Transactional Sex Is the Driving Force in the Dynamics of HIV in Accra, Ghana

According to the authors, the prevalence of HIV within the adult population of West Africa remains generally lower than 10 percent, while prevalence among sex workers (SW) is 21-74 percent. Therefore, a sizable proportion of HIV cases among adult men are presumed to be acquired from SW, but this has never been measured. The researchers conducted a study of behavioral and epidemiological characteristics of clients and other men in sex-work environments, to delineate the extent of HIV infection among clients of SW and the role of SW in the dynamics of HIV in Accra, Ghana.

The researchers conducted a cross-sectional study of SW's clients, boyfriends and male personnel of venues in 15 sites of prostitution around Accra from July to September 2001. Investigators administered a questionnaire and obtained urine samples, which were tested for anti-HIV antibodies. The authors calculated the population attributable fraction of prevalent HIV acquired from SW using a combination of data from their client survey, from ongoing sex-worker surveys, and from the national HIV surveillance system and the national census.

The study distinguished between two categories of SW in Accra: "seaters," who work from home; and "roamers," who solicit customers in bars, hotels, brothels or on the street. The investigators found HIV prevalence to be 4.9 percent among clients of roamers, 15.8 percent among clients of seaters, 17.5 percent among personnel of sex-worker establishments and 32.1 percent among boyfriends of SW. According to clients, condoms were used in 90 percent of intercourses. The scientists found non-use of condoms clustered in selected locations and independently associated with older age of client, frequency of intercourse with a sex worker in the last year and current urethritis.

Among the male population of Accra ages 15-59 years, the researchers found 84 percent of prevalent cases of HIV were attributable to transactional sex.

"In Accra, approximately four-fifths of prevalent cases of HIV in adult males were acquired from SW," the study noted. "Comprehensive interventions providing education, condoms and treatment for sexually transmitted diseases for SW and their clients should be approached as other public health priorities and provided in all cities, large and small, of West Africa," the authors concluded.