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chichi81 (f)
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Sexually transmitted diseases and
condom interventions among
prostitutes and their clients in Cross
River State
Eka Esu-Williams
AIDSCAP Field Office, Calabar
The Cross River State commercial sex worker project started in 1989 as a pilot program to
test HIV/AIDS and sexually transmitted disease interventions among full-time and part-time
sex workers, their partners and their clients. Three main locations were targeted: Calabar and
Ikom in the Cross River State in the first phase of the program and Port Harcourt where
outreach started in 1992 to test the replicability of the project outside the Cross River State.
The project activities were co-ordinated from Calabar which is 200 kilometres from Ikom and
180 kilometres from Port Harcourt. Approximately 800 prostitutes and 2,000 clients in Cross
River State have been reached through 17 sites (12 in Calabar and 5 in Ikom) for full-time sex
workers and ten sites (6 in Calabar and 4 in Ikom) for part-time sex workers. In Ikom, a large
population of paramilitary men, such as customs officials deployed at border posts between
Cross River State and the Republic of Cameroon have been targeted. In contrast, of the 25
sites estimated for full-time and 15 sites for part-time prostitutes in Port Harcourt, only
twelve were reached because they were more widely dispersed and prostitute groups were
more diverse when gauged by social and economic indicators. The Port Harcourt project
aimed to reach approximately 1500 sex workers and 3000 clients within an eight-month
period, January to August, 1992.
Preliminary contact with prostitutes and their clients was made in 1987 in Calabar by
members of the Cross River State AIDS committee. At the time, AIDS was hardly a topical
issue for the generality of Nigerians. Primarily it was regarded as a subject of concern for
prostitutes, foreigners, and Africans in East and Central African countries. It was not possible
to initiate a formal project before 1989 because of financial constraints, resulting in a
prolonged period of unstructured interaction with the target group. Nonetheless, this provided
the opportunity to build understanding and trust and to sustain dialogue on issues of common
interest with the target group. Also during this period, key members of the population such as
'chairladies' (leading prostitutes); their assistants; 'policing agents' responsible for
maintenance of law and order and welfare of prostitutes; hotel proprietors and managers and
others such as security agents with substantial influence or authority over the target
population were identified, and their support secured. It became apparent through this
interaction that the effectiveness of any HIV/AIDS and STD prevention and control program
aimed at sex workers and their partners would depend on the active participation in project
design and implementation of members of the target population.
The main objectives were to develop and implement an intervention program to reduce
the transmission of HIV/AIDS and STDs among prostitutes, as well as their partners and
clients, through providing STD services, condom promotion and health education.
224 Eka Esu-Williams
Supplement to Health Transition Review Volume 5, 1995
Target population
This includes women in full-time prostitution, resident in hotels and compounds; part-time,
non-resident prostitutes; clients and partners of prostitutes; and hotel owners and managers.
Often, hotel owners and managers establish sexual liaisons with prostitutes in exchange for a
wide range of favours.
Full-time prostitutes live alone or with their children and operate in easily identifiable
sites with well defined community structures. These structures provide the basis for program
implementation and sustainability. Low charges, approximately 50 cents per sex act, make it
imperative for full-time prostitutes to entertain a large number of clients a day, ranging from
two to twenty.
Part-time prostitutes who usually are low-income earners and students canvass for clients
outside big hotels and night clubs. They lack a visible social structure and working norm, and
often operate in small loosely organized groups. On the average, they receive one client per
day and charge over six times more than full-time prostitutes for a sex act.
Description of intervention
A major problem at the onset of the intervention was the prevalence of misconception and
apathy about HIV/AIDS and STDs, ignorance about condoms, and poor access to them,
which were compounded by the poor state of available health information and services on
these issues. To identify the specific knowledge gaps, and to determine the appropriate
strategies for HIV/AIDS and STD intervention, the collection of baseline KAP data, focus
group discussions and HIV seroprevalence survey were accomplished between 1988 and
1989. At the time approximately 1 per cent of prostitutes and 1.5 per cent of their clients were
HIV-infected. No baseline data were available on the prevalence of other STDs. A project
which focused on HIV/AIDS and STD prevention and control was overwhelmingly endorsed
by the sex workers, and enthusiasm to participate was expressed by key members of the
target group. These discussions buttressed earlier presumptions that health promotion
activities would best be served in this population if tied with actions which responded to the
perceived needs of prostitutes. These prompted the inclusion of additional activities including
advocacy of reducing official harassment and extortion; welfare activities for children;
improving the hygienic conditions of the hotels and compounds where the women live; and
later skills training.
