Interventions by and for Sex Workers
XI International AIDS Conference, Vancouver, July 10, 1996

Claudia: Gentlemen. Welcome to the nearly very last afternoon session, entitled "Interventions by and for Sex Workers." My name's Claudia Fischer. I'm a member of the international community of women living with HIV and AIDS. My co-chair is James Tickalong.

I'd like to welcome the sessions presenters. They bring with them a lot of experience, from which we hopefully all will be enriched.

A couple of housekeeping items before we begin. If you haven't noticed, we have to have a passion about order and punctuality. Each speaker has ten minutes for his presentation, and then we have five minutes of discussion, of questions and answers. The first speaker has not shown up yet, so there's a change in the program. Now the first speaker will be Ms [?] from France. She is presenting an abstract called "Preventive Actions Against HIV Infection Among Transvestite and Transsexual Sex Workers in Paris."

Speaker 1: Good afternoon, everyone. This presentation concerns preventive action carried out by an association called PAS[?], which aims at promoting the health of transvestite and transsexual prostitutes in Paris. This action is supported by grants from the French Ministry of Health and a NGO, Ensemble contre le SIDA. The activities of the first year of this community-based, preventive action have been analyzed in collaboration with the European Centre of the Epidemiology [?] of AIDS.

In 1993, a study was carried out to evaluate the pertinence and feasibility of preventive action against STDs and AIDS for transsexual and transvestite prostitutes in Paris. This study, which was presented in Yokohama, showed that this population is extremely heterogenous, due to its culture and lifestyle. The rapid turnover and illegal immigration excludes this population from the health care system, including prevention, and lead to high-risk practices for themselves and their clients.

With a method chosen for the study in which contact was made by transsexuals, the population was found to be relatively accessible. About one-third of the population was contacted in six months. This feasibility study concluded that it was urgent to set up AIDS education programs for these populations. In order to succeed, these actions must be carried out at the place of work, and the implementation of these actions by transsexuals themselves would give a greater chance of success.

In September 1994, a community-based preventive action among street-based transvestite and transsexual prostitutes was set up in Paris, with the objectives of developing HIV and STD prevention, and facilitating access to health and social services among sex workers. This action is designed and carried out by street transsexuals, including a medical doctor, a lawyer, and health professionals. The team works in collaboration with the French NGO, l'association AIDS, as well as the European Centre.

We met sex workers in the drop-in centre -- a mobile home -- once a week, in each of two different areas, between 10 in the evening and 2 in the morning, during the first year. Here, we see the Bois de Boulogne park, which is the most famous site for transvestite and transsexual prostitutes in Paris. The other area is on the inner-ring road of Paris, where a slightly different population is present. The large majority of the population are transvestites from North Africa.

Since September 1995, the number of stations has doubled, with now two stations a week in each area. The past drop-in centre has been set up as a friendly meeting place in the mobile home, where information and prevention materials are provided. 39,500 condoms were distributed during the year. The association has also provided help in accessing health and social services. A doctor is present twice a month in the mobile home, and gives also medical consultations once a week in a free and anonymous HIV/STD screening centre.

Since specific prevention materials were not available for these populations, an illustrated leaflet was designed, with the participation of transvestites and transsexuals themselves. Safer sex practices with clients and private partners are illustrated, and information is given on HIV and STD screening and treatments, services for drug users, gender transformation, etc.

During the first year, individual data on place of work, origin, age, accommodation, health insurance, duration of prostitution and lifestyle were recorded on each visit to the mobile home. 374 persons visited the mobile home, resulting in 2,192 contacts. For descriptive purposes, the individuals were classified in two main groups, according to their lifestyles. Transvestites who dress as women only at night represented 34% of the persons contacted, while transsexuals, who present female characteristics following hormone treatment or silicone doses represented 45%. Of 168 transsexuals contacted, only 9 had undergone genital surgery. 59 female prostitutes were also contacted. The transvestites were younger and had worked as sex workers for a shorter period of time than the transsexuals. Almost half of transvestites and transsexuals were of North African origin. 21% were of French origin. Nearly 80% of the population contacted were immigrants, a large fraction consisting of illegal immigrants.

To illustrate the work of the team, we describe the situation of two transvestites whose problems are representative of those encountered daily by this population. The first example concerns a French transvestite, age 24, who is a drug user. She lives in a hotel. (This is the case for 54% of the population; less than half of the population have stable homes. A consequence of this is the universal[?] demand for lodging.) She has no health insurance. (This is the case for 83% of transvestites and transsexuals. In contrast, about 99% of the French population are covered by the national health insurance. The lack of health insurance makes access to health care very difficult for this population.) She needed help for her drug problem. The PAS[?] team put her in contact with a service for drug users, where she found access to a methadone program; helped her to apply for an identity card (which had been refused because she had no fixed address); and supported her financially with regard to housing and food. In addition, she has been physically assaulted during sex work. The team went to the police with her, but the police didn't do anything.

In general, physical assaults are particularly frequent in this population. In a national study, [?] describe -- there's actually a mistake here, for the number. The postal number is actually 4644, and [?] displayed today. The frequency of physical assaults was found to be 52% for transgendered prostitutes during a five-month period, compared to 28% for female prostitutes.

