The ‘healthy brothel’: the context of clinical services for sex workers in Hillbrow, South Africa

http://www.eldis.org/

Jonathan Stadler and Sinead Delaney

Reproductive Health Research Unit, CHBH, Soweto.

History Workshop, African Studies Seminar

23, February, 2004

Sex workers are at considerable risk of infection from HIV and sexually transmitted infections. Public health messages provide information and skills for negotiating safer sex yet are not always realistic for women who earn a living from sex. Moreover, conventional health services often present barriers to sex workers seeking sexual and reproductive health care and treatment. In 1999 the Reproductive Health Research Unit (RHRU) launched a mobile clinic for sex workers in the inner city suburb of Hillbrow, South Africa. This paper draws on qualitative research amongst the women who attended the clinic. It describes the context of sex work and asks what impact the intervention had on women’s health seeking behaviours. We found that the clinic was acceptable in terms of the quality of the service rendered and its accessibility. The treatment was seen to be efficacious. This had a positive effect on health seeking behaviours. In addition, women reported a growing awareness of their personal health risks and the importance of using condoms. Most importantly the intervention had an impact on the immediate context of sex work and transformed the image of the hotels from sites of ‘dirt and disease’ into ‘healthy brothels’. We suggest that the impact of the intervention was more meaningful at this level than at the individual level. Our conclusions point out the limitation and potential of this type of intervention amongst sex workers in other contexts.

Key words: Sex workers, Hillbrow, health seeking behaviours, HIV/AIDS

Introduction

The AIDS epidemic has reached alarming proportions in South Africa. By 2001 it was estimated that 4.7 million men and women between the ages of 15 and 49 were infected. By 2002 the number of those infected had risen to 5.3 million. According to antenatal HIV surveys conducted by the department of health, pregnant women infected with HIV had risen from 22.4% to 26.5%. South Africans experience similarly high levels of other sexually transmitted infections (STIs). Four million episodes of STIs occur each year in South Africa. These epidemics pose a massive challenge to the public health system in terms of prevention, treatment and care.

Although AIDS affects all South Africans, the rate of HIV infection amongst sex workers is a significant concern (See Wojciki & Malala; 2001:100). In Hillbrow, sex workers face considerable danger of infection in their everyday working lives. In a survey in Hillbrow during 1997, 45% of 247 sex workers tested positive for HIV (Rees et al; 2000). Most disturbingly, those who had been working as sex workers for only three months displayed similar levels of infection to those who had been working for one year (Rees et al; 2000). The authors reported that ‘it is crucial that interventions address the issues of safe sex and access to good quality health care’ in this population (Rees et al; 2000, P.284).

Unfortunately, sex workers tend not to seek care from public health services. This is mainly due to their negative experiences of care in these settings (Muyinda et al, 1997; Wojcicky and Malala, 2001; See also Lawless et al, 1996). Sex workers fear that they will be refused service and may experience public humiliation by health workers. The location of public health facilities and their hours of operation are also inconvenient for sex workers. Furthermore, although efforts have been made to professionalize the sex industry this has faced considerable barriers. Sex work was only de-criminalised recently in South Africa (See also Gysels et al; 2002).

This paper reports on an on -going intervention initiated by the Reproductive Health Research Unit (RHRU) that provided clinical services for sex workers in the inner city suburb of Hillbrow, Johannesburg. The intervention aimed to provide sex workers with quality sexual health services, to treat STIs and other reproductive health disorders, and provide AIDS education and counselling in the hotels in which they worked. Ultimately the intervention aimed to reduce the incidence of STIs and HIV in the sex worker population.

Internationally, positive outcomes are associated with improving access to STI services.  Programmes combining outreach to commercial sex - workers with peer education and improved access to STI services have been described in Kinshasa (Laga, 1994), Nairobi and Zimbabwe (Ngugi et al, 1996),  Nigeria (Esu-Williams ND), Tanzania (Mwizaruba et al, 1994) and elsewhere (Damiba, 1990; Bradbeer, 1988; Chipfakacha, 1993; Sanchez, 1998; Jana, 1994).

