Of Truckers and Hookers, Attitudes and Behaviours

Southern Africa PrevalenceIf you can step back from the human tragedy for a moment, you have to marvel at the way in which HIV holds up a mirror many of the attitudes and behaviors that shape our modern societies. A classic example is the role that trucking routes have played in spreading the infection across the continent. Starting in South Africa and traveling north through Botswana, Zimbabwe and Zambia you can clearly see a pattern of high prevalence along the major transport routes of the ‘north-south corridor’.

Truckers in Africa live hard lives spending weeks at a time on the road with few rest stops. Where they do stop, the usual collection of services tend to spring up including predictably enough bars and brothels. Their journey times away from home are often exacerbated by the extended processing delays at borders within the region (the average wait on the Zimbabwe/Zambia border is currently about 3 days).

Zambia has what is referred to as a ‘mature generalised’ epidemic with more than 15% of the population diagnosed, so sex workers probably only account for about 1% of the total. However the prevalence amongst sex workers is very high and trying to stop the transmission of HIV between these vulnerable groups has long been recognised as an important step to preventing its further spread in the broader community. After all, most truckers and many sex workers have regular partners so what they catch at work is all too easy to bring back to their homes and villages up and down the continent.

For this reason a major HIV education and prevention project has been underway at the truck stops for the last 10 years and this week they presented an analysis of how attitudes and behaviours have changed over this time. On the surface there were some very encouraging findings, for example over 80% of those surveyed sex workers  and 50% of truck drivers had accessed voluntary testing for HIV.

However look a little deeper and the figures become somewhat more troubling. Despite the relatively high rates of testing, only 7% of men reported consistent condom use with their regular partners and sex workers reported that only 45% of their clients used condoms regularly. The truck drivers reported a much higher rate of condom usage when with sex workers but I know whose estimate I am more inclined to trust.

Crossing the Zambian Botswana border by pontoon

In truth, condom use for sex work is primarily a commercial decision, those who wish to have unprotected sex can always pay more for the ‘privilege’. Given that many of the working women come from severe economic hardship across the borders in Zimbabwe or DR Congo, their ability to bargain for a safe work environment is highly compromised.

Perhaps the most troubling finding was that amongst the youth living in these areas and deemed to be at risk (unmarried and unemployed), less than half had accessed testing and consistent condom use was less reported by less than a third of respondents.

So here we stand, ten years into some pretty intensive and expensive prevention campaigns for a well defined and relatively small population. Yet many of the key messages still fail to be getting through and if they are, they aren’t generating the desired behaviour changes. Sometimes you can only shake your head and wonder at the combination of social, economic and medical challenges this epidemic represents.

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