The second example concerns a 27-year-old transvestite who is HIV-positive and an illegal immigrant. She lived in a hotel and had no health insurance. After being hospitalized, she wanted to stay in France to continue to receive medical care. After PAS intervention, she obtained a temporary authorization to stay in France and, after hospitalization, PAS helped her to pay for her hotel room.

During the first year of the team's work, six of the 374 transvestites and transsexuals contacted throughout the year died of AIDS, representing a mortality rate of nearly 2%. This is 60 times higher than the AIDS mortality rate among men between 25 and 44 years of age in France. As a consequence of the need to support transvestite and transsexuals with AIDS, a housing project is being set up.

The living conditions of this population are extremely precarious. Working at improving the health and social living conditions of this population is the only means to get the HIV prevention method across. Besides primary HIV infection prevention, support of HIV-infected persons is essential. However, the task is difficult and requires an intensive partnership between the team and existing health and social services.

A further difficulty is related to the social marginalization of transsexuals. The numerous obstacles to changing the legal gender identity create insurmountable difficulties in finding legal work and housing, often making sex work the only possible choice. Social and legal recognition of transsexuals would therefore be an important step towards gaining access to the normal rights enjoyed by most people.

Thank you for your attention. We now have time for questions.

Aud: Hi. My name is Rick Lyons. I work with the Prisoners HIV and AIDS Support Action Network in Toronto, Canada. I was wondering if your project had any experience doing support and advocacy for transgendered and transsexual prisoners.

Speaker 1: Yes. As I was saying, there is a lawyer who is transgendered who works with us, and we work in collaboration with the AIDS Federation, which has a special service for people in jail. So we do work in partnership with them.

Aud: This is more of a comment; I just wanted to say that I'm grateful to hear [?] on stage referencing the need for social support for transgendered people. I have a friend who recently died and was very depressed after his change because, even in San Francisco, he found very few support services specific to -- her needs. So I just wanted to say thank you.

Speaker 1: You're welcome. I know it's one of the objective of PAS to have some [?] regarding legal and social recognition in this society, especially in France.

Aud: Hi, my name is Judy Mayo, and I have a question. I noticed that what she asked about when she first came in to talk to you, she said she needed help with a drug problem. And I didn't see any indication of a drug intervention. Although it's a really great project and I thought it was neat that they included some information regarding identity types of issues and that kind of thing, so it was broader in focus. But I was wondering if there was something involving the substance abuse issue that she had raised that was part of the intervention.

Speaker 1: Regarding this person, what we are doing is that we work in partnership with other organizations that have methadone programs. We have a medical doctor who we can refer to any kind of organization regarding people with drug problems.

Aud: Thank you.

Claudia: I'm very sorry, but we have to go on. Hopefully there will be time left at the end.

Speaker 1: Thank you once again.

Claudia: Our next speaker is Mr. [?]. He's from the Institute for Research in Sexuality and Gender from Beijing in China.

Speaker 2: Good afternoon. [?] As you know, there are more and more sex workers in China. In 1980, the first year of the economic reform, 200 sex workers were arrested in China. But last year, 250,000 sex workers and their customers were arrested by the government. In China, sex work is illegal. Sex workers who are found out are punished by a fine of about $600 US. That equals eight to ten months of the salary of a white-collar worker. If he or she is arrested a second time, he or she is put into a so-called reform camp (it is not a place, but something like this) for half a year to three years.

All Chinese people know that there are sex workers, but few people know why they do it or what they are doing. [?] This research is a part of the protest -- sorry. First of all, we want to know the social network and support system of sex workers. Secondly, we want to know why they accepted anal sex.

For example, we found female sex workers in hotel lobbies, massage halls, dance halls, singing halls, karaoke, or some bars. They were paid to be interviewed. But about 30 sex workers refused to be interviewed, mainly because they didn't trust me, others maybe because they were so busy. So the interviews were done before or after business. In North China, that means in the morning, but in South China that means in the evening. Because in South China, the policemen always arrest sex workers at night. So they do their job in the daytime.

There are [?] of sex workers. The highest is something like wife for pay: a long-term relationship, but for money. The lowest level is something like common wife in the mobile workers' group, but for money. Generally, speaking, in the larger cities in the South, sex workers were more open. Many can work alone. In the north, it's the other way.

Half of them know anal sex before they do this job. Most of them know from pornographic videos, which are very popular in Mandarin China now. 70% of sex workers had anal sex with their customers. Among the other 30%, who never had anal sex, only two had been working in this job for more than six months. So that means they are too new to have it.

In South China, there was a group controlled by sex workers, but it failed. Because if one of them was arrested, punishment for the other people would [?]. So they don't like to work in a group.

Whether or not sex workers accept anal sex mainly depends on whether the customer uses [?] or not, not how much money he gives her. Almost every sex worker has a real fight against anal sex, but they always fail. Because they can't report a rape to the police. No one takes care of them. They can't escape from the hotel or someplace. Almost all sex workers dislike such behaviour.

My conclusion is very simple. [?] in China, such ideas are not very common. Most people think sex workers are bad women who should be punished by the [?]. I think the leaders of my country may have forgotten the maxim "[?] Sex workers are our sisters. Thank you very much.

Aud: I'd like to ask whether your government is looking at [?] as [?] alleviating the situation for sex workers in China. And the second part of the question is, since this was a study, are there any prevention or intervention programs happening for sex workers in China.

