W O R L D B A N K W O R K I N G P A P E R N O . 3 7 Truck Drivers and Casual Sex An Inquiry into the Potential Spread of HIV/AIDS in the Baltic Region Marzena Kulis Mukesh Chawla Adam Kozierkiewicz Emilis Subata THEWORLD BANK W O R L D B A N K W O R K I N G P A P E R N O . 3 7 Truck Drivers and Casual Sex An Inquiry into the Potential Spread of HIV/AIDS in the Baltic Region Marzena Kulis Mukesh Chawla Adam Kozierkiewicz Emilis Subata THE WORLD BANK Washington, D.C. Copyright © 2004 The International Bank for Reconstruction and Development / The World Bank 1818 H Street, N.W. Washington, D.C. 20433, U.S.A. All rights reserved Manufactured in the United States of America First printing: June 2004 printed on recycled paper 1 2 3 4 06 05 04 World Bank Working Papers are published to communicate the results of the Bank's work to the development community with the least possible delay. The manuscript of this paper therefore has not been prepared in accordance with the procedures appropriate to formally-edited texts. Some sources cited in this paper may be informal documents that are not readily available. The findings, interpretations, and conclusions expressed in this paper are entirely those of the author(s) and do not necessarily reflect the views of the Board of Executive Directors of the World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply on the part of the World Bank any judgment of the legal status of any territory or the endorsement or acceptance of such boundaries. The material in this publication is copyrighted. The World Bank encourages dissemination of its work and normally will grant permission for use. Permission to photocopy items for internal or personal use, for the internal or personal use of specific clients, or for educational classroom use, is granted by the World Bank, provided that the appropriate fee is paid. Please contact the Copyright Clearance Center before photocopying items. Copyright Clearance Center, Inc. 222 Rosewood Drive Danvers, MA 01923, U.S.A. Tel: 978-750-8400 · Fax: 978-750-4470. For permission to reprint individual articles or chapters, please fax your request with complete information to the Republication Department, Copyright Clearance Center, fax 978-750-4470. All other queries on rights and licenses should be addressed to the World Bank at the address above, or faxed to 202-522-2422. ISBN: 0-8213-5894-4 eISBN: 0-8213-5895-2 ISSN: 1726-5878 Marzena Kulis is Health Operations Officer in Poland for the World Bank. Mukesh Chawla is Senior Human Development Economist in Human Development Sector Unit of the Europe and Central Asia Region at the World Bank. Adam Kozierkiewicz is Consultant to the same unit. Emilis Subata is Consultant to the same unit. Library of Congress Cataloging-in-Publication Data has been requested. TABLE OF CONTENTS Acknowledgments v Abbreviations and Acronyms vii 1. Introduction 1 2. Review of Previous Studies 5 3. Methodology 7 4. Data 9 5. Discussion 17 Appendix A: Survey Instrument 21 References 27 iii ACKNOWLEDGMENTS T his report was prepared by a team consisting of Marzena Kulis, Health Operations Officer, Poland (Task Manager), Mukesh Chawla, Senior Human Development Economist (ECSHD), Adam Kozierkiewicz and Emilis Subata, (both Consultants). Armin Fidler, HNP Sector Manager, ECA Region, and Eva Molnar, ECSIE Sector Manager, ECA Region, provided overall guidance and support. This report would not have been possible without the support and valuable contributions of Elena Kastlerova and Robert Kietlinski (ECSIE). Special thanks are extended to Aleksandra Banaszewska (Consultant) and Akshay Sethi (Consultant) for excellent background work for the report. v ABBREVIATIONS AND ACRONYMS AIDS Acquired Immune Deficiency Syndrome CSW Commercial Sex Workers EU European Union HIV Human Immunodeficiency Virus NGO Non-governmental Organization SEA Southeast Asia STI Sexually-transmitted Infections UNAIDS Joint United Nations Program on HIV/AIDS UNDP United Nations Development Program UNOPS United Nations Office for Project Services USAID United States Agency for International Development WHO World Health Organization vii CHAPTER 1 INTRODUCTION T he last two decades have been characterized by a dramatic growth in the volume of cross- border flows as well as by major changes in the nature of these flows, most notably in Europe, where a unified European network is being established under the aegis of the European Commission. In a recently issued proposal by the European Commission, the purpose of the Trans-European transport network was stated as being . . . essential to guarantee genuine freedom of movement of goods and persons, to bring the outly- ing, island and landlocked areas closer to the central regions and to create a bridge towards the countries of Eastern Europe and the Mediterranean basin.1 Today, the network is made up of some 75,185 km of roads, 20,609 km of which are planned, 79,440 km of conventional and high-speed railway lines, 23,005 km of which are planned, 381 airports, 273 international seaports, and 210 inland ports. The network also