sex work, and HIV in three South African cities
Leggett, J.D., M.Soc.Sci.
School of Development Studies
University of Natal, Durban
This study was designed to test the hypothesis that a positive
association exists between HIV infection and drug use among
commercial sex workers in South Africa. Since heterosexually
transmitted HIV has become one of the most serious threats to
development in the country, it is crucial to define any impact
that the growing illicit markets for sex and drugs may have
on HIV prevalence. Prior to this study, the connection between
these phenomena in South Africa had never been assessed.
Due to the
lack of available data in this area and the urgency of the situation,
a small, low-cost assessment was conducted. Using a short questionnaire,
a total of 349 female street sex workers were interviewed in
the three largest cities in South Africa-Johannesburg, Cape
Town, and Durban. The saliva of 249 of these women was submitted
to GAC Elisa testing.
to expectations, an inverse relationship was found between hard
drug use and HIV serostatus. While drug-using sex workers did
have higher client volumes, they had lower levels of HIV than
nonusers did. This may be due to the fact that most of the drug
users were white, while HIV is most severe in the black community
in South Africa.
Brief History of Drugs in South Africa
Prior to 1994, many of the street drugs most common internationally
were not readily available in South Africa. In particular, cocaine
and heroin use was not widespread. In their place, certain drugs
were abused in South Africa that saw very little popularity
overseas. Mandrax and Wellconal were the two hard drugs commonly
used or abused by sex workers in the late-apartheid era.
is sold in tablet form but is crushed and smoked in a combination
known as "white pipe." It provides a short-term "rush"
during which users lose control of their bodies (including muscular
collapse and drooling), followed by a prolonged feeling of intoxication.
Wellconal (known as "pinks" on the street, for the
pink color of the tablets) is crushed, dissolved in water, and
injected. It also provides a rush, in addition to opiate effects.
Both drugs are considered addictive, but have a natural "saturation
point" in any given period of time.
of these drugs is particularly well-suited to use during sex
work. While Mandrax has a disinhibitory effect, it impedes coordination
and judgment in much the same way as alcohol does. Wellconal,
like other opiates, makes human contact uncomfortable. Despite
the fact that it comes in pharmaceutically regulated doses,
"pinks" tend to kill off users for no apparent reason,
perhaps due to the fact that they are injected with unsterile
water. As a result, a strong stigma exists against injection
drug use in South Africa.
borders opened following the first democratic elections in 1994,
crack cocaine was introduced to the sex work industry. The first
police seizure of crack occurred in Johannesburg in 1995. The
drug was not seen in Durban until 1996. Crack immediately began
to displace Mandrax as the preferred hard drug of choice among
inner-city sex workers in all three of the largest cities. Mandrax
is still used by many users to "come down" following
a crack binge, or sometimes in combination with crack.
been slower to gain popularity, perhaps partly due to the stigma
against injection. Indeed, in the areas where it has emerged,
use has largely been limited to smoking in combination with
cannabis or the "chasing the dragon" technique of
vaporizing the drug on aluminum foil. Since the same syndicates
control the markets for both crack and heroin, it may be that
dealers are not pushing heroin as strongly as crack due to its
lower profitability. Heroin has become most popular among white
youth and among white sex workers in Johannesburg. It is marketed
to sex workers as a come-down drug for crack cocaine.
also be noted that South Africa is a major producer of high-quality
cannabis, which is in common use among most ethnic groups and
social classes. Total alcohol consumption is moderate by international
standards, but this is due to a large number of teetotalers
among the black majority. Alcohol abuse is common and consistently
heads the list of problem substances seen in rehabilitation
From the above, it should be clear that South Africa does not
have a major injection drug use problem at present, although
the potential exists for the rapid spread of such an epidemic.
However, it does have a large and growing problem with crack
cocaine, especially among sex workers. Research from another
country with both HIV and crack problems-the United States-indicates
that crack use may be as closely associated with HIV as injection
drug use due to its association with high-risk sexual behaviors
(Ross et al. 1998). There is also conflicting evidence about
the effects of intoxication from drugs and alcohol during sex
work on the ability of sex workers to negotiate safer sex practices,
with some studies finding an impact and some not.
