New research from Somalia has debunked the long-held view that discussions about sex are off-limits in this conservative nation, opening the door to a deeper understanding of sexual behaviour patterns and the possibility of more tailored prevention strategies.
"It's not so much the 'what' of the message as it is the 'how'," said Adrienne Testa, lead researcher in a recent study by the International Organisation for Migration (IOM). "Choice of researchers is key: in the Somali context we found that women who are familiar with the community did very well; men found it acceptable to talk to female researchers and were open about the risk behaviours they engaged in."
Somalia's three geographical divisions - the self-declared Republic of Somaliland in the northwest, the self-declared autonomous region of Puntland in the northeast and south-central Somalia - have an average HIV prevalence of 0.9 percent, according to UNAIDS. However, recent data indicates that HIV infections are rising sharply in hotspots like the northwestern port town of Berbera, on the Red Sea.
The IOM study was conducted in conjunction with the AIDS Commissions of Somaliland, Puntland and south-central Somalia on behalf of UNAIDS, with funding from the Global Fund to Fight AIDS, Tuberculosis and Malaria and the World Bank.
Until now, chronic political instability, and perceptions that cultural and religious barriers were insurmountable, has prevented in-depth research into sexual risk-taking behaviours and HIV prevalence in Somalia.
IOM's study participants included sex workers and their clients, people living with HIV, immigrants, internally displaced people, truck drivers and fishermen. The researchers also spoke to government representatives, pharmacists, sellers of tea and khat (a mild stimulant widely chewed in the Horn of Africa), and their clients.
The findings were based on responses from in-depth one-on-one interviews with participants and, for the first time in the Somali context, sex-worker diaries, in which 13 sex workers - 11 women and two men - wrote detailed accounts of each client over a 28-day period. The diaries chronicled condom use, the number of visits by a particular client and the occupation of the client.
"These diaries were experimental and showed that it is possible, if logistically difficult, to get detailed, useful information on the sexual behaviour of sex workers and their clients," Testa said.
High levels of risk-taking behaviour
Most sex workers reported entering the commercial sex trade after the death of a parent, to escape domestic violence or disputes with step-parents. Many were separated from their husbands or widowed.
Few sex workers or clients in Somalia consistently used condoms and their perception of the HIV risk was often low. "In general, men don't want to use condoms; they are synonymous with illicit sex, such as sex outside marriage, sex before marriage or sex for money," Testa said.
Sometimes the sex workers were also reluctant to use condoms. "I'm sceptical about it [using condoms] and believe it causes diseases," one sex worker told researchers. "They [clients] were the ones that want to use them [condoms], and I used to let it go but I am the one that does not like to use it. I don't think I am at risk [of HIV infection] ... I don't engage with anyone who is infected and I never injected myself with a needle."
Somali sex workers often did not use condoms because their partners objected, they desired pregnancy or feared HIV infection from condoms; Ethiopian sex workers were generally better informed and more likely to use condoms, but said they weren't always available or were too expensive.
Obtaining condoms can be difficult in Somalia. Not all pharmacists stock them, and many who do will not sell them to women; when available, they can cost as much as US$2, compared with $0.25 in neighbouring Ethiopia and $0.15 in Kenya. Somali sex workers reported exchanging sex for as little as US$0.50, so purchasing condoms significantly reduced their earnings.
The survey also found that internally displaced women, illegal immigrants and street children were particularly vulnerable to sexual exploitation and HIV, often resorting to 'survival sex' to earn a living, with some women accepting food, items for their children or khat in exchange for sex.
People living with HIV told researchers they faced severe discrimination, with some being forced to move from place to place once local communities discovered their status.
What next?
Testa said the IOM data demonstrated an urgent need to find ways of sensitively engaging at-risk groups in the HIV response. IOM and its partners are now embarking on an ambitious bio-behavioural survey that will determine HIV prevalence and include a much larger-scale study of sexual behaviours among at-risk groups.
"We are trying to identify where the next 1,000 infections are going to come from, so prevention programmes can be targeted," said Greg Irving, IOM's HIV programme officer for East Africa.
Findings from the survey will serve as the basis for Somalia's new national strategic framework for HIV/AIDS. According to the UNAIDS country coordinator, Leo Kenny, the new strategic framework will shift to a response more targeted at the most at-risk populations, such as sex workers and truck drivers, who can act as bridges to the general population and may well be driving the Somali epidemic.
The bio-behavioural survey will be repeated over time to monitor trends and measure the success of HIV programmes.
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