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With prostitutes charging just 20 shillings for sex – double for unprotected intercourse – some say social stigma has forced them to make false rape claims to access life-saving medication
A Kenyan sex worker looks for clients outside of her home. Photograph: EPA
In Kondele, sex is in high demand. Prostitutes charge clients as little as 20 shillings (14p), or provide sex on credit with the hope of being paid at the end of the month.
The area is a low-end red-light district in the western Kenyan city of Kisumu. The temptation for many women, given the low fees, is to make potentially dangerous concessions in order to earn more, such as forgoing condoms.
"Men who do not want to use protection pay double," explains Florence, a sex worker in the area. "We don't have money, and when you meet a client who offers to give you more money than you usually get, you have sex without protection even when you don't know his HIV status."
The latest UN figures, from 2012, show the number of people living with HIV in Kenya is about 1.6 million. Approximately 820,000 are women. Florence says after having unprotected sex with three or four men in a night, she visits a clinic the next morning to get emergency antiretrovirals, or post-exposure prophylaxis (Pep) treatment, which suppress the HIV virus if taken within 72 hours of infection. "We use these medicines regularly, but we make sure that we do not visit the same clinic as the nurses usually become suspicious," she says.
Sex workers who visit these clinics often falsely claim they have been raped. Over the past decade, Kenya has significantly improved post-rape care, and medical professionals regularly provide Pep treatment. To maximize uptake, neither women who have been raped nor health workers need to report the crime to the police, but this lack of regulation leaves the system prone to abuse.
"Anyone can go to any hospital or clinic in the country and make a report that they have been violated sexually," says Eunice Atieno of the National Empowerment Network of People Living with HIV and Aids in Kenya. "They immediately start receiving the therapy, sometimes without adequate adherence counselling. Some do not observe the window period with which the medication is supposed to be effective. In such incidences, we find some sex workers abusing the services."
Many sex workers claim they need to lie to access medication. "I don't say I am raped every time I go for post-exposure prophylaxis – there are times that I say that the condom burst," says Akoth, 26. "One thing I never dare say is that I am a sex worker, or that I have more than one sexual partner, because if the healthcare providers find out you are a sex worker seeking post-exposure prophylaxis, they send you away saying it is a self-made problem."
Lilian, 27, a fellow sex worker, agrees: "Accessing basic healthcare as a sex worker is difficult due to the stigma associated with the work. Accessing medicines for prevention of HIV is like trying to get milk from a chicken if you identify yourself as a sex worker, and that is why we pose as rape victims."
An HIV test is required before Pep is administered. Mandatory testing ensures that prophylaxis is not given needlessly to anyone who has tested positive. But that can create additional problems for sex workers, since under the HIV and Aids Prevention and Control Act (2006), non-disclosure to a partner is a criminal offence.
"Sex workers should be supported not only with services but also with adequate information on post-exposure prophylaxis once they access treatment at facilities," says Martha Opilli, at Keeping Alive Societies' Hope. "Most of our clients face harsh treatment because sex work is criminalized; however, there no clear laws or guidelines on how to handle a sex-worker suspect. This makes it difficult for our clients who are arrested and taken to court, because they are forced to test for HIV and sexually transmitted infection, and, if found positive, they are charged with attempting to infect intentionally. This increases [the likelihood of] dependence and sometimes abuse of post-exposure prophylaxis."
According to Dr Rachel Baggaley, a specialist on the World Health Organization’s HIV team, making pre-exposure prophylaxis (Prep) more widely available as an alternative to post-exposure drugs would be more effective, and less harmful for the women. "These [drugs] are not so toxic for the body, and the good thing is that they get into your bloodstream before the virus, [so] you've blocked it," she says. "If it's already there and you take the post-exposure drugs after that 72-hour window, you can't be so sure."
Sex workers would like to see the introduction of Prep drugs. "This will give us a variety of options to pick from when it comes to prevention. We are already satisfied with the different methods of preventing unintended pregnancies, but something should be done about diversifying the options of HIV prevention," says Akoth.
But Prep treatment is relatively new, and has been trialed only in small-scale studies in Kenya. Given the cost considerations of rolling out such treatment, it could be some time before these drugs are widely available, and, if they are, the question of whether sex workers will be able to access them will be key.
Maurine Murenga is a citizen journalist at Radar, Kenya, and Corin Faife is communications manager