Yaw Adu-Sarkodie, Rose - PowerPoint Presentation

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Yaw Adu-Sarkodie, Rose Adjei, Thomas Agyarko-Poku, Peter Wondergem, Monica Adhiambo Onyango, Jennifer Beard

Intimate Partners of Female Sex Workers

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Operations Research on HIV Risk among Key Populations in Kumasi, Ghana1 of 9 “short, sharp” qualitative studies conducted between 2010-2014Ghana Collaborators: School of Medical Sciences, Kwame Nkrumah University of Science & Technology (KNUST), FHI 360Sponsored by USAID & Ghana AIDS Commission Objective: Provide information to better tailor programming for key populations

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Our Study PopulationsGeographic Focus: Kumasi, Ashanti RegionYoung female sex workersPrisoners

Tertiary institution students engaged in transactional sex

MSM: adolescents and young adultsMSM: > age 30

Girls and women working in bars and restaurantsPeople who inject drugs

ART patients lost to follow-upIntimate partners of FSW

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Study ObjectivesBackgrounds and current situations of the types of men involved in intimate relationships with FSWEmotional, financial and other power dynamics within these relationshipsSexual behaviors, HIV knowledge and vulnerabilities of both partners

Use of harm reduction, support, & other health

services

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Key Background Statistics

Adult HIV prevalence in Ghana

(NACP)

2% National (2015)

1.8% Kumasi (2012)

HIV prevalence among FSW (IBBSS)

13.0%

Ashanti

16.3% Accra

11.1% National

HIV prevalence among

post-secondary students

Not known

HIV prevalence

of MSM (Ghana Men’s Study IBBSS)

13.6 Kumasi

34.3% Accra/

Tema

17.5% National

HIV prevalence among prisoners in

Ghana (GPS)

2.08%

HIV prevalence

among people who inject drugs

Not

known

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TerminologyIntimate partners (boyfriends/husbands) vs. non-paying partners vs. regular partnersAs defined by sex workers during FGDsArea Boys/Ghetto Boys: They are around and provide assistance but are not in an intimate relationship

Fresh Boys/Steady Boys: In relationship with SW

Roamers & Seaters

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Methods Table 1: Interviews

Methods

Participants

IDIs

24 men

2 IP FGDs13 men

FGD1: 6 IP of RoamersFGD2: 7 IP of Seaters

 

3 FSW FGDs

20 women

FGD 1: 8 Roamers

FGD 2: 6 Seaters (Ghanaian)

FGD 2: 6 Seaters (Nigerian)

Total Sample Size: 57

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Demographic Overview of Male RespondentsAge: range 20-60; mean & median 36Marital status:Number of children: range: 0-4 children; mean 1

Single

35

Married

12

Divorced

2

Cohabiting

3

Widower

3

Separated

1

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Characteristics of IP-IDIsMany of the intimate partners were individuals who left their homes to come and stay where the sex workers operate

A number of them have been with different sex workers and

protecting them for many yearsMost intimate partners were comfortable with their partners’ sex work–sex work is often what brought them together

Others hope she will quit so they can marry

“My partner only operates in the evening therefore during the day we make time to be with each other till she moves out to work in

the evening.” (IP IDI)

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Characteristics of IP-IDIs6 IDIs unemployed or described protecting SW as primary jobOther jobs included: Security guard

S

hop owner Operates drinking spotCar sprayer

Taxi driverM

echanicRestaurant food delivery Boutique attendant

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Length of time in relationship: Range 6 months-10 years: Mean 3.24 years40% said they do not have other sex partnersRelationships between IP-IDIs and SWs

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How the IP Enter into Relationships with FSWMost men reported meeting their sex

worker partners as regular

clients then became intimate partners. But others spoke of being friends first, mutual attraction, etc.

“Personally before I enter into a relationship with any sex worker I patronize their services and try as much as possible to be nice with them. I spend money initially on them buying gifts and other presents for them then later ask them to be in a relationship with me which they mostly agree to given how nice I have been to

them.” (IP Roamer FGD)

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Characteristics of RelationshipsOf the men participating in IDIs most considered

their relationship

serious and stable.

