in FSWs ranging from 47 [153, 188] –77 % [189], to 30 [153, 188] –50% [189]. A 1997 study by Mulanga-Kabeya et al. among 284 FSWs in Mali reported that of the 65–77% FSWs infected with several common STIs, about 50% were asymptomatic [189]. Another 2000 study by Desia et al . among 118 FSWs in India reported that of the 47% FSWs infected with Ct, Ng and Tv , about 30–40% were asymptomatic for Ct and Ng and missed treatment [153]. Based on vaginal discharge syndrome about 90% and 80% were treated in an absence of Ct and Ng respectively. Of those without infections, 40–50% were labelled infected and treated [153]. However in our study, we found 28% of FSWs infected but asymptomatic, and 27% without infections but labelled infected; an observation slightly lower compared to those reported in other studies. This implies that almost one-quarter of FSWs in our study would have missed treatment, whilst one-quarter would have received unnecessary treatment. Previous studies have reported varying degrees of findings between a positive LE urine dipstick result and infection among women [186, 187, 190-192]. A study by Obunge et al. among 1417 sexually active adolescent females in Nigeria found the LE

- 143 - urine dipstick test not sensitive but specific, and correctly identified one-third of Ng and Tv with 46.4% positive predictive value for Tv [193] as observed in Tanzania [190]. In Kenya and Tanzania, it predicted vaginitis and not cervical infections [187, 190], whilst in Zaire it predicted cervical infections [186]. In our study we found the LE urine dipstick test less sensitive but specific as reported elsewhere [193], with only one-tenth of Ct , one-quarter of Ng and almost half of Tv infections correctly identified. When the LE urine dipstick and reported symptoms was used, we found that discharge, odour, dysuria and lower abdominal pain correctly identified over 50% of infections. The sensitivity of these symptoms was above 80% and sensitivity above 70% for Ct, Ng , and or Tv . In Nigeria, only itch or odorous discharge correctly identified 50% Tv , 67% Ng and 37.5% Ct infections with specificity of 79% for Tv and Ng [193], whilst in Jamaica, odour, spotting after sex and friable cervix predicted Ct, Ng, or Tv infections with 46% specificity and 58% sensitivity [192]. Our findings imply that the LE urine dipstick test and symptoms performed better in predicting infections in FSWs. There are a number of possible explanations for this observation in our study. Perhaps, a combination of high prevalence of dysuria, vaginal and cervical infections in our study population may explain the differences observed compared to other studies that used the LE test.

5.7 Weaknesses

Our study has a number of weaknesses. Firstly, the study was conducted in 2003 and it is possible that some of the epidemiology of STIs in FSWs in PNG may have changed. Secondly, our data on symptoms were based on questionnaire elicited responses and did not include external genital or a speculum examination, although in chaotic outreach settings where these algorithms are used examinations would also be possible. Finally, we used the LE test as a surrogate marker of genital tract inflammation. While we did find it useful, it has a number of weaknesses that leads to false positive and negative results including reading the test outside of the recommended time frames, increased urinary specific gravity or altered colour of the urine from other substances [194]. Notwithstanding these limitations it improved STI detection if combined with symptoms in our study.

- 144 - Although the LE test alone has been found to perform well in the presence of vaginal infections ( Tv , vaginal leucocytes), it is generally not specific for viable infectious bacteria or able to determine microbial concentration thresholds and may not produce sensitive results in individuals with cervical infections. It’s usefulness in reliably and accurately determining whether or not an infection exists is greatly limited, and therefore generally not considered to be an adequate diagnostic tool.

The rationale for LE testing of urine was based on the hypothesis that Ct/Ng may also be present in the urethra of a high proportion of FSWs who have dysuria as well as multiple STIs. That said, the LE test provides a rapid result and can infer the presence of an infection that can allow for prompt initiation of further investigations or treatment. It can also serve as a definitive test for other conditions. It is easy to perform, non- invasive and inexpensive.

5.8 Strengths, conclusion and recommendations

Our study has a number of strengths. Firstly, our findings suggest that reported alone, symptoms in predicting and managing STIs may be of limited use and inappropriate in FSWs as reported by others [153, 195-198]. Diagnosis based on reported symptoms has been reported to lead to unnecessary and unaffordable treatment which may lead to antibiotic resistance; a great concern indeed. Secondly, in an absence of laboratory testing or pelvic examination, our findings represent an affordable alternative method of routine screening for STIs among FSWs in resource-poor settings, although the method is likely to leave some women with infection missed due to the high false positive rate. That said, this method is likely to optimise contact with FSWs who are unlikely to access STI testing and treatment services. However it must be stressed that in an absence of a laboratory diagnosis, due care must be taken with prescribing antibiotics by health care workers. Under this condition, stringent antibiotic treatment protocols for STIs must be put in place to reduce the possible misuse of antibiotics, plus diminish the view that it is alright to take antibiotics without adequate diagnosis. We recommend that this method is further evaluated in similar settings to better identify FSWs in need of further examination and treatment.

- 145 - CHAPTER 6

PERIODIC PRESUMPTIVE TREATMENT (PPT) OF COMMON CURABLE SEXUALLY TRANSMITTED INFECTIONS (STIs) AMONG FEMALE SEX WORKERS IN PORT MORESBY: MEASURING STI INCIDENCE AND PPT EFFECTS

- 146 - 6.1 Co-authors and Citation

L. Bauai, A. Masta, P.J. Rooney, M. Paniu, M. Sapuri, L. Keogh, J. Kaldor and C.K. Fairley. Submitted to Australian and New Zealand Journal of Public Health — 05/02/2010.

6.2 Abstract

Sexually transmitted infections (STIs) are common in female sex workers (FSWs). Our aim was to determine if three-monthly periodic presumptive treatments (PPT) would reduce the incidence of STIs in FSWs in Port Moresby. This was a cohort study conducted between November 2003 and September 2004. Female sex workers were provided with information about the study and informed consent was obtained. They were counselled and interviewed using a questionnaire. Testing by PCR for Chlamydia trachomatis (Ct ), Neisseria gonorrhea (Ng) , Trichomonas vaginalis (Tv) and serology for HIV were carried out at baseline and at 10 months. Each participant was given three- monthly (0 month, 3 months, 6 months and 9 months) oral doses of 2g amoxicillin, 1g probenecid, 625mg X 2 augmentin and 1g Azithromycin via direct observed therapy. We administered “once only” 2g Tinadazole per day over three days at the nine-month visit. The cohort consisted of 129 FSWs at baseline and 71 FSWs (55.1%) completed follow-up at 10 months. Among the 71 there was a significant decline in the proportion with Ct from 38% to 16% ( P = 0.001), Ng from 56% to 23% (P = 0.000) and Tv from 62% to 29.6% ( P = 0.000) between baseline and the 10-month visit. Of the 71 FSWs who were seen at both visits, 11 were HIV positive at T=0, and 15 were HIV positive at T=10. The PPT strategy was statistically effective in reducing STIs in the short-term but STI rates rebounded rapidly and even with three-monthly PPT, a significant number of HIV infections occurred. If PPT is to be very effective in FSWs where the force of infection is so high, then 100% condom use with clients and very high rates of partner notification, or 100% condom use, would be required if a very low incidence and prevalence of STI were to be achievable.

Keywords: periodic presumptive treatment; condom use; HIV; sexually transmitted infections; cohort study; female sex workers; Port Moresby; Papua New Guinea.

- 147 - 6.3 Introduction

Human immunodeficiency virus (HIV) was first reported in Papua New Guinea in 1987 [36] and increasing at an annual rate of 30% since 1997 according to UNAIDS [45]. Around 1998, the prevalence of HIV was estimated to be 0.34% among the adult population in Port Moresby [36], 0.37% in pregnant women and 0.19% among the adult population in the rest of the country [45]. However by the turn of 2004, the prevalence of the infection has nearly quadrupled in pregnant women to 1.4% [51]. More recent data indicate that the prevalence of HIV within the general population has risen nearly by seven-fold to 1.5% since 1997, and supports heterosexual transmission [52]. Human immunodeficiency virus (HIV) transmission can enter communities through high-risk core groups such as female sex workers (FSWs). If such individuals have a high prevalence of STIs and use condoms inconsistently, then HIV acquisition and transmission may occur more rapidly; both are common in Papua New Guinea.

Studies of FSWs in Papua New Guinea have reported high levels of sexually transmitted infections (STIs) including HIV in addition to low and inconsistent condom use. The reported rates for the four most common STIs in FSWs were in the range of 33–51% for Trichomonas vaginalis, 21–36% for Neisseria gonorrhea, 24–32% for Syphilis and 19–31% for Chlamydia trachomatis, and HIV was 0–17% [55, 58]. In these studies, nearly 78% tested positive for at least one of the four STIs and up to 45% had multiple infections. Reported condom use among FSWs was low and inconsistent and ranged between 0–63% of their clients and 0–34% of their regular sexual partners [55, 58, 81]. In a 1988 study, 85% of 407 FSWs surveyed reported inconsistent condom use with clients and 34% reported they never used them [58]. In another study in 2001, none of the 211 FSWs surveyed reported consistent condom use with clients or regular sexual partners (RSPs). Of those who had RSPs, all reported never using condoms with these partners [55]. The predominant heterosexual mode of transmission, increasing rates of HIV in the general population and pregnant women, the high rates of STIs and inconsistent use of condoms among FSWs all suggest that HIV transmission is likely to increase, particularly in FSWs.

- 148 - Adequate strategies that reduce the prevalence of STIs in FSWs, and in so doing reduce the risk of HIV acquisition and transmission, are therefore of great importance. A number of strategies have been evaluated and proven effective to reduce STIs among FSWs and they include targeted condom policies, peer education and empowerment and other elements of STI controls [76, 199]. However, in settings where laboratory facilities for regular screening are scarce, effective STI control has proven challenging [153, 185-187, 197, 198]. Alternative strategies that provide immediate treatment for FSWs in these settings are therefore important. Recently, one such strategy that has been explored is the use of periodic presumptive treatment (PPT) [199]. Periodic presumptive treatment (PPT) is the treatment of individuals presumed infected with one or more STIs, without attempting to make an individual diagnosis. The strategy is usually targeted at a core group of individuals with known high STIs, such as sex workers, and typically involves the administration of a single, oral dose of azithromycin or a combination of cefixime and azithromycin at regular intervals [199].

Our aim was to determine if three-monthly PPT would be feasible to reduce the prevalence of STIs among FSWs in PNG, a setting where the strategy has not yet been evaluated. If this strategy were able to reduce the prevalence of STIs, then it could potentially also reduce HIV transmission [128].

6.4 Methods

This was a cohort study of FSWs in Port Moresby, the national capital district of Papua New Guinea, carried out between November 2003 and September 2004.

We invited FSWs to participate in the study by asking peer educators who had participated in previous studies to advertise the study. The peer educators were from 12 sites that had been previously identified through a study describing sex work in Port Moresby and carried out in May 2003 [91]. The FSWs were invited to attend a day’s workshop about the study. Female sex workers were eligible to participate if they were 18 years or older, had received money for sex in the last month, not allergic to penicillin, had not taken antibiotics in the last month, were not currently enrolled in a similar study and intended to remain in Port Moresby for 10 months or more. We

- 149 - organised a preparation day that taught procedures of the study, how to collect vaginal specimens and obtained informed consent by thumbprint from FSWs for enrolment. We provided each FSW with a colour coded card that indicated specific dates of the testing and treatments.

In early November 2003 and at the end of September 2004, the women were invited to attend the School of Medicine & Health Sciences, Port Moresby, where they were pretest counselled and interviewed about their socio-demographic characteristics, history of STIs, current symptoms and sexual behaviours by trained staff. Transport was provided. We also obtained serum and self-collected vaginal specimens to detect Ct , Tv , Ng and HIV. These specimens were repeated again at 10 months where the FSWs were invited to attend the above venue to obtain serum and vaginal specimens as described above. All FSWs were asked to return for their results. They were encouraged to notify their regular sexual partners if test results were positive. The specimens were processed as described below. We provided HIV/STI information, condoms and lubricants. No payment was offered.

A Treatments

We provided presumptive treatment on four occasions (T=0 [Nov 03], T=3 months [Feb 04], T=6 months [May 04], T=9 months [Aug 04]). We administered the first treatment after the specimens were collected at the School of Medicine & Health Sciences, Port Moresby. Subsequent treatments (T=3 months [Feb 04], T=6 months [May 04], T=9 months [Aug 04]) were administered through an outreach by visiting the women in their respective sites and workplaces. The treatment was based on the standard STI Treatment Guidelines for PNG which included an oral start dose of Amoxicillin 2g, Probenecid 1g, Augmentin 625mg X 2 and 1g Azithromycin. We also administered Tinadazole 2g/day for three days at the nine-month visit. The medication was provided by the National Department of Health (NDH), HIV/STI branch in Port Moresby, which we pre-packed in dose set boxes. We administered all medication via direct observation treatment (DOTS).

- 150 - B Processing of specimens

The specimens that required PCR detection of STIs were directly placed in a cryovial and frozen at -80º Celsius at the School of Medicine & Health Sciences, Port Moresby, until they were transported to the Papua New Guinea Institute of Medical Research (PNGIMR) in Goroka for analysis. Self-collected vaginal specimens were rinsed with 5ml of PBS buffer (Orgenics Ltd, Yvane, Israel) and DNA extracted using Pure DNA Extraction Kit (Bioman Scientific Co. Ltd, Taipei, Taiwan). The specimens were then analysed for Ct, Tv and Ng using primer-specific polymerase chain reaction (PCR) technique using Applied BioSystem GeneAmp PCR System 9700 (Geneworks, Adelaide, Australia). Cell suspensions from blood specimens were centrifuged and DNA was extracted using lysis buffer solution with QIAmp-DNA Blood Mini Kit (Qiagen, Melbourne, Australia). Human immunodeficiency virus (HIV) was analysed using Hexagon HIV Diagnostic Kits (Human, Wiesbaden, Germany). All specimens were re-screened using Serodia (Fujeribio, Japan). Repeat reactive specimens were sent to the Central Public Health Laboratory (CPHL) in Port Moresby for confirmatory tests using Capillus (Human, Wiesbaden, Germany). Analysis of HIV was carried out at the school of Medicine & Health Science, Port Moresby.

