Johannesburg, South Africa (IRIN)
Commercial sex work, dominated by a focus on women, could be redefined as new research launched today in Nairobi, Kenya, sheds light on the complicated HIV prevention needs of what may be Africa's most deeply underground group at high risk of HIV - male sex workers.
The report co-authored by the United Nations Development Programme (UNDP) and South Africa's Sex Workers Education and Advocacy Taskforce (SWEAT) seeks to better understand the social contexts, sexual practices and risks, including that of HIV, among these men.
The professional debut of many of the 70 male sex workers surveyed in Kenya, Namibia, South Africa, Uganda and Zimbabwe was often prompted by the family rejecting the men's sexual orientation; for others, it was a way to survive in a foreign country.
Men reported being at risk of HIV in many ways, including the unavailability of speciality health services, the premium clients placed on unprotected sex, violence and the lure of substance abuse. Although the work often placed them at risk of substance and physical abuse as well as HIV infection, the researchers found that it also provided the men with a sense of freedom and empowerment.
The report cautions that mitigating these risks may require specialised HIV prevention services unlike those targeted at female commercial sex workers or men who have sex with men (MSM).
A series of interviews with male sex workers at a five-country workshop in Johannesburg, South Africa, and country visits to Kenya and Namibia has produced a significant addition to the paucity of data on male sex workers, according to Paul Boyce, a UNDP researcher.
While data on MSM from Malawi, Namibia and Botswana indicated that about 17 percent were HIV positive - almost twice the national prevalence rates of their respective countries - not much has been written on the specific HIV-risks of male sex workers, which may be higher than those of MSM.
While male sex workers reported working at a range of venues, including Namibian truck stops and Zimbabwean mines, most of the available information on male sex work has come from those operating in the sex tourism hot spot of Mombasa, Kenya, with limited data from a 2009 study in South Africa that showed male sex workers were twice as likely to engage in anal sex than MSM who were not selling sex.
Not necessarily the same old risks
Unprotected receptive anal sex carries almost 20 times the HIV risk associated with unprotected vaginal sex.
Interviewees told researchers that the unavailability of water-based lubricant, which reduces the risk of condoms breaking during anal sex, and the higher financial reward of unprotected anal sex, made consistent condom use difficult.
Some clients forced unprotected intercourse on sex workers, while others admitted to practicing unsafe sex due to the disinhibition often brought about by the drug and alcohol abuse that is reportedly part of the social scene in sex work. Drugs and alcohol also helped the men mentally cope with the omnipresent risks of this lifestyle, including police harassment.
South African male sex workers said substance abuse - not HIV infection - was the greatest threat to their health.
Those who tried to access health services for HIV testing and treatment, or the diagnosis of sexually transmitted infections (STIs), reported being ridiculed and stigmatized by health workers, even in countries like Kenya, where the Ministry of Health has introduced new guidelines on MSM and sex work, and health and HIV.
"[At the] government hospital, the nurses just [stand] in front of everyone and shout out loud to the people waiting for assistance: 'If you have HIV, go to room nine, TB room 12, STD [sexually transmitted disease] room 8,'" said one man quoted in the report.
"Nurses often call each other when they find out about someone being a male sex worker, saying: 'We have never had such a case' or 'come look at what his type of STI, we have never had it at this hospital before.'"
According to Boyce, while there is a growing trend to provide MSM with targeted HIV prevention and health services, such as the Health4Men clinics set up in South Africa, there may be a need to establish separate, specialized services for male sex workers apart from these.
"There's not always a close collaboration between MSM and men who sell sex because [MSM] often stigmatize them, so they're not really natural bedfellows," Boyce told IRIN/PlusNews. "Sex workers face specific issues... and male sex work can be more invisible and blurred within male-to-male sexualities and politics in ways that have not always helped to highlight the specific needs and issues of male sex workers."
Although SWEAT and the African Sex Workers Alliance (ASWA) have begun to address the issues of female sex workers in Africa, these organizations have largely ignored male sex workers. Yet Boyce noted that many male sex workers thought there was political power in being identified as a 'sex worker', because they believed it aligned them to these larger sex work organizations.
Risk and reward
In recent years here has been a greater focus on the social power of vulnerable groups in the HIV response, including the role of women in initiating sexual relationships and the fact that for some, sex work was a career choice.
Similarly, the new research showed that while male sex work was fraught with risks, the men derived a sense of freedom and independence from the increased access to cash and the ability to set their own working hours. It also helped build their self-esteem, establish social networks, and understand their own sexuality.
"The report highlights ways in which risk and safety are not dichotomous in the lives of male sex workers, but rather the contexts of sex work are associated with both vulnerability and protection, rejection and belonging, in complex ways," Boyce said. "This points to key issues that must be developed in future HIV prevention policy and counselling."
Aside from targeted HIV services, the report recommends that more research be conducted into the realties and HIV risks of male sex workers in Africa, and that larger sex work organizations such as ASWA incorporate men into their work.
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