Gender-Based Violence and HIV Risk among Female Sex Workers in Iringa, Tanzania: Implications for a Community Empowerment Response

Globally, female sex workers (FSWs) bear a disproportionate burden of GBV and HIV. Prior work has demonstrated how substance use overlaps with GBV and HIV to further increase FSWs’ risk for negative health outcomes. This dissertation explored how aspects of the sex work environment, including physical, social, economic, and political factors, facilitate alcohol consumption and influence FSWs’ risk for GBV and HIV in Iringa, Tanzania. The ways in which sex workers collectively mobilize to address these factors and access their health and human rights was also explored. Additionally, this dissertation examined FSWs’ experiences accessing justice for violence perpetrated against them. This study was nested within a community-randomized controlled trial of a combination HIV prevention intervention among FSWs in Iringa, Tanzania. Utilizing baseline data from the parent study, this dissertation first conducted logistic regressions to assess the relationship between substance use, GBV, and consistent condom use with clients among a cohort of 496 FSWs. Additionally, 24 FSWs were purposively sampled to participate in in-depth interviews (IDIs) which aimed to gain a nuanced understanding of the role alcohol plays in both HIV and GBV related risk in the context of venue-based female sex work, as well as women’s experiences accessing justice for violence perpetrated against them. Qualitative data analysis was facilitated through the framework approach, in which the researcher begins analysis with a list of a priori codes, informed by the literature, while allowing for other domains to emerge from the data. Quantitative results suggest that intoxication during sex work is associated with significantly increased odds of GBV (aOR: 1.67, 95% CI: 1.08, 2.59) and reduced odds of consistent condom use with clients (aOR: 0.59, 95% CI: 0.37, 0.95). Qualitative analysis suggests that routine interactions between FSWs and their clients at specific moments in time and space during the sex exchange process facilitate alcohol consumption and increase FSWs’ risk for GBV and HIV. Furthermore, participants revealed how they mobilize their collective agency to address these environmental factors to limit alcohol consumption, prevent GBV, and promote condom use among their colleagues. Finally, qualitative results suggest that FSWs are routinely denied access to justice for violence perpetrated against them due to their occupation, and face human rights abuses at the hands of the police when they report violence to the authorities. Findings from this dissertation highlight the need for community empowerment approaches for HIV prevention among FSWs to address the intersection between alcohol consumption, GBV, and unprotected sex. Such models should provide FSWs with the opportunity to mobilize their collective agency to disrupt aspects of the sex work environment that facilitate alcohol use and increase FSWs’ risk for GBV and HIV. Finally, this study suggests that future community empowerment interventions should also provide FSWs with the skills and knowledge to join together in solidarity, in tandem with key stakeholders, to demand access to justice for violence perpetrated against them. It is possible that such an approach could reduce violence and HIV among FSWs in Tanzania and in similar settings