October 12, 1997
Submitted by Michael Alpers, Director, Papua New Guinea Institute of Medical Research, Goroka
Final Report to Unaids: Police and Sex Workers in Papua New Guinea
SummaryA peer educator-based intervention for police, aimed specifically at reducing the frequency of gang rape of sex workers, was launched in mid-1996 as part of a larger intervention with sex workers. Considerable effort was placed on educating the higher levels of police management to the issues and good cooperation was attained. Police peer educators were trained and a comic book directly targeting gang rape was produced. Time limitation required a post-test among police within 9 months of the start of active intervention. Total condom use with casual and commercial sex partners rose from 49% to 70% and the frequency of gang rape was halved, from 10% to 4.8% (P=.05). Among sex workers, total condom use increased from 20 to 43%. Policewomen became actively involved in protecting sex workers and in several instances, sex workers were able to report and jail policemen who had raped them. In as much as rape and harassment by police had been one of the most important issues sex workers identified during the formative research phase of this intervention, progress has been substantial and in the best interests of all involved.
IntroductionThis is the final report covering 18 months of the project's life. During this time, considerable civil unrest has occurred in Port Moresby, the site of the project, and many days were underutilised due to the inability to go out onto the streets. Nonetheless, despite violence, theft and attacks on project personnel, the project has made much progress. This project has been executed as part of a larger one supported with funds from AusAID. The AusAID project is one component of a larger HIV and Sexual Health Project conducted with the PNG Department of Health over 3 years. The AusAID project overlaps to some degree, targeting female sex workers and transport workers (sailors, dockside workers) in two cities, Port Moresby and Lae. In Lae truckers are included, while only in Port Moresby policemen and security men are included. Operations are not basically separate, except for work among security men and police in Port Moresby. Accounting for both grants is kept strictly separate, with 5 staff salaries apportioned to this grant, as well as other specific operating costs. This is reflected in the final budgetary statement attached. Results reported here are for Port Moresby only.
As approved in the original proposal, the specific objectives of this intervention have been to:
Monitoring and evaluationMonitoring of activities has been accomplished with the use of weekly forms (see attached) and monthly summaries. These provide the numerical data for such processual indicators as number of peer education workshops held, number of peer educators trained, numbers of different educational materials distributed to different groups, numbers of condoms distributed, etc. In addition, for the first year, a weekly narrative was handed in by each outreach worker to describe activities, issues and problems. This was abandoned after one year and, instead, a weekly staff meeting summary report was submitted.
Baseline surveys were conducted with sex workers and their most high-risk client groups. As recruitment and training of personnel had to take place as the first priority and action had to start quickly, the timing of baseline surveys was staggered to take place before substantial intervention with each group began. Interviews were standardized after considerable pre-testing. Pre-testing of baseline interviews with sex workers actually began in 1995 before the project funding was approved, in anticipation of the coming intervention. Some client groups, such as sailors, are highly mobile and the analysis will combine those interviewed in both Lae and Port Moresby. Baseline questionnaire forms are attached. The following schedule of baseline and follow-up surveys have been accomplished.
Due to time constraints and shortage of staff to accomplish all the tasks required, only two groups have had any follow-up survey work. These are Port Moresby sex workers and policemen, and are marked with an asterisk in the above table. The first group to receive attention from the project was the sex workers, in March 1996. During this time, negotiations began with police officials to inform them of the project's intentions and concerns. While cooperative attitudes were noted immediately, official permission had to be granted by the Police Commissioner. After several months, a letter was received and the baseline surveys began.
Increasing the frequency of condom use among sex workers and their clients
Peer educationUsing the strategy of peer education required training. As no one in Papua New Guinea had those skills in 1996, a peer education trainer from the South Pacific Commission (SPC) was requested (Nemani Seru) and trained the managers and outreach workers associated with this project. Also attending the training workshop was one policeman from the police welfare unit.