A project with three main components was subsequently designed and implemented with
the following strategies.
(1) Health Education: on-site educational sessions held in the hotels and compounds for
prostitutes and clients; group discussions with key members of the target group; film shows
and distribution of materials, including condoms, in hotels and night clubs for part-time
prostitutes; outreach to all project sites by male and female peer educators; HIV/AIDS and
STD educational workshops for all members of the target population.
(2) Condom promotion and use were based on an initial distribution of free condoms
through peer educators to all project sites and at the STD clinic. This was later replaced by a
cost recovery arrangement which allowed condom vendors ('chairladies' and managers) to
earn a small profit from sales. Stressing the benefits of regular condom use and the savings
made from avoiding the practice of habitual self-medication with expensive antibiotics
(normally used prophylactically for STDs) enhanced the acceptability of use of condoms.
(3) STD services dispensed through a project clinic encouraged early diagnosis and
treatment of STDs and also provided a range of other clinical and preventive services
including counselling. The 'Special Clinic' was set up with the support of the State Ministry
of Health, which provided staff and equipment. The Clinic name and hours of operation were
STDs and condom interventions among prostitutes and their clients in Cross River State 225
Supplement to Health Transition Review Volume 5, 1995
determined by the target community, and in the first year it only admitted prostitutes and their
clients. By the second year the Clinic was open to the public following decisions reached by
the community members. Clinic attendance by prostitutes and clients was stimulated by
adopting a number of approaches. These included the referral of clients through prostitutes.
Sexual behaviour
Women's practices
At the baseline survey, many prostitutes (40%) reported having more than five different
customers per day, and 37 per cent reported between four and five customers. At the followup
survey, 52 per cent reported having 0-5 customers in the last two days. Forty-nine per cent
reported more than five customers in the last two days. The most common sexual practice for
prostitutes was vaginal intercourse (97%). Very few reported other sexual practices.
Nearly half (47%) of the prostitutes at follow-up reported having worked in commercial
sex for 1-2 years, and 38 per cent had worked for less than one year.
Clients' practices
It was evident from client reports at the baseline survey that frequent contact with prostitutes
over a period of years was quite common for the population surveyed. Thirty-seven per cent
of the men had visited prostitutes for 1-5 years, 31 per cent 6-10 years, 32 per cent for eleven
or more years. Clients most frequently reported having between six and ten contacts (35%)
per month. Twenty-nine per cent of men reported having 11 and 15 contacts per month, and
26 per cent reported between one and five contacts per month. At follow-up, men reported on
the number of sexual encounters with all partners (including spouses and girl-friends) in the
past week: 37 per cent of the men reported 0-1 sexual encounters, 36 per cent reported 2-3,
and 27 per cent reported four or more. Because questions on the level of sexual activity were
asked differently at baseline and follow-up, it was difficult to determine whether there was a
change in the number of partners, although it appeared that the number of partners per week
did decrease somewhat.
Men reported on the type of sexual encounters at the base-line survey. All of the clients
reported practising vaginal intercourse, half reported oral-penile intercourse, and only two per
cent reported practising oral-vaginal or anal intercourse.
Male-female comparison
Prostitutes had more sexual partners per day than the men, which was expected given the
nature of their occupation. Both groups reported the most common sexual practice was
vaginal intercourse. However, many more men than women reported oral-penile intercourse
as practice.
STD knowledge, history and treatment
STD knowledge was measured at the baseline survey for both sex workers and clients. When
they were asked to list which sexually transmitted diseases they knew, gonorrhoea was the
disease most frequently mentioned (97% of women and 96% of men), followed by AIDS
(17% of women; 34% of men). Knowledge of other STDs was quite limited. Only 14 per cent
of prostitutes and 29 per cent of their customers listed syphilis, five per cent of prostitutes and
17 per cent of customers listed chancroid, and none spontaneously listed herpes or chlamydia.
