Sex workers in Malawi have the highest prevalence of HIV, 70.7 percent compared to the national average of 14 percent. In fact, pooling the data available for 50 countries, female sex workers have a 14-fold higher risk of infection as women of a similar age in the general population.
To add to this, female sex workers are more likely to have unprotected sex with alcohol abuse being a major risk factor for unprotected sex. They believe alcohol and other drugs lower their inhibitions, increase courage to approach clients and help them cope.
In Malawi, 12.37 percent of men aged 15–54 reported paying for sex and not using a condom in the past 12 months. The burden of sexually transmitted infections (STI) other than HIV among female sex workers in sub-Saharan Africa is high, with half to two-thirds typically having a curable STI at any one time.
Women cite client refusal and client brutality as reasons for not using condoms. Where sex workers are poorly organised and have few alternative sources of income, they are less able to refuse a client who is unwilling to use a condom.
The likelihood of condom use is often undermined by competition, with clients going to other sex workers willing to have unprotected sex even if at higher rates. This suggests that what could impact an increase in condom use is sex workers presenting a united front to refuse clients who reject condoms.
It is, however, unclear to what extent the large HIV reservoir among sex workers is contributing to the HIV epidemic. Clients of sex workers are often referred to as a ‘bridge’ population for the transmission of HIV, meaning that they act as a link between high risk groups like sex workers and the general population.
A high HIV prevalence among the male clients of sex workers has been detected in studies across the world. Studies have also found almost half of the men paid for sex while in another relationship. Also most sex workers have intimate relationships and most of their partners are involved in other relationships. So, there is the potential for HIV to spread quite rapidly.
Other issues irk me about unprotected sex with a sex worker –what do sex workers do for contraception? Aren’t these men worried of fathering an illegitimate child? The motivation for a (married) man knowledgeable about HIV to have unprotected sex with a sex worker and have unprotected sex with his wife is beyond me!