includes traffic management, user information, and navigation systems. Reflecting the considerable opening of economies through the lowering of trade barriers, removal of capital controls and liberalization of foreign exchange restrictions, a major difference in these cross-border flows from the last major period of globalization in 1870­1914 is in the cross- border movements of people. There is little doubt that the opening up of economies--particularly in Eastern and Central Europe--has benefited large populations, especially in countries where cross-border movement of people tended to be restricted, and has been accompanied by increased opportunities for employment, higher productivity, and higher wages and earnings. At the same time, the increased traffic across borders provides greater opportunities for contacts and 1. Proposal for decision of the European Parliament and Council, on Community Guidelines for Devel- opment of Trans-European Transport Network, Brussels, 2001. 1 2 WORLD BANK WORKING PAPER interactions between people that have the potential of spawning new kinds of personal and social risks, including those associated with casual behavior characterized by little or no immediate personal or social responsibility. Besides increase in cross-border smuggling and associated organized (and unorganized) crime, the correlation between the movement of people and the propagation of disease and illness, particularly sexually transmitted infections (STIs) including HIV/AIDS, is also well-established.2 By creating opportunities to have sexual relationships with multiple partners, including with commercial sex workers, travel creates an environment that is conducive to the transmission of STIs and HIV/AIDS. For example, commercial sex activities are reported to be established well along major transport corridors in the Western African region, and the prevalence of HIV among truck drivers and commercial sex workers in the countries along the Abidjan-Lagos corridor is reported to be very high, significantly higher than the population prevalence rates among Togo, Cote d'Ivoire, Ghana, Benin, and Nigeria, countries along the Abidjan-Lagos corridor. Though the present situation in the border areas of countries in Eastern and Central Europe and in the former Soviet Union is nowhere nearly as alarming, increased international trade and cross-border flows across countries undoubtedly provide a channel for spreading HIV and other communicable diseases that, if timely action is not taken, can assume serious proportions fairly quickly. Notably, countries in Eastern and Central Europe and in the former Soviet Union-- particularly the Russian Federation and Ukraine--have shown the steepest curve for new HIV cases diagnosed in 2001, and for the region has a whole, the number of new cases of HIV increased by 25 percent in just one year. In 2001, over 250,000 new infections were estimated in this region, bringing to 1 million the number of people living with HIV. This region is also characterized as being one of the two--the other being East Asia and the Pacific--with the fastest growing HIV epidemic. All this is in sharp contrast to the situation in this region just seven years ago--the total number of HIV infections in countries of Central and Eastern Europe and the former Soviet Union was less than 30,000 in 1995. Between 1995 and 1997, however, the number of people living with HIV/AIDS in the countries of Central and Eastern Europe and the former Soviet Union increased five times, and since then the number of HIV/AIDS cases has been on the rise year after year. UNAIDS data indicates that the total number of people living with HIV/AIDS in Eastern Europe and Central Asia was close to 360,000 by the end of 1999, rising to about 700,000 by the end of 2000. While the threat of an HIV/AIDS epidemic cannot be taken lightly in any country of the region, four countries--Poland, Latvia, Lithuania, and Estonia--stand out as being perhaps the most vulnerable. First, the prevalence of HIV/AIDS is relatively high and is rapidly increasing in locations neighboring these countries in the east, like Ukraine, Kaliningrad, Belarus, and Moldova, where public health conditions are also rapidly deteriorating. Large-scale unemployment and economic insecurity, coupled with liberalization of social and cultural norms, has made the region fertile for an HIV epidemic. Unprecedented numbers of young people are not finishing secondary school, and with jobs in short supply, many are at a risk of joining the vulnerable groups of injecting drug users and regular or occasional sex workers. In the Russian Federation, drug use is almost three times more prevalent than it was five years ago and, according to a recent survey, an estimated one half of Russian college students had injected drugs (Kramer, 2000). The number of commercial sex workers is on the rise--in Moscow alone there are estimated to be as many as 70,000 commercial sex workers (Dehne and Kobyscha, 2000)--and most are between 17 to 23 years of age. Condom use in the sex industry is erratic, and there has been a huge increase in the number of newly-reported cases of syphilis--in Russia, for example, forty times more newly- reported cases of syphilis were reported in 2000 compared to 1987. 