Peer educators were trained in all target groups. A set of four modules was developed for training sex worker peer educators . Because these are all floating or street sex workers, they have no natural groups but keep moving around the city's venues on an individual basis to maximise their access to clients. Consequently, they can be brought in for training only in small groups. As of September 1997, 28 sex workers had completed all four modules, 37 had completed three, 62 had completed 2 and 137 had completed one, for a total of 264 women trained, at least, in part. In order to accomplish this, 78 sessions had to be held.
In August the police sent one of their welfare officers to attend the week-long training of peer educator trainers. After that, police peer educators were selected by the police themselves and began training. To date, a total of 32 policemen peer educators, representing 13 police stations, and 16 peer educators among police women (at 10 police stations) have completed training. These persons have been followed-up by the outreach workers to support and supervise their work. There have been up to 6 visits to some of the policemen peer educators, and up to five visits to policewomen. In total, 101 follow-up visits to policemen and 40 visits to policewomen peer educators have taken place. The policemen peer educators have organized workshops at police stations and headquarters. The men have held 10 and the women have held 6 workshops. Although no baselines were ever obtained from policemen's wives, under their own pressure, 10 peer educators among them have been trained. All police stations and barracks in Port Moresby have been covered by this programme. Thus, a large number of police and their families have been reached through this process.
Condom distribution and useThe best indicator that condoms are being distributed, are desired and being used is that the project is running out of large supplies of condoms repeatedly. In the mid-term report (Sept. 1996), it was stated that the project was running out of condoms and that AusAID had stated that a container of condoms was due to arrive into the country. In April 1997, these finally arrived and as of Sept 1997, all of those condoms have been distributed. It is interesting to note that policewomen have become more sympathetic to sex workers and have demonstrated this during the period when old and out-of-date condoms were still circulating although new ones had just arrived. They, having the new ones, would take the old ones from sex workers they saw holding them and give them the new ones.
The required government condom supply is greatly underestimated by those who order them. This situation may have been ameliorated had the social marketing of condoms component of the AusAID HIV and Sexual Health Project been successful. Because it has barely been developed, no inexpensive condom is widely available on the market. The least expensive is the brand that had been socially marketed earlier in 1991 by SOMARC, Protector condoms, which sell at K.75 for 3, i.e. at a price equivalent to approximately US10 cents per piece, at some urban shops. When condoms are unavailable, outreach workers advise sex workers and others to purchase these. However, they are not widely distributed and are not accessible where most needed. Currently, UNFPA has purchased 15,000 female condoms and has promised to give a large number to the project. These have been in the country for 5 months but are being held up by a debate over an accounting form. AusAID states again that another container load of male condoms is due soon.
In total, the project has distributed 845 female condoms and 68,200 male condoms to sex workers. Policemen and women in Port Moresby have received at least 188,000 condoms to date. The police distribute them to many men who they think are likely to have multiple partners, not just to police. Some also report that they give out strips of five to anyone coming to the police station with a complaint of any nature. Hence, they have become a major distribution force for the city. Security men have received only about 10,000 to date.
Evidence of the increasing use of condoms is found in the follow-up survey data, as well as anecdotal reports. Among the sex workers, in phase 1: Aug 95-March 96, a sample of 129 women with 347 clients had 693 acts, for which no condoms were used on 528 of those acts. This calculates to a use rate of 24%. By phase 2: Mar 96-June 1, in Port Moresby, after our workers had begun their outreach, the women had had 539 partners and 576 sex acts, during which condoms were used 253 times for a use rate of 44%. This represents a significant difference (p=.000, M-H chisq=138.27, Yates corrected chisq=137.00, 95% C.I.). Between June and October, when the survey was completed, there were no further significant increases (had risen to 49%).
These data also indicate an increase in condom use with non-clients. In phase 1, of the sample of 129 women, 83 had had sex with men other than clients, i.e. husbands, boyfriends, casual partners, for a total of 99 bouts of sexual intercourse. Of those 99 bouts, for 89 no condoms were used, making a use rate of 10%. By phase 2, out of 297 women, 158 had had sex the previous week with 190 men. Of a total of 378 bouts of intercourse, 258 had not had condom coverage, making a use rate of 32%. This increase also calculates as a statistically significant difference (p=.000, M-H chi sq=18.5, Yates corrected chi sq=17.46, 95% C.I.).