It was hypothesized
that the association between crack and HIV would hold true in
South Africa as well. Previous research (Leggett 1999) suggested
that crack users are compelled to maintain higher client volumes
to ensure adequate income, increasing the chances of exposure
to HIV. Additionally, the compulsion of addiction might lead
to a willingness to engage in unsafe sexual practices in exchange
for more money, and anecdotal evidence from street sex workers
interviewed in the past indicates that this is indeed the case.
It was also suggested that addicted sex workers are less likely
to bother to clean themselves between clients and generally
suffered from diminished hygiene, which could have an impact
on HIV transmission. Crack users were also viewed as more reckless
in their client choice and more likely to be raped, thus having
a greater chance of suffering violent intercourse that could
lead to blood-to-blood contact.
of the men who patronize crack-using sex workers also use the
drug, the effects on their sexuality are also relevant. Sex
workers interviewed stated that crack made men more violent.
It led to impotence, with the resulting frustration sometimes
ending in violence, including rape, once an erection was achieved.
It was also suggested that men on crack found it difficult to
achieve orgasm, which meant sexual sessions could be prolonged,
leading to increased wear and tear on the sex worker.
these arguments would also hold true for Mandrax, heroin, and
pinks, given that these are all strongly addictive drugs. It
was also hypothesized that other intoxicants, if used during
sex work, could cloud judgement and reduce self-control. Additionally,
although all data prior to the study suggested that intravenous
drug use was not widespread among sex workers, if the contrary
were to be found then it could clearly have an impact on HIV
in South Africa
It is generally agreed that HIV is primarily heterosexually
transmitted in South Africa, and that South Africa has one of
the fastest growing HIV epidemics in the world. As Figure 1
demonstrates, antenatal testing shows that HIV prevalence is
highly regionalized. On the low end, the Western Cape (where
Cape Town is located) displays antenatal rates of about 8 percent.
KwaZulu-Natal, where Durban is located, has rates of nearly
33 percent. The third site, Johannesburg, is in Gauteng, where
the rate is 24 percent.
1: Antenatal HIV rates by province
antenatal prevalence rates by ethnic group are no longer released
due to low numbers of nonblack subjects, early figures showed
the disease disproportionately impacting the black community.
Apartheid-era legislation forbade sexual contact between certain
delineated ethnic groups, and while such contact is no longer
prohibited, prejudice and ingrained social and cultural divisions
regionalization and ethnic specificity, any practice that serves
to promote sexual contact between people of different provinces
or different ethnic groups, such as sex work, is of great interest
to researchers. Despite the pressing need for such information,
very little research into sex work and HIV has been conducted
and it is presently impossible to gauge whether sex workers
contribute significantly to the spread of the disease. No study
has attempted to determine the extent of drug use among sex
workers nationally, or the effect drug use might have on their
As a "hidden" population, it is extremely difficult
to estimate the total number of female street sex workers operating
in the major urban areas of South Africa. Previous studies (Leggett
1999) have used the "tag and release" technique by
tallying the number of re-arrests recorded in police records,
but there are many flaws to this approach.
resources, it was decided to make use of the expertise of authorities
proficient in working with sex workers in each of the three
cities, and these experienced individuals administered the questionnaires.
As the nature of street sex work requires that the sex workers
congregate at specific areas where customers know to find them,
a sampling of all known street sites was seen as the best way
of obtaining a fair cross section of the population.
ethnic categorizations imposed during apartheid, the overall
study sample was just over 50-percent black, just over 38-percent
colored, over 8-percent white, and less than 3-percent Indian.
This small Indian sample, drawn exclusively from Durban, was
too small for separate analysis. The ethnic mix varied sharply
by region, with the Cape Town sample being largely colored and
black, Johannesburg being mainly black, and Durban being more
varied. These samples were considered by the interviewers to
be representative of the overall sex work population in each
area, although the Johannesburg sample was drawn exclusively
from the inner city and does not represent the sex work population
of the city as a whole.
ages ranged from 10 to 53 years old. Half the population was
under 24, and over 10 percent were underage (less than 18 years).
