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A Short History of HIV Prevention Programs for Female Sex Workers in Ghana

Lessons Learned Over 3 Decades

Wondergem, Peter MSc*; Green, Kimberly PhD; Wambugu, Samuel MPH; Asamoah-Adu, Comfort MA; Clement, Nana Fosua MA; Amenyah, Richard MD§; Atuahene, Kyeremeh MA; Szpir, Michael PhD

Author Information
JAIDS Journal of Acquired Immune Deficiency Syndromes: March 1, 2015 - Volume 68 - Issue - p S138-S145
doi: 10.1097/QAI.0000000000000446
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Abstract

BACKGROUND

Female sex work has a long history on the “Gold Coast” of Africa (now modern Ghana). Records from the 17th and early 18th centuries describe the existence of a community-based institution of “public women” in the southern part of the country. These women were slaves—acquired by the political elite from local communities—who were compelled to provide sexual services to local bachelors.1 Public women were generally accepted as playing an important social role in the community.

The institution has evolved over the centuries, and sex work is no longer socially acceptable in Ghana. Indeed, the law prohibits sexual solicitations, and the possession of condoms is considered as evidence in the prosecution of female sex workers (FSWs). FSWs are also exposed to high levels of abuse and extortion by the authorities; a recent human rights report based on a convenience sample notes that 34% of the respondents had been raped by a police officer.2

Despite the repressive social and legal environment for FSWs in Ghana, 52,000 FSWs were counted across the country in 2011; nearly 20,000 resided in the Greater Accra Region,3,4 where the capital city is located. The number of sex workers has increased considerably in the past few decades: As recently as the 1950s, only 213 FSWs were known in the city of Accra.5 Significant economic development, population growth, and migration may have been important factors that contributed to the dramatic increase of FSWs. One of the events that might have been especially influential was the construction of the Akosombo hydroelectric dam in the 1960s. The dam-flooded land, northeast of Accra, was inhabited by the Krobo people, who consequently faced severe economic hardships. In the wake of these difficulties, countless young Krobo women left Ghana in the following 3 decades to seek work in Cote d'Ivoire and other neighboring countries—all of which had a higher prevalence of HIV than did Ghana.6,7

These migrations may have played an important role in the rise of the HIV epidemic in Ghana. During the late 1980s, FSWs in Accra (who had recently worked in Cote d'Ivoire) were the primary population diagnosed with HIV.8,9 Since that time, the prevalence of HIV among pregnant women in districts where those sex workers originated has consistently been significantly higher than the national average.3 More recently, a booming economy in the southern part of the country, and unemployment and poor education in the north, may have augmented the “push-and-pull” factors for paid sex. This could explain the rising numbers of FSWs from the north in southern urban slums and increases in transactional sex among young women and older men.10

Whatever the causes, FSWs in Ghana are currently 10 times more likely to be HIV positive than the general population.3 They also contribute a substantial proportion of the new HIV infections in the country. A 2004 study reported that 84% of the HIV infections among males in Accra are attributable to interactions with FSWs.11 A 2010 modeling study of the HIV epidemic in West Africa suggested that 31% of new HIV infections in Ghana are related to sex work, either directly (sex workers and clients) or indirectly (partners of clients).12,13

The history and the data suggest that FSWs shoulder a significant burden of the HIV infections in Ghana. Here, we describe 3 historical phases of HIV prevention interventions among FSWs—recounting the results, the missed opportunities, and the nation's need to adapt to a rapidly changing epidemic. We explore the evolution of these interventions between 1987 and 2013, focusing on the coverage of the key interventions and the sociopolitical dynamics during that period. We also describe behavioral changes among FSWs associated with seeking health services and HIV prevention services between 1997 and 2011.