However, while clinical interventions promote impressive short term outcomes these are difficult to sustain. Public health interventions that address structural impediments to behaviour change are perhaps most effective; in Thailand a national campaign to promote and enforce condom use in brothels led to declines in STI incidence of more that 80% and reduced HIV incidence (Hanenberg et al, 1994; Nelson et al, 1996). Yet, as Evans and Lambert (1997) argue, interventions that ‘do not directly address the socio-economic context of women’s lives may succeed in reducing levels of STIs, but they may have a questionable impact on improving women’s health in the longer term’ (p.1801). The structural factors that continue to place women’s lives at risk remain.

Following the recent call for locating AIDS in its social and cultural context (Delius & Walker; 2001) we suggest that more attention needs to be placed on the contextual dynamics that place sex workers at risk. It is thus essential that we have a better understanding of sex workers as people, their interactions with their immediate context, and their divergent and varied reasons for entering sex work (Sedyaningsih-Mamahit, 1999:1113). Thus we argue that health seeking behaviour is a product of the complex interactions of histories, culture and political economy (See Evans and Lambert, 1997).

The paper begins by exploring the social organisation of sex work and an understanding of the risks that sex workers face in their everyday working lives. We argue that risk is shaped by both the locale of sex work and categories of sexual partner. Sex workers who operated from the hotels were generally at lower risk than those who worked the streets. However, women constantly drifted between these locales. Sexual partners were categorised as either romantic or paying partners. Sex workers tended to exercise greater control and power over clients than with romantic partners, particularly with regard to condom use. The second part of the paper describes how sex workers responded to the intervention in the Hillbrow hotels. We suggest that women used the clinic as a resource that helped them to transform the way they saw their bodies, their relationships and the hotel environment. By so doing they reshaped their working environment into the image of the ‘healthy brothel’. In our conclusions we explore the potential for this model to be implemented in other settings with sex workers.

Methods

The data presented in this paper are drawn primarily from focus groups and in depth interviews conducted with sex workers. Prior to the implementation of the clinic service nine focus groups and nine in depth interviews were conducted with sex workers in the Hillbrow area. Following one year of implementation 12 focus groups and ten in depth interviews were conducted with sex workers who used the hotel-based clinic. Where possible, interviews were conducted with hotel security and management. Additional insights were gleaned from reports written by the clinic staff. All interviews and focus groups were tape recorded and transcribed. A textual analysis identified common themes.

Throughout the discussion we emphasise the emic perspective by presenting sex workers’ own accounts of the intervention. This approach departs from much of HIV/AIDS research that relies largely on behaviour and knowledge surveys. Such surveys tend to explain risky behaviour and peoples’ failure to change behaviour as individual deficits – in knowledge, motivation, skills or risk perceptions. They neglect the importance of subjective experience, the interconnectedness of beliefs and practices, and the social, structural and cultural factors that shape sexual activity (See for example Díaz & Ayala, 1999; Collins & Stadler, 2000).

The context of sex work in Johannesburg

The history of sex work in Johannesburg is intimately related to the processes of migrant labour, urbanisation and the economic decline of the South African countryside during the early twentieth century. In the 1880s the newly established mining town of Johannesburg experienced a massive influx of male migrants who supplied the labour for the gold mines (See van Onselen, 1980). The demographic profile of early Johannesburg ‘offered substantial opportunities for prostitution’ (van Onselen, 1982:104). In 1886 the census reflected that a staggering 10% (1000) of all women over the age of fifteen were prostitutes (van Onselen, 1982:104). European migrants and unemployed, unskilled and destitute Afrikaans speaking women sought work in the town and became dependant on sex work to survive. In 1907 the first brothels were established in poor white working class suburbs in Johannesburg (Jochelson, 1999:221).

In the immediate post WWII period African women started to move into the urban areas in greater numbers. For example Bonner (1990) documents the large numbers of Basotho women who migrated to Johannesburg in this period and establish themselves independently in town through sex work and illegal beer brewing (See also Jochelson; 1999).

In the late 1940s and early 1950s government legislation restricted the movement of African men and especially women into White governed towns and cities. However, segregationist legislation such as the Group Areas Act began to break down in the 1970s. During the early 1990s the inner city of Johannesburg, notably Hillbrow, became a notorious site for sex work.