All but one of these children was black or colored. On the other
end of the scale, almost a quarter of the interviewees were
over the age of 30. Most of the older women were white or colored.
sample was notably younger than the other two, which is most
likely due to its ethnic composition. In Cape Town, the mean
age was 27, the median 25, and the mode 19, with a standard
deviation of 7.8. In Johannesburg, the mean age was 24, the
median 23, and the mode 18, with a standard deviation of 6.5.
The Durban sample had a mean age of 27, a median of 26, a mode
of 23, and a standard deviation of 6.6.
Town sample, while the largest and most geographically diverse,
may suffer from a certain amount of redundancy in that the several
individuals were re-interviewed in the second (saliva-linked)
set of interviews. It appears that nearly all the sex workers
at several sites were interviewed.
It is impossible,
given the imbalances discussed, to generalize about the sex-working
population as a whole on the basis of this sampling. But it
is possible to draw conclusions about the differences between
drug-using sex workers and their abstinent colleagues in each
of the urban centers.
As HIV in South Africa is so highly regionalized, the home origins
of these women are extremely relevant to a discussion of their
HIV status. Analysis of home origins shows significant amounts
of migration, including migration from higher HIV areas to lower
ones (e.g., from Eastern Cape to Western Cape or from KwaZulu-Natal
to Johannesburg). One of the unexpected findings of this survey
was the high number of sex workers in each city originating
from the Eastern Cape. Over 40 percent of Johannesburg sex workers
were from either Port Elizabeth, East London, the former Transkei,
or other parts of the Eastern Cape. Durban was the second largest
contributor of sex workers to the Johannesburg Central Business
District (CBD), with nearly a 20 percent share. Only a small
minority (6 percent) claimed Johannesburg as their hometown.
The same is true to a lesser degree in the Durban inner city,
where 14 percent said they were from Johannesburg, and 14 percent
from Cape Town. Similarly, in Cape Town, 47 percent of the women
polled were from outside the metro area. A surprising number
of women working in Cape Town were from small towns throughout
the country, but especially from the Western and Eastern Cape.
showed the greatest range of housing options, with women often
living together with a large number of housemates in a free-standing
home. The Johannesburg sample was almost entirely housed in
daily accommodation hotels in the immediate area of the interview.
Seventy-five percent of the sex workers in the Durban CBD resided
in residential hotels, while a similar percentage of black women
interviewed outside the inner city resided in informal settlements.
about illegal activity is always problematic, particularly when
the subject is as intimate as sex work. Nonetheless, the women
interviewed were quite forthcoming about their practices, and
this was facilitated by the experience of the interviewers in
working with this population group. Certain response areas should
be treated with some skepticism, however, and the motivations
of the sex workers must be kept in mind at all times. Some women
clearly exaggerated their popularity and income as a way of
emphasising their desirability, while others minimized their
participation in the market due to modesty.
the modal trends reflected a credible pattern of business activity
for the average street sex worker, or rather, two patterns.
A distinction needs to be made between inner city sex workers,
who tend to be lighter in complexion, and more remotely based
women report being in the business for shorter periods of time
than the other groups, with 58 percent having been in business
two years or less. Only 26 percent of the white women were so
recent to the business.
20 percent of the women reported having only one to five acts
of vaginal sex with clients per week, but this figure is heavily
skewed by statistics from poorer black women in more remote
areas. Thirty-one percent of black women had five or fewer clients
per week, compared to 16 percent of white women and 7 percent
of colored women. On the other extreme, 16 percent of white
women reported more than 30 clients a week, compared to 15 percent
of coloreds and 13 percent of blacks.
be expected, client volumes were tied to drug use. Only 16 percent
of those women who had less than 10 clients a week used hard
drugs, while 43 percent of those who had more than 20 clients
a week had a drug habit.
were also racially skewed-over 75 percent of white women reported
charging over R90 (U.S. $13) for vaginal sex, while 83 percent
of black women charged less than that. As a result, over half
the white women surveyed reported making over R1,500 (U.S. $218)
per week, while 80 percent of black women reported earning less
than R500 (U.S. $23) each week.
