Characteristics, sexual behaviour and access to health care services for sex workers in South Africa and Kenya

Sex workers in Sub-Saharan Africa are vulnerable to a range of factors that dispose them to poor health outcomes. In particular, they are at high risk of violence, injury, rape, discrimination and a spectrum of human rights abuses. Their vulnerability to HIV and other STIs are many fold greater than the non-sex worker population of the same age. Health care systems world-wide, and particularly in Africa, are not adequately responsive to the needs of sex workers. As a result, many sex workers do not receive adequate health services, education or HIV prevention tools. While the literature on female sex work in Africa is fairly robust, troubling research gaps are evident on male and transgender sex work, as well as on the intersections of migration and sex work. Mega-sport events have been associated with increased anxiety about sex work and human trafficking, with few studies tracking the impact of such events on local sex work industries over time. These fears were prominent during the 2010 FIFA Soccer World Cup. This PhD project consisted of three research projects based in South Africa and Kenya. It aimed to evaluate the impact of social and behavioural factors on the health of sex workers. To achieve this objective, it examined the effects of sex worker characteristics, migration status, and their relationships with commercial and non-commercial partners on sexual behaviour and access to services. Such information may assist in designing more effective health policies in addition to providing insights into the structural factors that affect sex work settings and heighten sex worker vulnerability to ill-health. The first research project consisted of face-to-face surveys with 1799 male, female and transgender sex workers in Johannesburg, Rustenburg and Cape Town. The second research project involved telephonic interviews in three waves with 663 female sex workers who advertised online or in newspapers in South Africa. The third component was a prospective cohort of 400 female sex workers in Mombasa, Kenya. The research findings indicate the diversity of the sex industry and the people who work in it. Sex work is an important livelihood strategy that provides an income for sex workers and their extended network of dependents. Migration is a vital component for exploring and understanding how many sex worker lives and work are structured in South Africa. Sex workers are subject to violence from their non-commercial partners as well as from police, while unprotected sex with non-commercial partners emerges as an important risk factor for HIV. The PhD research detected little significant changes in the sex industry due to the 2010 Soccer World Cup, and documents how strategic opportunities were lost to alter some of the structural conditions of sex work during a time of heightened sex work awareness, funding and scrutiny. Moreover, this thesis highlights the shortcomings of health care services in responding to the needs of sex workers. It recommends the rolling-out of specialised, sex work-specific health care services in areas of sex work concentration, and sex work-friendly services in mainstream health care facilities in areas of lower sex work concentration. Non-judgemental and empathetic health workers are a key component of responsive services. Lastly and perhaps most importantly, it underscores the importance of decriminalising sex work in order to safeguard sex worker rights and to protect individual and public health