Hillbrow was ideal for the study of sex work. It contained a large population of women who self identified as sex workers who operated from fixed locations. In a survey of hotels in Hillbrow, 27% of women openly admitted to engaging in sex work (Leggett, 2002). Sex work also took place in fixed locations - mainly the residential hotels, but also on the streets.

Hillbrow is one of the most densely populated suburbs in South Africa with an estimated population between 80 000 and 100 000 people. It consists mainly of retail outlets, high rise apartment blocks and hotels, most of which were built following the second world war up until the early 1960s (Beal, Crankshaw & Parnell; 2002; pp. 46, 50). During this stage of development, the suburb attracted young families and recent arrivals in Johannesburg and soon developed a reputation for a ‘bohemian’ lifestyle and a ‘bustling night life’ (Morris, 1999b; 671).

Although the suburb was restricted to whites, a large number of black people resided in Hillbrow. Despite efforts to remove black residents during the 1970s by the end of the 1980s there were more black residents (largely middle class) than whites (Beal, Crankshaw & Parnell; 2002, p. 60). In 1993 62% of residents of apartments in Hillbrow were black, 22% were coloured and 16% were white (Morris, 1999b).

Morris (1999a) relates the rise in commercial sex work in Hillbrow to the rapid decline of the suburb in the late 1980s and early 1990s. The closure of several prominent department stores and the de-gentrification of the neighbourhood accompanied the growth of the sex industry (1999a, p. 258). Many of the apartment buildings and hotels were unable to attract stable middle class families and offered serviced accommodation on a daily basis. These buildings catered to the growing population of sex workers (Morris 1999a, p. 259).

The social organization of sex work in Hillbrow

Figures published in 2000 estimated that there were between 5000 and 10 000 commercial sex workers in Hillbrow (Rees et al; 2000:283), of which a high proportion were children. Until 1997 sex work was a criminal activity and sex workers risked arrest and continuous harassment. However, in 1999 sex workers continued to complain of police incompetence, and complicity in the abuse of sex workers. The police were unlikely to take reports of rape and robbery seriously when reported by women known to be sex workers. Indeed, some sex workers alleged that the police arrested them and raped them in exchange for a release.

Most of the sex workers we interviewed were South Africans who originated from the rural areas of South Africa. A minority were from neighbouring countries such as Lesotho, Malawi, Mozambique and Swaziland, and Zimbabwe. These typically poorer areas have little to offer young women in terms of employment and educational opportunities. Rural employment markets are sharply divided between poorly paid labour on commercial farms, and few opportunities in the civil service as teachers and health care workers. Self employment strategies there were the only option even for educated young women. Sex work was often presented as the only way to survive.

A prominent discourse that surrounds sex work is whether women are forced to become sex workers or whether they make a conscious decision to do so. Sex workers in Hillbrow tended to stress the former, and highlighted their lack of agency in becoming sex workers. None of the women we spoke to had intended to enter into sex-work; rather they claimed to have been tricked into sex work. A 28 year old sex worker recalled her entry into sex work three years previously:

A friend who told me she was living very comfortable in Johannesburg with her boyfriend. I won’t be suffering anymore. She told me I will see singing stars. When I arrived here I asked about all these things she had told me about. She told me she was staying at Nest Inn and that she is a sex worker and that she expects me to do the same otherwise I won’t have a place to sleep or food to eat. I didn’t like the idea but I didn’t have a choice. As a result I started the same day. She borrowed me her short skirt

In her account she portrayed herself as a naïve country girl who was lured into sex work by the dream of a more glamorous and exciting life. Such narratives distracted attention from the personal role in the decision to enter into sex work and displaced the blame and stigma associated with sex work. The emphasis on trickery obfuscates individual agency. The following extract is another example:

I was a young innocent girl of about 18 years of age living back home in the Eastern Cape, I could not go back to school again because I had a child when I was fifteen years doing grade ten (…) then there's my sister who is a sex worker in Johannesburg; every time she visits us at home she is a new person with expensive clothes, cell phones, jewellery and other beautiful things. As a young girl who is struggling to survive I aspired to look like my sister. I asked her ‘what can I do to have all those things that you have’. She told me to go with her to Johannesburg to look for a job. When I arrived here at (…) Hotel she just dressed me in a short skirt and told me that she does sex-work and if I want to make money I must approach men and offer sex to them for a fee.