Among police condom use has also risen, particularly with commercial and casual partners. In the pre-intervention phase, out of a sample of 130 men, 33 had had sex during the last week with 57 women for 76 bouts of intercourse. The number of bouts of intercourse per woman ranged from 1 to 11. 39 of these bouts had not been with condoms, making a use rate of 49%. After the intervention had progressed and a re-survey conducted, of a sample of 197 men, 35 had had sex with 45 casual partners for 77 bouts of intercourse (range 1-10). Of these, 23 bouts had no condom coverage, making a use rate of 70%. Testing for significance, p=.006, uncorrected chisq 7.3;p=.007, M-H chisq 7.25; p=.011, Yates corrected chi sq 6.44). It also appears that the proportion of men seeking sex with 'rot meri' (women of the streets) has decreased from 25% to 18% between the two samples. This may not be significant and was never an objective of the project. Future re-surveys will be necessary to examine the reality of this trend.
With their wives and steady girlfriends, condom use did not rise significantly. In phase 1, 84 men (of 130) had had sex the previous week with 85 women for 229 bouts of intercourse, 206 of which had not been covered by condoms. In phase 2, 123 men (of 197) had had sex with 134 women, for 310 bouts of intercourse, 272 of which had had no condom coverage. This comes to a use rate of 12% (not significant, p=.5, Yates correction). One of the issues that arose in discussions with policemen's wives was that they would be insulted and angry if they saw condoms carried home by their husbands. Clearly, a great deal more work must be targeted at policemen's wives and, with policemen, some specific work concerning the options for safer sex within the family (or in important relationships).
Among security men, no follow-up has taken place. Baseline survey data indicated the following: of a sample of 154, men, 55 (36%) had had sex the previous week with 79 commercial sex workers for a total of 150 bouts of intercourse. Of these, 114 had not been covered by condoms, making a use rate of 24%. In addition, 85 men had had sex with 88 girlfriends and wives for a total of 252 bouts of intercourse, of which 246 had not been covered by condoms. The use rate with 'significant others' amounted to 2.4%. Given the high level of commercial sex, these men and their wives and girlfriends are at a high risk of acquiring HIV and a great deal more work must be accomplished with them.
Increasing knowledge and decision-making for safer sexThe earliest baseline survey among sex workers done in 1995 did not systematically explore the knowledge or risk perceptions of these women, as it was conceived as a trial of the method of survey for behavioural surveillance. By March 1996, the full questionnaire was utilised, but the sample size for the earliest period during which little training has been imparted is too small to use for a comparison. It can be used for comparing condom use rates because the denominator is really number of bouts of sexual intercourse, and not the number of women. Hence, a second survey will be necessary to test for a significant difference in levels of knowledge and risk perception.
However, among police the pre- and post-test sample sizes are adequate. These indicated very low levels of knowledge of non-sexual (actually non-heterosexual) means of HIV transmission both before and after the intervention. Information levels had changed, however, on STDs. Knowledge of the fact that some STDs may have no symptoms rose from 19% to 53%. Knowledge of ways to avoid getting HIV/STDs also rose, with 'always using a condom' rising from 49% to 64%. Levels of correct risk perception also changed among policemen. Among those considering themselves to be at high risk, the percentage of correct reasons rose from 33% to 75%. Among those who classified themselves as low risk, the percentage of correct reasons rose from 33% to 51%.
Sources of information also shifted. Asked if anyone had come to them to discuss HIV/AIDS, the proportion answering positively rose from 8% to 38%. When asked which agency they had learned about AIDS from, in the first survey the majority (93%) mentioned the PNGIMR. During the second survey, the proportion mentioning the Papua New Guinea Institute of Medical Research (PNGIMR) dropped to 84%, while the police peer educators rose to 13%. All other sources of information on the topic (TV, radio, newspapers, etc) dropped over the 9 months of measured intervention.