Speaker 2: I'll answer the second question first. As far as I know, there may be some programs to help sex workers in China, but I don't know details. I think some Chinese people are doing this [?]. And I don't think the government is looking at helping sex workers in China.

Aud: I really don't think your paper was able to adequately answer the question of why sex workers are into anal sex. Perhaps you should interview the male clients to find out why they force these women into anal sex. And perhaps if you look at the pattern of anal sex behaviour among women in several cultures, a lot of them are actively linked with the issue of virginity. So perhaps you should look into that issue.

Speaker 2: I don't think that's true in China, because sex workers tell me that most of the customers who want to have anal sex [?][?][?]. They want to try it. That's what the sex workers say.

Aud: I have two questions. The first is, is there any outreach carried out with the sex workers in China. My second question: I like your last words: "Sex workers are our sisters." I attended a forum at the Fourth World Conference on Women in Beijing. It was so sad to see that there were no sex workers from China making presentations during the discussion of sex workers' issues. Why is that?

Speaker 2: Some Chinese people say there were never any sex workers, but it's not true. Everyone knows there are. In some provinces -- especially in the Hunan province -- very often on the street.

Aud: I was glad to see a paper from China, and I agree that the force and violence are a real big issue. But the question I had -- it said that sex workers who came to the city planning on becoming sex workers were more likely to use condoms than those who became involved in sex work after they'd already left. Could you elaborate on that? Do you have any more information about what the difference is there?

Speaker 2: Yes. In the past several years, when sex workers have come from rural areas, they have not planned to do sex work. They wanted to find a job. But there was no way to find a job, so they became prostitutes. But now, and especially in the past year, some female workers in big factories lost their jobs. They have no jobs to do. So they have to go to the [?] to find a job. And they know it's easy to find a job as a sex worker. They know it. And they prepare to do this, because they need money. It's very simple. Yes, if they prepare to have such a job, they bring condoms. They put them in their tickets and give them to the customers. Because they prepared to do so.

Aud: I've been coming to these conferences -- not every conference, but the first one I came to was 1987. Prostitution is a crime in almost all countries. And even in the few countries where it is not specifically a crime, prostitutes are rounded up by police everywhere. Except for the presenters from the sex workers' rights movement, I believe you are the first to talk about the police and the law at the beginning of your presentation or perhaps even in your presentation at all. I want to commend you from that. I'm pleased. I would like to say that I think you should call the forced anal sex rape. And I really am pleased that you talked about that issue, because most people who have done presentations on prostitution at these conferences have ignored the working conditions in which these women work. You are one of the few who have noticed this, so I commend you.

Speaker 2: Thank you very much.

Aud: I'm [?] from Kenya. I just wanted to ask the speaker -- out of the study which you just carried out in China about this, what are you going to do for the sex workers there, after finding all this? You know -- I'm going to do something for them, like HIV and AIDS prevention work. Or identify a group of people who are living with AIDS right now, to start doing something?

Speaker 2: I personally want to do bigger research for sex workers, to let people know their situation, understand that they suffer [?], especially when the customers use force to push them into dangerous sexual behaviour. I want to tell everybody in China.

Claudia: Sorry, I have to interrupt; we have to go on. Thank you very much for your presentation. And here am I again, the stupid one, not knowing how to pronounce it. Our next speaker is Mr. [?]. He's from Vietnam. He's working for [?] and is the manager of the AIDS project in Vietnam. He's talking about peer education with commercial sex workers.

Speaker 3: Good day everyone. I am program[?] officer for [?] Vietnam. My spoken English is not too good, so I have copies of my speech over there, and I will give it to you after. Now, I will outline the main points. First, I will show you the [?] of HIV [?] in my country. [?] HIV [?] in Vietnam, June 1996, not actual[?]. At the end of the year 1996, the number of HIV-positive people will be more than 51,000, and the number with AIDS more than 1,200. And the new deaths, more than 900.

Much is said about peer programs for commercial sex workers. They work in many countries. But I think in Vietnam we need to think again about them. Because [?] just did a study into the effectiveness of using sex workers to educate other sex workers. This does not work so well in Vietnam. Peer education is a foreign concept, [?] When translated into Vietnamese, the concepts are not exactly the same as they are in English. The concepts were brought to Vietnam by foreigners. I will show you some differences. On the left, Vietnamese, and on the right, the same in English. Only one [?], no meaning in Vietnam.

After a training program in public awareness in 1990, people in Vietnam looked for at-risk[?] groups [?] not [?] in the early days, and even today it is not seen as so important. [?] study [?] shows sex worker [?] ideal. We were told they'd make the best educators. So many groups started peer education projects, training ex-commercial sex workers and ex-intravenous drug users in what to say and do for actively [?]. They are not peers in the true sense, because they are ex-peers. Only some projects use current workers and users; they are real peers.

[?] became concerned and decided to try it in Hanoi. [?] project using current peers and ex-peers, as a comparison. Also, there [?] other people educating commercial sex workers, who are nothing like peers. There is also the fact that neither commercial sex workers nor ex-commercial sex workers were very effective in terms of real behaviour change. But the non- ex-commercial sex workers were better at it than the real peers. Better still were the [?] of other people [?] who had never been commercial sex workers, both men and women.