The two accounts are very similar. As a young ‘innocent girls they found themselves duped into becoming sex workers. Tellingly, both accounts referred to the lure of expensive consumer items such as cell phones, clothes and jewellery, and the glamour associated with city life.  Although the women we spoke to were from impoverished backgrounds, their decision to enter into sex work may have been less of a survival strategy and more of an attempt to forge a new way of life for themselves - away from the dull existences they led at home. Gysels et al (2002) observe that sex work is the outcome of economic necessity is not necessarily always the case. Instead they assert that sex work can be regarded as an alternative ‘strategy for obtaining financial and social independence’ (p.180; our emphasis).

Sex workers operated from three locales: escort agencies, hotels and the street. Escort agencies were generally regarded as a more secure base from which to operate and the women who worked there earned more than the average sex worker (Morris 1999a, p. 261).

The street represented the most dangerous setting for sex work. Street based sex workers often used hard drugs such as crack cocaine. Others were immigrants from neighbouring African countries. Still others were young children (Mpeta, 2000). Street based sex workers were often more desperate than other women, and faced greater risks than the women who worked from the hotels. Public solicitation risked apprehension by the police and was extremely dangerous; women risked abduction, rape, assault and murder.

The hotels and some apartment blocks were often de facto brothels and provided accommodation and security for the tenants. Sex workers who worked from the hotels were also able to charge higher rates. Security guards protected the women against abusive clients and non payment. Some hotels claimed to have a condom only policy although this was not strictly adhered to.

Despite these forms of protection, incidents of violence and theft were often reported by the sex workers who worked from the hotels. (See also Wojcicky and Malala; 2001:104, 105, 106). The security guards themselves used physical violence to control the women. Tatania, a young sex worker, recounted how she was assaulted because she fought with another girl. ‘They started beating me with sjamboks (whip), fists and everything…’ She was so badly beaten that on one occasion she was hospitalised. While in hospital she received death threats to keep her silent. She eventually fled the hotel and found another base from which to operate

Failure to pay rent resulted in automatic eviction from the brothel. The rent collectors were unforgiving with rent defaulters:

When they come to the room to collect the money they knock on the door. Sometimes you have not slept the whole night and they come at five thirty and they wake you up (…). When you do not have money they tell you to get dressed quickly and give them the keys to the room. Sometimes you have a problem, perhaps you are menstruating…he will ask you what you want him to do about your blood?

A sex worker was caught trying to use counterfeit bills to pay her rent. She was locked out of her room for the day and had to find clients on the street to make the cash she needed to pay rent.

Financial desperation prompted sex workers to take risks that they would usually avoid. In a desperate attempt to earn extra cash women sometimes left the relative safety of the hotel to seek clients in central Johannesburg. To save on rental costs (estimated between R45.00 and R60.00) sex workers made use of public parking garages and recreational parks to have sex with clients. In these locations sex workers had far less control over their transactions and risked assault and unsafe sex.

T

hus although the distinction between street and brothel based sex work was important, hotels only provided relative safety for sex workers. Moreover, women drifted between the two locations depending on their specific circumstances and needs.

The distinction between street – and hotel – based sex work superimposed other social divisions between sex workers. Competition for clients was intense and often led to conflict. Distinctions based on age and ethnicity and country of origin most often emerged as the lines along which competition occurred. Adolescent women represented a significant proportion of sex workers in Hillbrow. Many youngsters worked from the streets but also dominated particular hotels. Older women resented their presence because they were seen to be more popular amongst customers.

Foreigners were also regarded as a threat, as ‘dirty’ and unsafe. Foreign sex workers often worked from the street and were prepared to have sex without condoms and for lower rates. As the following extract from a focus group with South African sex workers demonstrates, foreign sex workers were seen to be responsible for a general drop in standards:

Some don’t care about themselves…some don’t wash. It is dangerous. But you know some ladies from Maputo and Mozambique don’t care about themselves. They take clients even when they only have R20. If a client asks for sucking [oral sex] they do it, even without a condom. And when the clients come to us they think we all do the same thing.