METHODS

Our historical review of FSWs in Ghana explored the differences between HIV prevention interventions through time, changes in service access and coverage, and the use of HIV testing and counseling (HTC) services. We also investigated the median time of involvement in sex work and the changing prevalence of HIV and other sexually transmitted infections (STIs), namely chlamydia and gonorrhea. Comparisons are disaggregated by FSW type: “seater” or “roamer.” Seaters are home-based sex workers, whereas roamers are street-based or venue-based sex workers.3

We conducted 3 stages of data review. In March 2013, we conducted a literature search on several databases—PubMed, Embase, CINAHL Journal Search, Global Health, PsycINFO, POPLINE, and the International AIDS Society conference abstracts—using the search terms “female sex worker” or “prostitute,” or “transactional sex” or “sex trade” or “sexual exchange,” and “HIV” or “AIDS” or “STI,” and “Ghana.” We searched the literature for original research articles in the English language dating between 1987 and March 2013. A total of 133 articles were identified. Only articles that described the design and results of HIV prevention interventions among FSWs in Ghana were included (n = 17).

Second, we identified and reviewed project reports of HIV prevention interventions among FSWs in Ghana that took place between 1987 and 2013. The review focused on reports from organizations involved in HIV prevention services design and delivery: the Ghana AIDS Commission (GAC), West Africa Program to Combat AIDS and STI (WAPCAS), United States Agency for International Development (USAID), and FHI 360. We extracted information on the design, implementation, and lessons learned related to these FSW HIV prevention services and service delivery data including the number of FSWs reached, the number of FSWs that accessed HTC, and the number of FSWs that were screened for STIs.

Third, we compared data from published cross-sectional Integrated Biological and Behavioral Surveillance Surveys of FSWs in Ghana, including the median time of involvement in sex work and the prevalence of HIV, chlamydia, and gonorrhea. The authors reviewed these data to identify any trends or patterns in the implementation of HIV prevention programs to describe the interventions and their results and to explore changes in the prevalence of HIV, chlamydia, and gonorrhea over time.

First Phase: Early Experiments in an Evolving Epidemic (1987 to 1996)

In 1985, before the identification of Ghana's first case of AIDS in 1986, the National Committee on AIDS was formed under the leadership of Professor A. R. Neequaye of the Ghana Medical School. Neequaye was the principal investigator of Africa's first intervention that involved peer education for sex workers, which was initiated in May 1987.8,14 Private foundations—especially the American Foundation for AIDS Research, championed by the American actress Elisabeth Taylor—were the first to provide funds to Family Health International (now FHI 360) that implemented a pilot program for work that was considered to be controversial at the time.15

The small pilot project involved 6 sex worker leaders who were identified, recruited, and trained about HIV and its prevention. The leaders educated their peers on safer sexual practices and received a small stipend for their efforts. Condoms and spermicidal foaming tablets were also distributed at no charge by the peer educators.

The program documented some encouraging outcomes. The proportion of FSWs who understood that HIV could be transmitted from a healthy-looking man increased from 1 in 3 (in June 1987) to 9 in 10 women (in January 1988).16 The reported regular use of condoms or spermicides increased significantly from 13% to 89%. Similar programs were later expanded to Mali, Cameroon, and Mexico with similar results.16

In 1988, USAID cofunded the Ghana peer education program when the AIDSTECH Project was awarded to FHI 360.16 A follow-on program would later attempt to expand coverage in Accra. Other programs initiated at this time included attempts to provide home-based care and alternative sources of income for returning sex workers in Krobo.17 This period also saw the first handbook on HIV interventions for FSWs, which described the “targeting of prevention programs in Africa.” No account of these programs exists beyond 1990, when the national focus shifted to the general population.

These brief pilot programs provided evidence that “peer education may be an effective way to provide HIV/AIDS information to commercial sex workers, and it results in reports of increased condom use.”17 But, the opportunity to scale-up and achieve a meaningful impact during the earliest stages of the HIV epidemic was lost. It would be 6 years before interventions for HIV prevention among sex workers would start again in Ghana.

Second Phase: A Clinical Approach to Prevention Interventions for Sex Workers (1996 to 2006)

In 1996, the WAPCAS was initiated to control HIV and other STIs among most-at-risk populations, especially FSWs.18 Between 1996 and 2006, the Canadian International Development Association (CIDA) provided financial and technical support for WAPCAS through the Center Hospitalier Universitaire de Sherbrooke. During this period, WAPCAS was part of a regional project that was implemented in 9 West African countries: Togo, Cote d'Ivoire, Burkina Faso, Mali, Senegal, Guinea, Benin, Niger, and Ghana.18

The CIDA and the Ministry of Health (MOH) agreed that WAPCAS should use a “low-key” approach to its program activities because of the controversial nature of the target population. A 1996 memorandum of understanding required CIDA, the MOH, and WAPCAS to conduct annual meetings to review progress and to plan subsequent year's activities (which had to be approved by the MOH). These annual meetings were sustained throughout the project years.