A recent Gonococcal Sensitivity study conducted by PNGIMR in 2005 in collaboration with the NDH, showed that Neisseria gonorrhea isolates were sensitive to augmentin, azithromycin, spectinomycin, ceftriaxone, erythromycin and ciprofloxacin, with the exception of one isolate found to be resistant to ciprofloxacin [Source: Gonococcal Drug Sensitivity Study Final Report PNGIMR, Oct 2006]. The study was approved by the Research Committee of the School of Medicine & Health Sciences, Port Moresby, and the Medical Research Advisory Committee, National Department of Health, PNG.

C Statistical analysis

We entered and analysed data from interviews and laboratory test results using SPSS (Statistical Package for the Social Sciences, Chicago, Illinois, USA) version 15.0. We performed McNermar test to determine change in the proportions of STIs overtime based on (P <0.05). We stratified condom use with individual STIs and identified its effects based on (P <0.05).

- 151 - 6.5 Results

A total of 143 FSWs attended the workshop, of whom 129 agreed to participate in the study and had baseline specimens collected in November 2003. Of the 129 FSWs, 58 dropped out of the study and 71 remained in the study until the final follow-up visit in September 2004 (55% follow-up rate). The 129 FSWs ranged in age from 18 to 40 years old (mean age = 23.2) and most (74.4%) were between 18–25 years of age. A total of 129, 117, 103 and 71 received presumptive treatment at T=0, T=3, T=6 and T=9 respectively, and all 71 who received the final treatment were tested at 10 months. Table 6.1 shows the proportion of FSWs with STIs and reported condoms at the baseline level (first) T=0 and follow-up level (final) T=10 visits of FSWs. Table 6.2 shows the proportion of FSWs with STIs, reported symptoms and condom use among 58 FSWs (dropouts) compared to 71 FSWs (follow-up) and at first (T=0) 2003 visit.

Table 6.1. STIs and reported condom use at first (T=0 months) 2003 and final (T=10 months) 2004 visits

STIs and reported T= 0 T = 0 T= 10 T=0 –T=10 P value for a condom use N=129 N=71 N=71 N=71 (%) difference N (%) N (%) N (%) N (%)

HIV 21 (16) 11 (15) 15 (21) 4 (6) 0.125

Chlamydia trachomatis 30 (23) 27 (38) 11 (15) 16 (22) 0.001

Trichomonas vaginalis 53 (41) 44 (62) 21 (30) 23 (32) 0.000

Neisseria gonorrhea 48 (37) 40 (56) 16 (22) 24 (34) 0.000

Condom use clients 43 (33) 16 (23) 29 (41) 13 (18) 0.011

Condom use RSP b 25 (19) 8 (11) 22 (31) 14 (20) 0.004

aMcNemar test. bRSP= regular sexual partner.

Among the 71 FSWs there was a statistically significant decline in bacterial STIs between the initial test and the one at 10 months (P<0.01). Of the 71 FSW who were seen at both visits, 11 were HIV positive at T=0, and 15 were HIV positive at T=15. There was a statistically significant increase in the proportion who reported using condoms always with clients, with 23% using condoms always at T=0, and 41% using

- 152 - condoms at T=10. For regular sexual partners, 11% reported using condoms always at T=0 compared to 31% at T=10 (P= 0.004).

Table 6.2 shows the characteristics predictive of STIs among 71 FSWs (follow-ups) and 58 FSWs (dropouts) at the first visit. Table 6.2 shows that the 71 FSWs who remained in the study were generally at high STI risk compared to the 58 who dropped out.

Table 6.2. Comparison of the characteristics of STIs prevalence, reported symptoms and condom use among 71 FSWs (follow-up) and 58 FSWs (dropouts) at first (T=0) 2003 visit

STIs, symptoms & condom use T= 0 T = 0 T = 0 P value for a N=129 N= 71 N=58 difference N (%) N (%) N (%)

HIV 21 (16) 11 (15) 10 (17) 0.256

Chlamydia trachomatis 30 (23) 27 (38) 3 (5) 0.000

Trichomonas vaginalis 53 (41) 44 (62) 9 (15) 0.000

Neisseria gonorrhea 48 (37) 40 (56) 8 (14) 0.000

Condom use clients 43 (33) 16 (23) 27 (47) 0.001

Condom use RSP 25 (19) 8 (11) 17 (29) 0.032

Anogenital discharge 34 (26) 23 (32) 11 (19) 0.008

Lower abdominal pain, pelvic 37 (29) 28 (39) 9 (15) 0.003 tenderness

Genital offensive odour 33 (26) 26 (38) 7 (12) 0.000

Itching or irritation 31 (24) 25 (35) 6 (10) 0.001

Dysuria 24 (17) 18 (26) 6 (10) 0.022

Vaginal spotting or bleeding after 15 (12) 11 (16) 4 (7) 0.087 sexual intercourse

Genital ulcers/sores, lumps, blisters, 5 (3) 3 (4) 2 (3) 0.313 warts

3 symptoms + cLE> (++/+++) 69 (53) 47 (66) 22 (38) 0.000

aMcNemar test. bRSP = regular sexual partner. cLE = Leukocyte esterase.

- 153 - 6.6 Discussion

In this study of periodic presumptive treatment (PPT) involving FSWs, there was a significant decline in Chlamydia trachomatis (Ct) , Neisseria gonorrhea (Ng ) and Trichomonas vaginalis (Tv) infections between the first 2003 (T=0) and final visit 2004 (T=10). What was surprising was that nearly one-third of individuals had become reinfected with at least one bacterial infection at 10 months, only one month after receiving effective treatment. A further disturbing finding was that of the 6% (4 of 60) of FSWs who were initially HIV negative at T=0, became HIV positive in just 10 months of follow-up. This data suggest that three-monthly PPT for bacterial STIs significantly reduces their prevalence, but that in this population the force of infection is so high that PPT is rapidly overwhelmed without 100% condom use and careful partner notification.

Periodic presumptive treatment has been shown to rapidly reduce the prevalence of bacterial STIs in FSWs [126-128, 182, 184, 200-206]. For instance, a study among 407 FSWs in a South African mining community between 1996 and 1997 that involved monthly counselling, STI screening and presumptive treatment with a 1g dose of azithromycin for bacterial STIs, showed that the intervention resulted in a significant reduction in Ng from 5.2% to 3.4 [p = 0.075], Ct from 6.6% to 3.5% [p= 0.005], Ng and/or Ct from 10.9% to 6.2% [P< 0.001] and genital ulcers from 5.8 to 1.3% [<0.001] [126].

Although periodic presumptive treatment has been shown to rapidly reduce the prevalence of bacterial STIs in FSWs, its effects have also been shown to be short lived with rates of infections rapidly rebounding to pre-intervention levels. Our study and other previous studies have reported consistent findings. A study among 1938 FSWs in the Philippines conducted between February–October 2001 that involved a single round of presumptive treatment (PT), condom promotion and STI screening at one month post-PT and seven months post-PT, showed that the intervention resulted in a significant decline in the prevalence of Ng and/or Ct [127]. Wi et al. reported that after one month post-PT, the prevalence of Ng and Ct declined by 47% in brothel-based sex workers (BSWs), by 39% in street-based sex workers (SSWs) and by 28% in registered

- 154 - sex workers (RSWs) with prevalence remaining low six months later for BSWs (p=0.001) and SSWs (p = 0.05), but had returned to pre-intervention levels for the other groups [127]. In another impact study of PPT on the rates of STIs and HIV among FSWs and the general population in Carletonville, South Africa, the study reported that PPT resulted in little or no change in the prevalence of Ng , Ct , Syphilis and HIV after 24 months of behaviour change and 18 months of monthly PPT [207]. The possible explanation of this observation points to inconsistent use of condoms, which has been commonly reported in settings where the rates of condom use are low [199]. The observation indicates that to sustain STI reduction in this group, 100% condom use [111, 112] must form an integral part of effective STI control. It also brings to light the importance of a comprehensive strategy that extends these services to the clients and RSPs of FSWs [76].

Periodic presumptive treatment in addition to condom use has also been shown to reduce HIV incidence in FSWs [128]. A study among 531 FSWs in Zaire in 1988 that involved condom use, monthly STI screening and treatment, showed that the intervention resulted in a significant increase in condom use from 11% to 68% over a 36 month period [p=0.003] and a decline in HIV-1 incidence from 11.7/100 women years during the first six months to 4.4/100 women years over the last six months [128]. However, a randomised double-blind, placebo-controlled trial among 890 FSWs in Nairobi conducted between 1998–2002 that involved monthly screening and azithromycin chemoprophylaxis showed that the intervention resulted in a significant reduction of the incidence of Ct, Tv , and Ng [P<.001], but no effect was found in the incidence of HIV-1, and HIV-1 did not decline [200]. Our study design did not allow us to determine if the rate of HIV declined, but during the period that PPT was used we observed a rate of HIV of seven per 100 person years.

6.7 Weaknesses

Our study has a number of weaknesses. Firstly, the study was conducted in 2003 and may be less relevant today, although STI and HIV rates remain high in FSWs. Another weakness of our study was that we did not have complete follow-up of the 129 FSWs, and those who were followed up were at higher risk of STIs than those who were not.

- 155 - This would bias our results towards not demonstrating an effect of PPT but despite this we still showed a reduction. It is, however, important to appreciate that the force of infection among the 58 FSWs who were not followed up at 10 months is likely to be significantly lower, and therefore PPT may have had a more pronounced effect in this group.

6.8 Strengths, conclusion and recommendations

The PPT strategy was statically effective in reducing STIs in the short-term but STI rates rebounded rapidly and, even with three-monthly PPT, a significant number of HIV infections occurred. If PPT is to be very effective in FSWs where the force of infection is so high, then 100% condom use with clients [111, 112] and very high rates of partner notification, or 100% condom use, would be required if a very low incidence and prevalence of STIs were to be achievable [76, 182, 199]. For this to happen, considerable resources will need to be invested in prevention programs that incorporate behaviour change and address high risk practices among FSWs and their clients, but with a particular focus on their RSPs whilst at the same time improving STI control services [76, 208]. Table 6.3 below is an example of a cost estimate to implement a prevention program among FSWs, their clients and RSPs.

- 156 - Table 6.3. HIV Prevention Program Bugdget

Component Project Budget (AUD)

Description Component 0.55 % Total

Activity Line Items Contri- AUD bution

AUD$ Variable FRQ Proportion Year 1

I. Staff Salaries Project Manager 1,050 Month 12.0 1 100% 12,600 Project Coordinator 1,000 Month 12.0 1 100% 12,000 Field/Research Officers 630 Month 12.0 2 100% 15,120 Counselor 650 Month 12.0 1 100% 15,120 Peer Educators Incentives (FSWs) 200 Month 12.0 3 100% 7,200 Total National Staff Salaries AUD 38% 69,840

II. Other professional fees Honoraria for resource persons (e.g. Behaviour Change Specialist, HIV Advisor) 1,500 Unit 4 1 100% 6,000 Evaluation consultancy 4,000 Trip 1 1 100% 4,000

Total Consultants AUD 5% 10,000

III. Supplies and Materials Office Supplies 200 Month 12 2,400 Field Supplies/publications /IEC leaflets/banners/stickers/posters 300 Month 6 1,800 Videos/photographs/films 300 Month 6 1,800 Maintenance of Office/Equipment 100 Month 12 1,200 Sponsorship (AIDS day/other events) 500 Month 6 3,000

Total Supplies and Materials AUD 5.5% 10,200

IV. Travel and Transportation and Field Trips/Activities Field Travel (Data Collection e.g. KAPB, Focus Groups Discussion) 2,100 Unit 4 8,400 Local Travel (Other Provinces) 750 Unit 2 1,400 Radio shows/Discussion Forums 800 Unit 2 1,600 Vehicle Maintenance 1,500 Year 2 3,000 Fuel 575 Month 12 6,900 Insurance/Registration 1,050 Year 1 1,350

Total Travel and Transportation AUD 12 % 22,950

V. Training Staff/Health Workers Training 800 Unit 2 1,600 Research Skills -Field Workers Training 600 Unit 3 1,800 Peer Educators Training - TOTs (HIV knowledge & Behaviour Change) 500 Unit 6 3,000 Workshops and Conferences 600 Unit 3 1,800

- 157 - Component Project Budget (AUD)

Description Component 0.55 % Total

Activity Line Items Contri- AUD bution Resource Learning Center setup (Drop-in Centre) 2,000 Unit 1 2,000

Total Training AUD 5.5% 10,200

VI. Other Direct Costs Occupancy 2,000 Month 12 24,000 Utilities 350 Month 12 3,600 Communications 500 Month 12 6,000 Psychosocial support (special care, social, legal, etc. ) 350 month 12 4,200

Total Other Direct Costs AUD 21% 38,400

VII. Capital Expenditures Bus 7,500 Unit 1 7,500 Computer and Printer (Laptop) 2,500 Unit 1 2,500 Desktop computer and printer 1,200 Unit 5 6,000 Photocopier 2,500 Unit 1 2,500 Video camera 700 Unit 1 700 TV/Video player 350 Unit 1 350 Portable generator for training sessions 1,500 Unit 1 1,500 Digital Camera 500 Unit 1 500 Scanner 250 Unit 1 250 Office Furniture and Equipment 450 Unit 6 2,700 TeleFax/machine 300 Unit 1 300

Total Capital Expenditures AUD 13% 24,800

Sub Total AUD 161,590

X. Total Direct Costs

AUD 100% 185,390

- 158 - CHAPTER 7

KNOWLEDGE OF HIV RISK AND SAFER SEX PRACTICES AMONG FEMALE SEX WORKERS IN PORT MORESBY, PAPUA NEW GUINEA

- 159 - 7.1 Co-authors and citation

L. Bauai, M. Sapuri, J.M. Kaldor, C.K. Fairley, L.A. Keogh. Submitted to Asia Pacific Journal of Public Health — 28/08/09.

7.2 Abstract

Safer sex practice reduces the risk of contracting and transmitting human immunodeficiency virus (HIV). This study explored HIV knowledge, HIV risk perception, how this influenced safe sex and documented the practical barriers to adopting safer sex practices among female sex workers (FSWs) in Port Moresby, Papua New Guinea (PNG). We engaged local stakeholders to identify and recruit FSWs in 19 sites across Port Moresby using snowballing sampling technique. Female sex workers could choose to take part in either a focus group discussion or a face-to-face, in-depth interview using semi-structured questionnaires. A total of 174 FSWs took part in 16 focus groups and 32 in individual interviews. Using thematic analysis categorised under recurring themes, we examined responses and identified recurring themes in the data. The average FSW demonstrated adequate basic knowledge of HIV and her perception of HIV risk was high. In addition, the average FSW was aware condom use prevented HIV transmission, but her practice of safe sex was poor. Overall, only 6% (95% CI: 3– 11) indicated they used condoms at all times, 79% (95% CI: 33-47) used it sometimes and 15% (95% CI: 10–21) never used it at all with both clients and regular sexual partners. The findings demonstrate that adequate HIV knowledge and high HIV risk perception does not necessarily translate into safer sex practices. Moreso, adequate HIV knowledge alone, or high HIV risk perception, or both, are not enough to guarantee safe sex. In this group, we identified a number of structural (e.g. programming gaps) and environmental factors (e.g. poverty) that act as vital barriers to safer sex practices. One FSW stated that, “Our clients know we are desperate for money, it is not unusual for clients to sometimes offer more money in exchange for sex without condoms – and given my dire financial situation, it is a proposal I can hardly refuse”. We argue that HIV policies and program interventions must address these contextual barriers that hinder safer sex practices.