Conflict within the hotel sex worker population was also rife. Suspicion and hostility sometimes emerged as witchcraft accusations. A woman fled her hotel when she suspected that her fellow sex workers were attempting to bewitch her. Tensions even led to physical violence. A younger woman claimed that she had been beaten, harassed and stolen from by her co-workers.

Conflict between sex workers was also used to the advantage of others. An older, more experienced sex worker spoke of how she fuelled conflict to her advantage: 

I say to them ‘you think that just because this man fucks you every day giving you money he’s your husband? No. That’s not the case. If he wants to go and have sex with another girl, leave him alone … he’s not your husband he’s your client’. Then they will fight and I will just sneak that client to wherever he wants to go.

Experienced sex-workers frequently used their age and knowledge to exploit new sex workers[17]. New sex workers attracted the attention of clients and older women used them to trick and steal from her clients (see below). Thus, although sex workers recognized the need to cooperate and to stand together against exploitative brothel owners, police, abusive clients and boyfriends, achieving this was viewed as highly problematic due to the competitive nature of the sex work industry.

Despite the enmity between sex workers, older women protected their younger counterparts. They imparted valuable advice about condoms, fees, and other survival skills such as the ability to assess a client (or as they put it to ‘judge a steamer’). Sarah, a 25 year old sex worker recalled that her ‘friends showed me how they judge so that I could learn – watch and learn’. Similarly Mbali, a 29 year old sex worker remembers that her friend:  ‘told me to be careful so that clients don’t rob me and she also told me to use condoms always’.

These conditions provided the circumstances under which unsafe sex and physical abuse could occur. Sex workers were a highly heterogeneous group. Competition over clients led to intense conflict. Moreover, although the hotels provided protection, the tenants were constantly under the control of the security guards and the women were bound to an on-going financial obligation to pay rent that forced them to constantly seek work. Thus while hotel based sex work could be regarded as less risky, sex workers often drifted between the street and the hotel.

Clients, lovers and condoms

Sex workers categorised their male clients according to ethnic and racial stereotypes. This knowledge was vital to ‘judging’ clients or assessing the potential risk. For example, South African black men in general were seen to be untrustworthy as they tried to have sex without paying. In contrast, middle aged white men were quiet and reliable customers. Foreigners were also good clients as they respected the contractual nature of the relationship and honoured their payments. Zulu speaking men from KwaZulu-Natal were difficult to deal with as they totally rejected condoms. Asian men often demanded anal and oral sex which many sex workers said they found revolting.

Women were particularly wary of men who wanted to develop romantic relationships. Many sex-workers either lived with, or visited a permanent lover whom they described as a husband or a boyfriend. Most disclosed their occupation to these men, and many supported their male lovers through sex-work[21]. However, they drew a sharp distinction between their clients and their romantic lovers.

Relationships with clients were regarded as strictly ‘business’. Many sex workers complained of clients who wanted longer lasting, romantic relationships. They avoided men who tried to kiss them or seemed to want more than just sex. Even worse, sex workers complained that some men made tiny holes in their condoms to ensure that fluids would be exchanged during sex. Fluid exchange is regarded as integral to the construction of a longer term relationship (See Collins and Stadler 2000). A participant in a focus group articulated the tension between clients and lovers in the following way:

There are other problems because they expect you to act as if they are your boyfriend. They just forget that you are doing business…a person will say kiss me. I refuse (Our emphasis).

Despite these challenges, relationships with clients were regarded as more manageable and less risky than relationships with their lovers. Many women gave accounts of abuse and violence at the hands of their boyfriends. A young female sex-worker committed suicide after she fought with her partner. Another sex-worker was severely beaten by her partner when he discovered that she was attending the clinic 

Romantic partners also resisted condom use. A sex worker described her boyfriend’s rationale for not using a condom:

Our partners are hard-headed. They hate condoms and they say it brings AIDS. They even beat us. My partner says he does not want to be killed by the very same part of the body that brought him on earth [the vagina].

