Targeting HIV-prevention efforts on truck drivers and sex workers: implications for a decline in the spread of HIV in Southern Africa

HIV Prevention and Vaccine Research, Medical Research Council,
296 Umbilo Road Durban 4013 South Africa
Tel: +27 (0) 31 202 0777, fax: +27 (0) 31 202 0950, e-mail: ramjeeg@mrc.ac.za

The role of mobile populations in the spread of the human immunodeficiency virus (HIV) has been documented in several countries worldwide.1-4 The role of truck drivers and sex workers in the spread of HIV has been studied in Africa,5 India,6 and the USA.7 Due to the migratory nature of their occupation, truck drivers tend to have multiple sexual partners.

The potential roles of truck drivers and sex workers in the spread of HIV in southern Africa are being explored through a combination of qualitative and quantitative studies among these population groups in South Africa. Ten sex workers from five truck stops (Van Reenen, Reids, Tugela, Newcastle and Warden) in the KwaZulu-Natal Midlands were recruited as field workers. They were trained to obtain informed consent, administer a questionnaire to obtain socio-demographic data and collect a saliva sample for an HIV test from men they have sex with.

HIV prevalence and demo-graphic data for 194 women sex workers operating from these truck stops were obtained from an ongoing vaginal microbicide trial among sex workers.

The recommendations contained in this MRC Policy Brief were drawn from the findings of these studies.

Sociodemographics and migration patterns
The field workers interviewed a total of 320 men. The mean age of the truck drivers was 37 years and they had been in this occupation for an average of 8 years. Of the recruited men, 297 were black, 7 were coloured, 9 were Indian and 7 were white. Sixty per cent of the men reported having had a sexually transmitted disease (STD) in the previous 6 months. Thirty four per cent reported always stopping for sex during journeys.

Twenty nine per cent never used condoms with sex workers. Seventy per cent reported having wives/girlfriends, and only 13% had ever used condoms with these regular partners.

Anal sex was practised by 42% of the men. Only 23% reported ever using condoms during anal sex.

All the truck drivers travel-led to three or more provinces in South Africa and 65% travelled to neighbouring countries such as Zimbabwe, Malawi, Mozambique, Zambia, Botswana, Namibia, Swaziland and Angola.

The mean age of the 194 sex workers was 25 years and the average education six years. The mean number of years working as sex workers was 2,5 years.

HIV prevalence among sex workers and truck drivers
The overall prevalence among truck drivers was 56% (95% CI: 51-62%). One hundred and sixty eight (57%) black drivers were HIV positive. Five (71%) of the coloured men, 5 Indian (56%) and 2 (29%) of the white men, respectively, tested positive for HIV. Grouping men who were not black showed no significant association between race and HIV status. The prevalence at each truck stop was: Van Reenen 57%, Reids 52%, Tugela 50%, Warden 52% and Newcastle 95%. HIV prevalence at Newcastle was significantly higher compared to other stops.

Corresponding HIV prevalence for women at each of the truck stops was: Van Reenen 44%, Reids 42%, Tugela 62%, Warden 74% and Newcastle 64%. The overall HIV prevalence among sex workers was 56% (95% CI: 49-63%).

HIV prevalence by age for sex workers and truck drivers
The HIV prevalence among men increased significantly with age to a high of 69% among men aged 55 to 59 years. For the sex workers, HIV prevalence peaked at a much younger age at 20-24 years.4

The men in the study were on average about 12 years older than the women (37 vs. 25 years) and the age prevalence curves were quite different for men and women. These data suggest that older men have younger women as sexual partners at the truck stops.

The high HIV prevalence and low condom use among truck drivers and sex workers, as well as the complex web of travel and sexual mixing, create a milieu that is conducive to the spread of HIV and other STDs. The study highlights the urgent need to deal with the HIV epidemic across political boundaries in the southern African region. Further studies of the pattern of movement of the truck drivers could help to throw light on the temporal and geographic spread of HIV in the region.

Given that 70% of the men had wives and girlfriends in rural areas may have important implications for the spread of the virus to other communities.

· Information about the transmission of HIV and STDs, and about effectiveness of condom use with all partners needs to be targeted at truck stops, toll plazas, border posts and at the work places of truck drivers. Misconceptions about condom use need to be eliminated and the seriousness of untreated STDs needs to be emphasised.

· Condom distribution is recommended at truck stops, toll plazas, work places and border posts. A partnership needs to be formed between the Department of Health, the road freight agency, workforce unions and the trucking industry as a whole in order to impact on the reduction of HIV incidence in this high risk group.

· Provision of syndromic treatment and HIV counselling is recommended at strategic points along major trucking routes to allow easy access to care and counselling. Mobile clinics are urgently required along trucking routes to provide STD treatment and counselling to truck drivers and sex workers. Since the truck stops are easy to identify, effective interventions at these places could have a dramatic effect.

Mobile clinics are urgently required along trucking routes to provide STD treatment and counselling to truck drivers and sex workers. Truck stops are an ideal spot for HIV prevention activities, targeting both truck drivers and sex workers.

· Use truck drivers and sex workers to spread positive messages. Peer education programmes targeted at truck drivers and sex workers can be used as a bridge in the spread of positive attitudes regarding condom use and HIV education. A concerted effort is needed to target high-risk populations in a non-discriminatory manner, and to use their occupation to spread HIV-prevention messages and promote condom use throughout the rural and urban areas of southern Africa.

· Southern African initiative. There is an urgent need for southern African countries to work as a whole. Migrations of individuals from these countries occur on a regular basis. HIV-prevention programmes in southern African countries should work together to reiterate common prevention messages and target appropriate interventions. In this way, for example, South African drivers could be given access to STD treatment and counselling in any of the southern African countries that are part of this initiative. Further, import and export companies need to provide condoms and effective treatment for drivers from different regions to minimise erosion of their workforce.

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