Venezuela - the next frontier for HIV/AIDS: what about female PROTECTION?

L Faas¹, N Pernía² y A Rodríguez-Acosta³.

¹ Fundashon Contrasida Caribbean, PO Box 3716, Curacao. Netherlands Antilles.

² Asociación de Mujeres por el Bienestar y la Asistencia Recíproca (Ambar), Apartado 47423, Caracas 1041, Venezuela.

³ Tropical Medicine Institute, Universidad Central de Venezuela, Apartado 47423 Caracas, 1041, Venezuela.

E-mail: faas1@attglobal.net / E-mail: rodriguf@ucv.ve

ABSTRACT: CONTRASIDA (Non Government Organization) took a step in the fight against AIDS in Venezuela by introducing the female condom. One group that is particularly at risk for human immunodeficiency virus (HIV) infection is the Female Commercial Sex Workers (FCSWs). They can unknowingly infect their clients who might, in turn, infect their wives/ partners. This is what is referred to as "the sexual network theory": people are connected by their sexual contacts, and therefore form contact-patterns of sexual networks. CONTRASIDA developed a questionnaire and implemented a project that reached 1,000 women-the majority of which FCSWs in Venezuela. In the context of "the sexual network theory" CONTRASIDA organized workshops for housewives, female students and professionals. The study indicated wide spread acceptability of this barrier method by all the female populations in the project, as an effective instrument in the fight against HIV and other sexual transmitted diseases.

Key Words: AIDS, Female condom, FCSWs, Sexual transmitted diseases, Sexual diseases control, Venezuela.

RESUMEN: En Diciembre de 1997, CONTRASIDA (Organización No-Gubernamental) tomó un paso histórico en la lucha contra El Sida en Venezuela al introducir el condón femenino. Un grupo particularmente en riesgo para la infección con virus de inmunodeficiencia humana (HIV), y susceptible de infectar otros con el HIV es el grupo de las trabajadoras sexuales (FCSWS). Teniendo múltiples compañeros, quienes frecuentemente rehúsan usar un método de barrera, así las FCSWS están en gran riesgo para adquirir la infección. Además, como el HIV no puede detectarse dentro de los 3-6 meses de adquirir la infección, estas mismas FCSWS puede inconscientemente infectar sus clientes, quienes a su vez pueden infectar a sus esposas y/o compañeras (os). Esto último es lo que se denomina "la teoría sexual de red": gente conectada por sus contactos sexuales, y por lo tanto forma la llamada "modelos de redes sexuales". CONTRASIDA elaboró un cuestionario e implementó un proyecto de información que alcanzó 1.000 mujeres, la mayoría FCSWS en Venezuela. Dentro del marco de "la teoría sexual de red" CONTRASIDA incluyó también clientes/compañeros de FCSWS en los cursillos sobre el condón femenino. Además, organizó cursillos especiales para ama de casas, estudiantes y profesionales femeninos. Los resultados indicaron aceptabilidad amplia de este método de barrera por todas las poblaciones femeninas que participaron en el proyecto, como un instrumento efectivo en la lucha contra el HIV y otras enfermedades de transmisión sexual.

Palabras Clave: AIDS, Condón femenino, Trabajadoras sexuales, Enfermedades de transmisión sexual, Control de enfermedades sexuales, Venezuela.

Fecha de Recepción: 20/09/04    Fecha de Aprobación: 18/04/05

INTRODUCTION

Since 1992, Venezuela’s economical situation has deteriorated. Inflation and devaluation have caused companies to lay off employees, and as a result, more women are being forced to turn to prostitution as a means of earning a living, especially when educational opportunity is low and alternative employment scarce(1). This phenomenon is corroborated by the fact that in 1995, the Ministry of Health registered a total of 13.000 Female Commercial Sex Workers (FCSWs) in Caracas(2).

In 2003, this number had almost doubled to 25.000. There are strong indications that there is under- registration of women working in prostitution and that the actual numbers for Caracas might be 150.000. On a national level, the total number is estimated to hover between 500.000- 750.000, almost 4-8% of the total Venezuelan female population (11 million). In addition, some 40.000 children and adolescents under the age of 18 are involved in prostitution networks in Venezuela(2,3).

One of the first studies which quantified the percentage of men who make use of the services of sex workers is the much quoted American pioneer study on human sexuality "Sexual behavior in the human male"(4). They found that 69% of the men they questioned had experience with sex with prostitutes, but that many of them had only had one or a few experiences. Studies done in the United States in the seventies reported a much lower proportion of men who had ever paid for heterosexual contact (30- 45%)(5).