Others risked physical beatings and rejection by attempting to enforce condoms. A woman described her boyfriend’s response:

I have a boyfriend - he really hates a condom. He always beats me and has taken out four of my teeth. Even if I can runaway when I come back he will say I am his. That's the problem I have.

For others condom use defined the relationship as untrustworthy – like that of one between a sex worker and a client:

My boyfriend ran away because he doesn't want a condom. Some say they are not clients and some will agree to use a condom at the beginning as times goes on they will change and reject condoms.

On the other hand condom use was regarded as unnecessary in stable relationships or when trust had been established. The following dialogue in a focus group discussion illustrates this well:

Participant: A condom is a waste of time

Facilitator: What do you mean?

Participant: He is now mine and there is no need (…)

Facilitator: What made you to stop using the condom?

Participant: I am now used to him [Emphasis added]

While relationships with romantic partners were often fraught with ambiguity, those with paying clients tended to be clearer cut. Sex workers appeared to exercise greater control over sexual transactions that involved money. Clients were more amenable to using condoms. An older sex worker pointed out the different levels of risk between romantic partners and clients:

Our spinners [boyfriends] (…) have girl friends in most of these hotels. They don’t use condoms. He comes back to infect you. Clients can also satisfy you sexually if you don’t want a boyfriend. At least clients are using condoms but if your boyfriend is willing to use condom you can go on with your affair [Our insert]

In situations where clients refused to use condoms higher prices were demanded (see Wojcisky and Malala, 2001). A sex worker explained:

Yesterday there was a client who was offering ladies a lot of money like four hundred rand or one thousand rand to have sex with him without a condom, but most of us refuse because we know it is very risky (…) some did. We know them. They say money is money.

Sex workers exercised power over their clients in other ways. Trickery, cunning and skill were important aspects of sex workers’ identity, and expressed their power in difficult circumstances. This was particularly evident in the practice of bathula - tsotsi taal (gangsters lingo) meaning ‘to steal’. Sex workers often tricked naïve and drunk clients. One woman described her ability to stimulate men to the point of orgasm without penile penetration. This was regarded as bathula as the man would have paid for sex without actual penetration.

Other accounts described bathula as mugging. In one account a young man was taken to a room where unbeknown to him several larger women were waiting. As soon as he had removed his trousers the women jumped him, stealing his cell phone, watch, money and jacket. He was then thrown naked into the street. Some security guards participated in bathula, although management frowned on this practice as it was bad for business. Angry clients sometimes returned to take revenge. However, bathula was seen as the only way to supplement the meagre earnings from sex work. When asked why they stole from clients sex workers retorted, ‘Why are they paying us twenty rand?’ In some ways this can be seen as a form of resistance against the highly exploitative conditions under which sex workers work.

The ability to assess the potential risks posed by different categories of client, and women’s ability to exert a certain degree of power in these relationships was sharply contrasted with the relationships with lovers and permanent partners. The preceding discussion has highlighted the role of the locale and relationships in mediating risk. Importantly, risk was dependant largely on the particular circumstances, context and the definition of the type of relationship. Public health messaging that advocates for condom use, reduction in the number of sexual partners and abstinence are somewhat out of step with the contexts of unsafe sex in these women’s lives.

The healthy brothel

Most sex workers were loath to make use of the public health facilities at the Hillbrow clinic. Sex workers provided accounts of their rights being disregarded or abused. Of particular concern was HIV testing without pre and post test counselling. Moreover, women complained that the clinic lacked the appropriate drugs, had long queues and was often over crowded. The nurses also verbally abused women they suspected were sex workers and used the derogatory term magosha (loose woman, prostitute) to address them. A sex worker described the situation:

I think you know them and their attitude – they will ridicule you and say ‘you are a prostitute’, and ‘you piss us off…your kuku [vagina] is sick’.  (Our insert)

Not surprisingly, sex workers tended to seek treatment from pharmacists or if they had the money, general practitioners.

The RHRU conducted formative research in Hillbrow to develop recommendations to address the health needs of the sex worker population. Included in these recommendations was the need for friendly services; services offered in locations that are closer to where sex workers live and work, and during more suitable hours; targeted educational campaigns for sex workers; training sex workers as peer educators; sensitisation of the local police; one hundred per cent condom policies in sex work establishments; financial support for HIV positive sex workers; increasing employment opportunities and improving the education of women. (Pettifor, 2000; p. 41-42).

