LUSAKA, ZAMBIA — In a glittery dress and makeup done to perfection, Eliza says she is never mistaken for an ordinary client at a popular drinking spot in Kalingalinga, a township in Zambia’s capital.
Before she settles at the bar, a man beckons to her, and not long after, she disappears with him. She returns after an hour, ready for another client.
Eliza is a sex worker. (She asked that only her first name be used because sex work is illegal in Zambia.)
She says business is better for her now that she can have sex with some of her clients without using a condom. Since 2017, Eliza has been using an HIV prevention method known as Pre-Exposure Prophylaxis, or PrEP, which involves taking anti-HIV medications that prevent her from contracting the virus.
“Before being on PrEP, I could not easily have sex without condoms because I feared getting HIV, and that meant no money for me,” she says. “When I got desperate, I took the risk of having sex without condoms because of the money.”
Now, she can charge a client more if he does not want to use a condom, she says. And with three such clients a night, she can make enough money to get by.
The latest available statistics show 1.1 million people were living with HIV in Zambia in 2017. Sex workers are one of the groups most at risk, with an overall HIV prevalence rate of 56.4% in the country, according to UNAIDS.
PrEP was introduced to Zambia in 2017 as part of the government’s strategy to wipe out AIDS by 2030. Since then, 8,000 people have started taking the treatment, says Dr. Lloyd Mulenga, the National Coordinator for HIV at the Ministry of Health.
Mulenga says the treatment regimen provides 90% protection against HIV when followed properly.
Eliza says she learned about PrEP when health workers came to her community to offer HIV testing. She told them about her job, and after testing negative for the virus, she was referred to the hospital to start treatment.
But Eliza isn’t necessarily using PrEP the way she is supposed to. Doctors say it must be used alongside condoms, not instead of them, because it does not protect users from contracting other sexually transmitted infections (STIs).
Eliza acknowledges that having sex without a condom still leaves her at risk of sexually transmitted infections – she contracted syphilis after just a few months on PrEP – but she says that is of little worry to her.
“Any sexually transmitted infection is treated when I go for the routine tests,” she says. People who are on PrEP are required to undergo testing every three months.
But Dr. Mundia Mwitumwa, the registrar for infectious diseases at the University Teaching Hospital in Lusaka, says this approach is dangerous.
“The mindset with most people is the fear of being infected with HIV, keeping in mind that it is not a curable disease, while STIs are,” she says. But, she points out, contracting any STI can increase the chances of getting HIV, even if a person is using PrEP. Meanwhile, syphilis can render women permanently infertile.
Mwitumwa confirms that she sees many people on PrEP, especially women, come into the hospital with sexually transmitted infections. That’s why patients in the PrEP program are given a package that includes condoms every time they visit a health facility, she says.
PrEP is not designed to discourage condom use, she says, but instead to act as a back-up in cases where users are unable to negotiate using a condom, or when a condom fails. She says it’s up to health practitioners to communicate this clearly to users.
“We need to make sure that the message given out emphasizes condom usage,” she says.
Prudence Phiri, GPJ, translated some interviews from Nyanja.