Why were commercial sex workers and ex-commercial sex workers less effective in their field than some other people? Number one, commercial sex workers identify with [?], not with [?]. Number two, they do not have a wide social network, and mostly do not really discuss things with other commercial sex workers while working. Number three, Vietnam has a feudal tradition. We respect order and education, and [?]. So why would a commercial sex worker relate to and respect another. Why would they relate with ex-commercial sex workers who are being paid a small wage to talk to them? They ask, "Why should I listen? She's just like me. The same age. Number four, with only a narrow focus, how can the commercial sex worker or ex-commercial sex worker understand the wider picture, so that they can advocate to change the environment in which sex work decisions are made? Commercial sex work is a clear social evil in Vietnam, and part of their work is often [?] that they stop the woman working.

[?] has had better success with other, nonjudgemental people. For example, a 50-year-old male doctor, a 60-year-old female nurse educator. A [?] male [?] of 42 years of age (that's me). Why were these so much more accepted? These are the reasons. First, they have knowledge. They are reputable. They are skilled communicators. They are [?]. They know the system. They understand themselves and [?]. And mostly, they take responsibility.

One-to-one education works in Vietnam. With the [?] -- and it should be [?] to factory, medical, [?], educational venues for men and women. All are at risk. Programs should concentrate on behaviour [?] and change both the environment where sex work [?] and the behaviour itself. Why tell commercial sex workers to use condoms? They cannot insist that clients agree. Giving them condoms is a waste of time and money unless they change men's attitudes too. A peer in Vietnam -- who has the same level of power -- cannot relate with another. But funders want to [?] something, [?]. Surely [?] organization would need money to [?]. They are impressed and they give more money, because they believe it's working, like it does everywhere else. Vietnam needs money for programs, and funders are only confident in certain types of programs. Peer [?], for example.

What lessons have we learned? Number one, peer education as a concept in Vietnam has been funder- and foreign-drive. Number two, Peer education with commercial sex workers is more successful when the peer is in fact not a real peer in the true sense of the word, but it is not the most efficient method. Number three, many different people who are properly trained and have empathy with commercial sex workers, and want to the job of HIV-AIDS education, can be more effective than most commercial sex workers and ex-commercial sex workers in Vietnam. Number four, commercial sex work peers do not have a large enough social network within the industry, and do not really identify with this small part of their lives. [?] are not financially[?] efficient. Number five, communications skills are essential, both in the understanding of social network analysis and in field work. [?] Vietnam [?] nonjudgemental attitude and understanding [?] important attributes for field outreach workers.

Finally, I would like to say that Vietnamese are really good at one-to-one [?] for any issue. They have been doing this for centuries. One-to-one communication with a range of people [?]. Vietnamese need money for Vietnamese programs which have worked in the past. It is too late to continue to try overseas programs for [?]. HIV/AIDS is here, and [?]. Funders should support any new local initiative, and not only fund ones they believe will work. Programs for commercial sex workers need to change. [?] which can work efficiently and effectively with both men and women, in [?] of work and play[?]. Driver, government worker, doctor, teacher, etc.

Thank you very much. My paper will be available here after the conference.

Aud: [?] from the China Academy of Preventive Medicine. I have two questions for you. First, who's the best candidate you'd pick as educator for commercial sex workers? Second, does gender [?] educator and audience is most successful? For example, if you target female commercial sex workers, do you need a female educator.

The best candidate would be an educator, not a doctor. Male or female, it doesn't matter.

Aud: I would like to comment on what you've said. My name is [?]. I'm from the Free University of Amsterdam, and we're doing research on peer education in Indonesia. What we find is practically the same -- that peer education has very little effect in changing behaviour. But I think there is something similar between Vietnam and Indonesia, which is that, in both countries, the government is not taking responsibility for educating the clients of the sex workers. Which means that if you do peer education, you kind of say something like, you have to solve it with the sex workers. I don't think that peer education can exist without education of the clients.

Claudia: Thank you very much. And now I hand it over.

James: Good afternoon. My name is James [?]. I'm a street nurse with the BC STD Control Street Outreach Program. We'll just move right along here. The next presenter this afternoon is Helen Kornman, from Guatemala, and her presentation is La Salla, a novel education approach for sex workers in Guatemala City. Helen works for the Guatemala Association for the Prevention and Control of AIDS. Thank you, Helen, for giving me that in English, because it says it here in Spanish.

Helen: Before I start, a disclaimer. In some of the slides you will see the term "CSW": commercial sex worker. And, as Paulo from Brazil pointed out to days ago, all sex workers are commercial. So I apologize for the translations from Spanish to English. We didn't take that into account.

Sex workers are predominantly marginalized and discriminated against by all sectors of the population in Guatemala. They are often at tremendous risk for violence, rape and emotional abuse by their clients, the army and the police force. Currently there is no law in Guatemala which states prostitution is legal. Neither is there any law which states that it is illegal. As a result, sex workers do not have rights and are often subject to violence without being able to take recourse. The only law which binds them is a law concerning STDs, which states: Commercial sex workers are subject to periodical exams through the Centre for Prophylaxis." Currently, sex workers are supposed to take these exams every eight days.

Female sex workers are vulnerable to HIV, more so for their status as women than for their status as sex workers. And they often encounter burdens, including poverty, illiteracy, little or no access to education, male machismo, religious beliefs, war, and national destabilization. As a result of all these factors, [?] formed a program based on an already successful program in Costa Rica, called La Salla.