After the initial agreement, a social scientist was contracted to study the operation of sex work in Ghana. The study identified 2 types of sex workers: home-based sex workers and mobile sex workers.19 The home-based sex workers, called “seaters,” typically sit in front of their dwellings, waiting for clients. The mobile sex workers, called “roamers,” can be found along the streets, in bars, hotels, and brothels. Seaters mostly live in urban and semi-urban settings where there is security and protection by the landlords and “queen mothers.” Seaters are typically older than roamers (with an average age of 35 years versus 24 years for roamers).3 They usually have more clients per day (as many as 20) and charge less per sexual act.3,19 The WAPCAS intervention was initiated among the seaters in Accra because they were more organized and easier to reach than roamers.

Several HIV prevention strategies were eventually deployed, but clinical approaches (STI screening and treatment) were emphasized during the early years. WAPCAS tried to ensure sustainability and access to services by supporting the development of STI clinics within the MOH health facilities. The project began in 1996 with a single STI clinic in Accra.18

In 1997, the Minister of Health recommended the expansion of the program to other parts of the country. By the end of 2003, 15 clinics had been established nationwide, with priority given to locations with at least 50 seater sex workers. The STI clinics were also open to the general population with the hope that this would reduce any stigmatization of the clinics or the clients. A wide variety of clinical services were offered, including STI screening and case management based on a syndromic approach, the treatment of minor ailments, HIV counseling, prophylaxis for opportunistic infections (OIs), STI prevalence monitoring, and STI education. Several operational research studies were also conducted to inform the design of the interventions.20–22

Drugs for STIs were not readily available at government facilities at this time. WAPCAS initially procured STI drugs and later facilitated the inclusion of the STI drugs into Ghana's essential drug list. Tools were developed to monitor STI treatment and to capture clinical data from the field. Program monitoring tools were eventually adapted by the National AIDS Control Program and are currently used by Ghana's Health Management Information System.23

Outreach activities were a critical part of WAPCAS's work. Community health nurses, and at a later stage, peer educators visited the seater and roamer communities, promoted the sale of condoms and lubricants, and provided information about STI-related and HIV-related issues. They also mobilized sex workers for periodic medical checks. Between 1997 and 2003, more than 38,000 outreach visits were made to seaters and roamers [18]. And nearly 4000 seaters and more than 6700 roamers attended the clinics [18]. During this period, more than 9000 FSWs were screened for STIs and nearly 11,000 STIs were diagnosed and treated (Fig. 1). Because HIV testing was a cumbersome process—rapid HIV test kits did not yet exist—HIV testing was not emphasized by the program. Among the 1352 FSWs tested, 526 (41%) were seropositive for HIV.23

F1-10
FIGURE 1:
Prevalence of gonorrhea among female sex workers in Accra and Kumasi: 1998 to 2011.

WAPCAS sold condoms at a low cost rather than offering them for free to increase their desirability and to ensure affordability. WAPCAS negotiated and acquired several brands of condoms on credit from various sources, including the Ghana Health Service Family Planning clinics and the Ghana Social Marketing Foundation. Water-based lubricating gels and female condoms were also introduced for the first time. Condom promotion and sales increased over the years, and by the end of December 2003, more than 10 million male and female condoms had been sold to sex workers (Fig. 2).24

F2-10
FIGURE 2:
Condoms sales to female sex workers by sex worker projects in Ghana: 1997 to 2012.

In 2003, when nearly all of the seaters in Ghana had been reached by the program, WAPCAS received an additional year of support from USAID to intensify its focus on roamers in 4 of the 10 regions in Ghana. It was during this time that WAPCAS transitioned from the use of public health nurses to the use of social officers with backgrounds in the social sciences for the outreach activities. The project also greatly increased the number of peer educators who were used for this work. Nurses continued to provide clinical services to the sex workers at Ghana Health Service (GHS) facilities.24

The second phase of HIV interventions is notable because it suggests that an intervention can be initiated and sustained within government structures (through the MOH), although the cultural and political milieu is very hostile when the program begins. The sharp reduction in gonorrhea and chlamydia among seaters in Accra and Kumasi between 1997 and 2002 could also be a result of the WAPCAS project, which was at that time the only STI reduction initiative that focused on FSWs in Ghana.

