Determinants of HIV in Key Hotspots on the Southern Transport Corridor: Maputo to Swaziland

This 94-page report, published by the International Organisation for Migration (IOM), shares the results of a study to explore the key determinants of HIV along Mozambique's southern transport corridor, which runs between Mozambique and Swaziland. As stated in the report, the corridor runs through locations that have amongst the highest HIV prevalence of anywhere in the world. The report concludes that the situation along the corridor should be considered an emergency, and the hotspots should be saturated with combination HIV prevention programmes as well as intensified access to treatment and care services.

The report explains that hotspots are defined as areas where there is a concentration of people, bars, restaurants, and entertainment halls, as well as high opportunities for multiple concurrent sexual relationships. The research team worked in four areas that are considered hotspots- areas where mobile populations meet with resident populations and there are high levels of risky sexual behaviours. The areas included two border posts, an industrial area in Swaziland, and an area on the road from Maputo to Swaziland that has become a major stopping-off point for travellers, truckers, and people from Maputo.

The principal findings from the field work in the programme are recorded as follows:

• Sexual Networks: Sexual networks in the hotspots are characterised by multiple concurrent sexual relationships and inconsistent condom use. Across the board, people were able to explain the basic concepts about HIV as a disease and how it is transmitted. Reported testing for HIV was also high, the majority of people interviewed said that they had been tested for HIV. However, very few of the respondents went for regular testing. Given the high levels of unprotected sex taking place, the sporadic testing by the respondents was not an effective way of tracking HIV statuses. Some of the respondents stated that they had changed their behaviour due to their HIV status, or due to knowledge of HIV and AIDS. Case studies conducted in the field work clearly show that knowledge of HIV status does not automatically lead to safer sex practices. It was also clear that among the people interviewed there is an acceptance of the inevitability of non-exclusive relationships by both men and women.
• Condom use: The majority of the respondents stated that before the AIDS epidemic they had never used condoms in any of their relationships. The use of condoms is largely due to the fear of contracting HIV. Many of the women stated that they use condoms to prevent disease and the contraceptive pill to prevent pregnancy. Many of the interviewees explained that they did not use condoms when there was a trust relationship. People refer to trust relationships when they are talking about longer-term lovers and not just permanent partners. Trust is linked to refer to the length of the relationship, the level of commitment, and the quality of the relationship but not necessarily to sexual exclusivity. There are many more compelling reasons for both men and women for not using condoms than for using condoms.
• Changing Behaviour: A number of respondents showed some optimism about the potential for changing sexual behaviour. This optimism was, however, not confirmed in terms of the reported sexual behaviour among the younger generation interviewed during the research. A number of older male respondents in both Swaziland and Mozambique saw themselves as "victims" of young girls and blamed the children who were involved in sexual relationships with older men. The young people themselves indicated that contracting HIV and STI's was not something that concerned them. The young women interviewed during the research were generally involved in transactional sex and were practicing high-risk sexual behaviours, including unprotected sex, anal sex, group sex. As these young women were sought after by older men, their powers of negotiation were unequal to the fear of having unprotected sex, and the majority agreed to the non-use of condoms. Non-penetrative sex was also discussed. However, once again this was rejected by the majority of the interviews as impractical.
• Profile of women receiving payment for sex: The ages of the women interviewed ranged from 18-35, although there were clearly many underage girls working in the same areas. A reasonable living can be made from sex in relation to other jobs in the area. Sex workers usually make a minimum R2000 a month; they usually earn more if a client wants to stay longer, if they want oral or anal sex. The women working in the sex trade who were interviewed in the hotspots in Mozambique did not have any formal organisations. They worked from bars and roadside restaurants or in clubs in the small district towns. In Swaziland there were a number of self-identifying sex workers who worked either on the streets, in the bars or from their "yards" where a number of women live together in rented rooms. In all of the hotspots there was a significant amount of transactional sex taking place. For the informal traders crossing the Mozambique-Swaziland border, many of them see transactional sex as part of the "costs" of doing business. They tend to trade sex for non-payment of customs duties or the rapid processing of their transit through the border. Reasons for transactional sex are not merely economic but are complex, including pleasure sex, pleasure and comfort, protection, belief that one of the relationship will lead to marriage or a stable relationship, as well as alcohol abuse.
• HIV and AIDS Health Service Provision and health-seeking behaviour: The situation between Mozambique and Swaziland is different in terms of the type of health services that are offered in and around hotspots. Health services in the hotspots in Mozambique are provided through the government-run clinics. There are no private clinics offering services in these areas. Government clinics offer the full range of services linked to STI's and HIV. Swaziland has a more complex health system with a number of service providers. There are government clinics where treatment services are free in all the health facilities. The main service in the area of Matsapha are the government clinics and hospitals. Many people who took park in the study - health professionals, NGO staff members, sex workers and clients - had strong opinions about messaging on HIV and AIDS.

The report offers the following recommendations:

• both governments should attain long-term HIV financing and investment in NGO services including private sector engagement;
• both governments must address the vulnerabilities of mobile workers in the public sector;
• national partners should support the Zero Tolerance Campaign launched by the Ministry of Education;
• local partners should saturate the hotspots with intensified combination prevention programmes, and intensify migrant-sensitive health and outreach services;
• patient confidentiality and professional codes of conduct are a must;
• local partners should conduct male-oriented sensitisation programmes on the use of available health services and health seeking behaviour;
• increase accessibility of health facilities for mobile populations; and
• local implementing partners should conduct robust youth-targeted programming.