226 Eka Esu-Williams
Supplement to Health Transition Review Volume 5, 1995
High recognition by sex workers of gonorrhoea as a sexually transmitted disease may be
related to prevention behaviour, as 96 per cent of them stated that they examined their
customers for gonorrhoea or discharge.
At baseline, few prostitutes (14%) reported having had an STD in the past two years; 81
per cent of clients reported ever having had an STD.
When an STD clinic was established in Calabar for prostitutes and their clients in
December, 1989, there was a demand for one in Ikom and this was established in 1993. There
was no charge for examination and tests, but women and clients did pay for medicine and
treatment. While 76 per cent of clients and 93 per cent of prostitutes were aware at the
follow-up of the existence of the clinic, only one per cent of the men stated that they had
attended the STD clinic established as part of the intervention. However, clinic records
indicate that men are in fact attending the clinic. Eighty-seven per cent of prostitutes stated
that they had attended the clinic.
AIDS knowledge
Transmission
Knowledge of modes of transmission of HIV was measured for both groups at baseline and
follow-up. While knowledge at baseline was low for both sex workers and clients, the men
demonstrated greater knowledge than the women of sexual transmission (65% and 29%),
transmission through dirty needles (15% and 3%), and vertical transmission from mother to
child (4% and 2%). This discrepancy between prostitutes and clients remained at follow-up
for knowledge of dirty needles as a mode of transmission (51% of clients, 8% of prostitutes)
and mother-to-child transmission (25% and 4%), but a greater number of prostitutes than
clients identified sexual intercourse as a mode of transmission at follow-up (90% and 61%).
This was probably due to the intervention's intensive focus on sex as a mode of transmission.
Increases in knowledge of sexual and needle transmission were significant between
baseline and follow-up for both men and women. Prostitutes' knowledge of sexual
transmission increased from 29 to 90 per cent while the percentage of clients who identified
this mode of transmission increased from 65 to 81.
A high percentage of prostitutes and clients at follow-up recognized that healthy people
can transmit the AIDS virus (96% and 83%), compared to only 45 per cent of prostitutes at
the baseline survey, when this question was not asked of clients.
Means of protection
Means of prevention were also identified at follow-up. Eighty-eight per cent of sex workers
and 59 per cent of clients mentioned condom use as a method to prevent AIDS. Abstinence
was identified as a preventive measure by 42 per cent of clients at follow-up; however, only
one per cent of prostitutes mentioned abstinence as a method of avoiding AIDS. It seems
logical that women in the sex industry would be unlikely to readily identify abstinence as an
important prevention activity, as commercial sex is their primary or sole source of income.
Risk perception
Prostitutes and clients were questioned at baseline and follow-up whether they were worried
about getting AIDS. A higher percentage of prostitutes reported concern about AIDS, both at
baseline (84% of prostitutes and 68% of clients) and at follow-up (95% and 76%).
STDs and condom interventions among prostitutes and their clients in Cross River State 227
Supplement to Health Transition Review Volume 5, 1995
There was an association between ever-use of condoms and risk perception for clients.
Seven per cent of clients at baseline who reported having used condoms were worried about
AIDS, while only 31 per cent of those who had not used condoms were worried about AIDS.
At follow-up 85 per cent of male condom users perceived themselves to be at risk, compared
with 44 per cent of non-users.
This association was not apparent among prostitutes at baseline; 84 per cent who had
ever used a condom perceived themselves to be at risk and 74 per cent of those who had
never used a condom felt at risk. It is possible that prostitutes perceived themselves to be at
risk because of their work, regardless of their specific sexual behaviour. Clients have been
less likely to feel at risk.
Condom use
Sex workers
At baseline, 77 per cent of the women had ever used a condom, while at follow-up 97 per
cent had used a condom at least once. The frequency of condom use also increased at followup.
At baseline 11 per cent of sex workers always used condoms; at follow-up 23 per cent
always used condoms. The number of prostitutes who sometimes used condoms increased
sharply between baseline and follow-up, from 24 to 61 per cent. The percentage who did not
often use, or never used, a condom decreased between baseline and follow-up, from 62 to 16
per cent.
Clients
There was also a slight increase in ever-use of condoms among the clients at follow-up,
although the increase was not as large as among sex workers. Sixty-eight per cent of clients
said that they had ever used a condom at baseline; 76 per cent reported ever-use at follow-up.