Keywords: HIV knowledge; HIV risk perception; safer sex practices; condoms use; focus groups; poverty; female sex workers; clients; regular sexual partners; Port Moresby; Papua New Guinea.

- 160 - 7.3 Introduction

Papua New Guinea (PNG) has one of the most rapidly growing human immunodeficiency virus HIV epidemics in the Asia Pacific Region with heterosexual transmission accounting for an increasing fraction of all new infections [45]. In PNG, as in many developing countries, unsafe sex is the primary mode of HIV transmission [49]. In these settings, young females, especially female sex workers (FSWs), are the first group to be observed with the virus and are disproportionately affected [76, 82, 84, 199]. In 1998 in PNG, a study of 407 FSWs in Port Moresby and Lae reported an HIV prevalence of 17% (34 of 205) [58]. At the same time, the prevalence among pregnant women was 0.37% and among the adult population in the entire country was 0.19% [45]. Of the 407 FSWs surveyed, 85% reported not to have used condoms consistently with their clients, 34% reported never to have used condoms, and only 9% used condoms with their regular sexual partners (RSP) [58]. These findings are reported consistently for PNG [55, 58, 81]. Due to such risky sexual behaviours, it is widely perceived that FSWs will play a significant role in the HIV epidemic in PNG [12-16].

To date, condoms remain the single most effective means to reduce the transmission of sexually transmitted infections (STIs) and to protect against HIV [209-212]. In FSWs, a number of studies have shown an association between increased condom use and declined rates of STIs including new HIV infections [246, 247]. However, whilst condom production and distribution have increased worldwide [213] and safer sex messages continue to reach FSWs through social marketing, behaviour change communication strategies and public health policies [73, 76, 78, 99, 100, 115, 128, 136], these efforts have not always resulted in consistent condom use [108, 214, 215].

In an attempt to explain this outcome, a number of researchers have suggested that condom use in FSWs is determined by the social context within which the sexual behaviours occur [108, 179, 180, 216, 217]. In resource constrained settings, researchers find certain intrinsic factors that act as “barriers” rather than “enablers” to safer sex practices [108, 132, 140, 151]. These barriers include under development/poverty [151]; gender inequalities/cultural norms [179]; knowledge/risk perception [227]; negotiation ability/self efficacy [55]; and other aspects of the environment [108, 234].

- 161 - In the quest to understand the determinants of risky sexual behaviour among FSWs in Port Moresby, this paper reports on a study that explored HIV knowledge and risk perception and how these translated into safer sex practices. We aimed to document the practical barriers to safe sex practices and to contribute to programming decisions and HIV policy.

7.4 Methods

This study is the sixth component of a large United Nations Population Fund (UNFPA) Operational Research Grant. Details of the program funded by the Grant have been reported elsewhere [133].

The paper reports on a qualitative study that undertook an in-depth assessment of HIV knowledge, risk perception, sexual behaviours and safer sex practices among FSWs in Port Moresby, the national capital district of Papua New Guinea. The study was carried out in between April and June 2004. As part of the UNFPA Grant, a mapping and size estimation exercise was initially conducted in 2003 [91]. This exercise identified the locations where sex work takes place across Port Moresby. The data reported here were collected from FSWs across these locations (details of the locations, the method of identifying locations, and the method of recruiting FSWs has been reported elsewhere) [91, 133].

One-hundred-and-seventy-four FSWs ranging in age from 14–44 were recruited from 19 locations using recruitment from our earlier studies, existing HIV prevention programs and new referrals from FSW peer educators. The new referrals were contacted by the peer educators and invited to participate in the study (snowball sampling). Those who agreed to participate by verbal consent were fully briefed about the study objectives and procedures. They were asked to complete a structured questionnaire in which socio-demographic data were obtained. To be included in the study, participants had to be FSWs, aged 14 years or older, they must have received money for sex in the last month, and not be currently enrolled in a similar study. Participants then chose to either take part in a focus group discussion with other sex workers, or they chose to take part in an individual interview.

- 162 - FSWs who chose to take part in an in-depth, face-to-face interview were interviewed at times and locations convenient to participants. The interview was semi-structured with open-ended questions on HIV/STI knowledge, risk perception, sexual behaviours and safer sex practices. All interviews were conducted in local pidgin and lasted approximately one hour. Information was recorded verbatim, summarised and transcribed.

For FSWs who chose to take part in focus group discussions, a facilitator and two researchers facilitated the session with up to 10 FSWs per group. The same open-ended questions were employed as those used in individual interviews. All discussions were conducted in local pidgin dialect and recorded on tape. Recordings were translated, transcribed verbatim and reviewed for accuracy.

Interview data and focus group data were analysed together. Thematic analysis was used to identify recurring themes. The data in each theme were then contrasted and compared to identify commonly held perceptions, misperceptions and practical barriers and enablers to implementing knowledge held by FSWs. For each behaviour that we were interested in, the full range of practices were identified and, where possible, FSWs were allocated to a practice group so that proportions in each group could be reported.

7.5 Results

A total of 174 FSWs participated in a total of 16 focus group discussions and 32 in- depth interviews. Table 7.1 shows the demographic characteristics and socioeconomic information of the 174 FSWs. The largest age group comprised of young FSWs (14–20 and 21–30 years) in the most productive part of their lives. The majority of FSWs were divorced, poorly educated, exclusively sold sex for a living and had engaged in sex work for more than three years.

- 163 - Table 7.1. Demographic characteristics of female sex workers in Port Moresby

Characteristics of FSWs, aN=174 % or (mean) 95% bCI or (range)

Age (years) 14-20 36.2 29-43 21-30 32.2 25-39 31-40 19.0 21-25 41-50 12.6 8-18 Marital status Single 23.6 17-30 Married 35.0 28-42 Divorced 41.4 34-49 Religion (Christian) 100 98-100 cNo of children per FSW (mean) (2) (1- 4) Living arrangements Alone 32.8 26-40 Friends 24.1 18-31 Relatives 17.8 12-24 Protectors (guards of FSW) 12.1 7-17 Shared guest house with peers 6.9 4-12 Parents 6.3 3-11 Education None 30.0 23-37 Primary 70.0 63-77 Income besides sex work No 75.3 69-82 Yes 24.7 18-31 Place of sex work Port Moresby only 51.7 44-59 Outside Port Moresby 48.3 41-56 Years engaged in sex work 1-3 years 31.6 25-39 4-6 years 27.7 21-34 7-9 20.7 15-27 10 and above 19.5 14-25 No specific Years *(on and off) 0.5 .02 -3

* 1 person did not fit a = total number b= Confidence interval c= number

- 164 - A Safe sex practice

Data analysis revealed that the average FSW had engaged in unsafe sex with her paying clients and her regular sexual partner (RSP) despite adequate knowledge of HIV transmission through sexual contact and knowledge of the ability of condoms to prevent HIV transmission. About 99% (95% CI: 97–100) of FSWs believed unsafe sex with clients posed high risk, however only 6% (95% CI: 3–11) reported they used condoms at all times, 79% (95% CI: 33–47) used it sometimes and 15% (95% CI: 10–21) never used it. In contrast, only 37% (95% CI: 30–44) believed that unsafe sex with RSP posed some risk with 63% (95% CI: 56–70) believing it posed no risk. Consequently, the use of condoms with RSP was consistently low. A representative statement that was made by a FSW during the focus group discussion was, “I do not think my boyfriend will intentionally give me HIV” . We were interested in disparities between knowledge and sexual practices. We wanted to document in detail what FSWs knew, where their knowledge was poor and what they identified as practical barriers and enablers to safer sex.

B Widely held correct perceptions

Responses revealed that the average FSW had heard of HIV/AIDS including common sexually transmitted infections (STIs). She was aware HIV is transmitted through sexual contact and from a pregnant mother to her unborn child. She was aware that HIV is incurable and that the condom is the most effective method to prevent transmission. She was aware that abstinence and being faithful to one uninfected sexual partner (A, B) could prevent transmission. She also perceived herself vulnerable to contracting HIV, mostly through sex work, and was aware that unsafe sex increased her risks.

C Widely held misperceptions

Knowledge of transmission through blood contact was poor. In addition, knowledge of the association between STIs and HIV transmission was poor, as was the knowledge of the value of using lubricant with condoms. The average FSWs thought the virus could be transmitted through curses and thought it was possible to tell if someone had the virus. She perceived little or no risk was associated with unsafe sex when her RSP was

- 165 - concerned, but associated high risk with her paying clients. She did not identify the risks associated with marijuana/alcohol use and HIV vulnerability. She believed that seeking prompt treatment when sick, getting married and washing the genitals soon after ejaculation with Dettol could prevent HIV transmission. For example, one FSW believed marriage offered protection against the virus, “Once I get married, I will not have sex with clients and therefore I will not get HIV” .

D Structural and environmental barriers to implementing knowledge

The average FSW recognised that prevention methods, including abstinence and being faithful, were not realistic for sex workers. Whilst she felt condom use was a “hassle” and took “fun out of sex”, she mainly attributed unsafe sex with her RSP to “trust”. She felt that once trust is established between sexual partners, condom use was not necessary. Regarding her clients, she felt the use of a condom was necessary, but she faced practical barriers to insisting on its use. She mainly attributed this to fear of losing economic benefit. During the focus group discussion sessions, one sex worker stated that, “ Our clients know we are desperate for money so if they offer – it is a proposal I can hardly refuse” . Reasons for inconsistent condom use were attributed to client dislike (40%), trust (35%), lack of bargaining powers (22%) and a hassle to use (3%). Additionally, she often used marijuana, alcohol and home brew – a potent home-made concoction known to be a stimulant. She reported having had sex under the influence of a combination of these stimulants.

E Structural and environmental enablers to implementing knowledge

Responses on condoms revealed that the average FSW carried condoms with her at all times and knew where to obtain them at no cost. She was aware she could obtain condoms from her peer educator, the National AIDS Council and HIV aid agencies.

7.6 Discussion

In this study, we found that unsafe sex was common in FSWs despite adequate prevention knowledge and access to condoms. Female sex workers were aware of the risks associated with unsafe sex, but were inhibited by socio-cultural factors (poverty,

- 166 - gender inequity, cultural norms) to practice safer sex, an observation that has been reported in other studies [108, 214, 215, 217, 219, 220]. The findings of our study suggest that adequate knowledge and risk perception are insufficient to guarantee safer sex in settings where these “inhibitors” persist. In this paper, we will refer to these inhibitors as “structural and environmental barriers”. They may be responsible for the spread of HIV in FSWs.

Studies on the influence of HIV knowledge on the practice of safer sex have reported mixed results. While some have found conclusive associations [138, 221], others have found no association [222], supporting the findings of our study. Other studies have suggested that individual perception of threats to contracting HIV leads to adopting safer sex practices [223, 224]. However, studies by Maswanya et al. [225] and Stanton et al. [226] were inconsistent and noted that while young people were aware of their risk related to unsafe sex, they usually failed to adopt protective behaviours. Tawil et al. [215] suggested that knowledge of AIDS and the perception of being at risk of contracting it are factors that support protective behaviours only if the individual is enabled by her environment to adopt safe sexual behaviours. Our study found that FSWs were aware of HIV and considered themselves at high risk, but they were not always able to practice safer sex. They had a high tendency to underestimate their risks with their clients when money was the “ultimate benefit”. Possible reasons for this behaviour are that firstly, FSWs may not apply their knowledge to assess their risks during sexual encounters and consequently fail to translate knowledge to protective behaviours [227]. Secondly, it may mean that FSWs place financial survival above HIV risk [150, 228], and therefore their vulnerability to HIV at the time of making sexual decisions is a lesser risk than the risk of losing a client and the money that client will provide. All sexual decision-making involves the weighing up of a number of risks, where some risks will be accepted and others will not be accepted [229]. Thirdly, it may mean that the interpretation of perceived risks is based on the type of relationship and trust between the sexual partners [181]. Lear asserted that the use of condoms diminishes once trust is established in relationships. Furthermore, it may reflect the imbalance of power [218] between FSWs and their clients. Previous studies by Hulton et al . [230] and Kiirya et al . [231] found that safer-sex knowledge and the dynamics of

- 167 - sexual behaviour are two different phenomenons and suggested that they have little influence on one another, especially at the time the sexual encounter is being contemplated. They indicated that fundamental barriers to safer sex practices lie within the economic and socio-cultural context that shapes the sexual behaviour of people, with consistent observations reported by several studies [108, 119, 129, 140, 179, 217, 232-234]. Other studies have also looked at gender differentials on perceived HIV risk and sexual behaviour, and have indicated that females from “traditional cultures” are at risk [218, 235-237]. These reports are consistent with the findings of our study.

The association between risky sexual behaviours and poverty is well documented [29, 108, 123, 140, 179, 238], with observations consistent with findings among FSWs in PNG. The implications are that poverty may limit the ability to resist unsafe sex where the fear of losing an economic benefit is great. Also, the association between risky sexual behaviours and gender inequalities or culturally scripted norms is well documented to influence or weaken bargaining powers and decision making abilities to communicate safer sex [108, 140, 181, 216, 217, 232-234, 239]. The implications are that in situations where sexual partners are richer or more powerful, FSWs may be placed in subordinate positions to decide the terms of the sexual encounter as well as exercise control over the use of condoms. In these contexts, the ability to translate knowledge into safer sex practices is greatly inhibited.

7.7 Weaknesses

Our study has a number of weaknesses. Firstly, because sex work is illegal in PNG it was impossible to obtain a random sample of FSWs, however we were able to report on a large sample of FSWs due to a long and in-depth period spent gaining the trust of FSWs before data collection begun. Secondly, our findings may not be representative of all FSWs in PNG because we focused on FSWs in Port Moresby only, however consistent findings have been reported.

