The HIV rebound nobody is discussing

The world needs more prostitutes like Hawa Abdallah. At least that’s what many public health officials believe.

There’s something about the 25-year-old  – the harsh angle of her eyebrows, the way her red lipstick contrasts with the dirty walls, the cold stare she directs at passing men — that says she’s in control. Abdallah has sex with as many as 20 men every day in a brothel in Dar es Salaam, Tanzania’s largest city, where 1 in 20 residents and 1 in 3 sex workers are infected with the virus that causes AIDS.

But a series of simple steps have kept Abdallah healthy until now: She knows how HIV spreads. She is tested regularly. And she’s confident enough to insist that her customers use condoms every time. Just as importantly, she’s managed to avoid the assault, arbitrary arrest and extortion that plague the profession. Health officials say that unless more prostitutes start fitting a similar profile, the world doesn’t stand a chance at beating back the virus.

It’s not just sex workers, of course. The same applies to injecting drug users, men who have sex with men, inmates and other groups in which HIV rates have moved against the global trend, and continue to rise. Which is why experts with organizations as diverse as the World Health Organization and Human Rights Watch agree that government officials must do more to support these “key populations” — no matter how illegal their activities may be — if they want to see an AIDS-free generation within their borders anytime soon.

Halting the spread of HIV among these key populations comes down to a series of calculated risks for both governments and the individuals themselves. Abdallah’s calculations started several years ago.

She never intended to spend her nights negotiating in the dark with a never-ending stream of drunks. She wanted to be a hair stylist. But the young woman quickly discovered that no matter how busy her beauty salon became, no matter how many hours she put in cutting and braiding hair, she rarely earned more than $20 per day — not nearly enough to support her two young children and a long-term boyfriend who scrapes by as a motorcycle taxi driver.

Her first night in the brothel, she made close to $60 — triple the amount in a fraction of the hours. Her boyfriend discovered what she was doing and tried to make her to stop.  “I have refused,” she said. “It’s worth the risk.”

Among the most immediate of those risks: It’s illegal. Tanzanian law states clearly that men and women caught “loitering for the purposes of prostitution” can be locked up for three months. Male sex workers can be charged with “carnal knowledge against the order of nature” and punished with a minimum of 30 years and a maximum lifetime sentence. Officials consider both prostitution and homosexuality to be threats to the social order.

But of course, those same officials have also been preoccupied with a far more serious societal threat in recent years. When HIV began ravaging Africa, making its population the most-infected on the planet in the last decades of the 20th century, the virus struck Tanzania particularly hard. By the mid-90s, close to 1 in 10 Tanzanians were dying; a generation of children were orphaned; local economies buckled. And for years, the Tanzanian government lacked the resources to respond in force.

The situation changed to some extent in the early 2000s when the newly formed Global Fund to Fight AIDS, Tuberculosis and Malaria and the U.S. President’s Emergency Plan for AIDS Relief, among other groups, began funneling billions toward the cause. At long last, Tanzanian officials — like many of their neighbors in sub-Saharan Africa — had both bragging rights and the numbers to back them up. Treatment coverage jumped from 3.5 percent in 2005 to 55 percent in 2011. The number of health facilities providing HIV care and treatment services rose from a few dozen in 2004 to about 1,200 in 2012. Mother-to-child transmission of the virus plummeted. People started living longer.

With similar results coming in from around the world — including one from UNAIDS showing a 50 percent drop in new infections in more than 25 low- and middle-income countries over the previous decade — former Secretary of State Hillary Clinton stood before a crowd in Washington in 2012 and declared that “as we continue to drive down the number of new infections and drive up the number of people on treatment, we will get ahead of the pandemic, and an AIDS-free generation will be in sight.”

But optimism wasn’t running quite so high in the back alleys and brothels of the world –including Abdallah’s. While HIV prevalence among the general population has decreased to 5 percent in Tanzania, it’s on the upswing globally among “key populations” at the greatest risk for contracting and passing HIV, according to an August 2013 report from the Foundation for AIDS Research, or amfAR.

