Ser. SC;. Med. Vol. 31. No. 5, pp.609418.1990 0277-9536190 53.GIl+O.O0 Printed in Great Britain. All rights reserved Copyright a 1990 Pergamon Press plc A PILOT STUDY FOR AN HIV PREVENTION PROGRAMME AMONG COMMERCIAL SEX WORKERS IN BULAWAYO, ZIMBABWE DAVID WILSON, BABUSI SIBANDA, LILIANMBOYI,SHEILA MSIMANGA and GODWIN DUBE Department of Psychology, University of Zimbabwe, P.O. Box zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPO MP 167, Mount Pleasant, Zimbabwe Abstract-In a health education pilot study for a programme to reduce HIV transmission among commercial sex workers (CSWs), 113 CSWs were interviewed and observed in Bulawayo, Zimbabwe during 1989. The educational level of the sample was low and less than a quarter had another job, either as a self-employed vendor/hawker or a domestic servant. Inability to earn income in other ways was the major reason cited for engaging in commercial sex. Nearly half the sample went for check-ups every 3 months or more often. All interviewees had heard about AIDS, but they were uninformed about several facets of AIDS. CSWs reported that they worked an average of 3.6 nights a week, averaged 1.3 clients a night and charged a mean of U.S. $2.8 a session and U.S. $6.5 a night. CSWs reportedly saw a total of 221 clients in the past 7 days and used condoms with 87 (39.3%) clients. Nearly all CSWs said they had done something to reduce the risk of getting AIDS, but when asked what they had done, only 40% said they were using condoms more frequently and many cited ineffective precautions. CSWs who had a job, charged higher fees, experienced little client violence and believed that they were susceptible to AIDS were more likely to use condoms. Clients were a cross-section of Bulawayo society, with widely varying education, incomes and occupations and shared little except an interest in commercial sex. Ethnographic approaches demonstrated a lack of cohesion among CSWs and a consequent need to foster organized, motivated groups for health education, the importance of incorporating clients in health education and the feasibility of using bar security and sales personnel as health educators. It is concluded that health education is urgently needed among CSWs, but that it is equally important to direct health interventions at clients, many of whom are resistant to condom use. Key ~ordr-AIDS, prostitution, health education INTRODUCT’ION It is estimated that 50 million people in Africa, or 8% of the continent’s population, may have HIV by 1993 [I]. Central and East Africa will be more affected by HIV than any other geographical region [l-6]. Heterosexual transmission is the primary mode of HIV infection in Central and East Africa and commercial sex workers (CSWs: prostitutes) are at particular risk for HIV contraction and transmission [7-181. There is evidence that condom promotion inter- ventions may reduce HIV infection among CSWs in Kenya [19] and Zaire [20]. The importance of such interventions is demonstrated by studies in which a high proportion of males report contact with CSWs [21]. For example, 38.5% of a sample of 2753 male students [22], 24.7% of a sample of 173 working class men [23] and 15.8% of a sample of 893 school- boys (241 in Zimbabwe reported having coitus with a CSW. Epidemiological models underscore the importance of health interventions among CSWs and their clients [22,23]. Health education programmes among CSWs have been initiated in several sub- Saharan African countries, including Cameroon [25], Kenya [26], Nigeria [27], Senegal [28], Tanzania [29] and Zimbabwe [30]. However, CSWs have been largely ignored in the social science literature [31]. An ethnography of Zimbabwe’s largest ethnic group, the Shona, confined itself to the observation that commercial sex is encouraged by the separation of migrant workers from their spouses and by the desire of many women to have some financial independence and to be free of kin and onerous domestic duties [32]. Nascent health education activities among CSWs are likely to be vitiated by the absence of relevant health education and social research [33,34]. Zimbabwe’s national AIDS campaign began on 13 July, 1987. It is conducted in Zimbabwe’s three national languages, English, Shona and Sindebele, and it uses print and electronic media, posters and health personnel to advocate fidelity to one faithful partner or consistent condom use to prevent HIV transmission. Zimbabwe’s Medium Term Plan for the Prevention and Control of AIDS [35] recognizes the importance of health interventions among high risk groups and such activities are beginning [30]. The present study sought to use structured health education interviews and ethnographic interviews and observations to provide information relevant to the design and implementation of a programme to reduce sexual transmission of HIV among CSWs in Bulawayo, Zimbabwe. Background information Context. Zimbabwe is a landlocked Central African country bounded by Botswana in the west, Zambia in the north, Mozambique in the east and South Africa in the south. It has a population of over nine million, 50% of whom are under 15 and 26% of