2. See, for instance, the WB Project Information Document on Western Africa-Abidjan-Lagos Transport Corridor, World Bank Report No. PID 10754, 2002. TRUCK DRIVERS AND CASUAL SEX 3 Second, because of their geographical location, Poland, Estonia, Latvia, and Lithuania stand at the crossroads of the main east-west and north-south transport corridors, and represent the link between countries of the former Soviet Union and western Europe. The open borders and rapid transit threatens to broaden the sweep of the HIV epidemic, from Russia, Ukraine, and Belarus to Poland, Estonia, Latvia, and Lithuania, as drug injectors and sex workers come into contact with other population groups in these countries. In fact, there is already is evidence of alarming increase in the incidence of HIV/AIDS in these four countries. Like in other countries in Eastern and Central Europe and in the former Soviet Union, very few cases of HIV/AIDS were registered in Poland, Estonia, Latvia, and Lithuania before 1995. While the first HIV case in Poland was registered in 1985, in Latvia in 1987, and in Lithuania and Estonia in 1988, very few new cases of HIV were diagnosed each year up to 1994. However, as Figure 1 shows, recent years have seen an exponential rise in new HIV/AIDS cases, particularly in Estonia, Latvia, and Lithuania. In the year 2000, following an outbreak among injecting drug users in Estonia, the number of new cases increased 32 times above the number of cases recorded in 1999 and the number of HIV/AIDS cases increased fourfold. In Latvia, the cumulative number of HIV cases at the end of 1999 stood at 492. By October 15, 2002, however, the cumulative figures for persons infected with HIV had reached 2,385. Until the spring of 2002, when a huge outbreak of HIV/AIDS positive cases was detected in the Alytus prison, the rate of increase in HIV/AIDS cases was apparently much lower in Lithuania; the number of newly infected persons increased from 66 in 1999 to 72 in 2001. However, on July 5, 2002, 488 of the 1,727 inmates at the Alytus penitentiary in southern Lithuania were tested and found positive for HIV, adding 416 new cases in Lithuania in just one year. FIGURE 1: HIV/AIDS CASES (CUMULATIVE) 3000 2500 2000 1500 1000 500 0 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 Estonia Latvia Lithuania Source: Epidemiological Fact Sheets on HIV/AIDS and Sexually Transmitted Infections: Estonia, UNAIDS 2000; Epidemiological Fact Sheets on HIV/AIDS and Sexually Transmitted Infections: Latvia, UNAIDS 2000; Epidemiological Fact Sheets on HIV/AIDS and Sexually Transmitted Infections: Lithuania, UNAIDS 2000; Latvian AIDS Center, www.aids-latvija.lv, 2002; Lithuanian AIDS Center, www.aids.lt, 2002; Estonian AIDS Prevention Center, www.aids.ee, 2002. 4 WORLD BANK WORKING PAPER FIGURE 2: HIV/AIDS CASES IN POLAND (CUMULATIVE) 8000 7000 6000 5000 4000 3000 2000 1000 0 1995 1996 1997 1998 1999 2000 2001 2002 Source: Epidemiological Fact Sheets on HIV/AIDS and Sexually Transmitted Infections: Poland, UNAIDS 2000; Statistical Information of National Institute of Hygiene, Poland, September 2002; National AIDS Center Database and Publications, Poland. The rapid increase in new HIV cases in Baltic countries, as in the rest of the Eastern Europe region, is associated with intravenous drug use and homosexual and heterosexual contacts. According the last official data from the Lithuanian AIDS center as of May 23, 2002, 70 percent of all HIV/AIDS cases were infected through the intravenous drug use, 12.7 percent through homosexual contacts and 11.8 percent cases was transmitted through heterosexual contacts route. In Estonia, as of June 30, 2002, 91 percent of all HIV/AIDS cases were infected through the intravenous drug use, 2 percent through homosexual contacts and 7 percent cases was transmitted through heterosexual contacts route. In Latvia, as of June 30, 2002, 76 percent of all HIV/AIDS cases were infected through the intravenous drug use, 5 percent through homosexual contacts and 5 percent cases was transmitted through heterosexual contacts, other remaining unknown. The situation in Poland has been a little different, and although new cases of HIV positive are reported every year, the increase has not been as dramatic as in Estonia and Latvia. As Figure 2 shows, the number of new HIV cases has dropped from an incremental growth rate of 13 percent in 1997 to 10 percent in 2000 to 6 percent in 2002. In effect, therefore, Poland is the only country of the four where the number of HIV/AIDS cases has not doubled in recent years. In Estonia the total number of HIV/AIDS cases has increased 34 times relative to the 1997 level, in Latvia 26 times and in Lithuania 8 times. In terms of the incidence of HIV/AIDS, Estonia--with 18.99 persons with HIV/AIDS per 10,000 population--is by far the worst of all the four countries under review. In comparison, Latvia has