After 10 years (1996–2006) of financial and technical support to the WAPCAS FSW intervention, CIDA withdrew its funding rather suddenly and without a plan for sustainability. Before the closure of the project, WAPCAS had registered as a local organization and had secured financial support from USAID, the Danish government (DANIDA), and much later, the Global Fund.

Third Phase: Scaling up and Improving Quality (2006 to 2013)

Although surveillance data in the early 2000s indicated that the prevalence of HIV was higher among FSWs than it was in the general population, Ghana's national HIV prevention program did not focus on this population.25 A budget analysis as part of the Modes of Transmission study found that less than 2% of the annual HIV budget was allocated to prevention programs for FSWs or their clients.12 The GAC, which was established in 2000 as a prerequisite for World Bank funding, prioritized interventions for the general population during its first 10 years.26–28 These interventions targeted miners, truck drivers, formal-sector workplace programs, school children, and teachers. At the same time, USAID's funds were largely used for the social marketing of condoms for the general population, workplace programs, and the national “Love Life” HIV education campaign.26,27,29 The National Strategic Framework for 2001 (NSF I) and for 2006 (NSF II) had few references to FSWs, an indication of the low priority given to this population for HIV-related information and services.26,27

FSWs started to receive more attention in 2002, when a then-controversial study by WAPCAS revealed that sex work was the primary driver of the HIV epidemic in Accra.11 Based on this information, USAID Ghana issued its first large-scale request for applications for HIV prevention among FSWs, men who have sex with men (MSM), and people living with HIV (PLHIV).25

In 2004, the Strengthening HIV/AIDS Response Partnerships (SHARP) project was awarded to the Academy for Educational Development (now FHI 360) with USAID funds. Between 2004 and 2009, with some delays, the project attempted to increase healthy behaviors and access to HIV services among FSWs, their intimate partners, MSM, and PLHIV. The project marked an important shift in the delivery of HIV services to FSWs. It was the first time that peer education techniques were scaled up as the mainstay of HIV prevention. SHARP was also the first national outreach project that specifically targeted roamers and the intimate partners of FSWs.30

Under SHARP, the delivery of HIV services to FSWs was anchored by the brand, “I am someone's hope.” The heart of the campaign promoted 10 key behaviors for HIV prevention, and it included a program called “Peer Education Plus”—an effort to improve the consistency of peer messaging, peer educator skills, mentoring, and supervision. SHARP also provided access to affordable condoms and lubricants, drop-in centers, referrals to testing and counseling services, and STI services—an agreed-on minimum package of services.30 By the end of the project, SHARP and its 16 implementing partners had reached more than 25,000 FSWs, nearly half of the estimated number of FSWs in Ghana.3,30

At around this time, the national “ownership” of HIV prevention strategies for FSWs became more apparent. A Modes of Transmission study12 and Academy for Educational Development's integrated biological and behavioral survey among FSWs in 2006 and 2009 provided the evidence that was needed for Ghana's AIDS Commission to include FSWs in the National Strategic Plan (2011 to 2015).30–32 These events opened the door for the development of the national strategy for key populations, which was consisted of best practice approaches in HIV prevention, care, and treatment among FSWs and the formation of the national technical working group for key populations.33 This would allow the largest HIV donor in country, The Global Fund, to initiate funding for FSW interventions.