The frequency of use actually decreased from baseline to follow-up although the decrease
was not significant. At baseline eight per cent said that they always used condoms, and at
follow-up four per cent reported consistent use. Similarly, 37 per cent reported that they
sometimes use condoms at baseline, and 33 per cent reported this at follow-up. However, the
number of clients who reported that they never used condoms decreased from 34 per cent at
baseline to 29 per cent at follow-up.
Relation to AIDS knowledge
Condom use appeared related to the respondents' level of AIDS knowledge. While a higher
percentage of prostitutes using condoms frequently than those using condoms infrequently
were aware that AIDS could be transmitted sexually, there was a much greater relationship
between level of condom use and AIDS knowledge with the client population. At baseline,
only 49 per cent of clients using condoms infrequently knew that sexual intercourse was a
primary mode of transmission, while 89 per cent of those using condoms frequently knew of
this route of transmission.
Similarly, at follow-up 79 per cent of clients using condoms infrequently correctly
recognized sexual intercourse as a mode of transmission, while 91 per cent of those using
condoms frequently responded correctly. This suggests that if prostitutes and clients were
aware of sexual intercourse as a primary mode of transmission, they may have been more
likely to use condoms. Conversely, those men who use condoms frequently may have been
more likely to learn about the possible role of sexual transmission.
228 Eka Esu-Williams
Supplement to Health Transition Review Volume 5, 1995
Barriers and reasons for success
The major obstacles experienced occurred during the early part of the project. These included
apathy to HIV/AIDS; lack of confidence and trust of project staff; lack of co-operation of
hotel owners and managers; non-co-operation by clients or partners; irregular supply and
poor quality of condoms; low self esteem of sex workers; self-medication; and reluctance to
use condoms. While many of these have been satisfactorily addressed, adequate access to
clients and partners, mobility of prostitutes, and an increasing influx of young girls into
prostitution pose new challenges. The sale of condoms, though widely accepted, is hampered
by the inability of prostitutes to purchase large numbers of condoms, making accounting and
record-keeping tedious. The outreach program in Port Harcourt faced logistical problems,
given the distance between areas with large pools of prostitutes.
The key reasons for the success of the program could be the following.
(1) The extensive period of interaction with the target population and its involvement in
major decisions and activities of the program. Additionally, this interaction allowed the
promotion of community cohesion and setting up of relevant bodies such as the 'chairladies'
group and the hotel owners association with a mandate to discuss and decide on program
issues.
(2) The ability of project staff to respond to delicate matters such as police arrest or
detention, harassment and extortion, and their advocacy of appropriate rents and facilities for
resident sex workers and higher charges for sexual services to reduce the number of clients
per day.
(3) Official endorsement and support of project was an important factor in reducing
stigma, marginalization and interference, and also helped to build confidence.
(4) The flexible approach adopted in the implementation of activities proved very useful,
and allowed for greater participation in decision-making and reformulating aspects of the
program which were not yielding satisfactory results.
(5) Through its response to the perceived needs of the community, the overall good
intentions of the program became evident and attracted more co-operation. A narrow health
focus among a population which had suffered a lot of marginalization and stigmatization was
regarded as inappropriate to effectively mobilize the community for the program.
To conclude, the Cross River AIDS Committee intervention among prostitutes and their
clients in Cross River State has provided a community-based model for intervention aimed at
controlling the spread of HIV/AIDS and other sexually transmitted diseases. Condom
promotion constitutes an important part of any strategy for prevention and the acceptability of
condoms by prostitutes can be guaranteed when they are made affordable and available and
the women themselves see a clear health and economic reason for using them regularly.
Whereas prostitutes can be reached quite readily and are amenable to program interventions,
the same cannot be said of their partners and clients. Specific strategies such as using
motivated prostitutes, hotel managers, peers and outreach workers are useful ways of
reaching this subpopulation.
It is also important to promote a program which includes the development of vocational
skills to ensure that women in sex work do not depend exclusively on exchange of sex for
money but are able to earn additional income through other options. A literacy component
which includes literacy skills and reproductive health education has been introduced to build
self esteem and allow women to understand in a holistic manner issues around reproductive
health covering HIV/AIDS and STD; family planning, unsafe abortions, self medication and
infertility. A community approach in our experience provides the best way to ensure that the
program can be sustained long after donor grants become unavailable.
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