In Venezuela it is estimated that still as many as 30% of male adolescents experience sexual debut with a prostitute. As far as Venezuelan male adults are concerned, 65% of these are estimated to use sexual services of prostitutes on a regular basis(3). FCSWs have indicated time and again to CONTRASIDA that around payday (twice a month) profits are high, as a considerable part of the Venezuelan male population sets aside part of their pay-check to enjoy sexual services. Furthermore, FCSWs have indicated that Venezuelan men comment on their forming part of an extended sexual network consisting of sexual contacts with the wife, fiancé, lover and FCSW. CONTRASIDA has noticed that men, clients of FCSWs or otherwise, demanded access to the workshops on the female condom, stating that they wanted to be informed about the benefits of the device in the prevention of HIV/ STD’s. They requested equal access to the workshops, as they considered it a right to be informed, and showed willingness to assume responsibility in the prevention of the transmission of HIV/ Sexually transmitted Diseases (STD’s).

The analysis of the epidemiological data on HIV and STD’s as prepared by the Ministry of Health reveals that of the 7,350 individuals currently diagnosed with AIDS in Venezuela, 11% are women, and this percentage is rising. Almost 5% of women with AIDS are indicated to be sex workers. However, the majority of AIDS cases among women in Venezuela are diagnosed in the group of housewives, and young female professionals. Indeed, this pattern of infection affirms the sexual network theory noted above(6).

Under registration of HIV/ AIDS is a known fact. The Ministry now estimates that the actual number of AIDS cases is between 20.000-30.000. This would indicate that some 2,000-3,000 women have AIDS, 100- 150 of which are sex workers. The Ministry has also stated that an additional 200.000-300.000 individuals are HIV-seropositive, 20.000-30.000 of which are thought to be women. At least 1,000 to 1,500 of them are expected to be involved in sex work(6). FCSWs are not only at risk for HIV infection; the prevalence of STD’s (Syphilis, Gonorrhea, Human Papiloma Virus, etc.) is rising in this group. In 1995, doctors from the Ministry of Health examined 106.000 FCSWs nationwide and found that 10.000 of them (almost 10%) had sexually transmitted diseases, notably chlamydia, gonorrhea and syphilis. The total number of STD’s diagnosed that year in Venezuela (sex worker and non- sex worker populations) was 105.405, double the number of STD’s detected in 1994. Since 1995, the Ministry has not been able to present a STD update(2).

Considering the above, one might conclude that Venezuela does not have or has a limited HIV/ STD problem, and that FCSWs are only moderately affected. However, as noted above, epidemiological data from the Ministry of Health are to be considered incomplete due to under reporting and registration and in no way provide a realistic estimate of the prevalence of HIV, AIDS or STD’s. For instance, an epidemiological study conducted by CONTRASIDA in the gold mining areas of Venezuela (October 1996) in which 893 individuals participated, the results "clearly demonstrated that FCSWs are at particular risk for STD infection". Syphilis was diagnosed in 30% of all participating sex workers; whereas, in the group of housewife and female health care workers, prevalence was as high as 15%(7).

Selection of the zones where the female condom project was implemented

The female condom project was implemented in the zones of prostitution within the Federal District of Caracas, as well as in Mérida (Andean area to the West) and Nueva Esparta states (to the North) better known as Margarita Island(8). These three federal entities manifest so called "pull’ and "push" factors that are suspected to attribute to the HIV/ STD transmission in their respective FCSW populations and social networks.

Number and social division of participants: Caracas, Mérida and Margarita Island

A total of 435 women participated of which 80% were FCSWs, 10% were housewives and 10% were female students and professionals. The Non Government Organization (NGO): "AMAS +" made a special request to CONTRASIDA to include their members in these workshops. This group is made up of HIV seropositive women nationwide and strives to improve their living conditions as well as defend their human and civic rights. AMAS + considers access to information and access to a healthy sex life to be one of the basic rights of HIV seropositive women. Within this context, CONTRASIDA was invited to present the female condom to the participants of the first national encounter of HIV seropositive women in Venezuela, which was held in Caracas in October 1998. Fifty HIV- seropositive women from different Venezuelan federal entities attended.