- 168 - 7.8 Strengths

Our study has a number of strengths. Our findings highlight the importance of addressing the structural and the environmental barriers that confront FSWs. The findings also add to the body of knowledge that advocates a shift towards addressing intrinsic socio-cultural factors that determine sexual behaviours and mediate mutual sexual decision-making.

7.9 Conclusion and recommendations

National HIV framework must reflect these contextual factors, and policies (legal, political, economic) must support safe sex practices. For FSWs, firstly, it means addressing women’s empowerment — a vital element that will facilitate the adoption of safer sexual practices [101, 102, 108, 120]. Overall, it means inclusion of targeted efforts that invest in universal education, economic independence, gender equity, policy and law reform [76]. Community members who are willing to facilitate social change must be identified, mobilised and involved in this process. We recommend that programs aimed at FSWs must identify and collaborate with local women’s health organisations and other social groups that are skilled in challenging social norms that create social injustices among females. These groups can lobby the government, education and other social sectors and s trive for structures that give FSWs access to education, training and income-earning opportunities through vocational training, microfinance, poverty alleviation and community development schemes [76-78]. We believe that increasing access to income and productive resources will increase economic empowerment of FSWs. HIV programs aimed at FSWs must support efforts that ensure sustainable livelihoods for FSWs who rely on sex work for economic survival. These groups can also be instrumental in lobbying the law and policy makers to help raise the profile of FSWs and remove arbitrary restrictions, such as anti- prostitution laws, though media campaigns, community education and policy reform [76, 77]. They can collaborate with the government and ensure the inclusion of these structures into broad-based national policies.

Secondly, safer sex messages have reached most FSWs and they do not need to be convinced about it, however they need to be enabled to practice it. This means

- 169 - reinforcing the need to focus on gender-related factors that determine vulnerability [76, 77, 108, 139]. HIV programs have hardly ever targeted males with whom the final decision to practice safer sex rests. More often than not, clients and RSPs of FSWs are overlooked in intervention programs. We believe this is long overdue and recommend urgent specific behaviour change programs targeting men. This will call for community development programs that focus on gender-sensitive strategies and capacity-building of stakeholders to help create an enabling environment where mutual responsibility for safer sex practices is endorsed [76, 78, 108, 109, 120, 139]. Furthermore, prevention efforts must incorporate in their designs specific interventions that address areas of misperceptions identified in this study and avoid re-teaching what FSWs already know and what is deemed unrealistic (abstinence, be faithful), whilst advocating for drug and alcohol education programs. Female sex workers must have the means to protect themselves within their private and commercial sexual relationships. Given that FSWs in PNG are worst affected by the HIV epidemic, visible political leadership and supportive policies are required, without which we risk significant ramifications for the progression of HIV in FSWs. We argue that HIV policies and program interventions must address these barriers and the root causes of vulnerability.

- 170 - CHAPTER 8

CONCLUSIONS

- 171 - HIV is spreading rapidly in PNG. The spread is predominantly heterosexual, and FSWs are likely to play a significant part in the acquisition and transmission of the HIV epidemic based on the dearth literature available before my thesis. I therefore undertook a series of studies in 2003 and 2004, and these form part of my thesis presented here.

8.1 Literature review

Firstly, I undertook a systematic review of published and unpublished studies (Chapter 2) assessing the risks of sexually acquired HIV in FSWs in PNG; the first review ever to be undertaken in this group. The aim was to determine if there have been some improvements in the “indicators” for sexually acquired HIV in FSWs over time so as to evaluate if prevention efforts are having the desired impacts. Through the review I was able to show that the major risks for acquiring HIV in this group included high rates of inconsistent condom use with their clients (range: 0–63%) and regular sexual partners (range: 0–34%), with the highest reported in 2005 [81]. Whilst this indicates that condom use is rising, its use is yet to reach the desired level to protect FSWs from the HIV epidemic. Additional risks included the high prevalence of sexually transmitted infections and the four most common were: Trichomonas (range: 21–56%), Gonorrhea (range: 20–39%), Syphilis (range: 16–34%) and Chlamydia (range: 14–33%). The rate of STIs remained high and did not appear to change over time. The prevalence of HIV ranged between 0–21% and the proportion of FSWs with HIV rose disturbingly in 2002 to 21% [86]. The findings indicate that current HIV and STI control measures in FSWs are inadequate and must be addressed.

8.2 Mapping and size estimation of FSWs in Port Moresby

Then I undertook a mapping and size estimation exercise through a variety of means. In this study I applied key informant (KI), mapping, nomination and observation methods [162,163] and I was able to show that there were approximately 2000 FSWs in 42 locations across Port Moresby. This exercise was necessary to generate data on the size of the FSW population that did not exist at the time of the study; a key element to planning and implementing cost effective programs in this group. The method was rapid and simple but with challenge due to the illegal nature of sex work. That said, I am able

- 172 - to show that through these methods, plus with sensitivity, the so called “hidden populations” can be reached in settings where reliable estimates are not available. Whilst the data obtained can be used as a baseline to inform HIV programming, it provides the impetus for future research to evaluate the methods across Port Moresby and PNG as a whole to better inform national HIV policy.

8.3 Knowledge, attitudes, practices and behaviours (KAPB) survey

I also undertook a cross-section survey to determine the knowledge, attitudes, practices and behaviours that put FSWs at risk of the HIV epidemic. The findings of the survey place FSWs in PNG among the predominantly young, poorly educated and least employed who depended on sex work for economic survival. They initiated sex and engaged in sex work at a young age. They had substantial numbers of paying clients and non-paying sexual partners, and used condoms inconsistently. They frequently used marijuana and alcohol. They had basic HIV knowledge, were least knowledgeable about STIs and infrequently sought treatment services. They were least knowledgeable about risks of HIV and had concerns about HIV related stigma. A key intervention is to increase behaviour change programs that address the high risk practices among FSWs using a peer education approach whilst addressing issues that impede access to services. In addition, considerable resources will need to be invested in prevention programs involving the clients, including a major focus on the regular sexual partners of FSWs.

8.4 Reported symptoms associated with laboratory confirmed STIs

I also undertook a study to determine symptoms of different common curable sexually transmitted infections using questionnaires. Disturbingly, I showed that FSWs were least informed about STI symptoms and with laboratory confirmed infections, they poorly recognised associated symptoms. This implies that all HIV prevention education programs must also focus on STIs whilst improving access to STI services in this group. I was able to show that an approach that incorporates the LE urine dipstick test result greater than one and multiple reported symptoms may be useful for screening infections in FSWs in resource constrained settings. This approach, a potential feasible option, may provide the impetus for further research to evaluate it.

- 173 - 8.5 Periodic presumptive treatment (PPT) of common curable STIs

I tried an intervention that involved three-monthly treatments of STIs and showed that although the strategy was statistically effective in reducing STIs in the short-term, STI rates rebounded rapidly, and even with three-monthly PPT, a significant number of HIV infections occurred. I was able to show that if PPT is to be very effective in FSWs where the force of infection is so high, then 100% condom use with clients or very high rates of partner notification, plus 100% condom use, would be required if a very low incidence and prevalence of STI were to be achievable and maintained.

8.6 HIV risk perceptions and safer sex practices

Finally, I undertook a study to determine how HIV knowledge and risk perception influences safer sex practices in FSWs. The findings demonstrated that adequate knowledge of HIV risk does not necessarily ensure safer sex practices. I showed that in PNG, a number of structural and environmental factors including extreme poverty, gender inequity and other cultural norms, served as important barriers to safer sex practices. In this study, I strongly argued that the HIV epidemic will not be averted unless comprehensive approaches that encompass contextual factors are adequately addressed at policy and programmatic levels.

Taken as a whole, my thesis shows that HIV is spreading rapidly in FSWs and is likely to be a result of inconsistent condom use, high STI rates, barriers or poor access to adequate STI services, poor HIV/STI knowledge and issues of stigma including barriers to safer sex practices.

Urgent actions are therefore needed to reduce HIV in FSWs through these measures: (i) improved access to HIV prevention, adequate STI management and other support services; (ii) the creation of supportive environments, partnerships and policies that facilitate access to HIV/STI and other support services; and (iii) addressing contextual factors or structural issues that increase HIV vulnerability. At the heart of these measures are good policies, evidence-based interventions and ongoing research [106].

- 174 - Figure 8.1. Final review meeting UNFPA-WVI collaboration: Comprehensive models of HIV/STI prevention for FSWs and their clients in Asia Pacific – Key note speaker, UNFPA Asia Pacific Regional Representative

- 175 - Figure 8.2. UNFPA-WVI collaboration interim meeting in Malaysia 2003

Figure 8.3. UNFPA-WVI collaboration final review meeting in Bangkok 2004

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- 198 - Appendix A: Rapid Formative Research — Mapping and Size Estimation Tool

Female sex workers in Port Moresby 2003 1. Questionnaire for fixed establishment based female sex workers

Undertaken by World Vision International – Pacific Development Group PNG in collaboration with selected FSWs

Questionnaire identification number /__/__/__/__/

Special Code Format / S / DOB / E / S /

Port Moresby /__/__/

Introduction:

This mapping exercise is aimed at identifying specific locations and establishments where female sex workers are found and to estimate the population size in each of the location and establishment. The outcome of the mapping will serve as a baseline for HIV/AIDS related interventions among sex workers in Port Moresby.

Confidentiality and consent:

Your answers are completely confidential. However, your honest answer to these questions will be very much helpful. We would greatly appreciate your help in responding to these questions.

______

(Signature of interviewer certifying that informed consent has been given verbally by respondent)

- 199 - INTERVIWER’S CODE: /___/___/ INTERVIWER’S NAME ______

DATE of INTERVIEW /___/___/______/

CHECKED BY SUPERVISOR: Signature ______Date: ______

Questionnaire 1 – Mapping and size estimation of female sex workers in Port Moresby 2003 — (Fixed establishment based female sex workers)

Section A – Identification particulars of establishments/location

Name of establishment Name of location

Section B

Respondent Record appropriate code type 1- Sex worker /_____/ 2- Establishment owner

Question Question Coding category Skip No

B1 Type of establishment Hotel 1 →B2 Guesthouse 2 →B2 Disco 3 →B2 Bar/restaurant 4 →B2 5Kina house 5 →B4 Other (specify) ______6

- 200 - 2 Record name of establishment Specify______

3 Record name of locality where Specify______the establishment is found

4 Ask for house number, location Specify______and record

5 Are there sex workers in this Yes 1 →6 Establishment/house? No 2 →B9 Don’t know 88 →B9

6 How many sex workers are now No. of sex workers →B2 working in this /__/__/__/ establishment/house?

FILTER - CHECK Question B1 Ask Questions B2- B8 only for those who answered yes for (5) and (6) for Question B1 Otherwise GO TO B9

B2 Do the sex workers present Yes 1 themselves to this establishment No 2 every day of the week? Don’t know 88

B3 What do you think is the peak 12 – 14 years old 1 age range of sex workers 15 – 19 years old 2 working in this establishment? 20 – 24 years old 3 25 – 29 years old 4 30 – 40 years old 5 More than 40 years old 6

B4 What do you think is the 2 Kina Meri 1 classification of sex workers Disco meri 2 working in this establishment? Other 3 Don’t know 88

B5 What are the peak days for sex Fridays and Saturdays 1 work activity? Friday to Sunday 2 Thursday to Saturday 3 Saturday and Sunday 4

- 201 - Other (specify)______5

B6 What are the peak hours for sex 0600 to midday (1200) 1 work activity? Midday (1200) to 1800 2 1800 to 2200 3 2200 to midnight (0000) 4 After midnight (0000) 5 Midnight (0000) to 0200 6 Other (specify)______7

B7 What do you say is the average One per day 1 number of clients a sex worker Two to three per day 2 has in one day? Four to five per day 3 More than five per day 4 Other (specify) ______5

B8 Who do you think are most Students 1 clients of sex workers who come Business men 2 to this establishment? Government employees 3 Self employed 4 (READ OUT) Unemployed person 5 People engaged in an informal sector 6 Other (specify) ______7

B9 This is the end of the questionnaire. THANK YOU.

- 202 - Questionnaire 2 — Mapping and size estimation of female sex workers in Port Moresby 2003 — (Street based female sex workers using nomination)

Undertaken by World Vision International – Pacific Development Group PNG in collaboration with selected FSWs

Special Code Format / Date / Site / DOB / Initials /___/___/___/___/

Format identification number /___/___/___/___/

Port Moresby /____/____/

Introduction:

This mapping is aimed at identifying specific locations/streets where street based sex workers are found and to know the number in each of the identified locations or streets. The outcome of the mapping will serve as a baseline for HIV/AIDS related interventions among sex workers in Port Moresby. The frequency & date of visit to the street/place

1st Time /____ / Date ______

2nd Time / _____ / Date ______

3rd Time /_____ / Date ______

No Name of street or name of Day of visit Time of visit No. of sex workers place contacted

1st Visit

2nd Visit

3rd Visit

Remark: ______

Supervisor’s / interviewer’s code: /___/___/ Supervisor’s name______

CHECKED BY:

Name______

Signature ______Date: ______

- 203 - Questionnaire 2. – Mapping and size estimation of female sex workers in Port Moresby 2003 — (Street based female sex workers using nomination)

Section C

Respondent Record appropriate code type Date: ______Record name of site/location: Specify______Date of Birth: /_____/ Initials: /_____/ A. Sex worker (2 Kina Meri) /_____/ B. Sex worker (2 Disco Meri /_____/ C. Sex worker (Other) /_____/

Section D

Question Question Coding category Skip No

D1 Type of site Settlement 1 Urban village built on stilts over the sea 2 Water front/Warf 3 Peri urban slum 5 Other (specify) ______6

D2 Please Indicate your age 12 – 14 years old 1 range 15 – 19 years old 2 20 – 24 years old 3 25 – 29 years old 4 30 – 40 years old 5 More than 40 years old 6

D3 Have you received money in Yes 1 →D4 exchange for sex in the last No 2 →D15 one month

D4 Do you work in this site only Yes 1 No 2

D5 Are there sex workers in this Yes 1

- 204 - site? No 2 Do not know 88

D6 How many sex workers are No. of sex workers now working in this site /__/__/__/

D7 Do the sex workers present Yes 1 themselves to this site every No 2 day of the week? Do not know 88

D8 Do the sex workers who Yes 1 present themselves to this site No 2 work in other sites? Do not know 88

D9 What do you think is the 2 Kina Meri 1 classification of sex workers Disco meri 2 working in this site? Other 3 Don’t know 88

D10 What are the peak days for Fridays and Saturdays 1 sex work activity? Friday to Sunday 2 Thursday to Saturday 3 Saturday and Sunday 4 Other (specify)______5

D11 What are the peak hours for 0600 to midday (1200) 1 sex work activity? Midday (1200) to 1800 2 1800 to 2200 3 2200 to midnight (0000) 4 After midnight (0000) 5 Midnight (0000) to 0200 6 Other (specify)______7

D12 Can we contact other SWs in Yes 1 →D13 this site through you? No 2 →D15

D13 Are able to present them to Yes 1 →D14 the research team for No 2 →D15 counting?