The mobile clinic provided basic STI services, awareness and education and condom provision for sex workers who resided in the Hillbrow hotels. Twelve hotels where sex work was known to take place were selected and hotel rooms for the clinic were negotiated with hotel management. Regular visits to the hotels commenced in June 2000. The clinics visited each hotel for four days at a time in teams consisting of a nurse and community health workers. All clinic attendees were interviewed using a standard questionnaire and were screened and treated for STIs. They also received health education and free male and female condoms. Over a 15 month period over 1243 participants were screened and treated at least once.  About half of the participants presented with the symptoms of an STI. A referral network was also established for social welfare needs.

The decision to base the clinical intervention within the brothels was due to the relative stability of this environment. The hotels provided a permanent base from which to operate. Moreover, many hotel managers and staff welcomed the presence of the clinic. Although the location of the clinic potentially excluded street based sex workers, no restrictions were imposed on who could utilise the services.

In practical terms the location of the clinical services within the hotel had distinct advantages over conventional clinical services for sex-workers. Sex-workers who were too ill to travel (for instance, those who complained of severe abdominal pains) could easily access the clinic. Moreover, the women incurred no travel costs. Thus, location was a major factor that motivated sex workers to use the clinic. 

For us it really saves time because we are always busy. This has made life much better for us because we make money…you just say ‘shit I wish I could go to the clinic at Esselen [clinic] but I don’t have time’. But here (…) we just run to [room] 401 and tell the nurses about the broken condom. (Our inserts)

The location of the clinic also suited the lifestyle of sex workers who stayed up late, drank heavily and slept late into the day. They were able to ‘just wake up and go to the clinic’ (See Evans and Lambert; 1997).

Health seeking behaviors were also influenced by the perceived efficacy of the clinic to treat blood disorders. Sex workers expressed their concern with vaginal and inter-uterine cleanliness. They were constantly exposed to polluted, ‘dirty’ fluids and substances such as semen and ‘condom oils’. The physical release of the polluted substances and the release of blockage were regarded as highly desirable and signified a return to good health. A 29 year old woman who complained of reoccurring vaginal discharge recalled the effect of the medication she received from the clinic:

I like it if they gave us tablets, to clean our blood. There is a black tablet that is very strong. After I took it I vomited but in my urine there was no more yellow, only white.

Another important factor was the relationship between the clinic staff and the sex-workers. In contrast to the public health clinics the hotel clinic staff was sympathetic to sex workers’ problems and created an atmosphere of openness and honesty. As one sex worker put it: ‘they don’t shout at us but always give us those sweet talks’. A woman described her experiences of the clinic:  

They explain before they treat us. Everything is done through agreement. We get tablets for treatment, condoms and we also get a chance to sit down and get advice in the clinic. Everything is explained, the blood taken is not for AIDS tests but other infections are tested. They are really patient.

This had a positive impact on perceptions of health and the need to prevent disease. One woman noted that it was only once she had attended the clinic that she realised that she was sick and required treatment. Or as another put it, ‘although you don’t see that you are sick, when you go there they can see all those small sicknesses’. This sentiment was echoed by others:

Our health comes first that’s why we attend clinic. What makes me come to the clinic is that there are so many diseases like STI and HIV. If you regularly go to the clinic for STI’s check ups you won’t easily get infected with HIV, because we are scared of HIV/AIDS more than sexual transmitted infections.

The frequent clinic attendees were able to demonstrate a functional understanding of the logic behind regular examinations and check ups as a preventive measure as opposed to using health care services only when symptoms were noticed. 

Most importantly the services had a direct bearing on sex-workers’ knowledge and awareness of health and risk. Regular clinic attendees articulated the rationale for preventive measures and the dangers of unprotected sex. As one participant put it, ‘We are the ones with a problem because we use our bodies to do this job’.

The information sessions provided by the nurses also had a positive effect on condom use. A sex-worker remarked that she would not have sex with a client without a condom for fear of infection, but also because she feared the reaction of the clinic workers if she was infected.

