1. Addressing HIV/STI Risk Among Female Sex Workers A Group Model Approach Presentation at the 1st African Conference on Key Populations in the HIV Epidemic Dar es Salaam, Tanzania August 19-21, 2013 By Kushatha Mosienyane & Erin Smith RTI MARPs PROJECT

2. Agenda Problem statement Project information: Botswana HIV MARPs project Background: risk reduction model Project design Lessons learned Benefits of the group model Conclusion

3. Problem Statement The 2012 Biological Behavioral Surveillance Survey of high risk sub-populations revealed a 61.9% HIV prevalence rate among sex workers (SW) in Botswana. In a program review, only 16% of program respondents reported using condoms “often” and 80% said they regularly had unprotected sex with clients.

4. Problem Statement Program respondents reported clients preference for dryness during intercourse. To achieve this, drying agents are used prior to work. Condoms are not used, or often break. Of problems in the past year, customer and partner violence ranked #1, with 82% of participants reporting having experienced incidents of gender based violence (GBV).

5. Problem Statement High HIV prevalence, a preference for dry sex, and high incidence of GBV all propel the continuation of the HIV epidemic in Botswana, but sex workers face multiple challenges to sustained risk reduction: Fractured, highly mobile populations with little or no sense of community Exposed to physical and sexual abuse with little opportunity for recourse due to the illegality of sex work in Botswana A large percentage have a history of severe psychological shocks ( rape, physical and emotional abuse, abandonment, political conflict, etc.) All program participants reported regular use of alcohol during working hours

6. Project Information Botswana HIV-MARPs: a 5-year USAID project run by RTI International. Targets: female sex workers ; male clients of sex workers; men who have sex with men. Program Objectives: Develop and implement behavior change communication (BCC) strategies that move beyond abstinence and fidelity to motivate sustained behavior changes for risk reduction Bring services, such as voluntary HIV testing and counseling (HTC), closer to the target populations through outreach mechanisms Reduce barriers to access to care, and engage clients and providers in defining and monitoring service quality

7. Background: Risk Reduction Model Project staff identified a need to develop a different kind of intervention to increase risk reduction activities among FSW in Botswana. Based on multiple studies which show increasing solidarity and a sense of community among FSW has been effective in improving condom use, project staff reached out to the University of Botswana’s Dr. Tirelo Modie-Moroka, an expert in psycho-social and group counseling among sex workers. Together, this model was piloted, and rolled out to all project areas.

8. Risk Reduction Model Group Model Program Objective: Empower target populations to reduce their risk of encountering violence and of becoming infected or infecting others with HIV Build on multiple research reports showing that developing group solidarity is one of the most effective risk reduction techniques among sex workers Increase enrollment and adherence of ART

9. Project Design Technical officers of CSO’s working with key populations were trained in: Group counseling methods HIV risk reduction Substance abuse Gender based violence Poverty alleviation Sex workers rights Effective referrals for services

10. Project Design From 2011 to 2013, a total of 100 women aged 22 – 45 years were enrolled for the group counseling model across three districts Groups met twice a month, guided by facilitators with mentorship from the HIV-MARPs project specialist Discussion was open forum, allowing women to talk about whatever they wanted within the guidelines of the group objectives

11. Lessons Learned In the group settings, women found a sense of community and support that they had not previously received Women participating in the group model reported feeling groups were a safe environment to discuss matters that cannot be explored through more conventional models Groups offered a true peer experience where women were free to discuss their common daily problems such as, Causal factors influencing engagement in sex work, Realities of gender based violence Challenges behind leaving sex work for alternate employment Money struggles Relationship problems

12. Benefits of the Group Model The group setting allowed women to: Build relationships among themselves Create a safety net effect on the job which supported decreased risk taking Improve self esteem Improve sense of community Improve access to care and treatment services Increase enrollment into ART and improve adherence Develop protection strategies to decrease gender based violence Set common prices and insist on condom use during sex (refusing to accept more money for condom free sex)

13. Conclusion The group psychosocial counseling model for SWs in Botswana has yielded positive results: Offering a safe environment for sharing experiences Allowing SWs to build a network of trust among their peers Supporting positive choices towards risk reduction Accessing health services Increasing adherence, and in some cases Exiting sex work