La Salla was officially opened on February 14 -- Valentine's Day -- 1996. La Salla ("The Living Room") is a house -- a drop-in centre -- based in the red-light district of Guatemala City. The house is located three blocks from a heavily populated railroad track which has approximately 160 sex workers currently working in small, closet-like rooms. This area of the city was chosen in consideration of the fact that the majority of the women have low incomes and have little or no access to medical services, water, or electricity.

In addition to these women, La Salla has three other target groups: sex workers who are working in the streets, women who work in bars, and women who work in closed houses. It is difficult to estimate the entire population, since there is no mandatory registration of sex workers -- thank goodness! The Centre for Prophylaxis currently has 6,148 women registered, and 198 bars registered. But this is only a small percentage of all the sex workers who are working in Guatemala, and all the bars.

La Salla attempts to give a sense of solidarity by stressing it's existence as a place for all. It's objectives are to create a safe environment for sex workers; offer educational, medical and referral services related to STDs, HIV and AIDS; promote a sense of solidarity between women sex workers and improve self-esteem; and organize sex workers as a group to fight for their rights and safety. The basis of these objectives is to offer a place that the women feel is theirs, where they can take pride in the project. It is not a place of charity or social work. And yet it is a safe place for women to express concerns, relax and organize, in an environment free of prejudices, moral judgements, and pressure to leave their work.

Activities of La Salla include outreach and condom distribution and workshops on power, self-esteem and HIV, in brothels, bars and closed houses; meetings and celebrations each month: educational courses; and the formation of a sex worker committee. Some of these activities have been key in gaining the confidence and interest of sex workers. These include the monthly celebrations and condom distribution. As a result of several months of condom distribution, it has become clear that we also need separate lubricant distribution. Several outreach efforts are being made to locate lubricants, since several of the sex workers have expressed to us, "We won't use the condoms because we get so dry and irritated." Unfortunately, with no resources, we haven't been able to locate as many lubricants as we should have.

Recently -- this month -- a sex worker committee was formed, which has nine women on it. This committee will help make program decisions for the house and also organize around sex workers' rights issues. The goal of the project is, within a few years, to have sex workers running and managing the house themselves.

The current services in La Salla include two-hour biweekly medical consults, HIV testing with pre- and post-test counselling -- which are completely confidential and voluntary, weekly dental and psychological consults, weekly aerobic sessions, daily coffee, and access to shower and laundry.

As can be noted from this slide, the median attendance level has been approximately 90 each month. The service which has been most widely solicited at this time is the medical consults. The medical consults have often been a forum {Andrew: she said format but meant forum} to introduce other services to the women and to enter into conversations surrounding HIV, AIDS and sex workers rights. A small fee is being charged for the medical, dental and HIV tests, in order to self-sustain the service and also to give an incentive to the woman to view the services as professional and take ownership of them. However, a small fund has been developed for women who cannot afford to pay for these services.

It should be noted that all of the professionals who are working in La Salla are women. Once a sex worker enters La Salla, basic data is solicited from the woman to complete an intake sheet. The data is then entered into an [?] program. The following is an initial analysis of the 80[?] intake sheets:

I will present this to give you a better understanding of the population and intervention strategies, and how can we break down some common myths surrounding sex workers. But please note, this is only for this community within Guatemala City -- within a certain sector of Guatemala City -- and this should not be taken to then go out and say, "Oh, all sex workers are such-and-such --what I'm presenting now.

As noted in this slide, the majority of the women who have entered La Salla range between the ages of 20 and 30 years. The entire range includes women and girls from 15 to 54. It should be noted that the area of the railroad tracks often attracts women in their late 20s and 30s, due to the less restrained atmosphere. The majority of the women are Guatemalan, and yet 40% are from El Salvador. This high number of immigrants is due to several factors: several sex workers will leave their communities so as not to be discovered by family members and community members; displacement due to war and poverty; also, lack of visas and working papers, which excludes them from working in other areas in Guatemala.

6% of the population has identified themselves as being lesbian or bisexual, yet this number might be higher due to lack of confidence in reporting sexual preference, in a country where it is very difficult to do. 72% of the women surveyed are economically independent, either single, divorced or widowed. In Guatemala, the majority of the women depend economically on their husbands. As a result, a large percentage of the single, divorced or widowed women enter sex work in terms of economic need.

25% of the women have a stable partner. These partners at times do not know if their wives work, or in some cases obligate them to work in prostitution, and in other cases are very supportive of their work. 88% of the women who visit La Salla have children. The mean number of children is three, with a minimum of one and a maximum of six. This graphic displays the percentages of women who have children in comparison to their marital status. 80% of the single women, and a 100% of the divorced and widowed women have children, and yet do not have economic support from a stable partner.

The high percentage of single women who have children suggests a lack of contraceptive use. The women with stable partners have often expressed the lack of economic support from their partners also. The majority of the sex workers who visit La Salla leave their children in daycare or with family members while working. And the majority -- I should say, all -- expressed tremendous concern and love for their children.

Note that, in this slide, the educational level "none" equals no formal schooling. "Below standard" is attendance at the first years of primary school. "Standard" is some attendance at secondary. "Above standard" is completion of secondary, and/or one year of university or technical school. The majority of the sex workers surveyed have a below-standard education level, which makes access to other jobs very difficult, and often represent a high illiteracy rate. As a result, HIV prevention strategies for our project must be adapted to include visual, as opposed to written, materials.