In fact, HIV prevalence is 22 times higher among people who inject drugs. In low- and middle-income countries, men who have sex with men and female sex workers are 19 and 13.5 times more likely, respectively, to have HIV than their peers. Many researchers have long downplayed the rates in key populations, believing they represent only a “modest share of the epidemic globally” and represent a major concern only in countries with low-level epidemics. But amfAR contends that members of these groups are critical because they are often part of “dense, high HIV-prevalence social and sexual networks” that help the disease spread rapidly from one population to another.

Consider 22-year-old Abdul Rashid. After stumbling into a community resource center several miles from Abdallah’s brothel in Dar es Salaam, Rashid — still strung out on marijuana and cocaine — was tested for HIV. The results came back quickly: Positive. And he wasn’t a bit surprised.

Rashid enjoys having sex with female prostitutes at a brothel near his drug den. But the premium he pays for sex without a condom, combined with the high price of drugs, long ago left him in such a financial bind that he started having sex with men for cash. To top it off, police also recently arrested him for selling drugs and threw him in one of the local jails — notorious places for sex among inmates. Within the last few months alone, Rashid may have spread the disease widely within all four of the primary “key populations” in Tanzania. If those individuals then have sex with their partners — who are often not a part of the high-risk groups — the virus then spills into the general population.

Sitting in a filthy orange T-shirt on the floor of the drug center, Rashid seemed too dazed to care. “I have no option to change my status, so I must say, ‘OK, if that’s the case now, I have nothing to do,’” he said.

Of course, this situation isn’t unique to Tanzania. Key populations and their sex partners account for as much as 51 percent of new infections in Nigeria, 33 percent in Kenya, 80 percent in Morocco and 47 percent in the Dominican Republic. And according to some estimates, men who have sex with men alone could make up more than half of all new infections in Asia by 2020, amfAR reports.

“Unless effective strategies are put in place to mitigate the HIV burden in key populations, the global epidemic will worsen over time, preventing the world from realizing the dream of an AIDS-free generation,” the group warned in its August report.

That brings us back to Tanzania’s dilemma — similar to the one faced by most countries where prostitution is illegal. Should officials enforce the law of the land or facilitate safer testing and treatment for prostitutes in the name of public health? 

When drafting their “Strategic Framework on HIV and AIDS” several years ago, the government decided to take a calculated risk and “acknowledge the vulnerability of sex workers and men who have sex with men.” The document advocated for their access to HIV prevention information and services and, surprisingly, “for decriminalization of their activities.” Despite the worries of some that it would come across as a tacit endorsement of illegal activities, the officials decided to push ahead with this approach because the potential gains in the HIV fight could be huge.

And it’s worked, to a limited extent. A report published in June by Human Rights Watch found that “a few state hospitals and some nongovernmental organizations throughout the country” have succeeded in providing friendly services to the “most at-risk populations.” Through its health agencies, the government has also supported the outreach efforts by local governments and nonprofits. Even so, this limited success is “systematically undermined” by police officers who abuse their authority and often make things worse, the report concludes.

“The Tanzanian government has committed on paper to reduce the stigma for at-risk groups, but that commitment is meaningless if the police regularly rape, assault, and arrest them,” concluded Neela Ghoshal, the author of the Human Rights Watch paper. “The government’s HIV policy can’t succeed if police are driving away the very people the public health programs most need to reach.”

A survey by the country’s National AIDS Control Program in 2010 found that a full third of sex workers in Dar es Salaam reported being beaten by their customers, but few felt comfortable reporting the crimes to police. When Human Rights Watch interviewed 66 men, women and children who were current or former prostitutes, at least 23 said the police had forced them into sex — often in exchange for release from custody. Some of those police officers refused to use condoms, “making the police possible conduits for transmission of HIV and other STIs.”

As a public health worker in the city of Mwanza told the group, “Sex workers do not have a place to speak against injustices done to them … If they go to the police, the police just become their customers for that night.”

The situation is not much better at government health centers. The same Human Rights Watch report identified dozens of cases in which “health workers turned away sex workers and other key populations from health facilities, or publicly humiliated them.”