only 9.92 HIV/AIDS cases per 10,000 population, followed by Lithuania with 2.08 cases and Poland 2.0 cases. Region-wide, Ukraine has 50.9 cases of HIV/AIDS per 10,000, Belarus 14.8, Russia 8.8 cases, Romania 5.6 cases, and Bulgaria 0.5 cases. This study, probably the first of its kind in this region, is based on a survey that explores the practice of casual sex among truck drivers and commercial sex workers in the border areas of Poland and Lithuania at a point of time, and uses this evidence to extrapolate the potential impact on the spread of HIV/AIDS in these countries. The rest of the report is organized as follows. A review of similar studies carried out elsewhere in the world is placed in Chapter 2. Chapter 3 describes the methodology employed in this study, followed by a brief description of the data in Chapter 4. Chapter 5 contains a discussion of the results and policy implications. CHAPTER 2 REVIEW OF PREVIOUS STUDIES S urveys and studies conducted along highways in many parts of the world show that truck drivers constitute an especially vulnerable group who contract and spread HIV because of their high-risk behavior at truck stops where they engage in sexual contact with commercial sex workers. Nzyuko etal. (1997) find that HIV seroprevalence among truck drivers and their assistants along the Trans-Africa Highway in Uganda was 35 percent (1980s). In Kenya, east of Nairobi, 27 percent of truck drivers and their assistants tested HIV positive. HIV seropositivity was found to be even higher among sex workers who work on the Trans-Africa Highway, with 76 percent of sex workers in Lyantonde, a truck stop in southwest Uganda, testing HIV-positive. In a survey conducted by Ramjee and Gouws (2002) in South Africa at five truck stops, two sex workers from each of five truck stops were trained to obtain informed consent, administer questionnaires to obtain data on demographic and migration patterns, and collect saliva samples for HIV testing from their clients. Data on HIV prevalence and demographic characteristics of sex workers operating at the truck stops were obtained from an ongoing vaginal microbiocide trial. The results of the survey indicate that the mean age of the truck drivers (all men) was 37 years (range 18­71 years), and that of the sex workers (all females) was 25 years (range 15­49 years). Sixty-six percent of the men reported having a sexually-transmitted infection in the previous six months, and 37 percent always stopped for sex along the route. Twenty-nine percent reported never using condoms with sex workers, whereas 13 percent had used condoms with their wives. All men traveled to more than one province in South Africa, and 65 percent traveled to neighboring countries. Anal sex was practiced by 42 percent of the men. The overall HIV prevalence (in the two groups combined) was 56 percent. The Institute for Population and Social Research, Mahidol University, Bangkok, Thailand, investigated sexual behaviors of long-distance truck drivers in Thailand to define patterns and determinants critical to the transmission of HIV among 327 drivers interviewed in 1992. Forty-eight percent reported a commercial sex worker (CSW) as their first partner and 87 percent 5 6 WORLD BANK WORKING PAPER had contact with a CSW at some time. Median lifetime number of all partners was 29. About 40 percent of subjects visiting CSWs used condoms inconsistently or not at all. A UNOPS/UNDP study shows how land transport sector can uniquely contribute to spreading HIV. When roads and bridges are built, they link low and high HIV prevalence areas such as villages and cities, respectively--true not only domestically but also internationally. The impact of road construction on HIV spread for a low prevalence area pre- and post-road construction or improvement is seen in the case of the Mandalay-Muse Highway which, constructed in 1997, links Mandalay, Myanmar via Muse to Yunnan, China (Hsu 2001). An examination of the data shows an overall increase of HIV prevalence amongst injecting-drug users after the completion of the highway. A similar phenomenon was also observed in Guangxi, China, when the highway linking Kunming (Yunnan) to Nanning (Guangxi) was completed. Overall documented HIV cases for Guangxi jumped from 10 to 525 within this short three-year period. The improvement of National Highway One in Vietnam has also facilitated the increase of HIV cases in the North (Ha Noi and Hai Phong). This rapid increase in HIV prevalence in the North is associated with the improved linkages that characterized the pre-existing high HIV-prevalence area in the South, such as Ho Chi Minh City. A cross-sectional study was performed of 300 male truck drivers recruited in the port of Santos, Brazil, including a face-to-face interview and blood sampling for HIV and syphilis serology (Lacerda etal. 1997). The results of the study show that 72 percent of the participants were married. Forty percent reported having more than one sex partner; 21 percent reported sex with commercial sex workers; 14 percent reported sex with girls that they met on