“Personally

I have been with my partner for the past 13 years. We love each other despite the work she does. We believe we still have a future together.” (IP IDI)

A few

intimate partners

stated

that there was not much between them and

their

sex

worker partners.

They had other serious

girlfriends or wives elsewhere.

“There

is no way we can marry each other

.”

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Seriousness of Relationship15/24 IDIs considered their relationship to be serious“I consider it [relationship with SW] to be more serious than that even of my wife.”

“We are planning. I am hoping to get more money from getting another job then she can stop this job so that we marry

.”“It is love. I engage her in sex only during the day time because in the evening she works. Culture frowns on such acts but because of hardship I have to accept it. We do everything

together.”

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Seriousness of RelationshipBut many also said the opposite:“There is not much love between us and our sex worker partners. Even though we are with them we still have our serious girlfriends we wish to be with

.”

“No. We are just helping each other. There is no way we can marry each other. My partner sometimes even encourages me to introduce any lady I want to marry to her because she also has plans of going back to Nigeria to marry.”

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What the Male Partner ProvidesProtectionAll men interviewed reported providing protection to sex workers

Some only protect their girlfriend; some reported protection as a feeling of responsibility to the community

“They

protect us from clients who patronize our services but do not wish to pay…They protect us in our business. They also ensure we are not cheated by our clients. Some of them go with us anywhere we

go.” (FSW in FGD)

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Mutual Benefit/ExploitationMost relationships between sex workers and their intimate partners were symbiotic. FSW supports her IP financially and gives him gifts while he protects her in her work, provides companionship and intimacy, and may also contribute other forms of support.

Both men and women referred to helping one another financially, sharing resources, and supporting each other emotionally.

Roamers described seeking out fresh boys to be their boyfriends and protectors, referring to the beginning of their current relationship in transactional terminology.

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Benefits for the Male PartnerFinancial gains/Place to stay

“Our

inability to secure a job is what makes us to be with sex worker because they provide for us and gives us a place to lay our

heads.” (IP Roamers FGD)

“

We

are also motivated to get involved with them because of the assistance they give

us.” (IP Roamers FGD)

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Benefits for Male PartnerDrugs“What motivates me to be with my sex worker partner is that she buys drugs for me when I want to be high. She also makes me feel better than any other lady will make me feel

.

” (IP Roamer FGD)Love & Emotional Support

“Love is not just about sex.

Some of our clients become our intimate partners because of the way we treat them. Our attitudes toward them and how nice we attend to their needs makes them love us and want to be with us and help us quit the sex work

.” (FSW in FGD)

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FSW Benefits from IPFinancial Support/Gifts“My partner assists me in paying my child’s school fees. He treats my child as his own and supports me to take care of him. Despite the fact that I engage in this work, my partner also gives me money.” (FSW FGD)

Emotional

Support/Sex

“When things are not good she becomes frustrated and sad but I try to encourage

her. I supported her to visit the hospital when she is sick.” (IP IDI)

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Investing in Your Fresh BoyBoth men and women reported that these relationships become a serious financial investment in which women sometimes spend a lot on their fresh boy’s upkeep and education. “Some of the fresh boys have been to school. We even sponsor some of them through their schooling. Personally my fresh boy is in the polytechnic and I pay his fees

.” (FGD with FSW)

“There are many benefits one derives from being in a relationship with the sex workers. Some of the intimate partners were armed robbers but through encouragement and support from their partners they have stopped.

“ (IP IDI)

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Purchasing a Fresh BoySome roamers described a situation in which they might even be willing to purchase a fresh boy’s services from another sex worker. In these cases, “ownership” of that fresh boy’s services (protection and love/sex) was transferred to the purchaser.Many described this investment as equalizing the power balance within the relationship, enabling women to demand monogamy and high-quality protection while helping men to lift themselves out of poverty, move away from crime, or stabilize

financially.