That includes a case where a drug addict went for treatment after being attacked by a mob in Dar es Salaam and was denied anesthesia while the staff stitched up his wound. “I asked for it, and the nurse said, ‘We don’t need to. We are going to sew you without. We could inject you with poison rather than with anesthesia.” In another example, a gay man in the semi-autonomous region of Zanzibar asked to be treated for a sexually transmitted disease and was told to leave. “You already have sex with men,” a staff member told him. “Now you come here to bring us problems. Go away.”

Experiences like those create an atmosphere of fear and distrust that pushes these key populations so far underground, they become almost impossible to reach with HIV prevention messages, testing or treatment. “And that’s woeful,” said Dr. Ade Fakoya, a senior advisor to the Global Fund to Fight AIDS, Tuberculosis and Malaria. “Because it’s coverage of these very basic, essential interventions which is key to the death of the epidemic.”

Some organizations have managed to break through. As the sun sank a little lower one recent evening, some health workers partnering with the nonprofit Public Services International began setting up camp in the courtyard of Abdallah’s brothel.

She sat several feet away, watching as they erected an Army-green burlap tent and pulled out tables, pamphlets, rubber gloves and HIV test kits.

Because it was still early, and because the truck drivers and local drunks hadn’t started spilling from the nearby bars, many of the prostitutes were relaxing on the stoops outside their rooms. Some had begun drinking to brace for the hours ahead. Others played with their children.

About 150 women between the ages of 15 and 49 spend their nights in this particular brothel — a small fraction of the 7,000 plying the streets of Dar es Salaam — and most seemed to know the drill. When one emerged from behind the green flaps of the tent, another stood and entered for her check-up.

“We’re not afraid of these tests,” Abdallah said, unconvincingly. “I’ve done this before. So have they.” To prove it, she clutched the sides of her black floral purse — embroidered with the word “Sweet” — a little more tightly and headed into the tent.

Through Global Fund in Tanzania, PSI implements an HIV prevention program for sex workers. Here, a sex worker is tested for HIV in Manzese Slum in the Kinondoni District. Photo by the Global Fund / Mia Collis.

Sex worker Hawa Abdallah is tested for HIV in her brothel on the outskirts of Dar es Salaam. Photo by Mia Collis/The Global Fund

Program Manager Shahada Kinyaga watched her from a distance. “It wasn’t this easy in the beginning,” she said. “When we first approached them, they were thinking maybe we were police officers looking to exploit them or that we wanted to publicize their activity to get them into trouble. They wouldn’t let us come near.”

To change that, the PSI workers took the time to speak with a single sex worker, sharing health information and returning repeatedly. Eventually, that sex worker started sharing bits of the knowledge with her friends in the brothel — how to get free condoms, for example, and how to tell if a customer is infected with syphilis or herpes. In time, the women allowed PSI to hold workshops on building “negotiation skills” to convince their customers to wear condoms and to set up the HIV testing tent. Those diagnosed as HIV-positive began listening to the health workers about follow-up care at local clinics, and reported back about whether they were receiving the appropriate treatment. Bottom line: It’s not that the women didn’t want help — it was a matter of who to trust.

“So, more of them are doing this now,” Kinyaga said. “They are testing more regularly. They are using condoms more. Some of them don’t do it 100 percent of the time, but it’s a step.”

Inside the tent, Abdallah’s black-and-white striped pantsuit stood out starkly in the diffused light filtering through the burlap. She looked like a stylish prisoner in a war camp. She also looked worried.

These moments of dread — of waiting for test results — are part of the calculated risk Abdallah accepted from the beginning. But she tries to tell herself that if she plays the game well, if she insists that every one of her customers uses a condom every single time, if she tests regularly and receives follow-up treatment when needed, she stands a good chance of living to see her two children grow old. Within a few years, she’ll also have enough money in the bank to build a home and open her own beauty parlor. That endgame is why she’s here in the first place — why she says, “This is a good environment for me.”

Within 30 minutes, her test results are ready. Her face is stone-cold and will remain that way no matter the verdict. Abdallah knows that as long as she works in this brothel, the uncertainty will linger.

HIV-negative. For now.


 EDITOR’S NOTE: Jason Kane traveled to Tanzania with the Global Fund to Fight AIDS, Tuberculosis and Malaria. The international financing institution provides funding to countries to support evidence-based programs that prevent, treat and care for people living with the three diseases.