D14 See the team for further instructions

D15 This is the end of the questionnaire. THANK YOU.

- 205 - Questionnaire 3 – Mapping and size estimation of female sex workers in Port Moresby 2003 — (Street based female sex workers using observation)

Undertaken by World Vision International – Pacific Development Group PNG in collaboration with selected FSWs

Format code / Site /Date /___/___/___/___/

Format identification number /___/___/___/___/

Port Moresby /____/____/

Introduction:

This mapping is aimed at identifying specific locations/streets where street based sex workers are found and to know the number in each of the identified locations or streets. The outcome of the mapping will serve as a baseline for HIV/AIDS related interventions among sex workers in Port Moresby.

The frequency & date of visit to the street/place

1st Time /____ / Date ______

2nd Time / _____ / Date ______

3rd Time /_____ / Date ______No Name of street or Day of visit Time of visit No. of sex workers name of place observed

1st Visit

2nd Visit

3rd Visit

Remark: ______

Supervisor’s / interviewer’s code: /___/___/ Supervisor’s name______

CHECKED BY:

Name______

Signature ______Date: ______

- 206 - 3. Entry format – Mapping of street-based sex workers using observation

Section E – Identification particulars of street or place

Name of street or name of place or site

Section E

No Observation Coding category Skip

E1 Name of street or place where sex workers Specify ______are observed?

E2 The total frequency of visits, to the street or Total frequency of visits /___ /___ / place.

E3 The observed average number of female No. of sex workers /____ / ____ / street based sex workers on this street or Remark ______place.

E4 On the average, do the same numbers of Yes 1 sex workers present themselves to this No 2 street or place at different days? Remark ______

E5 What are the observed peak hours for 6:00 pm to 8:00 pm 1 observing sex workers? 8:00 pm to 10:00 pm 2 10:00 pm to midnight 3 After midnight 4 Midnight to 2:00 am 5 Other (specify)______6

E6 Which days are the observed peak days for Fridays and Saturdays 1 sex work activity in this street or place? Friday to Sunday 2 Thursday to Saturday 3 Other (specify)______4

E7 What do you say is the age range of sex 12 – 14 years old 1 workers working in this street? 15 – 19 years old 2 20 – 24 years old 3 25 – 29 years old 4

- 207 - 30 – 40 years old 5 More than 40 years old 6

E8 How many sex workers have you observed Number / ___ / ___ / ___ / in this site?

This is the end of the entry format

Questionnaire Guide 4. Questionnaire for mapping of institutions working on projects related to sex workers (Stake holders) Port Moresby, 2003

Undertaken by World Vision International – Pacific Development Group PNG in collaboration with selected FSWs

Format Code Institution /____/____/

Questionnaire Identification Number /___/___/___/___/

Port Moresby /____/____/

Introduction:

This questionnaire pertains to all institutions working on projects related to sex workers in Port Moresby. The purpose of this study to identify institutions that could help us with information on the locations where sex work takes plus the guesstimate of the sex worker population size in the various locations across Port Moresby. The outcome of this exercise will help plan appropriate cost effective interventions among sex workers. Knowing that this institution is one of the major stakeholders related to sex workers, we would greatly appreciate your help in responding to these questions. Your honest answers to these questions will be very helpful.

If this is not a convenient time for you to respond to the questions, we can come back again if you can set an appointment.

Section F - Appointment Set

No Appointment set Remark

Date Time

1

2

- 208 - INTERVIWER’S CODE: /___/___/ INTERVIWER’S NAME ______

DATE of INTERVIEW /___/___/______/

CHECKED BY SUPERVISOR: Signature______Date: ______

Questionnaire Guide 4 – Mapping of institutions working on projects related to sex workers in Port Moresby

Section G - Identification particulars of establishments

Respondent type A. PR or administration personnel Record appropriate code B. Project manager C. other (specify) ______/______/

Question Question Coding category Skip No G1 What is the name of this Specify ______institution? ______G2 What is the ownership? Governmental 1 Non-governmental 2 Civil society organization 3 Other ______4 G3 What are the types of HIV/AIDS intervention 1 services do you Poverty alleviation 2 Provide? Income generating activity (IGA) 3 (More than one answer is possible) Other (specify) ______4 (PROBE for more) G4 For how many years has Number of years this institution provided the service? / ___ / ___ / G5 How many beneficiaries No of beneficiaries do you have? / ___ / ___/___ /___ /

- 209 - G6 Are there sex workers in Yes 1 the site? No 2 Remark ______G7 What is the relative Minimum Maximum proportion of sex workers in this site? Remark ______G8 What other sites are you aware of that sex workers can be found List______G9 Which of the sites are safe to visit List ______G10 Are sex workers streets, or bars/nightclubs? Remark ______G11 What is the relative List locations______proportion of sex workers in each of these sites? Minimum Maximum Remark ______G12 Which sites have the highest numbers of sex workers? List ______G13 What hours (peak) do sex workers work? Remark ______G14 Where do sex workers work from? Are they stable or transient? Remark ______G15 Are sex workers local or from outside the site? Remark ______G16 What is the public perception of sex workers? Remark ______G17 Do sex workers cross Yes 1 borders to find clients? No 2

- 210 - Remark ______G18 Are the sex workers Yes 1 controlled by pimps or are they freelance? No 2 Remark ______G19 Who are the major clients of sex workers? List ______This is the end of the questionnaire. Thanks for your time to responding to the questionnaire

- 211 - Appendix B: HIV/AIDS/STI Behavioural Surveillance Survey (BSS) for Female Sex Workers Papua New Guinea - June–July 2003 (FHI Adopted)

001 QUESTIONNAIRE IDENTIFICATION NUMBER | ___ | ___ | ___ |

002 PORT MORESBY

003 PAPUA NEW GIUNEA

004 SITE ------

My name is ……………………………………………and I work for World Vision. The purpose of this survey is to help us to implement good prevention models (known to have worked in other countries) that will contribute to the reduction of HIV/AIDS/STIs transmission, vulnerability and impact among sex workers and their clients here in the city Port Moresby with particular reference to sites (12 chosen sites). Have you by any chance been interviewed in the past few weeks for this same study?

* if so, do not interview him/her again.

* if not, please proceed.

Confidentiality and informed consent: I am going to ask you some very personal questions that many people find very difficult to respond to. I assure you that your answers are strictly confidential. Your name will not appear on this form and will never be used in connection with any of the information you provide me. I also want to make it clear that you are not obliged to answer any questions that you do not feel comfortable answering and you may choose to end this interview anytime you so please. However, your honest answer to these questions will help the team better understand peoples’ perceptions about certain behaviours and attitudes in relation to HIV/AIDS/STIs in order to address adequately and respond positively to this issue. Hence, the team will greatly appreciate your help in responding to this survey. The survey will take approximately half an hour. Would you be willing to participate? Thanks for your time!

______

(Signature of interviewer certifying that informed consent has been given verbally by respondent)

- 212 - Interviewer visit

Visit 1 Visit 2 Visit 3

Date

Interviewer

Result

Result codes : Completed 1; Respondent not available 2; Refused 3; Partially completed 4; Other 5

005 Interviewer: Code | ___ | ___ | Name______

006 Date of interview : ___ / ___ / ___

Checked by Supervisor: Signature ______Date______

Contents

A: Individual Questionnaire 0. Questionnaire identification data (codes)

1. Background characteristics

2. Marriage, family, work

3. Sexual history: numbers and types of partners

4. Sexual history: paying clients

5. Sexual history: non- paying clients

6. Male and female condoms and condom use

7. Risky sexual practices

8. STI knowledge, health issues and STI treatment seeking behaviours

9. HIV/AIDS: knowledge, opinions, perceptions and attitudes

10. Risk perception and behaviour change

Checked ______Captured (1) ______Captured (2) ______

- 213 - Section 1: Background characteristics

No. Questions and filters Coding categories Skip to

Q101 In what month and year Month |__|__| were you born? Don’t Know Month 88 (Probe for best estimate) No Response 99 Year |__|__| Mama I karim yu long Don’t Know Year 88 wonem yia na mun? No Response 99

Q102 How old were you at your Age in Completed Years |__|__| last birthday? Don’t Know 88 (compare and correct Q101 No Response 99 if need be) (Estimate Best Answer)

Yu igat hamas krismas nao?

Q103 Have you ever attended Yes 1 school? No 2 → Q106 No Response 9 Yu bin skul tu o nogat?

Q104 What is the highest level of Primary 1 school you completed? Secondary 2 Higher 3 Yu pinisim wonem skul? None / No Response 9

Q105 In all, how many total years Years Completed |__|__| of education have you No Response 99 completed up to now?

Hamas pela yia olgeta Yu bin istap long skul?

Q106 Where were you born? This very neighbourhood 1 Other 2

- 214 - Mama bin karim yu long Don’t Know 88 wonem hap? No Response 99

Q107 What region are you from? Southern 1 Highlands 2 Wonem hap bilong dispela Momase 3 country em ples bilong yu New Guinea Islands 4 istap? Don’t Know 88 No Response 99

Q108 What is your religion? Protestant/Mainline 1 (Circle One ) Charismatic/Pentecostal 2 Traditional 3 Wonem em lotu bilong yu? No Religion 0 No Response 9

Q109 How long have you lived in Number of Years |__|__| this neighbourhood? Less than 1Year 00 Don’t Know 88 Hamaspela yia yu bin istap No Response 99 long hia?

Q110 Do you do sex work in this Yes 1 area No 2 No Response 99 Yu wokim dispela kain wok long hia?

Q111 Where else did you do sex Other cities 1 work before coming to this Rural towns 2 area? Never worked in other places before 3 No Response 99 Yu statim dispela kain wok long wonem hap pastaim long yu kam long hia?

- 215 -

Q112 Would you call yourself a Yes 1 migrant sex worker No 2 (someone who has to live Don’t Know 88 away from their family to No Response 99 work)?

Yu bai kolim yu yet olsem wanpela raunraun meri o wonem?

Q113 During the last 4 weeks, how Everyday 1 often had you had drinks At least ones a week 2 containing alcohol Less than once a week or never 3 /marijuana? Don’t Know 8 Would you say…..( read out No Response 9 and circle one )

Long 4 pela wik igo pinis hamas pela taim yu bin drinkim bia/spak drink?

Q 114 During the last 4 weeks, how Everyday 1 often had you smoked At least ones a week 2 marijuana? Less than once a week or never 3 Would you say…..( read out Don’t Know 8 and circle one ) No Response 9

Long 4 pela wik igo pinis hamas pela taim yu bin smokn marijuana?

Q115 Some people have tried a Yes No DK NR range of different types of Marijuana 1 2 8 9 drug. Which of the Yawa 1 2 8 9 following, if any, have you

- 216 - tried? Wai 1 2 8 9 Tunim bucket 1 2 8 9 Wonem kain spak drink yu JayJay 1 2 8 9 bin drink pinis? Read out list

Circle all that apply.

Section 2: Marriage, family, work

No. Questions and filters Coding Categories Skip to

Q201 Have you ever been married? Yes 1 →Q202 No 2 →Q204 Yu bin marit bifo o nogat? No Response 9

Q202 How old were you when you Age in Years |__|__| first got married? Don’t Remember 88 No Response 99 Yu hamas krimas na yu bin marit?

Q203 Are currently single/divorced Currently not married, living with other (Not married) sexual partner 1 →Q205

Currently not married, not living with other sexual partner 2 →Q206

No Response 9 →Q206

Q204 Are you currently married or Currently married, living with spouse 1 →Q205 living with a sexual partner? Currently married, living with othersexual partner 2 →Q205

- 217 -

Nao yu marit o istap wantaim Currently married, not living with spouse →Q205 wanpela man samting? or any other sexual partner 3

No response 9 →Q206

Q205 Does your spouse/partner have Yes 1 other wives? No 2 Don’t Know 8 Dispela man igat narapela No Response 99 meri tu o nogat?

Q206 At what age did you first Age in Years |__|__| receive money for sex? Don’t Know 88 No Response 99 Yu bin amas krismas na stat long kisim moni long ol man?

Q207 Do you earn money doing Yes 1 →Q208 other work other than sex No 2 →Q209 work? No Response 9

Yu wokim sampela narapela wok long kisim moni o nogat?

Q208 What is this other work? Yes No NR Sell farm produce 1 2 9 Wonem dispela narapela wok Sell betel nut 1 2 9 yu wok long en? Transient seasonal worker 1 2 9 Office work 1 2 9 Other 1 2 9

Q209 How many living children do None 1 you have? One 2

- 218 - Two 3 Hamas pikinini yu igat ol istap More than two 4 nao? No Response 9

Q210 Are you supporting anyone Yes 1 (children, parents, siblings or No 2 →Q301 others with income from sex No Response 9 work) now?

Sampela lain istap aninit long lukaut bilong yu nao o nogat?

Q211 In total, how many people are Number of People |__|__| you supporting now? Don’t Know 88 No Response 99 Hamaspela lain olgeta yu wok long lukautim nao?

Section 3: Sexual history: numbers and types of partners

No Questions and filters Coding categories Skip to

Q301 Now I’d like to ask you some Age in years |__|__| questions about your sexual Don’t Remember 88 partners. No Response 99

Nao mi laik askim sampela askim bilong kaop.em orait a.

At what age did you first have sex?

Wonem krismas bilong yu stret na yu stat long koap?

- 219 - Q302 Among all of your sexual partners in the last seven days (one week) how many were:

Insait long las wanwik yu koap:

- Paying clients/per day: those who Paying Clients |__|__| had sex in exchange for money? Don’t Know 88

No Response 99 - Hamas man I bin baim na koap?

- Non- paying clients/ perv day: Non-Paying Clients |__|__| those who do not give you mon ey in Don’t Know 88 exchange for sex (include spouse No Response 99 and regular sexual partners).

- Hamas ol ino baim na koap nating?

