“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”
The ‘healthy brothel’: the context of clinical services for
sex workers in Hillbrow, South Africa
and Sinead Delaney
Reproductive Health Research
Unit, CHBH, Soweto.
History Workshop, African
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.
Sex workers, Hillbrow, health
seeking behaviours, HIV/AIDS
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.
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.
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 &
The context of sex work in
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,
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
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 (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 naďve 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.
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.
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.
frequently used their age and knowledge to exploit new sex workers.
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
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
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.
However, they drew a sharp distinction between their clients and their
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
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
A condom is a waste of time
What do you mean?
He is now mine and there is no need (…)
What made you to stop using the condom?
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
naďve 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
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
Not surprisingly, sex workers tended to
seek treatment from pharmacists or if they had the money, general
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
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
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
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).
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.
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
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
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
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.
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
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
…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.
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
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.
Beal, J., Crankshaw, O. &
Parnell, S. 2002. Uniting a divided city: governance and social exclusion
in Johannesburg. London and Sterling Vancouver: Earthscan Publications
Bradbeer CS, Thin RN, Tan T,
Thirumoorthy T. 1988. Prophylaxis against infection in Singaporean
prostitutes. Genitourin Med 64(1):52-3.
Chipfakacha V. 1993.
Prevention of sexually transmitted diseases. The Shurugwi sex-workers
project. South African Medical Journal; 83(1): 40-41.
Endang R. Sedyaningsih-Mamahit.
1999. Female commercial sex workers in Kramat Tunggak, Jakarta, Indonesia.
Social Science & Medicine 49: 1101-1114
Damiba AE; Vermund SH; Kelley
KF. 1990. Prevalence of gonorrhoea, syphilis and trichomoniasis in
prostitutes in Burkina Faso. East African Medical Journal; 67(7):
Delius, P. & Walker, L. 2001.
AIDS in context. African Studies 61 (1): 5-13.
Díaz R.M & Ayala G. 1999.
Love, Passion and Rebellion: Ideologies of HIV Risk among Latino Gay Men in
the USA. Culture, Health and Sexuality. 1, (3):277-293.
Esu-Williams E, Phillips A.L.,
Githens W. AIDS prevention: a guide for working with commercial sex
workers - experiences from Calabar, Nigeria. AIDSTECH/Family Health
Flowers, Paul, Claire Marriott
and Graham Hart. 2000. The bars, the bogs and the bushes: the impact of
locale on sexual cultures. Culture, Health and Sexuality. 2000,
Vol.2, No 1, pp69-86.
Gysels, M., Poole, R. &
Nnalusiba, B. 2002. Women who sell sex in a Ugandan trading town: life
histories, survival strategies and risk. Social Science and Medicine
54: 179 – 192.
Rojanapithayakorn W, Kunasol P, Sokal DC. 1994. Impact of Thailand’s
HIV-control programme as indicated by the decline of sexually transmitted
diseases. Lancet 1994; 344: 243-45
Jana S, Bandyopadhyay N,
Mukherjee S. 1998. STD/HIV intervention with sex workers in West Bengal,
India. AIDS; 12 (suppl B): S101-S108.
Jewkes, R and K. Wood. 1999.
Problematising pollution: dirty wombs, ritual pollution, and pathalogical
process. Medical Anthropology.
Jochelson, Karen. 1999.
Sexually Transmitted Diseases in Nineteenth – and Twentieth – Century South
Africa. In Comparative Histories of Sexually Transmitted Diseases and
HIV/AIDS in Sub-Saharan Africa Philip Setel, Milton Lewis and Maryinez Lyons
(Eds.). Westport, Conneticut, London: Greenwood Press.
Laga M, Alary M, Nzila N et
al. 1994. Condom promotion, sexually transmitted disease treatment, and
declining incidence of HIV-1 infection in female Zairean sex workers. Lancet
1994; 344: 246-48.
Lawless, Sonia, Susan Kippax
and June Crawford. 1996. ‘Dirty and Diseased and Undeserving: The
Positioning of HIV Positive Women’. Social Science and Medicine, 43
(9), 1371 – 1377.