Mérida state

A total of 315 women participated, of which 20% were FCSWs, 35% housewives, and 40% were female students and professionals (graduates). Given the fact that the Ministry of Health’s registry shows a high incidence of HIV infection for this latter group, special attention was paid to it. Members of the homosexual community, including transvestites, expressed an interest in the female condom in the context of practicing protected anal sex, and requested participation in the workshops conducted by CONTRASIDA. This group represented 5% of the participants.

Margarita Island

Here, the total number of participants was 250, 50% of which were FCSWs, 10% consisted of housewives. Another 10% comprised female students and professionals as well as employees working in the tourism sector. The remaining thirty percent of all participants were members of fishermen villages of the Macanao Peninsula.

Fishermen populations are considered to be at high risk for HIV/ STD infection. Spending many months at sea with sole access to same sex members evokes what is called "situational bisexual and/ or homosexual behavior" often without condom use. At the same time, the female partners, who are left behind by the fishermen, tend to have sexual contacts with other men, as their steady partners leave them without economic support. Within this context, condom use is also unlikely(8).

CONTRASIDA was first invited to conduct the workshop on the female condom to members, both men and women, of the fishermen association of the Macanao Peninsula. However, during that workshop a female participant commented that in the fishermen village where she lives, Robledal, already 5 persons were diagnosed with AIDS. Robledal only has 1,000 inhabitants. She invited us to come to Robledal and discuss with the community not only the issue of HIV prevention but also the issue of discrimination of HIV seropositive people in general and of women with HIV in particular. The participant had noted that a fisherman with AIDS, still is considered a fisherman and a "macho" at that, whereas a woman with AIDS in Robledal is considered an outcast, a person to be avoided, deprived of marital rights or the right to have children. CONTRASIDA accepted the offer. More than 120 inhabitants of Robledal attended the meeting in which every possible doubt concerning HIV transmission and prevention was clarified. Human and civil rights of those living with HIV were discussed as well.

Logistics of the female condom project

From the very beginning the Caracas based NGO "AMBAR" and the Tropical Medicine Institute of the Universidad Central de Venezuela expressed a desire to cooperate with CONTRASIDA in the implementation of the female condom project. AMBAR defends the rights of FCSWs in Venezuela. It offers legal support to FCSWs, promotes solidarity amongst FCSWs and strives to enforce safer sex techniques in sexual contacts between FCSWs and their partners. The organization also offers courses on self-esteem and human rights(3).

CONTRASIDA and AMBAR have worked together on other occasions in fighting against HIV/ AIDS within the FCSW population. For this specific project, CONTRASIDAs role was to provide (a) the female condom, (b) the accompanying brochure and video tape that explained its correct use and, (c) the specifically designed female condom workshop dynamic(9). For its part, AMBAR agreed to facilitate entry to brothels and STD clinics of mayor activity in Caracas. It also organized two workshops for its 40 health messengers. These health messengers will continue to inform their peers about the female condom after the project has finished, thus ensuring continuity. AMBAR motivated brothel owners to support the project by inviting them to "mini-workshops" about the female condom. These "mini-workshops" were given one week before the workshops, directed to FCSWs working in the brothels, took place. Sensitization of brothel owners is essential for any project concerning prostitution to succeed.

In Mérida CONTRASIDA and AMBAR were fully supported by the NGO SOCIEDAD WILLS WILDE (named after the father of Oscar Wilde). This NGO’s main goal is to prevent HIV infection in homosexual men. WILLS WILDE conducts prevention workshops directed to this group, but also reaches out to the general population of Mérida. The NGO is managed by students of the Andean University and, as such, has access to younger populations, which facilitated our access to this group. WILLS WILDE is also the only NGO in Mérida that has reached out to FCSWs. All brothel visits were already organized upon our arrival and WILLS WILDE organized all 16 of the workshops given by CONTRASIDA and AMBAR.

In Margarita Island CONTRASIDA and AMBAR, were supported by the NGO CRIATEII (Centro Regional para la Investigacion, Atención y Trabajo en Enfermedades Sexualmente Transmisibles, Infecciosas e Inmunológicas). The executive director of CRIATEII, organized all the workshops for the general public and the tourism sector. The chamber of tourism facilitated access to the mass media to ensure that the general public would learn about the efficacy of the female condom(11) in the fight against HIV/ AIDS. The division of the National Found of Science and Technology Research (Fondo Nacional de Ciencia y Tecnología – FONACIT) in Nueva Esparta provided access to the University of that Federal Entity and financed the television and VHS set to show the videotape on the female condom. Regarding access to the settings for prostitution, CONTRASIDA accessed the "world sex guide- prostitution around the world" through the Internet where it found listed all the existing brothels in Margarita Island.