Diminishing selected factors that create barriers to safer sex
Power structures and gatekeepersThe power structures surrounding police, security men and sex workers have been addressed. For the police, the initial negotiations were held with both the higher authorities as well as meetings with policemen's wives. The wives were quite concerned about their husbands' behaviour after they had returned from Bougainville, where the police were utilised along with the army to fight the rebel Bougainville Revolutionary Army. Their men came home on edge and frustrated and beat them for little disputes around the house, then stormed out to drink and pick up women. They saw this as the situation leading to the greatest risk of acquiring HIV in their lives and began pressuring the top authorities to allow our project to begin work as quickly as possible.
Security firms were more difficult to convince of the importance of AIDS prevention than were police, despite the alleged deaths of several security men from AIDS. Security firms occupy a large wage labour sector in Papua New Guinea. The project has contacted a total of 32 such firms in Port Moresby. The actual number existing is unknown as many are not legally registered. After many months of rejection (even complaints about being approached by the project sent to the Director of PNGIMR), a few security firms became cooperative. They were then asked how we could convince those who reject our advances, which included the largest in the nation. They suggested that a workshop be held for security firms and be televised. In July, 1997, such an event occurred, with cooperation from the DOH, at which 27 security firms were represented. The TV workshop was quite successful.
Unfortunately, the number of outreach workers in the Port Moresby office (as in Lae) are stretched very thin. As the number of reported cases of HIV rises dramatically in PNG, visible concern has also risen and many meetings and workshops are called, taking up the time of the project personnel. While there are plans of training peer educators among the security firms and the firm managers have selected men for the purpose, it is considered necessary to interview each one before beginning. So far, 26 firms have submitted names of 42 prospective peer educators. For these reasons, the training of peer educators among security men has been slow to start, but will take place shortly.
Sex workers in Papua New Guinea have far fewer men (or women) who control their lives and incomes than do sex workers in Asia, for example. The chief gatekeepers are the owners of the venues where the workers gain access to clients and where they and their clients go to have sex. These are often older men who collect rent from them for rooms. In several cases, the project has made direct contact with these men and distributed condoms to them. Some, unfortunately, were found to be selling the condoms at exorbitant prices to the sex workers or their clients. This has been stopped. In some cases, these 'guest house' owners have adopted a 100% condom policy. Signs in Tokpisin have been placed in every room stating that only sex with condoms is allowed. If the owner finds out that condoms were not used, he will not allow the sex worker or the client to use his premises again. One owner stated that he liked this policy because, if one of the clients or sex workers got HIV, he could not be blamed. In the larger hotels, condom machines have been installed in the men's rooms and now the major hotel chain has developed a courtesy package cover, to be filled with condoms supplied by the project and with the hotel's name on it, to be placed in every room in the three hotels owned in Port Moresby. This chain also owns hotels in other cities and towns, therefore, this innovation has the potential for much wider spread.
Over the course of this intervention, police have raided some of these 'guest houses', and, in one instance in 1996, jailed 19 sex workers, of whom several were peer educators. This created a terrible delay in the project as the women thought they had been arrested due to their association with the project, and subsequently vanished. It took several months and a number of discussions with the police to bring this situation under control.
Lainaps (line-ups)As rape and harassment by police had been identified as a serious issue by sex workers during the earlier formative research phase of this project, an effort was made directly to target policemen, with special emphasis on prevention of lainaps, the term used for coercive group sex in Papua New Guinea. In the context of police work, both the sex workers and police have reported repeated situations in which known sex workers would be taken out of cars, drinking venues, or off the street, ordered into the police cars and taken to a police station, the police barracks, or to an uninhabited section of the city, and raped by a number of men in tandem. Practices were reported, such as calling other police on their radios and announcing that they had a 'public toilet' and inviting them to come to a particular location and join in. At the barracks, younger policemen were initiated into the practice within the police sub-culture of Port Moresby.