50% of the sex workers who visit La Salla utilize drugs or alcohol. Again, this number might be lower, since the women will often not report alcohol and drug use. 86% of those who use alcohol or drugs, use alcohol. More commonly used drugs include marijuana, cocaine and tranquillizers. IV drug use is not common among sex workers due to high costs and the lack of accessibility of needles in Guatemala. But this does not mean that there is no IV drug use. It's just lower.

33% of the women who visit La Salla have been working less than five years. 28% have been working five to 20 years. The women have expressed advantages to working longer, since they often have regular clients and more protection within the sex worker community, yet also express that, after two to three years, it is somewhat harder to leave the environment. And this is for a large range of reasons.

The range of salary per client is $1.65 to $8.18 (US). 60 to 63% of the women who visit La Salla make $2.50 per client, making a regular day's salary for an average number of seven clients $17.50. Factors which affect good and bad days include rain, end of pay periods, number of hours worked, emotional state, menstrual cycle, etc. On a good day, a maximum number of clients is 25. As a result of the high number of clients, lubricant used with condoms is essential.

This graphic compares condom use to the rate of incidence of STDs. The incidence of STDs increases with the decrease in condom use. In spite of the fact that 27% of the women say they are using condoms 100% of the time, they have a 25% rate of STDs. This may conclude they are contracting STDs from their stable partners, which oftentimes they are not using condoms with, and/or they have not disclosed completely that they are using them maybe 80 or 90% of the time. It is very disconcerting that 60% of the sex workers have said that they are using condoms only "sometimes" or "almost always." One of the main goals of La Salla over the next year will be to lower this statistic.

Gonorrhea, papilloma and syphilis are the highest reported STDs. To date, La Salla has completed 55 HIV tests, which have been voluntary, and only two have tested positive. This low rate of positives among sex workers is representative of HIV incidence rates among sex workers in several parts of the world, and helps to break down the longstanding myth that sex workers have a high incidence of STDs and are spreading the virus -- and, as I've heard one too many times at this conference, are the driving force behind the virus.

In conclusion, I want to say that after five months of operation, which isn't a lot of time, La Salla finally believes an effective HIV/AIDS prevention and sex workers' rights program must provide a safe environment for sex workers to express concerns and feelings; provide sex workers' basic medical and supportive services within a healthy environment, free of drugs and alcohol; sex worker rivalry diminishes in a setting where they can share problems and advice, and organize to protect their rights. This is definitely a main goal, which is a process which we feel very dedicated to, and yet we know it is a process which will take time.

Thank you.

James: We're almost out of time. We have time for one very quick question of Helen. There will be time at the end of the session, if anyone has any additional questions.

Aud: I would like to start by congratulating Helen on a wonderful presentation, and a very impressive new project. [?] I really enjoyed it, Helen. What I'd like to do is just to make a comment about the last two, in general. And that is to say that often what we've done is inflict on projects a foreign -- whether it is Vietnam or whether it is the United States. Wherever they're from, these funders are foreign to many of us. Their priorities are not the priorities of the actual projects. And I would like to draw attention to what Helen said about the sex workers who are -- that they're supporting sex workers on your committee of nine. And this is the place at which the involvement of sex workers is important, not whether or not they are the appropriate peer educators. That's not really an issue. Who does the actual education, I think, is not the important home. I think we're seeing, from Helen's presentation, the position of sex workers in decision-making positions is the important point. And I wanted to congratulate you for that, and encourage people here not to get caught up on this idea of whether peer educators are appropriate or not, but on the question of whether sex workers in this country -- no matter what country it is -- driving this program. This is the question. And, again, I want to congratulate you for doing that, Helen. Thank you.

Helen: Thank you.

James: This afternoon's session has one other substitution. Standing in for [?] will be Maria Alena Boromeo. Her presentation will be: Communications Patterns Related to STD: Findings from a Qualitative Research Activity Among Female Sex Workers in Manila and [?] City, Filipines.

Maria: Good afternoon, everyone. As mentioned, I am presenting on behalf of Dr. [?], who unfortunately wasn't able to come for her presentation. I was initially hesitant, when I was asked to present, because I was never directly involved in this project. However, I strongly felt that this study is very relevant, and therefore I would like to share it with you. I will try to handle your questions at the end of the presentation. However, for those questions that I cannot answer, I would refer you to some of the persons behind this project -- specifically AIDSCAP.

So, the title of this study is Communications Patterns Related to STD: Findings from a Qualitative Research Activity Among Female Sex Workers in Manila and [?] City, Filipines. There are three objectives of this study. The first is to document of the user perspectives on STD and available health services of STD care. The second is to document the user perspectives on STD and STD-related health care-seeking and preventive behaviours. And the third is to identify communication characteristics of users and providers.

The study used an open-ended, semi-structured interview format. The design used was purposive[?] sampling. A standard training for interviewers was done. Regular supervision of interviewers was also ensured. Although this is a qualitative study, data analysis emphasizes the range of responses generated, and the frequency distribution of the quoted open-ended responses. This frequency information is included to indicate whether a response was common of intermediate frequency or [?]. The interpretation of the meaning of answers was based on content analysis of responses, and a comparison of [?] issues in different [?] treatments.

The most frequently mentioned sources of information about STDs: first, television, radio and movies. The second was fellow workers and health care workers. It is notable that clinic-based printed material, such as posters and pamphlets, have rarely been mentioned as a source of information. And that both clients and establishment owners or administrators were also rarely mentioned as a source of communication.