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“Some new sex workers even pay to have the services of our fresh boys. This they however do after consulting the sex worker whose fresh boy they want to have. After coming into agreement they pay to the sex worker to have their fresh boys.” (FGD with FSW)“I met my fresh boy in a night club. He looked handsome so I liked him. I enquired about him from a friend who told me he had a girlfriend who was also a sex worker. We met with the girlfriend to negotiate with her to allow me have him as my boyfriend. She agreed and I had to pay her GHC 3,500 [USD 1,150] on the backdrop that she has spent a lot on my fresh boy

.”

(FGD with FSW)

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Trust & Intimacy May Conflict with Condom UseMost FSW described unprotected sex with an intimate partner as a sign of trust, love, faithfulness, and commitment.

“We

use condoms with our clients so there is no way we can use condoms with our intimate partners too. We have unprotected sex with them. They will even question why we do not want to use condoms with them and even doubt our love for them

.” [All the participants agree to this.] (

FGD with FSW)“Our fresh boys do not use condoms with us and they also make us enjoy the sex. Some of our fresh boys have oral sex with us which we enjoy very much. This we cannot do with our clients.

We also engage our clients for money but for our fresh boys it is for love. We bathe together with them and do all kinds of things with them.” (FGD with FSW)

 

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Women often Drive Decision to Not Use CondomsAs described by both men and women, the decision to not use a condom within intimate relationships was often driven by the woman. “The sex workers never accept their partners to use condoms with them. They always complain when you want to use condoms with them as they use condoms with their clients.” (FGD with IP)

“The

sex workers question the faithfulness of their partners who want to use condoms with them. They believe any intimate partner who wants to use condom with his partner do not trust them.” (IP Seater FGD)

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Incidents of physical violence mentioned by IP and FSW Some boyfriends of roamers stated that they coerce their SW girlfriend to give them anything they demandViolence fueled by drugs/alcohol

“Personally

when I ask my partner for anything she can’t say no for fear of me beating her. Even when she does not have what I am asking her at the moment she makes a way to get it for me

.” (IP Roamer FGD)

“Normally I love to have sex with her early in the morning before she starts work or late in the night when she had closed. She however sometimes denies me sex giving me excuses of tiredness or accusing me of having sex with other sexual partners. This results in arguments and sometimes fights especially times when I have smoked marijuana. I once got drunk and came home late. Out of anger she hit me with a bottle and I also hit her back till she became unconscious. I had to take her to the hospital afterwards...Since that incident we have never fought again

.” (IP IDI)

Violence within Relationship

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Reasons for Male Partner Violence Arguments related to money, not

giving the man money

Woman out

with a client for an extended period of time without

informing man

Disrespect

and

jealousy

R

efusal

to have

sex

Man

suspects the client is more than a

client, may

be having a relationship with

FSW

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Explanations of Violence“Sometimes when we rush in only to realize our partners have extended the time without answering our calls we become infuriated and beat them.” (IP Roamer FGD)

“My

fresh boy once informed me he is leaving for school but he did not. I decided to visit another boy in our neighbourhood and before I knew my fresh boy just appeared from nowhere. He hit me so hard at the back and started beating me. It took the intervention of a certain lady who kept shouting for help for me till I was rescued

.” (FSW in FGD)

“There are times arguments result between . . . partners which culminate into violence. This is normal in every relationship. It is even during these violent situations in the relationship that the love and bond shared is strengthened.” (IP Seater FGD)

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Reciprocal Violence“Some

of the intimate partners hit their partners while their partners sometimes hit them back with either or both of them getting hurt. The police are sometimes involved in such violent act

.”

“Suspicion and jealousy is the cause of beating in the relationship of sex workers and their partners. I was once chatting with a lady who was passing by, from nowhere my sex worker partner came to pour urine on the lady and hit me. I became very angry and beat her.” (IP Roamer FGD)

“Normally the ladies here have an advantage and they sometimes get support from their friends and other colleague sex workers to fight and beat their partners

.” (IDI 14) “I have seen a lot here. They normally hit their partners with bottles while others use sharp edges such as blades and knives

.” (IDI 22)

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Summary Conclusions for Service ProvisionValue the relationship. Don’t assume always exploitative, though benefits pass in both directions.Identify sources and demonstrations of power by both men and women Understand relationship dynamics in order to target key vulnerabilities, i.e., condom use, violence, different dynamics between seaters and roamers in boyfriends.

