Sunday, December 27, 2015

"There Is Hunger In My Community": A Qualitative Study of Food Security as a Cyclical Force in Sex Work in Swaziland

Swaziland has the highest HIV prevalence in the world - 32% of adults are currently living with HIV - and many Swazis are chronically food insecure - in 2011 one in four Swazis required food aid from the World Food Programme. In southern Africa, food insecurity has been linked to high-risk sexual behaviors, difficulty with antiretroviral therapy (ART) adherence, higher rates of mother-to-child HIV transmission, and more rapid HIV progression. Sex workers in Swaziland are a population that is most at risk of HIV. Little is known about the context and needs of sex workers in Swaziland who are living with HIV, nor how food insecurity may affect these needs.

In-depth interviews were conducted with 20 female sex workers who are living with HIV in Swaziland. Interviews took place in four different regions of the country, and were designed to learn about context, experiences, and health service needs of Swazi sex workers.

Hunger was a major and consistent theme in our informants' lives. Women cited their own hunger or that of their children as the impetus to begin sex work, and as a primary motivation to continue to sell sex. Informants used good nutrition and the ability to access "healthy" foods as a strategy to manage their HIV infection. Informants discussed difficulty in adhering to ART when faced with the prospect of taking pills on an empty stomach. Across interviews, discussions of CD4 counts and ART adherence intertwined with discussions of poverty, hunger and healthy foods. Some sex workers felt that they had greater trouble accessing food through social networks as result of both their HIV status and profession.

Informants described a risk cycle of hunger, sex work, and HIV infection. The two latter drive an increased need for 'healthy foods' and an alienation from social networks that offer material and emotional support against hunger. Services and interventions for sex workers which address the pathways through which food insecurity generates vulnerability to HIV and social marginalization, build sex workers collective efficacy to mobilize, consider poverty alleviation, and address social and policy level changes are necessary and likely to have the greatest success.

Below:  Cycle of food insecurity, sex work, and HIV

...Social Support
Both sex work and HIV are highly stigmatized in Swazi society. Informants tended to deal with these stigmas separately and were often more willing to disclose their HIV status than their occupation. However, living with HIV was often associated with promiscuity and so it was difficult for informants to totally disentangle the two identities. Women reported mixed strategies and varied responses from their friends and family in response to disclosure of either their HIV status or their engagement in sex work. Sex work was rarely disclosed to social network members who were not already part of the sex worker community. Some informants reported receiving financial assistance from other community members from time to time, while others reported widespread distrust among sex workers and fierce competition for clients that sometimes became violent.

Informants assumed that their families would react negatively or treat them poorly if their occupation was revealed. Some informants reported that their family and friends already suspected or assumed that they were engaged in sex work. Reactions ranged from tacit though disapproving acceptance of food and financial support that was funded by sex work, to outright ostracism.

Informant: I’m afraid to tell them, even at home I haven’t told anyone. They once asked me where do I get the money. I deceived them that I have a boyfriend who gives me money. Then I’m able to help them.

Interviewer: Those who are asking you, they know that you’re not working?

Informant: It’s just that I send the money and they won’t ask me much.
-Winile (34, peri-urban)

You see it can happen that some may neglect me. Like I said, at home some are Christians. If they can hear about this they can neglect me… It is just that now it’s my life, there is no other way I can get money.
-Nomthandazo (23, peri-urban)

Disclosure of HIV status tended to elicit better, although still mixed, reactions from an informant’s social network. Some informants described receiving both material and emotional support from family after revealing their status. Other informants reported being shamed and excluded by their families or their spouse’s families and being denied material – especially food – support.

They treat me well. They sometimes buy me things like vegetables. My aunt has a garden so she brings me some vegetables. They bring me any Swazi food they have.
-Nokubonga (31, peri-urban)

At one point [a support group member] told us … that she is not welcome at her marital home. You see. She continued to tell us that she is not given food at her marital home. We had to help her by donating some money so she may be able to buy some mealie meal [course maize flour] for her children.
-Phila (30, urban)

The same informant reported losing her job and feeling driven back to sex work as a direct result of HIV stigma:

Informant: I used to work for one lady in a salon then one day I had gone out to the toilet she opened my bag. Because I was new in the salon I had not told her anything about my status. She would then monitor me because I think she saw the ARVs.

Interviewer: Did she ever see you taking them?

Informant: She saw them in my bag when she opened it, and she monitors my actions more, so when I get cuts then she would tell me not to touch so many things. This shows that so many people are not well informed about HIV. She monitored everything I did. She would also talk bluntly in front of the customers. Then I opted to stop working. When she asked me why I just told her I couldn’t work for her anymore I would rather stay at home and get a job I don’t know about. That’s the reason I ended up taking up the job am doing right now because no one judges you there.
-Phila (30, urban)...

Full article at:

1Rollins School of Public Health, Emory University, Atlanta, USA.

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