were understandably reluctant to admit to unsafe sexual activity,
although many eventually did so with some coaxing. Twenty-eight
women, or about 8 percent, admitted to occasional condom-free
sex with clients, at least for oral sex. Eighty-two percent
of this group were black women, and 78 percent of this group
were HIV positive. Over 70 percent of these cases were found
in Durban, but this likely has more to do with interview technique
than actual prevalence.
would seem to call for greater HIV education among the black
community, but other studies have assessed the general knowledge
levels of the disease to be high among this grouping (Varga
1997), and attribute inconsistent condom usage to sociocultural
factors and gender-related coercion.
or under 3 percent, admitted to performing anal sex with clients,
but there did not appear to be any special correlation with
ethnicity or HIV status in this category.
All of this
must be weighed against the fact that over 70 percent of those
sex workers with boyfriends said they did not use condoms with
these partners, and that over a third of these men were using
drugs other than alcohol.
were the number of women who reported not using any form of
contraception other than condoms (50 percent), as the women
interviewed indicated a high rate of condom breakage. Although
this information was not directly solicited, there were many
complaints about government-issued condoms, including the fact
that they were generally too small and thus subject to breakage.
of the sex workers contacted were pregnant at the time of the
interview or had recently given birth. One sex worker indicated
that crack use caused amenorrhea, and that users would only
become pregnant following a period of incarceration.
The sex workers were questioned about which drugs they used,
how much they used, how often they used them, when they used
them, where they used them, and how much they spent on a single
session of use. A question aimed at understanding whether certain
substances were used prior to entering into the field of sex
work was invalidated due to early misapplication.
considerable difficulties in acquiring accurate information
on drug use via self-reporting. Nonetheless, the responses from
the sex workers with regard to drug use formed a consistent
pattern. White, high-income, high-client-volume, inner city
women reported high levels of drug use, while poorer, black
women in more remote areas did not. Higher income colored and
Indian women in inner city areas tended to follow the white
pattern, while those in more remote areas followed the black
be expected, there was a strong link between drug abuse and
ethnicity. Eighty-one percent of the white women interviewed
reported at least weekly use of crack or Mandrax, as compared
to 25 percent of colored women and 6 percent of black women.
considerable regional variation between reported drug abuse
prevalence. Twenty-six percent of Cape Town interviewees, 14
percent of Johannesburg interviewees, and 41 percent of Durban
interviewees reported using "hard drugs" (drugs other
than alcohol and cannabis, generally Mandrax or crack) at least
occasionally. With regard to frequency of use, 73 percent of
those who said they had ever smoked cannabis said they currently
did so "daily" or "frequently," compared
with 72 percent of lifetime Mandrax users and 81 percent of
crack users who were current daily or frequent users. A further
20 percent of lifetime Mandrax users and 7 percent of lifetime
crack users said they had quit using the drug after a period
of at least weekly use. Thus, the women were sharply divided
between those who had never tried drugs, those who used them
chronically, and reformed chronic users. Very little casual
use of hard drugs was seen. For the purposes of this analysis,
a "hard drug user" is considered anyone who uses or
previously used either Mandrax or crack cocaine regularly.
reported heroin use and three women reported "pinks"
use, and only one of these women reported daily use of each
drug. All six of these women were white, and only one (a "monthly"
user of pinks) was HIV positive.
variation in numbers of interviewees reporting drug use may
have been due in part to interview technique, but is largely
attributable to sampling. For example, the Johannesburg sample,
although drawn from a notorious drug area, was 86-percent black.
Of the 12 white women who were interviewed in Johannesburg,
eight admitted hard drug use.
of the three metro regions there were pockets of women in which
no interviewee reported using drugs. This was in line with expectations-some
of these areas are remote from any known drug outlets. There
were also areas where reported drug use was very high. In the
Durban CBD, 75 percent of the women reported the use of drugs
other than alcohol and cannabis.
a very strong relationship between the sex worker's place of
origin and her likelihood of using hard drugs, regardless of
interview site. Nearly 65 percent of women originating from
Johannesburg reported hard drug use, as did 60 percent of women
from outside South Africa. Women originating from Durban (18
percent), rural areas (19 percent) and the Eastern Cape (8 percent)
were far less likely to report using drugs.