Relationships between Roamers and Fresh Boys seemed most likely to be volatile and exploitative but Fresh Boys were most articulate about HIV prevention interventions.

Facilitate collaborations between men in sex work communities, area boys, and other stake holders including police, health providers.

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What now?

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Gender Sensitive ProgrammingStage 1: Do no harm: eliminate of gender stereotypes that lead to vulnerability and damage men’s and women’

s ability to benefit Stage 2:

Recognize men and women are different due to physiology and socially constructed gender

roles and design prevention, treatment, and care programs to fit these different needs Stage 3: Transformative interventions:

work with men and women to redefine gender norms and encourage healthy sexuality

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Questions/Comments?

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AcknowledgementsThe brave women and men who were willing to tell us their storiesKumasi Research Team

Ghana

AIDS Commission—Kyeremeh AtuaheneUSAID Ghana—Peter Wondergem & Emmanuel Essandoh

FHI360—Kimberly Green. Sam Wambugu, Nana Clement Fosua, Yussif Ahman Abdul Rahman, Debbie Kwablah, Henry Nnagai,

WAPCASBoston University Research AssistantsPhotos by Nana Kofi Acquah

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ReferencesBosu WK, Asamoah-adu C, Akuamoah S, Biney EE. Integrated Bio-Behavioural Surveillance Survey of Non- Paying Partners of Sex Workers. West African

Programme to Combat AIDS and STIs & Ghana AIDS Commission. 2010.

Abbey M. WHY SOME MEN PERSISTENTLY REFUSE TO USE A CONDOM DURING TRANSACTIONAL SEX: A Study Conducted in the Greater Accra Region of Ghana. 2005. Asamoah-Adu C, Khonde N, Avorkliah M. HIV infection among sex workers in Accra: need to target new recruits entering the trade. JAIDS [Internet]. 2001 [cited 2012 Jun 18];28(4):358–66. Available from: http://journals.lww.com/jaids/Abstract/2001/12010/HIV_Infection_Among_Sex_Workers_in_Accra__Need_to.9.aspx

Ghana AIDS Commission, President's Emergency Fund for AIDS Relief (PEPFAR), USCenters

for Disease Control, University of California San Francisco (UCSF) Global Health Services. The Ghana Men's Study: Integrated Biological-Behavioral Surveillance Surveys and Population Size Estimation among Men who have Sex with Men (MSM) in Ghana. 2013.

Ghana AIDS Commission & FHI360. Integreated Biological and Behavioural Surveillance Survey of Female Sex Workers & Clients of Female Sex Workers. 2011. Abbey M. WHY SOME MEN PERSISTENTLY REFUSE TO USE A CONDOM DURING TRANSACTIONAL SEX: A Study Conducted in the Greater Accra Region of Ghana. 2005.

Asamoah-Adu C, Khonde N, Avorkliah M. HIV infection among sex workers in Accra: need to target new recruits entering the trade. JAIDS [Internet]. 2001 [cited 2012 Jun 18];28(4):358–66. Available from: http://journals.lww.com/jaids/Abstract/2001/12010/HIV_Infection_Among_Sex_Workers_in_Accra__Need_to.9.aspx

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Research funded by PEPFAR, USAID,Project SEARCH

The studies were implemented by Boston University in collaboration with the Kwame Nkrumah University of Science and Technology with support from the President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for International Development under Project SEARCH Task Order No. GHH-I-00-07-00023-00, beginning August 27, 2010. The content and views expressed here are the authors’ and do not necessarily reflect the opinion or policy of USAID or the U.S. Government.

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Most study participants (men & women) had some knowledge about HIV, its transmission and consequences.

A few did

not know anything about HIV and some

did not know anybody

with HIV.

Most understood

the use of condoms and how they protect from HIV

infection.

HIV Knowledge