Female sex worker informants felt that health care workers were the most trustworthy source of information on STDs. They also felt that friends with STD experience were a good source of information. Yet informants also felt that they could not trust advice from co-workers. This may be a reflection of the reality of friendship formation and the degree of social cohesion among different groups of female sex workers.

In other words, when the social circumstances are conducive to women forming friendships, these friends form an important part of the communication network. But, on the other hand, in those circumstances where there is a high degree of competition between women for clients, protection for other individuals in the setting of commercial sex, or other valued resources, there is a high level of distrust and correspondingly weak or nonexistent communication links between co-workers.

This has intervention design implications, because peer education approaches are likely more effective among groups of female sex workers whose social circumstances are conducive to forming trusting relationships with co-workers than among groups where female sex workers are highly competitive and distrustful of each other.

When asked to describe the feelings they had about conversations with health care providers, the respondents gave a range of descriptions, from quite positive to quite negative. The most positive description reflected a sense of relief, because they learned that their infections could be cured, or found that they didn't need to worry as much. Others simply said that they were comfortable, satisfied or happy with the conversation. Many informants described the conversations as "fine" or "okay" -- a response that could be interpreted as a favourable assessment of the conversation they had with the providers; or as a hesitation to answer the question openly.

Another group of informants described the conversation as leaving them with a sense of shame after the first consultation. Feeling nervous, very hesitant, or afraid. Health care providers were reported to be one of the kinds of people female sex workers can talk to about STDs.

Questions about how female sex worker informants would feel about talking to their male partners about STDs: The findings suggest that female sex workers may feel more comfortable talking with men they have more stable relationships with than with clients. But follow-up questions suggest that, for some, they are able to talk to clients about STDs, because it is already a topic discussed in the work environment, or the clients are already aware of STDs.

Those who found it difficult to talk to clients about STDs indicated it was difficult to talk about the topic with someone they don't know. They are afraid of reprisal from clients, and are concerned that clients will suspect that they themselves are infected with STDs. For stable partners, however, some female sex workers associate familiarity with each other with a mutual understanding conducive to talking about STDs. On the other hand, among those who thought it would be difficult to talk to their stable partners, some women described themselves as someone who found it difficult to discuss this topic, or as someone who wanted to avoid discussing their commercial sex activities. 84% of informants who responded said it was possible for health workers to help notify their partners of their infection.

Women were also asked what they learned about how to avoid an STD from communication sources they used. The most frequent responses were: use of condoms, abstinence, not going out with customers, not going out with unfamiliar customers, choosing customers, avoiding sex work contact with different partners, or with infected persons. Intermediate answers were: have a regular checkup, proper hygiene, or washing genital areas before and after intercourse. Rare answers were: be loyal to one partner, screen blood, and avoid blowjobs.

The strategy of choosing partners in some way emerges as a clear message these women have received, along with condom use and abstinence. This information is echoed, and further elucidated, by examining the responses to a pair of complementary questions asked during the clinic interview portion of the TIR (targeted intervention research) activity. For this field work, patients at health centres or clinics were asked what providers told them about the treatment and prevention of STDs, and the health care worker was also asked to specify what advice they give to patients, other than instructions regarding medications.

The first group of messages are considered relevant STD-related health communication messages. The questions directed at health care workers assumed that they give drug compliance advice, and it is therefore not surprising that there are no responses for health care workers for these questions. Therefore they have no ability to confirm whether or not the messages regarding washing genital areas before and after sex explicitly advises against vaginal douching.

Another set of messages can be described as problematic for a variety of reasons. The messages about choosing partners, and monogamy, are impractical or unrealistic for a commercial sex worker population. The message about being careful about discharges is impractical unless further specified to include consistent and effective use of condoms. The message regarding dietary behaviours and taking a rest are again not effective for preventing or curing STD infection, unless taking a rest is further specified to mean abstaining from sex during the treatment period. The message about doing wrong things is vague and potentially accusatory in tone. Health care workers are important sources of information. However, with the exception of condom use, several messages that seem to have penetrated to female sex workers are either too general or impractical or ineffective, given their prior decision to work in the sex industry. A corollary to this statement is also true: that providers are in some cases using vague or inappropriate health education messages. These findings justify an effort to refine and upgrade clinic-based communications with a program designed to introduce standardized and priority messages, as well as giving clinic staff basic skills in interpersonal communication.

These types of interventions would benefit greatly by developing and distributing materials that facilitate the provider-patient encounter. Message contents for STD prevention are poorly developed. Gonorrhoea as a catch-all term can be used as a starting point to move into the approach of discussing syndromes. There is a need to emphasize descriptive terms of STD symptoms in the local language. [?] STD care for female sex workers should be promoted, there is a need to address prophylactic antibiotic use for preventing STDs. And partner referral for steady partners should be addressed.

Promoting routine use of STD health services, peer education can be utilized only in some groups of sex workers with social cohesion, and the creation of more user-friendly STD services is needed to improve female sex workers' perceived quality and benefit of STD care.

Thank you.

James: Thanks very much. We have about eight or ten minutes left in this afternoon's session, and for Maria's time, she does have a couple of minutes for questions. I understand that there are people who would like to make comments or ask questions of other presenters, and they can take that time after Maria is finished. Thank you.

