Sex workers operating in East Africa are generally aware of the HIV risks of unprotected sex, but for many of them, the extra cash incentive clients often offer for sex without a condom is worth the risk.
"I personally don't care about HIV when I see someone who can offer big money for one hour of sex," said Scola Ndyigiza, a sex worker in the capital, Bujumbura. "I can get 100 dollars from one client when I have unprotected intercourse with him. Imagine, when I get more than five visitors a day, I become rich and pay all my debts... when I try to get them to use condoms, I get less than that."
According to Basilisa Ndayisaba, coordinator of local NGO Society for Women against AIDS in Africa (SWAA-Burundi), which raises awareness among sex workers on condom use and HIV risk, despite their best efforts, many sex workers in Bujumbura remain apathetic about condom use.
"We face cases of those [sex workers] who agree to protect with condoms but others come to tell us that they have failed to use it or just have forgotten it," she said.
According to UNAIDS, more than 70 percent of Burundi's sex workers have been reached with HIV prevention messages. However, according to the country's latest progress report for the UN General Assembly Special Session on HIV/AIDS, HIV prevalence among sex workers remains very high, at about 38 percent, compared to the national average of 3 percent.
In Kenya, preliminary results of a study conducted in the capital, Nairobi, by the University of Nairobi - due to be released in 2011 - reveal that 900 out of 2,978 sexual encounters experienced by 161 sex workers surveyed, were unprotected.
The main reasons for failing to use a condom were given as client violence or promises of extra cash for unprotected sex.
Of 143 commercial sex workers tested for HIV, 39 returned positive results, representing an HIV prevalence of 27 percent, significantly higher than the national average of 7.4 percent. The 39 HIV-positive sex workers had a total of 177 unprotected sexual encounters during the study period.
"I can't lie that I don't know how important condoms are - I know. But I can't count how many times I have slept with men without it, not because I like it, but some men tell you they like it without a condom," said Eunice Mueni, 23, who plies her trade in Nairobi. "If you refuse, they beat you; some tell you they will give you double money. You fear being beaten and you like more money also, so you are in a dilemma and you just give in."
According to Elizabeth Ngugi, lead author of the study, sex workers often find it hard to negotiate safe sex. "They might have the information on the need for safe sex, but when commercial sex workers are faced with violence they cannot negotiate for that safe sex and hence many of them reporting unprotected sex," she said.
"Further, because they are desperate for money, it is hard for them to put off a man who wants unprotected sex and promises to pay more," she added.
Ngugi noted that the neglect of sex workers by HIV programmes meant they were not always equipped with the skills to reject unprotected sex.
"If they are not treated as human beings, then they wouldn't even listen to the messages. Everybody - including commercial sex workers - must be treated as critical partners in HIV prevention," she said. "Young commercial sex workers are naïve and they have neither the skills nor the courage to negotiate safe sex."
Bringing violent men to justice is often out of the question due to the illegal nature of sex work, and according to sex workers, their tormentors are sometimes officers of the law.
"One time I met a client and he told me he will to do it without a condom - I tried to negotiate and he just removed a gun and placed it inside my mouth saying he would blow out my brains," said Mueni. "You can't reason with such a person."
"Some tell you they are police officers and they will arrest you because you are engaging in crime," she added.
Poverty is one of the main reasons women are forced to put up with violent men and take HIV risks. Burundi, for example, is one of the world's poorest countries, with more than 80 percent of the population living on less than US$1.25 per day, according to the UN Development Programme.
SWAA-Burundi has come up with a scheme to provide sex workers willing to leave the trade with small loans to start businesses. Jacqueline Kanyana gave up sex work and now runs a successful business that grew from selling mobile phone airtime to selling clothes and food in Bujumbura.
"Imagine that I get HIV when I am poor and I have children to take care of," she said. "I decided to stop unprotected intercourse because I need to... prepare my future."
"Now I can go in Kampala or Nairobi to bring goods that I sell in different markets in Bujumbura," she added.
But SWAA-Burundi officials say the loans are often unsuccessful, especially given that the women have little or no knowledge of basic business and accounting skills. "Some of them can't use the loans properly and come back to us saying that they failed to use the money in business," said Ndayisaba.
"What we do for them for the moment is to go on sensitizing them on the importance of protection and we even deliver to them condoms to protect them; sometimes we organize seminars to teach them and at the end we deliver educational kits to let them know much about AIDS," she added.
But according to Nicholas Muraguri, head of Kenya's National AIDS and Sexually Transmitted Diseases Control Programme, educating the sex workers without doing the same for their clients only deals with half the problem.
"Of course it would be difficult to convince people to agree that they should not seek services from commercial sex workers, but the best places that you would reach such people with prevention messages are drinking joints, because those who patronize such places are the most likely to seek sexual services from commercial sex workers," he said.
"It would be generally useful to make people see the need to use condoms with all their sexual partners, including commercial sex workers," he added.
This article was produced by IRIN News while it was part of the United Nations Office for the Coordination of Humanitarian Affairs. Please send queries on copyright or liability to the UN. For more information: https://shop.un.org/rights-permissions