The survey on the acceptability of the female condom

The questionnaire developed by CONTRASIDA evaluated the level of knowledge about the adequate use of the female condom obtained through our workshops and general impressions of this barrier method, as well as the likelihood of its continued use by FCSWs and other female groups in the areas included in the project.

Number and social division of survey participants

A total of 264 individuals participated in the survey, representing 25% of all participants. 159 of those surveyed were FCSWs, representing 60.2% of total survey sample size. Housewives represented 9.8% of survey sample size, female students 5.3%, and health professionals likewise. Individuals not belonging to any of these social categories were classified as "others" and comprised 17% of the survey sample. These were predominantly female police patrol officers from Mérida who had requested participation in the female condom workshop, as well as female lawyers and administrative personnel employed in Caracas. 2.3% declined to answer the question on professional activity.

Sixty- eight percent (68%) of all surveys was conducted in Caracas, 28% in Mérida and 4% in Margarita Island. Prostitution settings in Margarita Island were not favorable to survey implementation, the same applied to the situation encountered in the Macanao Peninsula. Thus we must conclude that representative data were obtained for the Caracas and Mérida areas (in each case more than 20% of all workshop participants), but not for Margarita Island.

Ninety-one percent (91%) of all FCSWs participating in the survey are from Caracas, the remainders of 9% were FCSWs from Mérida. As far as participating housewives and female students were concerned, these were equally divided over the two cities mentioned before. Participating health care professionals were predominantly located in Mérida (85%), and 15% in Caracas. Sixty percent (60%) of the category "other" comprised the earlier mentioned female police patrol officers from Mérida, and 40%, mainly, female administrative personnel, were citizens of Caracas. With the exception of the group of FCSWs from Mérida, all social categories defined in the survey comprise more than 10% of the total number of workshop participants of each sub group, indicating that this survey is representative. This is particularly the case for the group of FCSWs: a total of 481 FCSWs attended the female condom workshops, of which more than 30% participated in the survey.

The questionnaire evaluated ideas and opinions about the female condom, not actual practical experiences obtained through its use. Only 17 participants, all FCSWs from Caracas informed us about their experiences with the female condom after having used the two free samples provided by CONTRASIDA. For them a separate survey was designed. This sample, however limited, represents 10% of all the FCSWs that participated in the general survey.

The high percentage of women of 40 years and older that participated in the survey, expresses a clear interest of this group in HIV/STD prevention and implicates they do not consider themselves free of risk. Statistical data provided by CONTRASIDA’s AIDS information line indicate just the opposite: older women express no personal interest in learning about prevention strategies to avoid HIV/ STD infection. When they call it’s usually to ask HIV related information for somebody else they know. This difference can best be explained by the fact that in our survey 70% of women older than 40 years were FCSWs from Caracas and these have been amply sensitized by AMBAR to the issue of HIV/ STD’s and the need to prevent infection. Nevertheless, housewives represented a considerable percentage, 16%. We noticed that many brought their adolescent daughters to the workshops. This suggests that interest in HIV prevention of the daughters be transmitted to their mothers, though the opposite could also be the case.

Venezuelan AIDS statistics prove older women to be particularly vulnerable to HIV and STD infection: already 20% of all Venezuelan women diagnosed with AIDS are between 40 and 60 years old. Thus, efforts should be made to actively motivate older women in Venezuela to participate in HIV/ STD prevention programs. Our experience shows they are open to it.

Self reported sexual activity and male condom use by FCSWs

Almost 40% of the sex workers that participated in the survey indicated to have 10 to 20 sexual contacts weekly, followed by 26% that indicated to have 21 or more sexual contacts per week. 28%, mostly older FCSWs, had nine or less partners per week. The remaining 6% indicated to have less then 2 partners per week, or declined to answer the question.

Only one third of the FCSWs reported always using male condoms with clients. 43% stated to use the male condom most of the time, and 15% indicated male condom use about half the time. The remaining 8% stated to never use the male condom or to use it less than half the time. 4% declined to answer.

The first part of this report shows there are numerous reasons why male condoms are not always used in prostitution settings. Client refusal is only one of them. The fact that FCSWs can control the use of the female condom could positively influence this situation, but promotion of the use of the female condom alone will not suffice. A multifaceted and coherent HIV/ STD prevention plan for this group needs to be developed. The introduction of a 100% condom policy would be particularly instrumental. The 100% condom program is an attempt to ensure, by administrative means, that condoms are used in commercial sex establishments. These include: mandatory use of condoms by FCSWs with all clients, monitoring of condom use in brothels (e.g. checking of waste baskets), motivating FCSWs to get regular STD check-ups, and, sanctioning brothel owners for non- compliance, which could imply closure of their establishments in case of repeated violations(10).

