Something for all, and special measures for those at greater risk

Cross-cutting themes

Involvement of private sector

Community and local experiences

Imaginative approaches to fundraising

Unprotected sex continues to fuel the HIV epidemic. Therefore, broad prevention campaigns aimed at the general public are still necessary. At the same time, it makes strategic sense to focus first on specific populations including sex workers, men who frequently visit sex workers, and drug users, as well as geographic areas where rapid HIV spread has become an emergency. These range from categories as large as "young people" and "women" to those as precisely defined as sex workers, migrants and soldiers.

Messages for the general public

A number of options are promoted in prevention campaigns directed at the general public. One message is to abstain altogether from sex – or, for young people who have not yet become sexually active, to postpone the start of their sex life. Another is to engage in sex that involves no penetration. As a further option, people are encouraged to have sex with only one other person – someone who will never have sex with anyone else. Mutual fidelity is protective, of course, only if both partners stick to the rules and were uninfected to begin with. Finally, the consistent and correct use of condoms (either male or female condoms) for every act of sexual intercourse protects both partners from HIV and other sexually transmitted infections.

These are not either/or choices. People may adopt different prevention strategies at different points in their lives, and good prevention campaigns emphasise that many options are available which reinforce each another.

In campaigns directed at "the general public" it must be remembered that half of the population is male, and that men have not only responsibilities but their own factors that make them vulnerable to HIV infection. (This is discussed in more detail in the next chapter, under the heading "Men: also vulnerable, but in different ways.") These campaigns must provide specific and programmatic information on risk behaviours and options for safer behaviours including referral to relevant services to reduce HIV risk.

Reaching sex workers and their clients

In many countries, HIV was first identified in the sex work population. As the epidemic grew, international agencies, governments, and NGOs recognised the need to create interventions to diminish HIV transmission in commercial sexual encounters. Initially, programmes focused mainly on the promotion and distribution of condoms to sex workers, and dissemination of information. Most of these programmes were targeted at the sex worker alone, ignoring the clients. They took inadequate account of the marginalised, illegal status of women that contributed so much to their vulnerability, and of the fact that ultimately it was the male client who had to be convinced to use a male condom.

In the past decade, educational and enabling strategies have been the two main elements used when addressing sex work and STIs and HIV/AIDS. The most successful projects include components of education, condom provision and empowerment, and target not just the sex workers but the other people who are directly involved, above all the clients, owners and managers of sex establishments, and those who influence commercial sex activity, such as police and law enforcers; health officials; those who can influence perceptions towards sex work; community leaders; the media; neighbours and families.

The most effective comprehensive projects are frequently those carried out by men or women who are or have been sex workers. This approach is usually referred to as peer education. But in addition to providing advice, counselling, and information that focus on individual risk behaviours, programmes should pursue objectives such as increasing the sex workers’ bargaining power (both individually and collectively) to insist on safer sex.

Examples of Best Bractice

Senegal: Preventing transmission of HIV among sex workers and clients

Leadership issues summary

Leadership level(s): national health authorities

Contribution to success: ability to build on an existing, realistic approach to public health problems; understanding of cost-effectiveness of targeted intervention

In Senegal, HIV prevention measures aimed at sex workers were reinforced by measures among the general population from which the sex workers’ clients are drawn. Along with risk-reduction (largely through promoting the use of condoms), efforts were also made to reduce vulnerability.

In many countries, prostitution was ignored until the advent of AIDS, when it became clear that sex workers were very vulnerable to HIV infection and could in turn quickly pass the virus on to large numbers of other people. In Senegal, however, services for sex workers’ have existed since the profession was legalised in 1969. Registered sex workers have since then been required to have regular health checks, and are treated for curable sexually transmitted infections if necessary. This system of registration provided a framework within which to approach sex workers with educational and health campaigns.

Once the threat of an HIV epidemic became clear, decision-makers in Senegal immediately understood that sex workers were at extremely high risk both of contracting HIV and of passing it on to their clients. Preventive interventions focusing on the promotion of condom use with clients were immediately put in place, and treatment of sexually transmitted infections moved up the list of health priorities. Many sex workers began to join support groups to safeguard their health in the face of AIDS. Over 30 such groups were established.

Prevention efforts were also made to reach populations that may be regular suppliers or consumers of casual sex, whether or not in exchange for money. These include mobile populations such as migrant workers and transport workers. Locations where casual sex may take place, such as weekly markets, are also becoming targets for more active prevention efforts.

Before the HIV epidemic, condom use in Senegal was extremely low, less than one per cent. And indeed, it remains low as a method of contraception or between spouses. However, in casual sexual relationships - exactly those targeted by the AIDS prevention campaign - condom use has risen dramatically. In a 1997 population survey in Dakar, more than two-thirds of men and close to half of women who had had casual sex in the past 12 months used a condom with their last such partner.

Information and condom promotion targeted at sex workers seems to have been even more effective. In a 1998 study of prostitutes, 99% reported that they had used a condom with their most recent new client, and 97% with their most recent regular client. In the capital, Dakar, the HIV prevalence rate among sex workers appears to have remained stable at around 17% since 1993.

Côte d'Ivoire: Programme for care and prevention among female sex workers and their partners

Leadership issues summary

Leadership level(s): NGO working with government health authority and external donors

Contribution to success: willingness to empower sex workers, despite their semi-legal status; seeking cooperation from members of the sex workers’ milieu as well as the women themselves

Since its start in 1991, the Programme for STI/AIDS care and prevention among female sex workers and their partners (PPP, in French "Programme de Prévention et de Prise en Charge des MST/SIDA chez les Femmes et leurs Partenaires") has targeted three main groups: sex workers (both professional and non-professional); their clients and sex partners; and the owners and operators of locations where the sex trade occurs.

The sex trade in Côte d'Ivoire has an ambiguous status, being illegal, tolerated by the legal authorities, and widely used by men from all sectors of society. A large proportion of the women are migrants from other countries, a factor which increases their vulnerability.

PPP has taken a pragmatic approach, starting with research on the target populations. In 1993/94, the National AIDS Programme became PPP’s institutional "home" within the country’s health system, overseeing its administrative and financial management. It has since been extended to four other cities: Bouaké, Daloa,

Korhogo and San-Pédro. Staff includes health educators, sociologists, and government social workers, along with peer educators recruited from among the sex workers.

A major focus has been community mobilisation and education. Activities include educating and involving all interested parties in prevention work, from the local government authorities to the leaders of immigrant communities, owners of bars or hotels in which sex work takes place, and leaders among the community of sex workers. Educational meetings are held in places where sex workers live or work. The meetings' curriculum includes information about HIV and other sexually transmitted infections (STI), prevention methods, testing, and STI services.

Peer education is carried out through recruitment of sex workers who perform outreach to other prostitutes in their places of work, as well as organizing educational meetings. Training sessions for peer educators are held every two months at the Clinique de Confiance operated by a project with similar objects, Projet Retro-Ci. The programme distributes free condoms in places where the sex trade is carried out, and in some health centres. It has also attempted to involve sex workers and hotel or bar owners in this distribution.