Because the other thing you ask yourself is, if this person does not want to use the condom, what is it that he wants to infect me with? Even if he promises you more money (this) cannot buy your life. The other thing is, how would the nurse think of you when you go to the clinic and she finds out that you are sick again? She will think that you don’t take care of yourself.

The clinic staff also introduced new forms of female controlled prevention technology that allowed sex-workers to protect themselves against clients who insisted on having unprotected sex. One woman talked of how she had started to use female condoms with clients who were drunk and didn’t realise that they were having protected sex. Finally, although the clinic initially aimed its efforts at the female sex workers a number of male clients also consulted clinic staff. 

At an individual level sex workers reported that the clinic had a positive impact on their health seeking behaviors. This outcome was not in it self very remarkable given sex workers’ experiences in other health care settings: the clinic provided easily accessible, high quality services for a specific group of women. 

The clinic was able to meet an immediate and pressing need to improve the reach of clinical services to a population that was in great need, and thereby addressed a public health crisis of significant proportions. As we mentioned earlier one of the major criticisms of this approach is that it provides only temporary and limited relief. However, the location of the intervention within the hotels had unintended consequences that are important to consider.

Of notable interest was the way in which the clinic transformed the image of the brothel and the women who worked and lived there. A woman who lived in one of the hotels explained:

In some of the hotels girls say clients are happy because if they attend the clinic that means they are clean and looking after themselves…Some people will always like you when you are clean. Most of them when they look at you they will say that you look like you have AIDS, but I would tell them I couldn’t be having that because there is a clinic at this hotel that I attend. We tell them that we are being checked and examined regularly and you will see him being relieved and some look happy when they hear that.

Not surprisingly the hotel management were supportive of the initiative. They noted the improved health seeking behaviour as well as the increased popularity of those hotels that were visited by the clinic. As the head of hotel security at one of the hotels put it:

(…) if the clinic is running in the hotel then the clients will see that we are taking care of ourselves and they more clients we get.

The clinic was also used by the sex workers as a marketing tool to promote the image of the hotels. Sex workers displayed their clinic cards to wary clients and pointed to the posters that advertised the clinic.  As one woman put it, this made clients feel ‘free and safe’. The clinic was thus appropriated by the women to enhance their status, to remove the stigma associated with being sex workers. At the same time this rehabilitated image of the hotels had a meaningful effect on attitudes towards condom use and safe sex. Sex without condoms was at odds with the image of the ‘healthy brothel’. An older sex worker suggested that the clinic actually encouraged men to use condoms because  

…when they learn about the clinic they can then see how serious (…) STIs are so they will make sure that we use condoms with them.

Conclusions

This paper has suggested that it is possible to provide quality and acceptable services outside of the conventional clinical setting. Locating clinical services within the hotel/brothels of Hillbrow provided the women who worked and lived there with an accessible service. Sex workers responded positively to the clinic and changed aspects of their health seeking behaviour. However, the intervention also prompted a shift in perceptions of the brothels from ‘diseased and dirty’ to ‘safe and healthy’. This new image created an environment in which safer sexual practices were more possible.

AIDS interventions have typically followed the path of changing individual behaviours by equipping people with the necessary information and skills. However, as many have observed, there is a significant gap between knowledge and practice. The focus on behaviour change at an individual level is highly inappropriate for women who earn a living from sex work. We have suggested that interventions need to shift the main focus from the individual to the locales in which sex work takes place. This can create greater possibilities for behaviour change.

A significant limitation of the intervention was in its inability to have as great an impact on the relationships that placed sex workers at greatest risk, namely their stable or long term partners. As the paper demonstrated, it was within those types of relationship that condom use and safer sex were most problematic and difficult to impose. It was also within these relationships that women were less likely to be able to exert their influence and power. 

Given this limitation the health brothel model has broader applicability in similar contexts. Recently the National Roads Agency made up of truck driver union and business interests have collaborated with the national department of health to implement the ‘Trucking against AIDS’ program. Several permanent and temporary clinics have been set up on major trucking routes in South Africa to provide truckers with quality sexual health care services. Truckers who are low users of health care services are also identified as vectors in the spread of the AIDS epidemic. Sex workers who base themselves at truck stops have started to utilise these clinics.

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