Q303 With how many different sexual Number in the previous day |__|__| partners in total you had sex with in Number in the last 7 days |__|__| the previous day and during the last Don’t Know 88 seven days (one week)? No Response 99

Hamaspela man olgeta yu koap wantaim ol long las wanwik?

(Include spouse(s) and live- in sexual partners)

(Note: Check total numbers of partners in Q303 to make sure the numbers match).

- 220 - Section 4: Sexual history: paying clients

No Questions and filters Coding categories Skip to

Q401 On the last (previous) day you Number of Clients |__|__| worked, how many clients did you Don’t Know 88 have? No Response 99

Hamas man tru ibin koapim yu long dispela las taim yu bin koap?

Q402 The last time (most recent sex) you 5-10K 1 had sex with a client, how much 10-20 K 2 money did you receive? Higher 3 Don’t Know 88 Hamas mani dispela laspela man No Response 99 ibin baim yu taim em koap wantaim

yu?

Q403 The last time (most recent sex) you Yes 1 had sex with this client did you and No 2 →Q405 your client use a condom? Don’t Know 8 No Response 9 Yutupela ibin putim kondom tu o nogat?

Q404 Who suggested condom use that Myself 1 →Q406 time? My partner 2 →Q406 (Circle one) Joint Decision 3 →Q406 Don’t Know 4 →Q406 Husat ibin toktok long kondom No response 5 pastaim?

Q405 Why didn’t you and your client use Y N a condom that time? Not available 1 2 Too expensive 1 2

- 221 - Bilong wonem na yutupela I bin Partner objective 1 2 usim kondom? Don’t like them 1 2 Add other locally appropriate Used other contraceptive 1 2 categories after pre- testing I didn’t think it was necessary 1 2 Circle all answers mentioned Partner didn’t think it was necessary 1 2 Don’t think of it 1 2 Other ______Don’t Know 1 2 No Response 1 2

Q406 With what frequency did you and Every (all)Time 1 all of your clients use condoms at Almost Every Time 2 all times over the last 7 days? Sometimes 3 Never 4 Hamaspela taim yu putim kondom Don’t Know 8 insait long wanmun yu koap long No Response 9 em?

Section 5: Sexual history: non-paying partners

No Questions and filters Coding categories Skip to

Q501 Filter: Check Q302

Had Non- Paying Partner |___| Has No Non –Paying Partner |___| →Q601 Nogat man ino save baim ___| Man isave koap na ino baim ___|

Q502 Think about your most recent non – Number of times |__|__| paying sexual partner. How many Don’t Know 88 times did you have sexual No Response 99 intercourse with this person

previous day or per day over the last 7 days?

- 222 - Hamas taim yu koap wantaim dispela man ino save baim insait long wanmun?

Q503 The last time (most recent sex) you Yes 1 had sex with this non-paying sexual No 2 →Q505 partner, did you and your partner Don’t Know 8 →Q505 use a condom? No Response 9

Dispela taim yu bin putim condom tu o nogat?

Q504 Who suggested condom use that Myself 1 →Q506 time? My partner 2 →Q506 Joint Decision 3 →Q506 Husait itok bai yupela I putim Don’t Know 4 →Q506 condom pastaim? No response 9

Q505 Why didn’t you and your partner Y N use a condom that time? Not available 1 2 Too expensive 1 2 Bilong wonem na yuno putim Partner objective 1 2 kodom long dispela taim? Don’t like them 1 2 Add other locally appropriate Used other contraceptive 1 2 categories after pre- testing I didn’t think it was necessary 1 2

Partner didn’t think it was Circle all answers mentioned necessary 1 2 Don’t think of it 1 2 Other ______1 2 Don’t Know 1 2 No Response 1 2

Q506 With what frequency did you and Every (all) Time 1 all of your non-paying partners use Almost Every Time 2 condoms at all times over the last 7

- 223 - days? Sometimes 3 Never 4 Hamas taim yu putim kondom taim Don’t Know 8 yu koap wantaim dispela man ino No Response 9 save baim long wanmun yu em?

Section 6: Male and female condoms and use

No Questions and filters Coding Categories Skip to

Q601 Filter: See Q403, Q406, Q503, Q506

Condoms not Used |___| Condoms Used |___| → → Q604 Ino putim kondom
Putim kondom

Q602 Have you ever heard of a male Yes 1 condom? No 2 Don’t Know 8 Yu save long kondom bilong man? No Response 9 (show picture of sample of one: I mean a rubber object that a man puts on his penis before sex.)

Q603 Have you ever heard of a female Yes 1 condom? No 2 → Q701 Don’t Know 8 → Q701 Yu save long Kondom bilong ol No Response 9 meri?

(show picture of sample of one: I mean a rubber object that a female puts into her vagina before sex.)

Q604 Have you and any sexual partner Yes 1 → Q701

- 224 - ever used a condom No 2 Don’t Know 8 Yu wantaim ol dispela lain yu save No Response 9 koap wantaim save long putim kondom tu o nogat?

Q605 Do you know of a place or a person Yes 1 from which you can obtain No 2 → Q607 condoms? No Response 9

Yu save long wonem hap bai yu kisim kondom?

Q606 Which places or persons do you Y N know where you can obtain Shop 1 2 condoms? Pharmacy 1 2 Market 1 2 Yu save long sampela hap o man yu STD Clinic 1 2 inap kisim kondom long en? Hospital 1 2

Family Planning Centre 1 2 (Do not read out options but probe NACs 1 2 and record all answers) Bar/ Guest House/ hotel 1 2

Peer Educator 1 2 Any Others? Health Patrol Team 1 2

Outreach workers 1 2 Ol sampela hap moa yu save bai yu Traditional Birth attendants 1 2 kisim kondom? Traditional Healers 1 2 Friend 1 2 Other ______1 2 Don’t Know 1 2 No Response 1 2

Q607 How long does it take you to obtain Within walking distance 1 a condom close to your house or to Within an hour 2

- 225 - where you work? Within a day 3 More than a day 4 Em bai kisim yu hamas haua o minit Don’t Know 8 long go long wanpela kondom ples No Response 9 klostu long haus bilong yu na kisim?

Q608 Do you / can obtain condoms free of Yes 1 charge? No 2 Don’t Know 8 Kondom yu baim o yu kisim No Response 9 nating?

Q609 How many condoms do you Number of condoms on hand | __ personally have on hand right now? | __ | No Response 99 Yu igat sampela kondom nao o nogat?

Section 7: Risky sexual practices and behaviours

No Questions and filters Coding categories Skip to

Q701 Have you ever been involved in the Y N following sexual practises? Oral Sex 1 2 -Oral Sex Anal Sex 1 2 -Anal Sex Same sexual intercourse 1 2 -Same sex sexual intercourse Group sex 1 2 -Group sex No response 9 Yu bin koap long kain ol pasin belong koap tu o nogat?

- 226 - Q702 Have you ever been sexually Y N assaulted? Line Up 1 2 If so what kind? Rape 1 2 Don’t Know 1 2 Ibin gat wanpela taim yu bin wokim No Response 9 dispela pasin tu o nogat?

Section 8: STI knowledge, health issues and STI treatment seeking behaviours

No Questions and filters Coding categories Skip to

Q801 Have you ever heard of diseases that can be Yes 1 transmitted through sexual intercourse? No 2 → Q806 No Response 9 Yu save long sampela sik yu inap kisim taim yu koap?

Q802 Can describe any symptoms of STIs in Y N women? Abdominal Pain 1 2 Vaginal Discharge 1 2 Inap yu kolim sampela sain bilong meri I Foul Smelling Discharge 1 2 kisim sik nogut (STI)? Burning Pain on Urination 1 2 Vaginal Ulcers/Sores 1 2 (Do not read out symptoms but probe for Swelling in the Vaginal Area 1 more answers and circle 1 for all 2 mentioned and 2 for all not mentioned). Vaginal Itch 1 2

Other ______1 2 Don’t Know 1 2 No Response 1 2

Q803 Can describe any symptoms of STIs in Y N men? Penile Discharge 1 2 Burning Pain on Urination 1 2

- 227 - Sampela sain bilong man igat sik nogut Penile Ulcers/Sores 1 2 (STI)? Swelling in the Groin 1 2 Other ______1 2 (Do not read out symptoms but probe for Don’t Know 1 2 more answers and circle 1 for all No Response 1 2 mentioned and 2 for all not mentioned).

Q804 Have you had a vaginal discharge during Yes 1 the last 12 months? No 2 Don’t Know 8 Yu lukim susu o sua long ples bilong No Response 9 pispis?

Q805 Have you had a genital ulcer/sore/itch Yes 1 during the last 12 months? No 2 Don’t Know 8 Yu lukim sampela sua o skirap samting No Response 9 long ples bilong pispis?

Q806 At present, do you have any pain when Yes 1 passing urine? No 2 No Response 9 Nao yu save pilim pen taim yu pispis o nogat?

Q807 For how long do you have this pain? Number of day | __ | __ | No Response 99 Dispela pen em stat long wonem taim?

Q808 With this symptom, how long after first First day 1 experiencing this did you seek treatment? Within seven days 2 Within a month 3 Taim em pen, yu istap hamas dei na yu Never 4 kisim marasin? No Response 9

- 228 -

Q809 Do you consider these sores, discharge, Yes 1 itch or the pain to be symptoms of some No 2 illness or infections? Don’t Know 8 No Response 9 Dispela yu save ting em sampela kain sain bilong sik o nogat?

Q810 With these symptoms, how long after first First day 1 experiencing these did you seek treatment? Within seven days 2 Within a month 3 Taim em kamap, yu istap hamas dei na yu Never 4 kisim marasin? No Response 9

Q811 For these episodes, where did / would you Y N prefer to seek advice for treatment? Friend 1 2 Self Medication 1 2 Taim dispela samting kamap husat I bin Traditional healer 1 2 tokim yu long kisim marasin? STD Clinic 1 2 Government Hospital 1 2 Family Planning Centre 1 2 Pharmacy 1 2 Private Doctor 1 2 Health Patrol Team 1 2 Outreach health workers 1 2 Did nothing until symptoms went away 1 2 Other ______1 2 Don’t Know 8 No Response 9

Q812 Did you tell any of your sexual partners Yes 1 about these symptoms? No 2 No Response 9

- 229 - Yu bin tokim wanpela bilong ol dispela lain yu koap wantaim long ol dispela sain o nogat?

Q813 Do you think that these illness or infections Yes 1 you have can be passed on to your sexual No 2 partners? Don’t Know 8 No Response 9 Yu ting dispela sik em iken kalap long narapela lain yu koap wantaim tu o nogat?

Q814 While you had these symptoms, did you do Yes 1 anything to prevent passing the infection No 2 → Q817 on to your sexual partners? No Response 9

Taim yu ikat dispela sain/sik yu bin wokim sampela samting long stopim em bai kalap long narapela man?

(seeking treatment is excluded)

Q815 If yes, what exactly did you do? Abstain from sex 1 (Record verbatim, then code) Use a condom 2 Took Medication 3 Sapos yu tok yes yu bin mekim wonem Other 4 samting tru long stopim dispela sik ikalap long narapela man o meri?

Q816 Did you receive a prescription for the Yes 1 → Q817 medicine? No 2 Don’t Know 8 Yu bin kisim pas bilong marasin long No Response 9 dokta tu o nogat?

Q817 Did you obtain the prescribed medicine? Yes, I obtained all of it 1

- 230 - I obtained some but not all 2 Yu bin kisim stret dispela marasin dokta I did not obtain the medicine ibin raitim long en o nogat? 3 Don’t Know 8

No Response 9

Q818 How much did you pay for the medicine? Kina / Toea | __ | __ | 1-9 Yu bin baim hamas long dispela marasin? 10-19 20-29 30-39 40-50

Q819 Did you take all the medicine prescribed? Yes 1 No 2 Yu kisim olgeta marasin ol givim yu long Don’t Know 8 en? No Response 9

Q820 If not why did you not complete all the Y N medicine prescribed? Forgot 1 2 I felt better after the first day 1 2 Sapos nogat bilong wonem na yu no I shared with a sick relative 1 2 pinisim dispela ol marasin? I usually keep some for next time 1 2 I did not like the taste of it 1 2 It made me more sick 1 2 found a traditional substitute 1 2 Don’t Know 8 No Response 9

- 231 - Section 9: HIV/AIDS: knowledge, opinions, perceptions and attitudes

No. Questions and filters Coding categories Skip to

Q901 Have you ever heard of HIV or the disease Yes 1 called AIDS? No 2 No Response 9 Yu bin save long dispela sik HIV o AIDS o nogat?

Q902 Do you know anyone who is infected with HIV Yes 1 or has died of AIDS? No 2 Don’t Know 8 Yu save long sampela man husat ikat sik HIV o No Response 9 dai long AIDS?

Q903 Do you have a close relative or a close friend Yes, a close Relative 1 who is infected with HIV or has died of AIDS? Yes, a close Friend 2 No 3 Yu igat sampela wantok igat HIV o dai pinis No Response 4 long sik AIDS?

Q904 Can people get HIV through unprotected sexual Yes 1 contacts No 2 Don’t Know 8

Q905 Can people protect themselves from HIV the Yes 1 virus that causes AIDS by using a condom No 2 correctly every time they have sex? Don’t Know 8 No Response 9 Yu ting sapos ol man I putim kondom long olgeta taim ol koap bai sik AIDS inoinap kalap long narapela man?

Q906 Can people get HIV from mosquito bites? Yes 1

- 232 - No 2 Moskito kaikaim manYu ting ol iken kisim Don’t Know 8 HIV? No Response 9

Q907 Can people protect themselves from HIV by Yes 1 having one uninfected faithful sex partner? No 2 Don’t Know 8 Sapos wanpela man istap wantaim wanpela meri No Response 9 tasol husit inogat HIV bai ikat HIV o nogat?

Q908 Can people protect themselves from HIV virus Yes 1 by abstaining from sexual intercourse? No 2 Don’t Know 8 Sapos ol man meri ino koap na istap nating bai No Response 9 ol I kisim sik HIV o nogat?

Q909 Can a person get HIV by sharing a meal with Yes 1 someone who is infected? No 2 Don’t Know 8 Sapos yu kaikai wantaim man igat sik HIV bai No Response 9 yu kisim tu o nogat?

Q910 Can a person get HIV by getting injections with Yes 1 a needle that was already used by someone else? No 2 Don’t Know 8 Sapos yu usim sut nidel wantaim narapela man, No Response 9 bai yu kisim HIV tu o nogat?