two-thirds of the women reported using alcohol, with 38 percent
reporting drinking more than three drinks at a sitting. Dagga
is the most commonly consumed illegal drug, with 26 percent
of the women admitting some use, and 18 percent reporting daily
use. Twenty-three percent of the women reported using alcohol
before working, and 15 percent used dagga before or during sex
a significant relationship between use of hard drugs and high-client
volumes, with about half of the nonusers having 10 clients a
week or less, and 44 percent of the users having more than 20
clients per week. Clearly, a drug habit requires greater client
numbers in order to fund the addiction.
value for crack use was 10 rocks, or R500 worth of crack, per
night. This total cost may not come from the women's income,
though. Many women have effectively shifted out of full-time
sex work into the business of procuring drugs and providing
company during drug use. About one quarter of the women reported
having over 20 percent of their clients requesting drugs. Sometimes
these requests also included sex, but many others were more
requests for "company." This often involved disrobing
and the occasional attempt at oral sex, but the inability of
most men to attain an erection while high on crack or Mandrax
made sex-to-orgasm very rare in these encounters.
a significant relationship between the number of years spent
in sex work and hard drug use, with women in the business for
more than 4 years being more than twice as likely to use hard
drugs as women who have entered the field in the last year.
This suggests that drug use is adopted as a coping mechanism
to deal with the work, and eventually becomes an important reason
for staying in the business.
and drug use
This research was commissioned principally to test whether a
positive association exists between use of hard drugs and HIV
seroprevalence among commercial sex workers in South Africa.
This was not found to be the case. Hard drug users were actually
less likely to be HIV positive (27 percent) than nonusers (56
negative relationship was found between self-reported drug use
and HIV status among arrestees in South Africa by Parry et al.
(1999). Parry noted the high tendency to deny drug use as one
possible explanation for this finding. In the present study,
however, levels of drug reporting are much higher in areas where
this would be expected and denials of drug use generally correspond
with low-income levels. For example, in the Durban CBD, 75 percent
of the women admitted to hard drug use, but 70 percent of the
hard drug users were HIV negative, while half of the nonusers
tested positive. This can be compared to those interviewed in
the Durban suburbs of Chatsworth and Wentworth, where the mean
income was R357 per week; none of the women in this area reported
using drugs, and 67 percent tested positive for HIV.
A far more
accurate predictor of HIV seroprevalence within this population
is ethnicity. Black sex workers show substantially higher levels
of HIV than other ethnic groups. Over 66 percent of black sex
workers in the sample were HIV positive, compared to 18 percent
of whites and 17 percent of coloreds. Areas of sex work that
were exclusively or almost exclusively black had by far the
highest rates of HIV. One drug-free location truck stop contributed
disproportionately to the HIV rate for Cape Town. All the workers
tested at this site were black, and none of them reported using
drugs. Of the 11 women tested at this site, 10 were HIV positive.
Most reported weekly incomes of between R150 and R200. This
group comprised nearly half of the 21 women who tested positive
in Cape Town.
association between ethnicity and HIV status seems to be behind
the inverse relationship between HIV and drugs, as whites (71
percent) and coloreds (42 percent) are more likely to use hard
drugs than blacks (10 percent). Even within an ethnic group,
however, use of drugs makes no difference in HIV status. Isolating
just the black sample showed equal portions of drug-user types
tested positive (66 percent). Drug use within this population
apparently has no bearing on whether the individual is HIV positive
or not. Similar tests could not be run for other ethnic groups
due to lack of sufficient numbers. However, combining all nonblack
sex workers into one category likewise showed no relationship
between drug use and HIV.
an analysis of variance (ANOVA) on the results, with HIV as
the dependent variable and race (excepting the small Indian
sample) and drug use as dependent variables, showed that race
is highly associated with HIV, drug use is not, and the interaction
between race and drug use is not significant (p = 0.057).
is precisely the sex workers least likely to be using drugs-the
poorest black women-who are most susceptible to HIV/AIDS. These
are also, ironically, the women with the lowest client volumes,
as there appears to be an association between high-client volumes
and drug use.
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