the road; 16 percent had sex with other men's wives; and 3.3 percent reported sex with men during the past year. The findings of this study confirm the high potential risk of this group for HIV infection and other sexually-transmitted diseases. A survey of 71 drivers along major trucking routes in Florida shows similar findings (Stratford et al. 2002). Among all interviewed, one-third had had frequent sexual intercourse on the road with multiple partners, but few used condoms. Commercial sex workers were their most frequent partners for on-the-road sex. The risk was compounded by occupational conditions, which motivated truckers to drive long hours, often using drugs to stay alert. Sex, alcohol, and drugs were perceived as quick, effective stress relievers during down time on long, lonely trips. Despite their high-risk behaviors, truckers tended to consider themselves at low risk for HIV infection and expressed a number of misconceptions regarding HIV transmission. For example, many truckers did not associate HIV risk with heterosexual contact or think that condoms were effective in preventing HIV transmission. CHAPTER 3 METHODOLOGY I n order to record and describe the incidence of casual sex among truck drivers and commercial sex workers in the border areas of Poland and Lithuania, surveys were conducted at four border crossings in Poland and the duty station in Vilnius in Lithuania. The border crossings selected in Poland included: (i) Bezledy, crossing to Kaliningrad, North of Poland, (ii) Bobrowniki, crossing to Belarus, East of Poland, (iii) Terespol, crossing to Belarus, East of Poland, and (iv) Dorohusk, crossing to Ukraine, East of Poland.3 In both studies, truck drivers were selected sequentially at the waiting lines, and interviews were conducted by trained interviewers. Given the sensitivity of the subject, particular attention was paid to the selection and training of interviewers. The eight interviewers selected were young male University students, from the Institute of Public Health, Faculty of Medicine and Sociology, Jagiellonian University and Faculty of Management in University of Czestochowa. All interviewers had working knowledge of Polish, Russian, and English languages. Extensive training was provided to all interviewers, which lasted over 10 hours in total, spread over two sessions. The purpose of the study and background of the subject was explained to the interviewers, and they were instructed in detail in the way the interview had to be conducted. Special emphasis was placed on explaining the purpose of the study to the respondents so that they clearly understood the real significance and importance of the exercise. The interviewers conducted mock surveys amongst themselves in the three languages in order to test their vocabularies and explore potential conversational patterns. 3. A common characteristic of each of these border crossings is the long waiting time for truck drivers, and thus enhanced opportunities for casual sex. This also provided interviewers with better access to the respondents. 7 8 WORLD BANK WORKING PAPER The survey instrument was a two-part questionnaire (attached as Appendix A). The first part of the questionnaire consisted of background questions, and covered demographical and occupational aspects. The second part of the questionnaire contained questions related to sexual life and sex-seeking behavior, and also included questions related to awareness of sexually- transmitted diseases and HIV/AIDS. The first part of the questionnaire was completed through direct questioning, while the respondents themselves filled in the second part. The survey instrument was tested in interviews with a few international truck drivers at the A4 National Highway (Krakow-Katowice). Minor adjustments were made in the questionnaire, but the difficulties associated with the interviews and the sensitive nature of the subject became very apparent at this stage. Questionnaires completed in this phase served as reference probes for the full study. Interviews were conducted between June 4th and 10th, 2002, by two interviewers at each border crossing between 8 a.m. and 6 p.m. Interviewers approached all truck drivers non- selectively as they were queuing for the crossing. A visiting coordinator, whose visit was not announced, supervised the interviewers. A total of 1,572 interviews were conducted, at an average of 196 per interviewer. The average time for the interview was 25 minutes, including recording of unsuccessful attempts when the respondent refused to participate immediately or soon after beginning. In case of refusal, a special form was used, indicating reasons for refusal and nationality of the driver who refused. In all, 901 (57.3 percent) truck drivers agreed to participate in the interview process and answer all questions.4 The most frequently stated reasons for refusal were: (i) fear of being identified (by, for example, noting number plates), (ii) work fatigue, exhausting drive, (iii) break for meal, (iv) general lack of interest in any study, and (v) fear of contact with strangers (mostly Western European drivers). The least number of refusals came from Bezledy and the most from Terespol. The differences in the response rate varied by the interviewer, and ranged from 40 percent to 74.18 percent.5 In Lithuania, the truck drivers were interviewed at the duty customs station in Vilnius city and the interviews were carried out by highly-qualified social workers (two female and one male). The structured questionnaire prepared for the study in Lithuania was much simpler and less detailed than the improved questionnaire used in Polish study. The questionnaire consisted of background questions covering demographical and occupational aspects, and questions related to sexual life and sex-seeking behavior. In order to facilitate the interview process and get the trust from the interviewees, the truck drivers were offered a package of condoms and only then were requested to participate in a survey. 4. Interviewers noted that most non-respondents traveled on EU and Russian registration plates. It is not possible to make any inferences related to bias from this information. 5. In addition to location of interviews, these differences probably reflect differences among interviewers in being able to establish rapport with respondents. CHAPTER 4 DATA 6 O f the 901 who completed the questionnaire, most (39.5 percent) were in the 31­40 years age group, followed by 36.6 percent in the 41­50 age group, 16.8 percent in the 21­30 years age group and 7 percent above 50 years. A little over 90 percent of all respondents were married; 6.4 percent were single, while others were divorced or widowed A little over 48 percent of all respondents had completed secondary schooling, while a little over 43 percent reported completing college (Figure 3). As Figure 4 shows, most drivers (33.4 percent) were of Polish nationality, followed by Belarussian (27.7 percent), Russian (20.4 percent), and Ukrainian (13.8 percent). The remaining 4.6 percent were Armenian, Moldavian, Lithuanian, Czech, Kazakh, German, Slovak, Georgian, and Latvians. Note that very few were Western European nationals. Most respondents (39.8 percent) stated that they had been in the international transport driving profession for 6­12 years (Figure 5). A little over 20 percent of all respondents had been in the international transport profession for 3-5 years, followed by 17.1 percent for 13­20 years and 9­1 percent for over 20 years. As Figure 6 shows, most respondents (48.4 percent) declared that they travelled abroad two or three times a month, followed by 24.4 percent who travelled abroad once every week on average. A little over one-fifth of all respondents travelled abroad once a month, while 5.7 percent of all respondents travelled abroad once in two or more months. On average, more than four-fifth of all respondents spent four months or more away from home in the last year, while 9 percent of all respondents spent two or three months on the road. In the last month (Figure 7), 37.2 percent of all respondents stated that they spent more than 6. Detailed descriptive analysis of the survey data for Poland can be obtained from the ECSHD internal web page http://ecaweb.worldbank.org:8080/eca.nsf/Staging+Area/77E15CF15596AD4485256D120067C90E? OpenDocument. 9 10 WORLD BANK WORKING PAPER FIGURE 3: TRUCK DRIVERS EDUCATION (N = 896) 60% 48.2% 50% 43.8% 40% 30% 20% 10% 5.5% 2.6% 0% Primary Secondary College University FIGURE 4: TRUCK DRIVERS NATIONALITY (N = 900) 50% 40% 33.4% 27.8% 30% 20.4% 20% 13.8% 10% 4.6% 0% Polish Belarussian Rusian Ukrainian Other FIGURE 5: YEARS WORKED IN INTERNATIONAL TRANSPORT (N = 900) More then 20 y. 9.1% 13­20 years 17.1% 6­12 years 39.6% 3­5 years 20.6% 1­2 years 8.7% Shorter then 12 y. 5.0% 0% 10% 20% 30% 40% 21 days away from home, followed by 26.3 percent (15­21 days away from home), 23.9 percent (8­14 days) and 11.1 percent (1 to 7 days). As Figure 8 shows, the most frequent directions of travelling reported for the previous month were Germany (37.4 percent), Poland (27.3 percent), Russia (29 percent), and Netherlands (15.3 percent). Total number of countries mentioned as destinations in the recent month was 36, spreading from Iraq, Iran, and Kazakhstan in the East to Ireland and Spain in the West. TRUCK DRIVERS AND CASUAL SEX 11 FIGURE 6: NUMBER OF TIMES TRAVELED ABROAD LAST YEAR (N = 897) Once a week or 24.5% more often 2­3 times a 48.4% month Once a month 21.4% Once a two 5.6% months or rarely 0% 10% 20% 30% 40% 50% FIGURE 7: NUMBER OF DAYS TRAVELED LAST MONTH (N = 895) More then 21 days 37.2% 15 to 21 days 26.3% 8 to 14 days 23.9% 1 to 7 days 11.1% No trips 1.6% 0% 10% 20% 30% 40% FIGURE 8: DIRECTIONS OF TRAVELING (N = 876) Germany 37.4% Russia 29.0% Poland 27.3% Netherlands 15.3% Belgium 13.0% France 10.2% Italy 6.4% Czech Republic 6.4% Ukraina 4.9% Lithuania 3.8% Denmark 3.7% Austria 3.7% UK 3.4% Spain 3.3% Belarus 3.2% Slovakia 2.5% Hungary 2.4% Switzerland 1.5% Other 8.1% 0% 10% 20% 30% 40% 12 WORLD BANK WORKING PAPER FIGURE 9: PLACES WHERE DRIVERS STOP FOR THE NIGHT (N = 892) Parkings 95.1% Gasolin station 7.4% Motels 