In 2010, USAID awarded FHI 360 with the SHARPER (Strengthening HIV/AIDS Response Partnerships with Evidence-based Results) project. SHARPER built on the momentum of SHARP, but on a greater scale, reaching FSWs in all regions of Ghana. SHARPER expanded the essential package of services to FSWs by providing greater access to safe spaces through discreet drop-in centers that offered sexual and reproductive health and basic health care support. It added anonymous counseling through telephone-based crisis counseling and weekly short message service (SMS) messages that reinforced the following 10 key behaviors: (1) use condoms consistently and correctly, (2) use non-oil–based lubricants properly, (3) get tested and know HIV status, (4) disclose HIV status to regular partners, (5) promptly seek appropriate and effective treatment for STIs, HIV, and OIs, (6) adhere to treatment [STI, OI, antiretroviral therapy (ART)], (7) reduce the number of multiple and concurrent sexual partners, (8) eat healthy, (9) protect against other infectious diseases such as tuberculosis, malaria, and diarrhea, and (10) actively participate in program design and implementation. Linkages with care were strengthened during this time with the aid of several interventions, including peer-led referrals, support from “Models of Hope” (HIV-positive peer educators based in clinics) and PLHIV case managers, increased access to PLHIV support groups, and daily ART adherence reminders through the SMS “LifeLine” service. The impact of these interventions on adherence and survival of those enrolled in ART is not known.

In light of the impact of violence on the lives of FSWs—perpetrated by police, intimate partners, and clients—the SHARPER project adapted an emergency response system from Avahan in India.2,3 The network involves “M-Friends” and “M-Watchers,” people in the community who address sexual and gender-based violence and rights violations against key HIV-affected populations. Individuals in positions of power who are “key population friendly” are identified and trained as M-Friends. They include lawyers, human rights advocates, police, and members of the local government and health care workers. M-Watchers are leading peer educators (FSWs or MSM) who identify and report abuses (within 2 hours of being notified) to the local USAID-implementing partner. Networks have been established in all 10 regions of Ghana, with 350 M-Friends and M-Watchers deployed within their communities.34,35 Given the level of institutionalized police violence against FSWs, SHARPER, and other USAID partners secured an agreement to train police. A unique aspect of the training involves a mandatory preservice education and testing of recruits as part of their certification process.

In 2010, the Global Fund provided financial support to GAC and the Adventist Development and Relief Agency to provide comprehensive HIV prevention services to FSWs in locations where no interventions were in place. A 2011 integrated behavioral and biological surveillance study among FSWs measured an HIV prevalence of 11.1%.3Figure 3 depicts the decline in HIV prevalence among seaters and roamers in Accra and Kumasi between 1998 and 2011.

F3-10
FIGURE 3:
Prevalence of HIV among female sex workers in Accra and Kumasi: 1998 to 2011.

The third phase of interventions saw a number of measurable successes. In 2011, 72.2% of the roamers in Accra said they had visited an HTC center, whereas only 20% of the roamers reported doing so in 2000 (Fig. 4). A similar pattern was observed for roamers in Kumasi and seaters in Accra and Kumasi. During FY 2013, 40,508 FSWs—78% of the total estimated number of FSW in Ghana—had been reached with the agreed minimum package of HIV prevention messages. In the same period, more than 22,300 FSWs (55%) received HTC; 1223 of these women tested HIV positive and all of these women were enrolled in care and treatment services. In addition, more than 20 million condoms were sold to FSWs at the hotspots.

F4-10
FIGURE 4:
Female sex workers in Ghana reporting an HIV test in the last 12 months: 2000 to 2011.

DISCUSSION

HIV prevention services for FSWs have evolved considerably over the past 25 years in Ghana. At the start of the global HIV epidemic, Ghana served as a testing ground for peer education among FSWs for the first time in Africa.16 Although Ghana's government welcomed this pioneering initiative, an unfortunate shift of priorities by the government and the donors in the early 1990s marked the beginning of a 6-year period when the HIV epidemic among FSWs was neglected at the national level.

When Canadian financial support for sex worker interventions was established in 1996, a model emerged that centered on government clinical facilities and which emphasized STI services and condom use. A more comprehensive approach—which used peer education as the central element of a package of services—was introduced in the early 2000s. Since then, coverage has been continuously expanded, and new services have been added, such as drop-in centers, HIV care, support, and treatment, and support for survivors of gender-based violence. Importantly, the Government of Ghana included sex worker interventions in its latest National Strategic Plan (2011 to 2015) and established a technical working group to guide the expansion of coverage and improvement of the quality of key population interventions. Linkages with clinical services beyond STI care were strengthened at a later stage (from 2012 onwards), and the provision of ARTs for FSWs has yet to be documented.