Such a program should also be supported by a media campaign advising men to use condoms in extra-marital relations. A political commitment, while not a necessary component, can enhance success of the 100% condom policy program.

By housewives, health care professionals and female police patrol officers

More than forty percent of housewives, health care professionals and female police patrol officers participating in the survey indicated to have an average of 2-4 sexual contacts per week, the remainder had 1 sexual contact or none. The overwhelming majority of this group, almost 80%, stated never to have used a male condom. In effect, they had never seen one. 16% indicated to use the male condom about half the time. Only 3.5% stated to use the male condom most of the time. Not one participant of this group used the male condom all the time. 0.5% declined to answer.

The above is particularly disconcerting if we realize that only 4.1% of all women in Venezuela diagnosed with AIDS are FCSWs, almost 96% are young women, female professionals and housewives. Indeed, being married seems to be the greatest risk factor for HIV in Venezuela. Lack of information and inability to negotiate safe sex with their husbands/ partner, causes this situation. In this context the female condom shows clear benefits. It can easily be presented as a contraceptive method, without mentioning male infidelity and fear of HIV/ STD infection.

By female students

Eighty percent (80%) of the female students participating in the survey stated never to have had sex. This concurs with the statements made by young women participating in the workshops expressing interest in the female condom because they were preparing themselves for sexual debut. The 20% that did state to have sexual activity, indicated to have 2 to 4 sexual contacts weekly, 75% of which indicated to use the male condom about half the time and 25% never or less than half the time. We have mentioned before that these young women unanimously stated to have boyfriends who refuse to use a male condom. As a result they consider the female condom as a viable alternative to becoming infected with HIV/ STD or having an unwanted pregnancy.

Knowledge of existence of the female condom prior to workshop implementation

The vast majority or 80% of all survey participants, irrespective of social class or level of education, had never seen a female condom. This was to be expected since CONTRASIDA introduced the female condom in Venezuela only in December 1997. However, almost 50% knew about its existence prior to participation in our workshop and 6% (all FCSWs from Caracas) had had the chance to use it.

Acceptability of the female condom on future use

The great majority of the women who participated in this study recognized the potential advantages of the female condom. These include protection of the vulva; the compatibility with any type of lubricant (water based or oil based); the ability to insert it prior to intercourse; and the ability of women to control, or at least influence, their use. For men, advantages of the device include the fact that it does not constrict the penis, as does a latex male condom, allowing the penis to move freely inside it and sense friction. In addition, the polyurethane membrane better transmits body heat than latex does(11).

More then 70% of all women that participated in the survey thought it would be easy to insert the female condom and 63% opined that it would not cause any discomfort. 30% indicated to believe that the female condom could produce an intense climax, caused by the mobility of the internal ring in the vaginal tract during intercourse. An overwhelming majority of women that participated in the survey, with the exception of one sex worker and one housewife, believe that the female condom can effectively protect them against HIV/ STD’s and unwanted pregnancies.

Considering the above it is not surprising that over 80% of FCSWs participating in the survey stated they liked the device, followed by 66% of the female police patrol officers. 60% of the housewives stated to have a favorable impression, as well as 50% of the participating health professionals and female students.

Furthermore, 75% of the participating FCSWs expressed preference for female condoms over male condoms, and 56% reported that they thought the device would be well accepted by clients as well as steady partners. 73% of all housewives preferred the female condom to the male condom and 65% believed that their husbands would like it. 57% of female students preferred the female condom but only 50% believed the device would favorably impress their boyfriends. 57% of health care professionals preferred the female to the male condom, and as high as 65% opined their partners would like it. Lastly, 77% of female police patrol officers preferred to use the female condom and 53% thought that their partners would be in favor of its use.

However, as much as 18% of FCSWs in the Venezuelan survey opined that their clients would totally refuse the female condom and 20% of female police patrol officers were convinced that their husbands would act in the same way. In these cases safe sex can simply neither be negotiated: neither with the male condom nor with the female condom.

