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Sex Workers fight AIDS
Grassroots Participation, Peer Education, and HIV Prevention by Sex Workers in South Africa

American Journal of Public Health (12.01) Vol. 91, No. 12, P 1978-1986; Catherine Campbell, PhD; Zodwa Mzaidume, BA, DipN

Although participatory peer educational approaches have increased in both popularity and practice among sexual health promoters in both rich and poor countries, they have met with varying degrees of success. Recently, peer education has been described as "a method in search of a theory." It has been argued that peer education "suffers from an inadequately specified theoretical base," which does not address the important social and cultural factors implicit in the approach, and that this gap undermines the ability to learn from peer education's successes and failures.

In this six-month preliminary report of a three-year study in a shack settlement in a South African mining town, the authors examined the extent to which a grassroots community-led program has served to mobilize existing sources of social capital or to create new social resources. The sex worker peer education program is located in a geographically isolated shack settlement, housing about 400 people in conditions of extreme poverty. Most residents are female sex workers, landladies or landlords (who sell liquor and provide free lodging to sex workers, who attract clients to their liquor businesses), and the amaHumusha (unemployed men who make their living on the fringes of the sex and liquor business).

The peer program was designed with three goals. The first was to increase women's sense of control over their health. The second was to provide opportunities for the collective re- negotiation of social and sexual identities in ways that would increase the likelihood of condom use and early obtainment of sexually transmitted infections treatment. The third was to encourage a community context that was supportive of the first two goals, both through mobilizing existing social capital in support of the program's success and through creating a new source of health-enabling social resources in the form of the peer education network.

Baseline interviews, conducted with sex workers before the establishment of the peer education program, revealed that although their knowledge of HIV was high, no one used condoms. The interviews that formed the basis of this preliminary report were conducted by the first author with 30 members of the community (7 sex worker peer educators, 15 sex workers, and 8 male amaHumusha). These interviews, which averaged 3 hours in length, included a detailed life history, questions about the peer education program, and questions focusing on various dimensions of social resources in the community.

For the purposes of this early report, the authors provided a micro-qualitative description of the early stages of the sex worker-led peer education program and indicated that useful information was obtained on community dynamics that have shaped the early development of the program. According the authors, there is no doubt that the program has generated a great deal of attention and controversy and that existing community divisions and fault lines have provided a fertile field for the polarization of opinions and responses that has fueled much of this controversy. The extent to which this attention will result in meaningful behavior change remains to be seen.

The program has made no significant contribution to the economic development of the community. With regard to psychological confidence, the extent to which the program succeeds in building women's confidence remains to be seen. Certainly it succeeded in transferring both supplies of condoms as well as "expert" knowledge about sexual health promotion into the hands of ordinary people. If the program should achieve its goal of increasing condom use over its 3-year life, it will be by a route that is somewhat different from that proposed by textbook advocates of concepts of participatory development and of social capital.