In Sudan, 4.8% of FSWs used drugs and 14.5% reported substance abuse among their clients.198 In Syria and the Republic of Yemen, 10%199 and 2%200 of FSWs injected drugs, respectively.
KNOWLEDGE OF HIV/AIDS Levels of HIV knowledge among sex workers appear to vary substantially in MENA. In Afghanistan, only 4% of FSWs in one study had heard of HIV/AIDS,201 but in another study most FSWs reported knowing of HIV/AIDS, though very few ever tested for it.202 In Egypt, all FSWs were aware of HIV and some of its transmission modes, but still had misconceptions about its transmission.203 In the Islamic Republic of Iran, FSWs were found to be significantly less knowledgeable about HIV/AIDS than both youth and truck drivers.204 In Lebanon, almost all FSWs were aware of HIV/AIDS, its transmission modes, the condom’s role in prevention, and other prevention measures.205 However, 21.5% of these FSWs perceived no chance of becoming infected with HIV, possibly because of condom use.206 In two studies in Pakistan, 60%207, and 68%–98%208 of FSWs reported ever hearing of HIV/AIDS, but only 15%–39% of FSWs felt at risk of HIV infection.209 In Somalia, both men and women not engaged in sex work were found to know more than FSWs about HIV/AIDS.210 In Sudan, 75.5% of FSWs were aware of HIV and its symptoms, and 54.9% were aware of some of its transmission modes.211 In the Republic of Yemen, 85.9% of FSWs perceived no high risk of HIV infection.212
198
Ati, “HIV/AIDS/STIs Social and Geographical Mapping.” UNAIDS, “Notes on AIDS in the Middle East and North Africa”; Syria National AIDS Programme, “HIV/AIDS Female Sex Workers.” 200 Štulhofer and Božicevic, “HIV Bio-Behavioural Survey.” 201 Action Aid Afghanistan, “HIV AIDS in Afghanistan.” 202 World Bank, “Mapping and Situation Assessment.” 203 Egypt MOH and Population National AIDS Program, HIV/AIDS Biological and Behavioral Surveillance Survey. 204 Tehrani and Malek-Afzalip, “Knowledge, Attitudes and Practices.” 205 Hermez et al., “HIV/AIDS Prevention among Vulnerable Groups.” 206 Ibid. 207 Ali and Khanani, Interventions Aimed at Behavior Modification. 208 Bokhari et al., “HIV Risk in Karachi and Lahore, Pakistan.” 209 Ibid. 210 Corwin et al., “HIV-1 in Somalia.” 211 Anonymous, “Improving HIV/AIDS Response.” 212 Štulhofer and Božicevic, “HIV Bio-Behavioural Survey.” 199
FSWs seek treatment for STIs through selftreatment or through friends rather than through knowledgeable health personnel.213 They continue to suffer from unavailability of medical and support services,214 and continue to fear pursuing such services due to social stigmatization, marginalization, and law enforcement.215 All of the above factors contribute to the precarious and vulnerable position that FSWs endure in MENA.
ANALYTICAL SUMMARY Commercial sex is prevalent all over MENA, although at lower levels compared to other regions. Economic pressure, family disruption or dysfunction, and political conflicts are major pressures for commercial sex in MENA. Roughly 0.1% to 1% of women appear to exchange sex for money or other commodities, and a few percentage points of men report sexual contacts with FSWs. Accordingly, commercial sex networks are the largest of the three key priority group networks in MENA. There is considerable evidence on HIV prevalence and risk behavior practices among FSWs in MENA. Earlier evidence suffered from methodological limitations, but the quality of evidence has improved significantly in recent years. Regardless, all evidence suggests that HIV prevalence continues to be at low levels among FSWs in most countries, though at levels much higher than those in the general population. HIV does not appear to be well established in many commercial sex networks in MENA. In three countries, however (Djibouti, Somalia, and Sudan), HIV prevalence has reached high levels, indicating concentrated HIV epidemics in at least parts of these countries. Nevertheless, HIV prevalence in these countries is at lower levels than those found in hyperendemic HIV epidemics in subSaharan Africa. FSWs report considerable levels of sexual risk behavior including roughly one client per calendar day; low levels of condom use, particularly in areas of concentrated HIV epidemics among 213
Tehrani and Malek-Afzalip, “Knowledge, Attitudes and Practices.” Mohebbi, “Female Sex Workers and Fear of Stigmatisation.” 215 Zargooshi, “Characteristics of Gonorrhoea.” 214
Commercial Sex and HIV
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