Q911 Do you think that a healthy looking person can Yes 1 be infected with HIV, the virus that causes No 2 AIDS? Don’t Know 8 No Response 9 Man ino luk olsem sik man iken igat HIV tu o nogat?

- 233 - Q912 Can a pregnant woman infected with HIV or Yes 1 AIDS transmit the virus to her unborn child? No 2 → Q913 Don’t Know 8 → Q913 Pikinini istap long bel bilong mama husat igat No Response 9 sik HIV/AIDS inap kisim tu o nogat?

Q913 What can a pregnant woman do to reduce the Y N risk of transmission of HIV to her unborn child? Take Medication 1 2 (Antiretrovirals) 1 2 Mama bai mekim wonem long stopim sik Other ______1 2 HIV/AIDS long go long pikinini? Don’t Know 1 2 No Response 1 2 (Do not read out the list but circle all that are mentioned)

Q914 Can a woman with HIV or AIDS transmit the Yes 1 virus to her newborn child through No 2 breastfeeding? Don’t Know 8 No Response 9 Pikinini inap long kisim HIV/AIDS taim em drin susu bilong mama husat igat HIV/AIDS o nogat?

Q915 Is it possible in your community for someone to Yes 1 get a confidential test to find out if they are No 2 infected with HIV? Don’t Know 8 No Response 9 Yu ting em gutpela long ol manmeri iken hait na sekim ol yet sapos ol igat HIV?

(By confidential, I mean that no one will know the result if you want them to know it)

Q916 I don’t want to know the result, but have you Yes 1 ever had an HIV test? No 2 → Q920

- 234 - No Response 9 Mi no laik save tes itok wonem, tasol yu bin igo sekim blut long HIV tu o nogat?

Q917 Did you voluntarily undergo the HIV test, or Voluntary 1 were you required to have the test? Require 2 No Response 9 Sapos yu sekim pinis,yu yet igo o sampela man itokim yu long sekim na yu wokim?

Q918 Please do not tell me the result but did you find Yes 1 out the result of your test? No 2 No Response 9 Yu noken tokim mi tasol, sapos yu sekim pinis, ol itoksave long yu pinis o nogat?

Q919 When did you have your most recent test? Within the past year 1 Between 1-2 years 2 Wonem taim tru yu bin wokim dispela tes? Between 2-4 years 3 More than 4 years ago 4 Don’t Know 8 No Response 9

Q920 Would you be willing to share a meal with a Yes 1 person you knew had HIV or AIDS? No 2 Don’t Know 8 Bai yu hamamas long kaikai wantaim wanpela No Response 9 man o meri husat igat HIV/AIDS o nogat?

Q921 If one of your peers becomes ill with HIV, the Yes 1 virus that causes AIDS, would you have No 2 anything to do with her? Don’t Know 8 No Response 9 Sapos wanpela fren bilong yu iksim HIV yu ting

- 235 - yu ken helpim em long sampela samting?

Q922 If one of your peers has HIV but does not look Yes 1 sick, should she be allowed to continue sex No 2 work? Don’t Know 8 No Response 9 Sapos wanpela bilong ol girls igat HIV na ino luk olsem sikmeri bai ol iken raun long koap nambaut o nogat?

Q923 If you become ill with HIV, would you keep it a Yes 1 secret and continue to work? No 2Don’t Know 8 No Response 9 Sapos yu igat HIV bai yu haitim na wokim dispela wok nambaut na raun istap?

Q924 If you knew a client had HIV, would you still Yes 1 sell sex to him? No 2 Don’t Know 8 Sapos wanpela man igat HIV/AIDS bai yu koap No Response 9 wantaim em long kisim moni o nogat?

Q925 Do you think sex workers should be required Yes 1 (involuntary) to undergo HIV testing No 2 Don’t Know 8 Yu ting em gutpela long olgeta raunraun meri No Response 9 long sekim ol yet long HIV/AIDS?

Q926 Should HIV testing for sex workers be Yes 1 voluntary? No 2 Don’t Know 8 Yu ting em gutpela long ol raunraun meri yet No Response 9 igo sekim HIV long laik bilong ol o nogat?

- 236 - Section 10: Risk perception and behaviour change

No. Questions and filters Coding categories Skip to

Q1001 What are the chances that you might catch No chance 1 HIV? Would you say there is no chance, a Moderate chance 2 moderate chance or a big chance? Big Chance 3 Don’t Know 8 Yu ting sanses bilong yu long kisim HIV em No Response 9 bikpela, liklik o nogat?

Q1002 Have you made any changes in your sexual Yes 1 → Q1003 behaviour to avoid HIV? No 2 No Response 9 Taim yu harim sik HIV yu bin poret liklik na senisim kain raunraun bilong yu o nogat?

Q1003 When did you start making these changes? Within this month 1 Within the last 12 months Sapos yu senisim, wonem taim stret yu stat 2 senisim dispela kain pasin bilong yu? Longer than 12 months 3 No Response 9

Q1004 What changes have you made? Always use a condom 1 Sometimes use a condom 2 Wonem ol dispela senis yu wokim long laif Have fewer partners 3 bilong yu yet? Seek prompt medical treatment for STIs 4 (Record verbatim) Other 5 ______No Response 9 ______

Q1005 If you were infected with HIV, would you tell Y .N anyone or you will keep it a secret? Tell someone 1 2 → Q1006

- 237 - Keep it a secret 1 2 Sapos yu igat HIV, bai yu tokim sampela lain Don’t Know 8 o bai yu haitim? No Response 9

Q1006 Who will be the first person you would tell if Y N you were infected with HIV? Relative 1 2 Friend 1 2 Sapos yu igat sik AIDS, bai yu tokim husait Regular sexual partner 1 2 tru pastaim? Casual sexual partner 1 2 Other 1 2 Don’t Know 8 No Response 9

- 238 - Appendix C: Rapid Risk Assessment (to determine HIV risk and when exposure to risk occurred)

“Based on weighted sum of STI risk factors via interview (2 or more) plus interview augmented with a urine dipstick”. STI history taken:

SW identification number /code: Class/type code: Age:

History: Yes No

Current and past STIs

Current Contraception

Surgical procedures

Other medical illness

Current medication: (Prescribed, over the counter, illicit, self medication, herbal concoction)

Allergic to any antibiotics

Which antibiotic if known----

Presenting signs & symptoms:

Anogenital discharge

Genital offensive odour

Itching, tingling or burning irritation

Lower abdominal pain, pelvic tenderness

Dysuria (painful urination)

Vaginal spotting, or bleeding after sexual intercourse

Dyspareunia (painful sexual intercourse)

- 239 - Rashes in the genital or anal area

Genital ulcers/sores, lumps, blisters, warts

Fever, fatigue, lack of energy

Menstrual irregularity

Persistent or recurring diarrhea

Problem (symptoms) description:

Onset within one month:

Onset more than one month

Character: ( e.g. discharge, abdo pain, dysuria, itch, sores etc)

Duration: (1 day, 1 week, > 1week etc)

Relationship to sexual intercourse

Relationship to urination

Familiarity / similarity to previous problems

Aware of STI problems of regular sexual partner (s)

Most recent sexual activity/ behaviour:

Sexual intercourse with clients this week

Sexual intercourse with regular sexual partner this week

Condom use with clients during recent sex act

Condom use with RSP during recent sex act

Use of lubricant with condoms

History of same sex sexual intercourse

History of group sex

History of anal sex

History of oral sex

History of rape, forced or group sex

- 240 - Sexual intercourse under the influence of marijuana, wai or alcohol

Location of sexual activity –(outdoor)

Location of sexual activity –(indoor)

Sexual activity outside Port Moresby

Sexual contact with foreigners in Papua New Guinea

Exposure to blood:

History of and current tattoos

History of previous blood transfusion/ infusion

Sharing of razor blade

History of injecting drug use

Urine leukocyte esterase dipstick test outcomes greater than 1+ (based on the concentration of white blood cell enzymes) Scale:

Urine dipstick Negative

Urine dipstick Trace

Urine dipstick >+1

Urine dipstick >+2

Urine dipstick >+3

- 241 - Appendix D: Explanatory Statement: Periodic Presumptive Treatment (PPT)

Human immunodeficiency virus is becoming a major issue around the world and claiming many lives. In many developing countries, sex workers are mostly affected, many of whom are in their most reproductive years. Recent studies continue to show an increasing HIV trend in sex workers but this trend can be averted. We are therefore conducting a study to enable us to put in place best prevention models that will contribute to the reduction of HIV/STIs transmission, vulnerability and impact among sex workers. At this stage, we will only be focusing on sex workers in Port Moresby where HIV is most advanced.

The aim is to determine if three-monthlyPPT would be feasible to reduce the prevalence of STIs. If this strategy was able to reduce the prevalence of STIs then it could potentially also reduce HIV transmission in FSWs. This study will commence in November 2003 and close in September 2004.

We are asking female sex workers to participate in this study. If you do not wish to participate, you are under no obligation to do so. However, if you wish to participate, you will be only eligible if you are 18 years or older, have received money for sex in the last month, not allergic to penicillin, have not taken antibiotics in the last month, not pregnant, not currently enrolled in a similar study and intend to remain in Port Moresby for ten months and more.

The study involves a three-monthlypresumptive STI treatment in between pre and post testing of STIs, including HIV. So, you will be required to undergo several laboratory tests. We will obtain self-collected vaginal swabs, urine and serum samples from you at the start of, and toward the end of, the study. These will be tested for STIs. During this time questionnaires for rapid risk assessment will be handed out to you and interviews will be conducted by trained staff. The interviews will last for about one hour. Some of the questions will be very personal and you may find it difficult to respond, but your answers are strictly confidential. Your name will not appear on any form and will never be used in connection with any of the information you provide. I also want to make it clear that you are not obliged to answer any questions that you do not feel comfortable answering and you may choose to end this interview anytime you so please. However, your honest answer to these questions will help the research team identify what is needed in order to address adequately and respond positively to issues that affect female sex workers.

Pre and post counselling will be offered by trained staff before laboratory samples are obtained and test results are handed out. HIV/STIs prevention education will be offered in addition to ongoing behaviour change communication strategies. We will be providing behaviour change training for selected FSWs as peer educators who will reach out to the wider sex worker community in Port Moresby with ongoing risk

- 242 - minimisation education. Time will be allocated to answer all your questions through a workshop (preparation day) where you will be provided with information about the study and obtain informed consent by thumbprint for enrolment. Also, you will be taught procedures of the study, how to collect vaginal and urine specimens, provided with necessary specimen containers and pseudo names. We will provide each participant with a colour coded card that indicates specific dates of the testing and treatments regimen. At each of the selected sites for the study, we will nominate one FSW who will act as a point of contact for all FSWs in that particular site.

Each participant will be given three-monthly (0 month, 3 months, 6 months and 9 months) oral doses of 2g amoxicillin, 1g probenecid, 625mg X 2 augmentin and 1g Azithromycin via direct observed therapy. We will administer “once only” 2g Tinadazole per day over three days at the nine-month visit. In total, four rounds of PPT will be offered to you during the life of the project. Food will be provided but money will not be offered. Free transport to and from sites to the Medical School will be offered. You will also receive free HIV information, IEC materials, condoms, lubricants, hats and other handouts. The study has been approved by the Ethics and the Medical Research Committees. You are welcome to speak with any of the committees or committee members. Thank you.

Signature (FSW):

Date:

Facilitator:

- 243 - Appendix E: Legal and Ethical Considerations

There are legal and ethical issues associated with this study. The following are explanatory notes that identify the major issues and proposes solution where necessary. Civil issues are categorised under: Liability in battery Liability in negligence Liability for disclosing confidential information

Civil Issues

Liability in battery The participant must be competent to consent The consent must be based on adequate information The consent must be voluntary The consent must not be against the public interest

Obtain valid (signed )fully informed consent from participants

The project will ensure that both foreseen and reasonably foreseeable risk to participants are minimised

Consent may operate as a defence

Liability for disclosing confidential Health /research team and participants confidentiality will exist information Informed consent of participants will be required before any discloser of information can be made unless it is authorised by statute.

Liability in negligence if : Project will ensure that the duty of care is not breached to either Breach of duty of care participants or a third party Breach of duty caused by suffering Care advice information and treatment information will be the or damage requisite legal standard. Damage is compensable at law

Ethical Issues

Informed consent Fully informed, both in written and orally, about the nature,

- 244 - purpose, significance and context of the treatment and procedures before the study. Voluntary consent Competent participants only to consent

Confidentiality Confidentiality will be obtained Use of pseudonyms Raw data use only Any information that may be published will be released in such a way that an individual’s identity will not be divulged A statement as to which persons involved with the study will or may have access to details of a participant’s identity will also be included, whilst assuring participants that protection of their privacy is maintained. The contribution made by participants will subsequently be appropriately acknowledged and provision made for feeding back the knowledge obtained through the research process to such individuals.

Fair and Just Enrol and control study with the appropriate number of participants Participants will be encouraged to remain in the study although one may wish withdraw from the study at any time Project will take appropriate step to liaise with the appropriate ethical committee representatives to plan for the most appropriate handling of potentially sensitive issues

Compensatory Mechanisms Participant’s rights will always be protected under common law

Duty of care Project staff will have moral obligation to always treat participants accordingly Staff will have duty of care to provide non- judgemental professionally appropriate levels of care

Autonomy Participants will be given every opportunity to obtain information about the study Participants able to withdraw at any time Respect for individual human dignity be maintained at all times

- 245 - Issues of coercion A requirement for a statement about the voluntary nature of participation will be included Participants will be given every opportunity to exercise freedom of choice, this study will not use coercive measures to coax people to participate Clear explanation of the use of the PPT made available to participants

- 246 - Appendix F: Rapid Formative Research — English FGD Guide

Focus group discussion and topic guide

Good morning/afternoon and thank you all for coming.

My name is ______and together with me are my colleagues (the research team). We are from World Vision Pacific Development Group, Papua New Guinea.

Read the following as it is

After I conduct a brief introduction, we will be talking to you about several different issues.

We will be asking you questions pertaining to issues related to HIV/AIDS in your locality, your general HIV knowledge, HIV risk perception, condom use, safer sex practices and the challenges to adopting protective behaviours in the sex industry. We will conclude the session by asking you for your recommendations on how best to address the problem and what programs might need to be incorporated in the programming decisions for sex workers in the future.

Potential use of data

The gathering of this information is to gain further insight into those aspects of HIV risk reduction interventions among sex workers.

MAJOR RULES:

Issue of confidentiality

Please be assured that any information we collect from you will be strictly kept confidential. Specifically, the research team and other participants will not directly share the information in a way that would reveal an individual’s personal identity.