Acceptability of female condom after initial use

A group of 17 FCSWs used the free female condom samples right after these were given to them. After sexual contact with the client was completed they informed us about their experiences with the female condom. All FCSWs were from Caracas and none of them had used the female condom before. 65% of these women were aged 20- 24 years. They were mostly young FCSWs from "Residencia Catania". 35% of the sample were women 40 years and older. These represented FCSWs from the Nuevo Circo area (mature FCSWs), and street prostitutes.

Almost 60% felt it was easy to insert the female condom and the remainder stated that it was somewhat difficult. 59% stated that the female condom did not cause any discomfort, 23% stated it felt somewhat uncomfortable, and 18% were undecided.

These results differ from those obtained through the survey evaluating "future use of the female condom" when some 70% indicated that it would be easy to insert the female condom. Only 8% thought it would be somewhat difficult. In that survey, 63% stated to believe that the female condom would not cause any discomfort, 8% stated to believe it would feel somewhat uncomfortable, 23% could not decide one way or the other, and 6% suspected it would be a totally uncomfortable device.

The conclusion is that 43% of the participants thought that first time insertion of the female condom was more difficult then expected. In addition, 15% of the participants experienced more discomfort than was anticipated, although none experienced total discomfort. However, international studies have indicated that practice reduces these problems.

In 47% of all cases, the penis entered between the device and vagina and in 10% of all cases the external ring was pushed inside the vagina during intercourse. This is best explained by the fact that these FCSWs could not participate fully in the workshop on the correct use of the female condom, because clients demanded sexual attention and interrupted their attention.

In spite of the above, 94% of the FCSWs stated to like the device, 14% higher then when these FCSWs only contemplated using a female condom. As much as 82% expressed preference for the female condom over the male condom. Respondent bias is the most probable cause of this favorable evaluation. Considering that CONTRASIDA was providing the female condom free of cost, the women obviously did not want to be impolite and give a negative evaluation.

The reaction of the clients also influenced the positive evaluation of the female condom by the FCSWs as they reacted far more favorably then FCSWs had expected: 70% of the clients stated to like the device, whereas FCSWs thought that only 56% would do so. In addition, all FCSWs opined that the female condom would protect them against HIV and STD’s.

Innovative uses of the female condom as indicated by FCSWs

80% of the FCSWs surveyed recognized the known advantages of the female condom such as its ability to protect the vaginal tract and vulva, its compatibility with any type of lubricant, the ability to insert it prior to intercourse and the ability of women to control its use. However, during the workshops, FCSWs discovered innovative uses of the female barrier method that were heretofore unknown.

Use of the female condom during menstruation

FCSWs indicated to CONTRASIDA that menstruation frustrates their working schedule, because menstruation inhibits sexual contact with clients. Thus menstruation represents loss of income for an average of one week per month. For many FCSWs this is an unacceptable situation. As a result they have resorted to insertion of cotton rolls and sponges into their vagina to halt the flow of menstrual blood. This indeed enables them to continue working, but all agree that it is not very hygienic.

Menstruation also causes problems in the personal sphere. Most family members of Venezuelan sex workers are not aware that their spouse, mother, daughter or sister works in prostitution. Consequently sex workers find it hard to explain to family members why, once per month, and always during menses, they stay at home. FCSWs were quick to point out that the female condom solves both problems: it permits a totally hygienic sexual contact, where there is no contact what so ever between menstrual blood and the penis of the client, and sex work can be continued throughout the month.

The female condom as a means to practice hygienic sex in the absence of water

In low paid prostitution settings, working conditions are extremely poor, and most clearly defined by the fact that water is not available. Only the female condom permits FCSWs working in these settings to offer sexual services in a way that is safe and hygienic to both sex worker and client.

Use of a single female condom during consecutive sexual contacts with the same client

FCSWs informed CONTRASIDA that they prefer to end the day by picking up a client "to wake up with". Such a client pays well for sexual services offered all through the night. Revenues may amount to US$ 150 to US$ 200, FCSWs where quick to point out they would only have to use one female condom with such a client. They realized that a single female condom would effectively protect them against HIV and other STD’s, no matter how many times the client requested vaginal sex. A male condom, on the other hand, needs to be replaced after each and every ejaculation.

The female condom as a tool to diminish the possibility of unprotected rape during sex work

Nights with clients have intervals where the FCSW falls asleep and it is not uncommon for clients to abuse the lowered state of consciousness of the FCSW, penetrating her without protection. This is in effect rape during work. Venezuelan FCSWs believe that the female condom diminishes the probability of unprotected sex during a "to wake up with" deal, because once the female condom is correctly inserted, the FCSW will be protected even when the client tries to penetrate her when asleep. The possibility of unprotected sex or rape is further diminished by the fact that it is virtually impossible for the client to remove the female condom unnoticed.