4.7% Cross-border 2.0% Hotels in cities 1.3% Company/unloading place 1.1% Other 1.9% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% FIGURE 10: NUMBER OF SEXUAL PARTNERS IN THE PLACE OF RESIDENCE (N = 830) 90% 80% 70% 85.8% 81.0% 78.9% 60% 73.6% 50% 40% 30% 20% 14.0% 10.4% 9.7% 9.5% 10% 6.3% 6.7% 5.3% 7.3% 7.0% 2.8% 1.7% 0% 21­30 years 31­40 years 41­50 years Above 50 years No partner One partner Two partners Three and more An overwhelming majority of drivers (95.1 percent) stopped at parking places for the night. Some respondents driving to Western European destinations reported staying at motels and hotels for the night (Figure 9). The part of questionnaire that contained sensitive (and potentially embarrassing) questions relating to the respondent's sexual life was filled by respondents themselves. This part was considered as completed in 95 percent of cases of questionnaires that were regarded valid. Five percent of the respondents refused to reply to any question from this part of questionnaire, sometimes declaring their attitude to the subject (for example, "abandoned prostitution," "this is not to be publicly discussed," and so forth). A little over four-fifth of the respondents who answered the question on number of partners at the place of residence claimed that they had only one partner in place of residence (Figure 10). TRUCK DRIVERS AND CASUAL SEX 13 Almost 7 percent of the respondents said they had no partner at all, while 12.1 percent stated they had more than one partner in their place of residence. Over 20 percent of the respondents in the age group 21­30 years claimed to have more than one sex partners at their place of residence; similar figure for the other age groups was 12.3 percent (31­40 years age group), 9 percent (41­50 years age group) and 7 percent (over 50 years age group). In terms of nationality, single sex partner in the place of residence was declared by 89.8 percent of the Polish nationals, 80.2 percent of the Belarussians, 75 percent of the Russians, and 72.2 percent of the Ukrainians. Taking into account intensiveness of traveling, one issue that was explored related to the frequency of sexual contacts that the respondents experienced last month. One-fifth of the respondents chose not to answer this question. A little over 31 percent of the respondents declared they had four or more sexual contacts a month while another 29.4 percent declared three or four contacts. Younger respondents stated higher frequency of sexual contacts relative to the older ones, and the share of respondents who declared 11 and more contacts a month was 2.5 times higher among the younger age group relative to the eldest age group. There was no obvious relationship between education and frequency of sexual activity. As regards nationality, Ukrainian, Russian, and Belarussian respondents stated they had more sexual contacts across all age groups relative to the Polish respondents (Figure 11). Ninety-one percent of the respondents answered a direct question related to having sexual contacts while on the road, that is, casual sex or sex with partners other than their regular partners. Of those, as Figure 12 shows, 57.7 percent claimed they never had sex with partners other than regular partners, while 36.7 percent stated that they sometimes had sex while traveling and 5.6 percent claimed they always had sex while traveling. Among those who claimed to have casual sex, most (45.8 percent) were in the youngest age group (21­30 years), and the least (27.1 percent) in the oldest age group (50 years and above). Most Polish nationals (62.8 percent) claimed not to have casual sex, while most Russian nationals (51.4 percent) claimed to have casual sex while on the road. As Figure 13 shows, most casual sex took place in Poland and Russia (35.8 percent and 35.2 percent, respectively), followed by Belarus (20.5 percent), Ukraine (18.8 percent), and Germany (9.1 percent). FIGURE11: NUMBER OF SEXUAL CONTACTSA MONTH (BY NATIONALITY OF RESPONDENT) (N = 721) 21.8% 17.9% 11 and more 17.4% 8.1% 18.4% 28.5% 5­10 times 22.9% 25.8% 36.8% 31.1% 3­4 times 34.8% 42.3% 23.0% 22.5% 1­2 times 24.9% 23.8% 0% 10% 20% 30% 40% 50% Polish Belarussian Russian Ukrainian 14 WORLD BANK WORKING PAPER FIGURE 12: SEXUAL CONTACTS ESTABLISHED WHILE TRAVELLING (N = 818) Never 57.7% Sometimes 36.7% Always 5.6% 0% 10% 20% 30% 40% 50% 60% FIGURE 13: COUNTRIES WHERE SEXUAL CONTACTS TOOK PLACE (N = 176) Poland 35.8% Russia 35.2% Belarus 20.5% Ukraina 18.8% Germany 9.1% Kazakhstan 2.3% Spain 1.7% Lithuania 1.1% Italy 1.1% Belgium 1.1% Other 2.3% 0% 10% 20% 30% 40% Responding to the use of condoms during sex with their regular partners, 10.8 percent of respondents who answered that question admitted that they always used condoms at home, 27.6 percent sometimes used condoms at home, while 61.6 percent never used condoms at home. Younger respondents were more likely to use condoms compared to the older ones--13.8 percent of the youngest respondents used condoms at home always, while only 5.6 percent of the eldest respondents used condoms always at