This practice was strongly targeted by a number of strategies. Diagrams and demonstrations were used during the peer education training to show the men how rapidly HIV can spread through such group sex events. A comic book specifically about lainaps, in which an HIV negative sex worker is forced into sex with numerous police, who later are shown to be HIV positive (see attached). The story was designed in order not to place blame on sex workers but to illustrate the possibility of acquiring HIV from the semen of previous men in the line or queue. The flip chart given to each peer educator also has a specific drawing illustrating the practice, though not among police, in order to bring it to immediate attention when discussing risk behaviours in the PNG context.
In sum, it appears these efforts have begun to bear fruit, at least among the police. In the pre-intervention phase, 10% of the men (n=130) stated they had been in a line-up during the previous week, whereas this was reduced to 4.2% post-intervention (n=197). The average number of men involved has not changed significantly, 4.22 vs 3.58. Among the security men, 11% of a sample of 154 stated they had been in lainaps the previous week, with an average of 5.29 men per event. As the security intervention develops, it will be important to target this highly risky practice among these men also.
Enabling approaches: raising self-esteemIn addition to reducing the frequency of lainaps, this project aimed at enabling safer sex among the sex workers of Port Moresby using several approaches. Sex workers had asked for help with learning about make-up and improved personal appearance and learning to use bank accounts. Accordingly, three sessions have been held with a professional hairdresser/make-up specialist. She taught about personal hygiene as well as improved dress and appearance. Individuals have been helped to secure a bank account and one sex worker (and another in Lae) has been taken onto the staff as a full-time worker. She has also been selected to go to the Manila AIDS meeting in October and attend a special meeting for the networking of sex worker projects throughout the region. Interest in literacy has not emerged but will be examined.
It appears that some sex workers find that their level of knowledge about HIV is far greater than that of the surrounding communities in which they live. As sex workers in PNG are far less stigmatised than in many nations, they are respected for this knowledge and requested by the youth group, women's groups and others in their communities to give talks about HIV. The video collection at the project house has initiated a lending system for sex workers, who use them in educating the communities in which they live.
While it has always been difficult for a sex worker to gain redress for rape or theft, it has been nearly impossible for her to prosecute a policeman. There are now some indications of change. In August 1997, one of the 'guest houses' that is a regular part of our project outreach, was raided by 6 policemen who took advantage of the situation to rape two sex workers. The sex workers were arrested but they managed to lay complaints against the police officers. All 6 policemen were jailed, pending court, and the sex workers were set free. A newspaper article chronicling this event is attached. A few months before this event, a non-sex worker woman laid complaint against being raped by the police. It appears that increasingly more women may become willing to stand up for their right not to be raped by police, a positive sign for progress in both HIV prevention and human rights.
Facilitating STD treatmentAt the time the project began AIDS patients were not visible in the communities and sex workers did not see the importance of STD treatment and safer sex practices. Over the 18 months of the project's life (March 1996-September 1997), this has all changed rapidly. Several workers have buried their sisters and other relatives with confirmed cases of AIDS, and many have seen people in their communities die of what they believe must be AIDS. AIDS has finally become an issue discussed in public by senior politicians and the reported confirmed cases of HIV have risen rapidly. Table 1 shows the national official statistics on HIV.
Table 1. Confirmed incidence of HIV infected persons per year in PNG
Given their increasing experience with AIDS, sex workers in Port Moresby have generally become more amenable to perceiving the need of safe sex and STD treatment. During phase 1, 34 out of 87 (39%) women stated they currently had symptoms of STDs, whereas during phase 2, 40 out of 297 women (13%) stated they had current symptoms. Over that period, women had been shown STD slides, two comic books about STDs and sex workers were distributed, peer educators were given STD photo albums to use for education, and a special entrance and day at the government STD clinic had been set up for sex workers. Project personnel accompanied these women to the clinic and provided transport. Such a reduction, if real, needs to be validated with clinic data.