The female condom as causal agent of orgasm in the context of sex work

Time and again Venezuelan sex workers have told CONTRASIDA that they do not experience orgasm in sexual contacts with clients. A total of 159 sex workers participated in the survey (30% of all participating sex workers) and during follow up 14 (10%) of these stated to have experienced orgasm when using the female condom. Orgasm was experienced in two different ways: internal and external. Internal orgasm was reached because the internal ring of the female condom moves up and down in the vaginal tract during intercourse, thus stimulating the "G" point. External orgasm was reached by allowing the client to touch the clitoris indirectly, by massaging the part of the female condom that protects the external labia. Sex workers emphasized that the clitoris normally is off limits to clients, for reasons of hygiene. Only the protection offered by the female condom made them allow the clients to touch it.

During the workshops, CONTRASIDA had noticed that female health care professionals, and especially MD’s, do not consider themselves to be at risk for HIV/ STD infection. The economical and social well being of this group creates the feeling that HIV can not affect them personally and this explains why they are not willing to pay that much for the female condom. Note the high percentage of female students that are willing to pay up to US$ 3.50 for the female condom (92%). An additional 8% is prepared to pay even more. Undoubtedly, this is due to their perceived high risk for HIV infection and fear of unwanted pregnancy.

Remarkable is also the reaction of the housewives, who are almost just as motivated to purchase the female condom at high cost as the group of FCSWs is. These women indicated to CONTRASIDA that they were aware that their husbands had extra marital affairs, but that the introduction of the male condom in their marriage was virtually impossible, as this would suggest infidelity on their part. We have mentioned earlier that the female condom can easily be presented as a contraceptive method, without mentioning fidelity and HIV/ STD- issues.

DISCUSSION

A study conducted in the Netherlands in 1991(5) indicated that 2.8% of five hundred 18 to 50 years old heterosexual men reported having had contact with a prostitute in the previous year. Half of these men had a steady partner. 13.5% reported ever having paid for sex. In a pilot study on the sexual life style of the British between ages 16 and 64, the data indicated that only 3.6% of the men had ever paid for sex. In this British study in which respondents were recruited at their workplace found that 6.4% of the men had ever gone to a prostitute(5).

A sample of men in Lisbon showed older men having had their sexual initiation with a prostitute more often (25%) than younger men (3.5%). In the year preceding the interview, 7.6% of the men living in Lisbon had been to a prostitute. The decline of the extent to which men experience sexual initiation with prostitutes points to a change in the sexual morals in many Western countries in the last decades(5).

All show a marked rise of prevalence of HIV and in women in particular

At the national level the Federal District of Caracas shows the highest prevalence of AIDS (162 cases per 100.000 inhabitants, and a total of 3,699 cases diagnosed until June 1998), followed by Margarita Island (33 cases per 100.000 inhabitants, and a total of 116) and Mérida (25 per 100.000, total 180). Rise of HIV is particularly alarming among young women, and especially in those studying at the universities located within the federal entities selected for the study (MSAS, 1998). The Ministry of Health(6) suspects that young women at university practice sex work in order to be able to pay for their education (pull factor). These young women are at great risk for HIV/ STD infection because they work independently of each other and do not: (a) have access to information about safe sex, (b) interchange information with colleagues, and (c) admit they are practicing sex work and, (d) seek medical check- ups.

Some entities border areas with high incidences of HIV/ STD’s

Mérida is situated closely to Colombia. The current economical crisis in Colombia (devaluation of the peso by 10%) promotes migration of women to Venezuela in search for better living conditions (push factor). Most of them end up working in prostitution. Colombia does not have a mandatory STD control system for FCSWs, thus Colombian FCSWs that come to Venezuela have a higher probability of being infected with HIV/ STD’s. Once in Venezuela, illegal status and fear for deportation, prevents them from actively accessing STD clinics.

Margarita Island has become a sex-tourism spot and, as such, represents a source of hard currency income for women of the lower social classes in Venezuela (pull factor). Although popular notion has it that clients of FCSWs in Margarita Island are mostly foreigners who are sensitized to condom use, there are indications that the opposite is the case. Foreign men are under the impression that HIV/ STD’s are not a problem in Venezuela and therefore condom use is not necessary in FCSW settings.

