They were aware that HIV is transmissible through sexual contact and pregnant mothers to unborn children. Most FSWs correctly identified condoms as the most effective means of preventing transmission. They were also aware of other prevention methods such as abstinence and being faithful to one uninfected sexual partner. In addition, they were aware that HIV is incurable. Most had heard of Neisseria gonorrhea and Treponema pallidum syphilis , but very few cited Chlamydia trachomatis and Trichomonas vaginalis as other STIs.
They were aware that STIs can be transmitted through unprotected sex and are preventable and treatable. Widely held misperceptions On the other hand, most had limited knowledge about HIV transmission through blood contact. Very few mentioned blood transfusion as a mode of transmission, and none was aware of HIV transmission through the sharing of infected needles or injecting drug use. One FSW showed her lack of knowledge by asking: As one FSW said: Some believed that seeking prompt treatment when sick, washing the genitals soon after ejaculation with an antiseptic household cleaner, and getting married could prevent HIV transmission.
One FSW confidently stated: Although she believed that sexual intercourse with multiple sexual partners increased HIV risk, somehow she had misperceived that sexual intercourse with one partner would protect her against the virus.
Over three-quarters stated that they had received STI treatment at least once in the past, yet they were generally not aware of the symptoms associated with these infections. Most had limited knowledge about the role of STIs in HIV transmission and the value of the use of lubricants with condoms. This is new to me, but how? Risk perception Participants were asked about their perception of HIV risk and how they perceived this risk in both sex work and their private sexual relationships.
They were also asked about risk in relation to marijuana and alcohol use. Data revealed that although most FSWs were aware of HIV risk through sexual contacts, most perceived themselves as more at risk of infection through sex work than through their private sexual relationships.
Sexual behaviors and practices Participants were asked about their most recent sexual encounter and asked whether they used condoms consistently with clients and RSPs. Although most FSWs perceived themselves as more at risk of infection through sex work, condom use with clients was low and inconsistent.
Barriers and enablers of safer sex practices Participants were asked about safer sex practices and what they believed were the enablers and challenges in consistent safe sex practice.
Data from the short questionnaire also revealed that each FSW had an average of three condoms at hand and during the FDG sessions claimed to carry them at all times. Practical barriers to implementing knowledge Most FSWs recognized that prevention means, such as abstinence and being faithful to one sexual partner, were unrealistic for sex workers. The single most important factor that stood out was the fear of losing an economic benefit should they try to insist on condom use.
Twenty-two percent felt they were unable to negotiate condom use, reflecting contextual factors placing FSWs in a weak position to negotiate safe sex.
During the FGD sessions, one sex worker stated: Nearly all FSWs who use these substances reported to have had sex under the influence of one or a combination of them but saw no obvious links with HIV risk. Discussion In this qualitative study of FSWs in Port Moresby, we were interested in the disparities between knowledge and sexual practices.
We wanted to document in detail what FSWs knew, how it translated into safer sex practices, where their knowledge was poor, and what they identified as practical barriers and enablers to safer sex. We found that although the majority of FSWs were adequately informed about HIV transmission through sexual intercourse and prevention through condom use, this knowledge rarely translated into safer sex practices.
The findings suggest that significant barriers to the practice of safe sex confront FSWs, an observation that has been reported elsewhere. In this article, we discuss the implications of contextual barriers to safe sex in the context of sex work. Studies on the influence of HIV knowledge on safer sex practice have reported mixed results.
Although some have found conclusive associations, 34 — 36 others have found mixed results 37 , 38 consistent with our findings. Although some studies found association between individual perception of HIV risk and safer sex practices, 39 , 40 others have found mixed results 41 , 42 consistent with our findings. This implies that safer sex is complex and determined by several factors in different settings. In this study, several factors acted as barriers for FSWs to implement safer sex knowledge.
There are a number of possible explanations for this outcome. It may reflect a lack of ability of FSWs to assess risk and apply knowledge during a sexual encounter. Here, economic deprivation limited the ability to resist unsafe sex and increased the ability to make unhealthy choices when the fear of losing a paying client and the economic benefit was imminent.
In an environment that offers fewer economic choices for FSWs, economic deprivation is likely to influence risky sexual behaviors and heighten exposure to HIV infection. About one-quarter of the FSWs in our study felt that they were in no position to negotiate condom use, as mentioned previously, 8 reflecting a cultural norm that relegates females to passive positions, 28 , 48 , 49 thereby weakening bargaining abilities.
Irrespective of adequate transmission and prevention knowledge, the interpretation of a personal sense of perceived risk took a whole new meaning.
Our study has a number of limitations. In spite of this, we were able to report on a large sample of FSWs, most of whom were participants in our existing HIV programs. Finally, our data were collected through focus groups; therefore, it did not allow us to collect individual stories of condom use negotiation due to the private nature of this information.
Although there was a general consensus that negotiation of condom use is challenging, this would need to be explored further through one-on-one interviews. That said, our study offers insights into the risky sexual behaviors of FSWs in Port Moresby from which programmatic decisions are recommended.
Our findings highlight that safe sex practice is not determined by the availability of, access to, and promotion of condoms alone, but also by complex contextual, emotional, and other environmental factors. Until effective strategies are implemented to address these factors, no progress on HIV will be sustained. A comprehensive HIV prevention framework that seeks to work toward changing long-standing contextual factors that increase vulnerability in FSWs is required.
Males are therefore crucial to sustaining safe sex 3 , 60 , 61 and must be targeted in programs that are gender sensitive, promote messages of safety, and mediate mutual responsibility for safe sex. FSWs must have the means to protect themselves within their private and commercial sexual relationships. We argue that HIV policies and program interventions must address these barriers, including the root causes of vulnerability.
To all who contributed one way or another to this work, your efforts are appreciated. Footnotes The authors report no conflicts of interest in this work. Papua New Guinea Update. Accessed Oct Human immunodeficiency virus and other sexually transmitted infections among female sex workers in two major cities in Papua New Guinea.
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