Leggett, T. 2002. A den of
inequity? Inside Hillbrow’s residential hotels. SA Crime Quarterly,
Malala, Josephine. 2001. The
other side of health: The perceptions of disease, illness and the body by
sex-workers in Hillbrow, Johannesburg. Unpublished Dissertation (BA
Honours), Faculty of Arts, University of the Witwatersrand, Johannesburg.
Morris, Alan. 1999a. Bleakness
and Light: Inner-city transition in Hillbrow, Johannesburg. Johannesburg:
Witwatersrand University Press.
Morris, Alan. 1999b. Race
relations and racism in a racially diverse inner city neighbourhood: a case
study of Hillbrow, Johannesburg. Journal of Southern African Studies. 25 (4)
Mwizaruba BK, Mwaijonga CL et
al. 1994. HIV/AIDS education and condom promotion for truck drivers, their
assistants and sex partners in Tanzania. In Focusing Interventions among
Vulnerable Groups for HIV Infection: Experiences from Eastern and Southern
Africa. NARESA monograph no. 2 1994
Mpete, C. (2000). ‘Nearly half
the hookers on streets of Jo’ burg are children’. Saturday Star, 29
Nelson KE, Celentano DD,
Eiumtrakol S, et al. 1996. Changes in sexual behavior and a decline in HIV
infection among young men in Thailand. New England Journal of Medicine; 335:
Ngugi EN, Wilson D, Sebstad J,
et al. 1996. Focused peer-mediated educational programs among female sex
workers to reduce sexually transmitted disease and human immunodeficiency
virus transmission in Kenya and Zimbabwe. Journal of Infectious Diseases;
174 (Sup. 2):S240--247.
Pettifor. A.E., M.E. Beksinska,
H.V. Rees. 2000. High knowledge and high risk behaviour: A profile of
hotel-based sex workers in inner-city Johannesburg. African Journal of
Reproductive Health; 4(2) 35-43.
Rees, H., M.E. Beksinska, K.
Dickson – Tetteh, R.C. Ballard and Ye Htun. 2000. ‘Commercial sex workers in
Johannesburg: risk behavior and HIV status’. South African Journal of
Science; 96 June 2000. 283 – 284.
RHRU 2000. Women at Risk: A
survey of … Unpublished internal report. Soweto: Reproductive Health
Research Unit, Department of Obstetrics and Gynaecology, University of the
Sanchez J, Gotuzzo E,
Escamilla J, et al. 1998. Sexually transmitted infection in female sex
workers: reduced by condom use by not by a limited periodic examination
program. Sex Transmitted Diseases;25: 82-89.
Van Onselen, C. (1982) Studies
in the Social and Economic History of the Witwatersrand 1886-1914, Volume 1.
New Babylon. Johannesburg: Raven Press.
Varga, C.A. (1997). The condom conundrum:
barriers to condom use among commercial sex workers in Durban, South Africa.
African Journal of Reproductive Health 1(1):74-88.
Williams, B., Gilgen, D.,
Campbell, C., Taljaard, D. and MacPhail, C. 2000: The Natural History of
HIV/AIDS in South Africa: a biomedical and social survey in Carletonville.
Johannesburg: Council for Scientific and Industrial Research,.
Wojcicki, J and Malala, J.
2001. Condom use, power and HIV/AIDS risk: sex – workers bargain for
survival in Hillbrow/Joubert Park/Berea, Johannesburg. Social Science and
Medicine 53, 99-121
Unpublished data from a survey of sex workers in Hillbrow is also
referred to in the paper (RHRU, 1999).
1986 the Acts (Blacks (Abolition of Passes and Co-ordination of
Documents) Act of 1952 and the Blacks (Urban Areas) Consolidation
Act of 1945) stipulated that Africans could reside in an urban area
if they had official permission to do so and if they were born in the
area, had a single employer for 10 years or had lived in town ‘lawfully’
for 15 years. Those who did not qualify sought temporary urban residence
if they could find employment. Individuals were prohibited from bringing
their families with them to the urban areas who would remain in the
rural areas or Bantustans. This effectively separated millions of men
and women and divided families. (Morris; 1999b:668)