All entities show a boost in economic activity with implications for HIV/STD transmission

Mérida, besides being a mayor food and cattle producing state, functions as a go- between state between Colombia and the rest of Venezuela- all merchandise coming from Colombia has to be transported over the Mérida highways to other parts of Venezuela and vice versa. The importance of attracting and expanding tourism on Margarita Island for state revenues is obvious. In both cases economic activity is followed by a rise in prostitution (pull factor).

These entities suffer from the presence of other diseases of epidemic proportions

From a public health care and political point of view, the treatment and prevention of equine encephalitis and dengue in Mérida, Margarita Island and Caracas, are considered to be more important than the adequate diagnosis, treatment and prevention of HIV/ STD’s (push factor). None of these federal entities have a comprehensive education plan directed to HIV/ STD control, neither for the general public nor for FCSWs and their social network.

Already as many as 500.000-750.000 women in Venezuela, or 4-8% of the total female population, work in prostitution. In addition, 65% of Venezuelan male adults (almost 5 million) access commercial sex on a regular basis. As condom use is still limited in both groups, they form an important part of the infrastructure along which HIV spreads in Venezuela. In order to curb the impact of HIV/ STD in the Venezuelan society in general, HIV/ STD prevention programs should give priority to FCSWs and integrands of their sexual network.

CONTRASIDA’s study has shown that working with FCSWs always implies the promotion and the defense of human rights of this group. In other words HIV/STD prevention messages directed to FCSWs, such as the promotion of safer sex techniques through the consistent use of male and female condoms, can never be presented separated or isolated from human and civil rights issues. Any NGO that professes to work to the benefit of FCSWs, without expressing a clear spirit of activism, will fail.

This study shows that the "prostitution setting" is of direct influence on the acceptability of the female condom, and on how this acceptability is defined. The prostitution setting also determines affordability of the female condom. Campaigns directed at the promotion of the use of the female condom among the group of FCSWs, should realize this and adapt its messages accordingly.

The female condom received wide scale positive reactions among FCSWs as well as other groups of women that participated in the project in Caracas, Mérida and Margarita Island. They were enthusiastic to use it. CONTRASIDA’s study shows that contemplating future use of the female condom results in extremely positive evaluation of the product. Upon using the product for the first time, these positive evaluations are tempered due to complications, presented especially during insertion of the device and upon penetration. However, studies have indicated that continued use of the female condom diminishes these problems by 25%. In other words, practice and experience result in correct use of the female condom. In order to avoid that women discard the product out of frustration, they should be informed that using the female condom correctly is a learning process.

The high price set by Venezuelan pharmacies is the main obstacle for the continued use of the female condom, with the exception of Isla Margarita where the most important obstacle is accessibility of distribution outlets of the female condom. Affordability of the female condom can be safeguarded by government policies that set limits to its pricing. FCSWs believe that the female condom offers specific advantages in the context of sex work and empowers them to remain free of HIV/ STD infection.

Venezuelan men and clients of FCSWs in particular, are excluded from current HIV/ STD prevention campaigns. Given the amount of men accessing FCSWs and the fact that they form part of an extended sexual network through which HIV/STD can easily spread, all should be done to reach this group with effective HIV/STD prevention messages.

Such a campaign should focus on sexual rights of men, e.g. the right to have access to adequate information on how to prevent HIV/ STD infection, instead of blaming men for the spread of HIV/ STD’s(12,13). CONTRASIDA has noticed that men, clients of FCSWs or otherwise, demanded access to the workshops on the female condom, stating that they wanted to be informed about the benefits of the device in the prevention of HIV/ STD’s. They requested equal access to the workshops, as they considered it a right to be informed and showed willingness to assume responsibility in the prevention of the transmission of HIV/ STD’s.

Such a campaign should also respect cultural values, focusing on the positive aspects of machismo rather then insisting on the negative impact of this phenomenon on the Venezuelan HIV/ STD epidemic. For example, a message like "a macho" man knows how to protect himself and his partner from HIV/ STD infection" invites men to behavioral change.

At least 15% of all FCSWs in Venezuela are women from the Dominican Republic(3). These migrate throughout the Caribbean Basin Area including the Netherlands Antilles and Venezuela, in search for better living conditions(14). HIV/ STD’s do not respect territorial boundaries and this implies that the implementation of HIV/ STD prevention strategies(15), such as the promotion of the female condom(16), should not be limited to Venezuela only, but be extended to the areas mentioned above. This would also be in accordance with the objectives of the UNAIDS.

references

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