Aud: When you say "address the prophylactic use of antibiotics to prevent STDs," I'd like you to explain how you address that. And regular visits are also questionable. What good to regular visits do to go to an STD clinic? It's too late!

Maria: The first question is on the prophylactic use of antibiotics for STDs. It think because in the Filipines sex workers are required by law to submit themselves to regular STD checkups. So what the workers do is that, before they go to the clinic, they self-medicate. So this is what we're trying to address now.

Aud: You're trying to tell them to stop? What do you mean by "address"?

Maria: This is what the national program is doing now. Aud: Are you telling them to stop taking the antibiotics on their own?

Maria: Yes.

Aud: That's what I wanted to know. "Address" is vague. I'm curious; is AIDSCAP doing anything to stop the mandatory testing?

Maria: It should be the national government who --

Aud: When is the national government going to decriminalize prostitution and end the mandatory testing? They've known for a long time that those are ineffective and that most prostitutes do not go, and it's a useless program. When are they going to end it? And when is the mayor of Manila going to stop trying to kick women out of [?]? And when are they going to let these women organize and make their businesses work safely? It's a long time AIDSCAP has been working there. Let's get something done!

Maria: Could AIDSCAP address that, [?]?

[?]

James: In the remaining time, if anyone has any questions of any of the panelists up here, they can ask. All of the microphones are working.

Aud: I just would like to reinforce the idea that Helen referred to me about the term "commercial sex workers." We've been saying for five years already that people shouldn't use the term, which is really very wrong, because sex work is commercially based. So we should say "commercial doctors," "commercial researchers" --commercial whatever.

The other thing is that it's very sad for me, after many years of activism, to still see prostitution or sex work related to poverty. And some of the presenters here have reinforced[?] the idea that the poor women in their countries have no working possibilities, so they go to prostitution because of the poverty, or because of the need. And we always forget that, if we're talking about sex, we cannot just forget the idea of pleasure. This is an idea that has never been brought up. And Helen showed in her presentation that some of these women have been sex workers for five or ten years. So it does not mean that it's just a matter of poverty, or this idea of victimizing health workers -- that they go to sex work just because there are no other job options.

The third point is that, in the next conferences, I would like people -- that maybe some of us will be organizing long tables[?] about sex workers, that there are male sex workers as well. We exist!

Helen: Our project is based around female sex workers. However, we have another project that is beginning to think about working with male sex workers. We saw it as very different issues. Not different issues, but needing to be dealt -- in different situations. And so that's the reason that that was chosen. But this project is starting to get off the ground and have some talk about that. So I wanted to address that.

The other thing I wanted to address was, in my presentation I did make reference to economic status. However, I was very careful to say "some" of the women. And I just want to reinforce that, and to say that, within the area that we are working in -- within Guatemala City, and the actual area -- it is a very low economic area. That's why I had said "some."

Aud: My name Beth Wolgemuth. I'm with the Sex Workers' Alliance of Toronto. I'm also with the Network of Sex Work Projects. I would like to thank the people who came out in support of those members of the Network who are here to speak to the issue of the inclusion of the representative from Burma. I see that the Burmese representative did not show up. But nevertheless, at the last three AIDS conferences, prostitution -- in fact, prostitutes -- have been much more represented. We actually have very little representation at this conference.

And I can't help but think that a presenter from this government would never have been included at Japan, or at Berlin, or at Amsterdam. There were way, way too many prostitutes from other countries besides the northern ones. There was protest in Amsterdam over the killing of prostitutes in Burma. That has been confirmed. That is not some hysterical statement being made by the Network. We have much documentation. We discussed this as a worldwide network in Amsterdam. We discussed it again in Berlin. And we discussed it again in Japan. This is an outrage to all members of our project. It is not just a northern issue.

It is an outrage that we were not consulted on the sex worker content at all. The Network represents almost 200 organizations worldwide. We don't represent -- we network with almost 200 organizations. It's very loosely knit; we're not funded. However, we were told we would have representation at this conference. That members of the Network would clearly have representation. We did not. We did not even get scholarships. None of the sex workers from Africa were given scholarships -- not one. We had money at the last conference.

So the fact that this inclusion was at this conference, where there were very, very few sex workers and sex worker groups from around the world, I think is very significant. And I appreciate the support of those of you who showed up.

ACT UP Rep: I'm going to ask that everybody here who finds it deplorable that an international conference would invite as a speaker a person from a country -- a member of the Ministry of Health --that actually murdered 22 prostitutes because of their HIV status -- if there's anybody who finds that as frightening and deplorable as I do, I would ask them please all to step towards the front so we can join hands together in a recognition of the need to protect the human rights of all people with HIV.

James: While this is happening I'd just like to thank everybody for coming out and showing the support that you did for this afternoon's session.

Aud: I'm in shock that they're being allowed to do this.

ACT UP Rep: "Twenty-two women -- sex workers were sent back. They were arrested at the border. They were shot. Twenty-two people killed because of their HIV status. If there is anyone in this room who can accept that, fine. Don't join us. The rest please join us for a minute of silence for all the people with AIDS whose human rights are not being protected."

Priscilla Alexander: "I would like to request a moment of silence for every sex worker who is arrested in this world; who goes to jail in this world; who is raped in this world; who is killed in this world; who is beaten in this world; who gets STDs in this world; who gets HIV in this world; and the lack of care for them from almost every single government of this world."