Poverty of opportunity for women selling sex in Lahore, Pakistan : knowledge, experiences and magnitude of HIV and STIs

Abstract

Background: According to the UNAIDS’ estimates, the incidence of HIV infection has decreased by 19% over the last ten years. WHO estimated in 2005 that approximately 448 million cases of four major curable STIs occur in adults in the age group 15-49 years. Most at risk populations including women selling sex engage in behaviours that lead to HIV transmission. Health care providers are considered to play a pivotal role in the provision of preventive and curative services to individuals suffering from HIV/AIDS and STIs. The HIV epidemic in Pakistan is concentrated among injecting drug users and Hijras (transgenders).

Methods: The research involved both qualitative and quantitative research methods leading to Paper I – IV. In Paper I, individual interviews were conducted and then analyzed using the content analysis method. Respondent driven sampling was used to collect data for paper II and III, where in addition to administering a structured questionnaire, biological samples were collected to estimate the prevalence of HIV, T. pallidum, N. gonorrhoeae, C. trachomatis and T. vaginalis. Furthermore, structured questionnaire was administered to collect data for paper IV among health care providers.

Results: Limited opportunities, poverty, financial burdens, and the desire for more material assets have made girls and married women in Lahore enter and become trapped in a “web” of selling sex. Whereas 91% of women selling sex were married, 0.7% were infected with HIV, and an additional 18.5% were suffering from different curable STIs. Only 19% and 83% of the participants were aware of the terms HIV and AIDS, respectively, and only 37% had correct knowledge about transmission and prevention of AIDS. The odds of being infected with C. trachomatis and N. gonorrhoeae were 2.1 (CI 95%; 1.1-3.8) and 1.9 (CI 95%; 1.1-3.5), respectively, if women reported “not always” using condoms as compared to if they reported “always” using condoms. There were varying knowledge levels and misconceptions regarding STIs. Approximately two thirds of the women considered themselves to have had STIs in the six months preceding the survey. Women selling sex who reported consistent condom use were 1.5 times (CI 95%; 1.1-2.2) more likely to seek treatment than women who did not consistently use condoms. The treatment received did not follow any standard treatment guidelines, influencing both effectiveness and compliance. Forty-five percent of the healthcare providers had correct knowledge about the transmission and prevention of HIV, and 82% were not aware of syndromic management of STIs. Only 10% could cite the ‘correct treatment’ of gonorrhoea, syphilis and vaginal discharge. The odds of having the ‘correct knowledge’ of diagnosing gonorrhoea and syphilis were 2.1 (CI 95%; 1.2–3.8) if the healthcare provider was a female medical doctor working in the public sector.

Conclusions: Poverty, the drive for materialism, and the desire for money are the major driving forces for resorting to selling sex, depicting a social behavioural change. HIV infection and STIs among women selling sex were relatively low in this study, which is possibly due to a high condom use, relatively low numbers of sexual partners and availability of clinical services, including syndromic management. However, there exists a high risk for a concentrated HIV epidemic among women selling sex due to their low level of knowledge about HIV, attitudes, risk behaviour and sexual practices. The level of knowledge about STIs remains low among women selling sex in Lahore, Pakistan. Furthermore, health-seeking behaviour for STI treatment is influenced by ability to pay and ease of access, as well as availability in the private sector. Even though health care providers in Lahore were providing health care for both HIV/AIDS and STI patients, the low levels of knowledge and practices and poor attitudes regarding the management of HIV infection and STIs emphasize that further intensive training is needed to improve their ability to correctly diagnose and subsequently treat patients infected by STIs.