Results from the Avahan project indicate that where the coverage of FSWs is high, a consistent package of prevention services is offered, structural barriers are addressed, FSWs develop agency in representing their needs, condom use increases, STI prevalence decreases, and HIV prevalence stabilizes.36 The data presented in this article indicate that the prevalence of gonorrhea and chlamydia decreased at the same time that the interventions increased their outputs (STI treatment, condom distribution, number of individuals reached) and coverage—around the year 2006 for seaters and around 2009 for roamers. The sustained trend suggests an association between the expansion of the interventions and a positive impact on FSWs, when WAPCAS and SHARPER were able to reach the majority of the seaters and roamers across the country. In addition, condom sales and the use of HTC services had increased substantially over the previous 2 decades.

The reduction in HIV prevalence in the sex worker population requires a more complex explanation. Three factors seem to be at play: a possible decline in incidence, deaths among HIV-positive sex workers, and a high turnover of sex workers including those with HIV. A decline in incidence could have stemmed from the rapid scale-up of combination–prevention activities that occurred under the SHARPER project. However, access to ART only became available on a wider scale around the time of the most recent HIV surveillance study of FSWs conducted in 2011. The National AIDS Control Program reported that by the end of 2009, only a quarter of eligible PLHIV were on ART and about a third of that population in 2010.37 Treatment coverage was much lower before that time. It is possible that FSWs had less access to ART than the general public because of stigma and discriminatory practices by health workers and perhaps because the referral services might not have been very effective. Therefore, it seems very likely that the mortality of FSWs was part of the reduction in HIV prevalence. Finally, because FSWs spend a limited time in the trade (typically 5 or 6 years),38,39 HIV-positive sex workers may have left the trade for reasons other than their health.

We should note that the use of Integrated Biological and Behavioral Surveillance Surveys data to interpret trends has its limitations because each study used slightly different methods at different times. Although this would indicate that some caution is warranted, the consistency of the trends across 2 sites (Accra and Kumasi) suggests to us that the data represent actual trends.

The effort to reduce the impact of HIV on FSWs in Ghana continues to face important challenges. First, Ghana needs to use HIV incidence testing as part of its routine surveillance efforts, so that it will be able to track changes in the epidemic over time. Second, as the nature of sex work continues to evolve, it will be important to have current strategic information and the resources to develop and expand new intervention packages on a national scale. For example, local implementing partners of SHARPER identified hidden subpopulations of young FSWs with a large daily volume of sex clients but with little knowledge of condoms or the risk for HIV.35 Changes in client preferences and the socioeconomic environment in Ghana may have led to increases in transactional sex among young women.40 Third, funding for HIV prevention work is diminishing.41 Fourth, although combination prevention has increased in scale, the quality of the services is variable and needs to be more consistent to optimize outcomes. Fifth, 80% of HIV infections among FSWs are concentrated in 3 regions of Ghana: Greater Accra, Ashanti, and Eastern. Resources need to be focused in these regions to achieve the greatest impact. Sixth, Ghana should evaluate the cost-effectiveness and the outcomes of the national key population program to inform policy and programming for the key populations. These evaluations should inform budget allocations based on the value of the interventions, which should maximize health gains for the key populations. Finally, most HIV interventions in Ghana have largely ignored male sex workers and the intersection of drug use and vulnerability to HIV infection. Future interventions should be designed to consider these populations and behaviors.

To achieve results akin to those of Avahan, the government, donors, and FSW organizations need to collaborate to (1) increase the coverage of HIV prevention services and HIV care among FSWs, (2) apply recently established service delivery standards and apply them to improve the quality of services, (3) support the development of FSW networks, community-based organizations, and initiatives that address structural barriers, (4) measure incidence over time, and (5) support research and innovations to help the national program adapt to an ever-evolving HIV epidemic among FSWs in Ghana.

ACKNOWLEDGMENTS

The authors acknowledge the support of Dr. Peter Lamptey, FHI 360, for his insights into the early stages of Ghana's FSW interventions, and Stefan Baral, The Johns Hopkins University, for his comments on the interpretation of the findings. We are also grateful to Jill Leonard, FHI 360, for her support with the literature review.

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Keywords:

female sex workers; HIV prevention programs; Ghana; history

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