- 247 - Consent for participation and tape recording

At this point it is important that we obtain your verbal consent for conducting the session.

Understand that this is more for your protection than anything else. We will read the consent form out aloud to you (the group). “Your remaining in the session indicates that you have voluntarily agreed to participate in this focus group discussion. You have the right to refuse to answer any questions and to end the discussion if you find it necessary to do so. However, for the sake of accuracy and efficiency, we will also be tape recording these sessions, unless anyone has any objections.”

Role of facilitator/note taker

Amongst the research team is a facilitator. She will be in charge to steer the discussions. The facilitator will bring the discussion back to the topic should it go beyond or outside the main discursive theme. She will not give any indication (verbal or physical) that would encourage certain types of comments or discourage other types of comments. In short, she will guide the discussion, being careful not to lead the discussion. It is our role to facilitate, but your role to tell us what you think. The scribe (note taker) will have the sole responsibility of capturing the sessions as accurately as possible. This will include not only your responses, but your non-verbal clues as well, the physical environment, atmosphere of the session, as well as other vital characteristics of the session.

Importance of focus group

In this group, everybody should feel free to talk. Each and everyone’s opinion is important. It is very important that every member of the group gets a chance to express their opinions and views.

Agreement to disagree

In this group there is no right or wrong answers. Everybody should express themselves and opinions the best way they see fit. However, when you express your opinions, you are encouraged to be honest in your views of how you perceive HIV risk in your profession and private lives, how condom use fits into HIV risks, how HIV knowledge translates into safer sex practices and the challenges you face in adopting 100% condom use. We would like you to focus your comments on the discussion and not toward each other or members of the staff.

Focus Group Discussion Report Form

Topic: HIV knowledge, risk perception and safer sex practices

Date: ______

District: ______

- 248 - Site (circle type): i Water front/Wharf area ii Peri urban slum iii Settlement iv Guest house

Facilitator: ______

Scribe: ______

Group: AM, AF: ______

Duration: ______

Community Liaison Person: ______Participants’ Characteristics: Age group SW Class type Number of participants Site/location

AdditionalComments:______

______

Focus group discussion topic guide

♦ Before we get into the discussion, we would like to know what you expect from the discussions and what you really want to get out of it.

♦ Before we get into the discussion itself, we would like to start by collecting the following information on your general background:

- 249 - Please indicate if you have received money/gifts for sex in the past month:

Yes __ No ___

I. Background

Please tell us about:

Age:

Age group: (14-20)______(21-30) ______(31- 40) _____ (41- 50)______

Sex worker Classification: 2K Meri______Disco Meri ______Other______

Educational Status: None______Primary______Secondary______Tertiary______

Marital Status: Single______Married______Separated/Divorced/Widowed ______Boyfriend ______

Religion: Christian ______Secular______Paganism ______Other ______

Residence: Settlement ______Urban Slum______Stilts ______

No of Children: 1______2 ______3 and >______None ______

Living arrangement: Alone_____ Friends_____ Relatives_____ Protectors ______Parents _____

Source of income: Sex work only _____ Other work besides sex work ______Government Support_____

Place of Sex work: Port Moresby only_____ Outside POM ______Outside PNG_____

Years engaged in sex work: (1-3) _____ (4-6) _____ (7-9)_____ (10 >)______Other_____

Status engaged in sex work: Fulltime _____ Part time _____ Casual (on and off) _____

Other______

Earnings per each sex act: (< 9 Kina) _____ (10-20K)_____ (21-30) _____(31-40K) _____ >40_____ Other_____

Who are your clients: Foreigners _____ Office workers_____ Local floating rich men ______Police/Military men______Seamen_____ Wharfworkers_____ Factoryworkers_____ Students_____ Street vendors_____ Drivers_____ Boskrus_____ other _____

Where do you find customers? Probe

- 250 - 2. HIV/AIDS Knowledge

2.1 We would like to hear all you know about HIV

Let us talk about how HIV is transmitted

Probe

Would you give us some examples of the different ways through which people can get HIV? We also want you to tell us some of the local beliefs as to how people can get HIV.

(Do not read options) -From a pregnant woman to the unborn child

-From toilets

-By sexual intercourse

-By shaking hands

-From blood transfusions

-Through injections

-From mosquitoes

-From razor blades

-From sharing utensils

2.2 In what ways do you think people can prevent themselves from getting HIV?

Probe

Would you give us some examples of the different ways to prevent HIV?

(Do not read options) -Abstinence

-Being faithful to one uninfected partners

-Using condoms correctly and always

-Have fewer sex partners

-Seek prompt treatment for STI

Probe further

- 251 - Are there other methods?

In your opinion, do you think people with HIV can ever get rid of it?

2.3 When you hear AIDS, what comes to mind? We would like you to share what you know about the disease.

Probe

How did you come to know about this?

2.4 How do you think the AIDS virus is transmitted?

Probe

Would you give me some examples (Do not read options)?

-From a pregnant woman to the unborn child

-From toilets

-By sexual intercourse

-By shaking hands

-From blood transfusions

-Through injections

-From mosquitoes

-From razor blades

-From sharing utensils

Probe further

In your opinion, can you get AIDS from a healthy looking person?

In your opinion, how do you see the disease, how serious is AIDS in your community?

What could be the consequences of AIDS?

How are people affected with AIDS treated in your community?

Have your lifestyles, behaviours, practices changed because of AIDS? If so, why and how, If not, why not?

2.5 How can one prevent getting AIDS?

Probe

- 252 - Would you give us some examples?

(Do not read options)

-Abstinence

-Being faithful to one uninfected partners

-Using condoms correctly and always

-Have fewer sex partners

-Seek prompt treatment for STI

Probe further

Are there other methods?

3. STI Knowledge

3.1 We would like to hear all you know about STIs. When you hear of STI what comes to mind?

Probe

Would you give me some examples?

(Do not read options)

-Gono

-Syphilis

-Trichomona

-Chlamidia

3.2 We would like you to tell us how people get STIs — how STIs are transmitted.

Probe

Would you give me an example?

3.3 In what ways could people prevent themselves from getting STIs?

Probe

Would you give us an example?

3.4 Would you describe or tell us about the signs and symptoms of STIs?

- 253 - Probe

Would you give us an example?

3.5 We would like to hear your opinions about what people should do if they get an STI.

Probe

In your opinion, tell me if STIs are curable?

What do you think people should do if they have STI?

In your opinion, should people with STIs go for treatment and why?

What would be the best places to provide STI services? (List them)

Where do you generally seek treatment for STIs? (List them)

-Where should people receive STI treatment?

-Where would you like to get STI treatment?

-When was the last time you had STI treatment?

-Where did you get STI treatment?

Which is the most preferred place for STI treatment and why?

We would like to know your opinion about STI treatment services in your locality:

- Are you utilising it? If not, why?

- What are the problems you generally face in going to the place where they provide such treatment?

How could people provide STI service for group such as yourself?

Suppose a person is suffering from STI, in what ways do you think he will get HIV?

In your opinion, are there methods that people could use to avoid getting STI immediately after having unprotected sex?

We would like to know other methods people use in your locality to cure STI other than going to a doctor

Would you tell your sexual partners if you have an STI; if yes why and if no, why not?

Would you seek STI treatment for yourselves if you know that your sexual partner is infected?

- 254 - Suppose a person is having STI and is taking treatment — if the signs and symptoms of STI disappears before completing the tablets, what should he do?

Suppose a person is prescribed STI medicines for treatment, in your opinion should the person complete medication?

3.6 In your opinion, what do you think is the relationship between HIV and STI?

Probe

Would you give me examples of similarities?

Would you give me examples of differences?

3.7 How do you relate multiple sexual partners with HIV/AIDS and other STIs?

Probe

Would you give me an example?

4. HIV Risk Perception:

4.1 What comes to mind when you hear HIV risk perception?

Probe

Would you give us some examples?

What other views do other people have to share?

4.2 We would like to know how you personalise HIV risk.

Probe

Would you give me an example?

Has anyone else had a similar experience?

4.3 How do you see HIV in relation to sex work?

Probe

Would you give me an example?

4.4 What comes to you mind if we say someone is at no risk of catching HIV?

Probe

Would you give me an example or explanation?

- 255 - 4.5 What comes to you mind if we say someone is at moderate risk of catching HIV?

Probe

Would you give me an example or explanation?

4.6 What comes to you mind if we say someone is at high risk of catching HIV?

Probe

Would you give me an example or explanation?

4.7 In your opinion, how likely do you think you are of becoming infected with the HIV?

Probe

Would you give me an example or explanation?

How would you rate yourselves at risk of the infection (no, low, moderate, high) and why?

4.8 How likely do you think your clients are of becoming infected with the HIV and why?

4.9 How likely do you think your regular sexual partners are of becoming infected with the HIV and why?

4.10 In your opinion, of your clients and regular sexual partners, who is more likely to expose you to HIV and why?

Probe

Please give us many instances, examples or explanations as possible?

4.11 We would like you to know about the different problems you face in the sex industry.

Probe

Give examples of some of the serious problems that you face?

Anyone had similar experiences?

How do you see HIV in relation to these problems?

If a person gets AIDS, who else (at all) do you think are affected because of the disease?

4.12 When you get together with your peers, do you talk about STI/HIV/AIDS? How often does the topic of HIV come up in conversation and what is it that you talk about?

- 256 - 4.13 We would like to hear if you are worried about getting HIV and why.

Probe

Would you give me an example or explanation?

Has any one else had a similar experience?

5. Knowledge of HIV risk verses condom use (safe sex):

5.1 What comes to mind when you hear the term safe sex?

Probe

Would you explain to me what 100% condom use is?

Would you explain further?

Is there any thing else?

5.2 In your opinion, what are the determinants of safe sex in your profession, private sexual lives and your community?

Probe

Please give us many examples as possible.

5.3 What determines unsafe sex in your profession, private sexual lives and your community?

- (Please elaborate on the causes, its consequences and prevention strategies)

5.4 What do you perceive as the major challenges to adopting safer sex practices (protective behaviours)?

Probe

Would you give us an explanation?

Tell us how feasible condom negotiation is in both your professional and private life situations

5.5 We would like you to tell us about all other problems you face in the sex industry.

Probe

Give examples of some of the problems that you face.

- 257 - 5.6 We would like you to tell us how your knowledge of HIV risk influences your decision to use condoms with your clients and regular sexual partners.

Probe

In general, how many clients do you have sex with per day?

In general, how many regular sexual partners do you have sex with per day?

In your opinion, amongst which of your sexual partners contribute most to HIV transmission in sex workers? Why?

We would like to learn of the dynamics of communicating condom use with the different categories of sexual partners and explain why?

In your opinion, should safe sex be practiced equally amongst your clients and regular sexual partner? If yes why, and if no, why not?

What are your reasons for choosing to use or not to use condoms with the different categories of sexual partners?

If you have a permanent partner or husband, do you use condoms with him?

5.7 We would like to know how you perceive condom use and factors for non- utilisation.

Probe

Do people use condoms with different categories of sexual partners?

Do you have the intention to ask your sexual partners to use a condom?

Would you explain further?

When people use condoms, what are the major reasons why they use them with their different sexual partners?

When people do not use condoms, what are the major reasons why they do not use them?

What are the greatest obstacles to condom use with clients and regular sexual partners?

What can be done to help you to use condoms regularly?

Is there any thing else?

5.8 Please tell us some of the problems you have experienced while using condoms.

Probe

- 258 - (Do not read options)

-Clients refused to use a condom

-Client offer extra cash for no condom use

-Regular sexual partner refused to use a condom

-No condom when one is wanted

-Condom breakage

-Condoms wasted time - took fun out of sex

-Condoms reduced pleasure

-Condom use fetches less money sometimes

-Sex is dry – no lubrication

-Drunk during sex

-Cannot negotiate safer sex

-Do not request condom with regular sex partners

5.9 Can you tell us where you could get condoms in your locality?

(List all)

5.10 Are the current condom outlets favourable for maximum utilisation by you?

Probe

Where have you gotten most of your condoms?

How many of you are currently carrying condoms?

If current outlets are not favourable, what are the other means which improve utilisation?

5.11 Though knowledge seems high, risk behaviour reduction among sex workers is said to be low. What do you think are the main reasons?

Probe

(Do not read options)

-No idea

-Poverty

- 259 - -Unemployment

-Substance abuse

-Others

5.12 We would like you to tell us about the relationship between drug or alcohol use and safer sex practices.

Probe

In what ways does drug use influence safer sex -would you explain further?

Has anyone else had a similar experience?

5.13 Would you say drug or alcohol contributes to HIV infection?

Probe

Would you give me an explanation?

6. Overall preventive measures

6.1 What are the most important preventive measures being taken by the sex worker?

Probe

Please mention all preventive measures.

Which ones are more feasible and acceptable methods of prevention for you?

6.2 At the present time, what are you doing to protect yourself from the virus? If yes, what are you doing to protect yourself against AIDS?

Probe

(Do not read options)

-Use condoms

-Avoid certain types of men

-Have fewer partners

-Regular clinical check ups

-Use spermicides

- 260 - -Exit sex work

-Other

6.3 We would like to you to tell us what you would like to do to protect yourself from HIV but seem impossible.

Probe

Would you give us some an examples

Is there anything else people would like to do, but can't always do?

Why can't people always do what is necessary to protect themselves?

Why is it that people sometimes protect themselves, but not always?

7 Evaluation

What did you like best about the discussion? (What has been most helpful to you?)

What did you like least about the discussion? (What was least helpful to you?)

What should be changed?

Do you have any other advice about the discussion?

8. Conclusion

Our purpose was to learn more about your perception on HIV/STIs and how it could be prevented. Do you have anything else to share on this? Do you suggest anything, comment on and recommend mechanisms from your own opinion to avert the emergence of new HIV infection and other STIs in sex workers? Have we missed anything? This is the end of our discussion.

Thank you very much for your participation in the discussion .

- 261 -

Minerva Access is the Institutional Repository of The University of Melbourne

Author/s: Bruce, Eunice Adjoa Kwansemah

Title: Studies of female sex workers in Port Moresby, Papua New Guinea

Date: 2010

Citation: Bruce, E. A. K. (2010). Studies of female sex workers in Port Moresby, Papua New Guinea. PhD thesis, Medicine, Dentistry & Health Sciences, School of Population Health, Melbourne Sexual Health Centre, The University of Melbourne.

Persistent Link: http://hdl.handle.net/11343/35500

File Description: Studies of female sex workers in Port Moresby, Papua New Guinea

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