Population Council Research that makes a difference

16th International Conference on AIDS
and Sexually Transmitted Infections in Africa (ICASA)
4–8 December 2011

Abstract

"Male circumcision scale-up, risk disinhibition, and female sex workers in Zambia: A qualitative exploration"
Sharon Abbott, Nicole Haberland, and Drosimn Mulenga

Background
The Zambian National Male Circumcision (MC) Strategy and Implementation Plan 2010-2020 was adopted by the Ministry of Health In 2009 with the goal of making high-quality and safe MC services accessible to all males on a voluntary basis. MC services typically include in-depth counseling for males about wound healing, partial protection and abstinence in the healing period, although little information is provided to female sexual partners. According to the 2007 ZDHS data, 5% of men report visiting a female sex worker (FSW) the past year. This qualitative exploration, embedded in a longitudinal study of risk compensation, investigated FSW's knowledge of MC, their ability to negotiate condom use, and their experience with clients who have been medically circumcised.

Methods
Twenty in-depth interviewers were conducted with FSWs working in Lusaka using a semi-structured interview guide. A convenience sample was recruited from clubs, bars, brothels, and streets frequented by FSWs. An effort was made to interview FSWs who serve clients from various socioeconomic classes, as well as those who were brothel and street-based.

Results
Most FSWs were familiar with MC. More than half of the sample reported that MC could reduce the risk of transmission of STIs, but they also believed MC had no effect on HIV transmission. The remaining portion reported that MC reduced risk of transmission of STIs and HIV for men, but were unsure if there was a protective effect of MC for women. Although the majority of the FSWs reported that clients - regardless of MC status -requested unprotected sex, circumcised clients tried to negotiate unprotected sex on the basis that they were protected from diseases. Few believed men's claims that their circumcision status made them "clean." More than MC status of clients, the need for money and being intoxicated were risk factors for unprotected sex. Additionally, several FSW reported engaging in unprotected sex as the result of coercion or the threat of violence. Further, a few FSWs reported having had recently circumcised clients, as evidenced by stitches still being present in their circumcision wound. One stating his wife refused him sex. Although condoms were used regularly with clients, the majority of FSWs reported that they did not use condoms with their steady partners.

Conclusions and Recommendations
Findings from this exploratory study suggest that FSWs are facing pressure from circumcised clients for unprotected sex because of their MC status. The data also indicate some MC clients are resuming sex prior to the end of the recommended post-surgical abstinence period. In particular, early sex puts FSWs and their partners at increased risk. As MC services are scaled up in sub-Saharan Africa, it is critical that all women, including FSWs, be provided with information about MC, particularly the limits of its protective effect for men and women. It is also recommended that MC providers work with organizations that offer services and support to FSWs to disseminated information about MC as part of program scale-up.

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