Improving knowledge and practice of safer sexOne way in which the project has improved the practice of safer sex is with the introduction of water-based lubricant for sex workers, anal sex and, in general, for anyone wishing to use it. Professional sex workers elsewhere have strongly advised of its value and this is corroborated by sexual health specialists. For this reason, using AusAID funds, an order of 10,000 single use packets of Wet Stuff from Australia was made. The lubricant was re-packaged and re-labeled as 'Swit Gris', a Tokpisin brand name, implying pleasure and slipperiness. A study conducted on the acceptability of the female condom in 1994 demonstrated that many PNG couples appreciated a highly lubricated condom. For this reason, it was felt that 'Swit Gris' would be acceptable. It is now available and given out freely by the sex worker peer educators (see enclosed samples).
Gradually, new ideas in sex work are spreading. Condom skills, in particular, have been emphasised. Sex workers are asked to practice putting a condom on (a phallic model) in the dark or blindfolded and have been shown the technique of putting a condom on with the mouth.
Encouraging normative change among clients of sex workers towards safer sexMaking changes in the norms of police sub-culture should begin with the enculturation process of the recruit. By February, 1997, a unit on HIV and STDs had been instituted by the police peer educators in the curriculum of Bomana Police College. In this way every recruit is exposed early to information on the topic.
The major clients of sex workers with whom this project works are sailors, dockworkers, police (not really clients in that they seldom actually pay for sex), security men and, in Lae, truckers. There are other important groups, such as civil servants, soldiers, mine workers, construction workers, and loggers. These have not been targeted in any way by this project. Among all of the men in the transport industry, however, many peer educators have been trained, materials and condoms distributed and outreach work continued. A considerable number of the clients of sex workers are men from the slum communities in which they live. Recently, the sex workers have initiated HIV education for some of these slum (called 'settlements' in Port Moresby) communities.
One other method of reaching clients as well as the general public that has begun is a telephone hot line. This telephone line was activated in June 1997, but remains to be advertised and therefore, has not been well utilised yet. One issue that slowed down its use was that no one was trained to do telephone counselling. By early September, 2 of the project's outreach workers had completed HIV counselling courses and several more are scheduled to undergo training in October. T-shirts advertising the hotline number are under production.
A newsletter to be sent to all the peer educators has been suggested, mainly by the sailors. This innovation is under consideration and may be useful for reinforcing messages among those who are literate. This may not be too useful for many sex workers directly, but could impact on their lives through better education for their clients.
Developing the capacity of AIDS prevention workers to carry out and evaluate behavioural change projects within the context of an active NGOAt the time of proposal writing, a local NGO had shown interest in working on this project, but when later asked to participate, this NGO refused. As no local NGO could be found to work as a collaborator on this project with the PNGIMR, a new NGO was founded which could take on AIDS work. This NGO, known as Action for Community Health, has been closely associated with the project but is too undeveloped yet to carry out any substantial aspect of the work. Consequently, the project has remained one carried fully by the PNGIMR.
The Project's FutureA full evaluation is required for this project, one which includes a qualitative evaluation of the processes and strategies utilised. This should be examined from the points of view of the recipients (sex workers, police, etc), project workers at all levels, and community members. Follow-up quantitative surveys are also required in order to measure change in specific items of knowledge and practice. Secondary modes of confirmation, for example, STD clinic records, may also be of use.
With the completion of this funding period, it is clear that considerably more work must be accomplished. Additional funds will be sought for further work with security firms, army and other known groups of men who are frequent clients of sex workers. It is expected that AusAID funding will continue, although a gap may occur during 1998-1999. New sources of funds will also be sought to continue the growth of this project into other sectors of the population. It is obvious, however, that foreign donors cannot be depended upon forever and that new habits (eg. buying condoms, decreasing numbers of sexual partners) and new facilities (eg. friendly, accessible and correct STD clinics) must become part of a new social order in Papua New Guinea, either by way of government or the NGO sector.
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Last modified: September 15, 1998
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