home. Conversely, 49.3 percent of the youngest respondents did not use condoms at home anytime, compared to 75.9 percent of the eldest respondents. A reverse pattern is noticed with regard to the use of condom during casual sex. Two-thirds of all those having casual sex claimed to use condoms always while having casual sex (Figure 14). Fifteen percent used condoms sometimes, while the remaining 18.4 percent never used condoms even during casual sex. Younger respondents use condoms more often (74.7 percent) compared to the elder respondents (51.7 percent). Taking nationality into account, 76.5 percent of Russians, 67.5 percent Belarussians, 66.4 percent Poles, and only 57.6 percent of Ukrainians declared they "always" used condoms while traveling (Figure 15). TRUCK DRIVERS AND CASUAL SEX 15 FIGURE 14: CONDOM USE (HOME; N = 802; TRAVEL; N = 419) 18.4% Never 61.6% 15.0% Sometimes 27.6% 66.6% Always 10.8% 0% 10% 20% 30% 40% 50% 60% 70% Home Travel FIGURE 15: USING CONDOMS WHILE TRAVELING (BY NATIONALITY) (N = 403) 21.2% Ukrainian 21.2% 57.6% 11.2% Russian 12.2% 76.5% 17.5% Belarussian 14.9% 67.5% 20.8% Polish 12.8% 66.4% 0% 10% 20% 30% 40% 50% 60% 70% 80% Always Sometimes Never In response to a very direct question regarding type of sex, most respondents indicated preference for coital and oral sex. Of the 796 who answered that question (which permitted multiple responses), 96.6 percent indicated that they practiced coital intercourse, 21.5 percent practiced oral sex, while 4.5 percent practiced anal sex. Oral intercourse was most common among younger respondents (31.4 percent) and decreased with age. As regards awareness of modes of HIV/AIDS transmission, 91.7 percent of the 889 respondents identified heterosexual contacts as a cause of HIV/AIDS infection. A further 62.8 percent identified needles (when used by drugs addicts) while 59.7 percent identified homosexual contacts between males as causes of HIV/AIDS transmission. A little over 3 percent did not know how HIV/AIDS is transmitted. Sexual contact with women was identified as a cause for HIV/AIDS transmission regardless of education level, while transmission through infected needles was identified as a cause by the more educated. Polish truck drivers were least aware that homosexual contacts with men and use of infected needles of drugs users could cause transmit HIV/AIDS. 16 WORLD BANK WORKING PAPER An overwhelming majority of respondents (72 percent) did not feel that they were in any danger of contracting HIV/AIDS because of their indulgence in casual sex, regardless of their education level. Sixteen percent of all respondents felt they were at risk, the rest being uncertain. Russian truck drivers most commonly admitted they were in danger of contracting HIV/AIDS (21 percent), while only 10 percent of Polish truck drivers perceived any risk. When asked to identify the single-most important way of limiting HIV risk, the most frequently mentioned proposal was to use condoms (19.9 percent), followed by abstain from sex with commercial sex workers (12.8 percent), have sex with one partner only (8.2 percent), and legalizing commercial sex and bring it under supervision, including medical control (7.9 percent). Some respondents suggested educating drivers about the risk of HIV/AIDS transmission and selling condoms in automated selling machines placed in parking lots. Lithuania Case Study The study in Lithuania was of a much smaller dimension, both in terms of number of interviews as well as details of the questionnaire than the study in Poland. One hundred truck drivers were randomly selected from the customs stop in Vilnius, and a questionnaire was administered to all of them. Most truck drivers (42 percent) were Lithuanian, followed by Belarussians (19 percent), Russians (16 percent), Poles (9 percent), Ukrainian (5 percent) and others (9 percent). Most drivers were between 33­42 years of age (54 percent), followed by 23­32 years (36 percent). Sixteen percent of the drivers were over 43 years of age, while 12 percent were under 22 years of age. Most respondents (53 percent) have been working in international transport for less than 10 years, followed by 35 percent who have been in international transport for 10-20 years and 12 percent over 20 years. Thirty-eight percent of the respondents made two international trips last month, followed by 27 percent (one trip), 17 percent (3 trips), and 16 percent (4 trips). On average, 40 percent of the truck drivers spent 18­23 days on the road, followed by 30 percent (more than 24 days on the road), 16 percent (12­17 days) and 10 percent (6­11 days). In terms of direction of traveling during the last month, the most frequented destination was Russia (40 trips), followed by 40 trips to Lithuania, 36 trips to Poland, 19 trips to Germany, 12 trips to Belarus, 7 trips each to Ukraine and Italy, 5 trips to Spain, 4 trips to Netherlands and 2 trips to Finland. Most truck drivers (78 percent) stop at parking lots for the night, followed by roadside motels (14 percent), and hotels (8 percent). Forty-five percent of all respondents indicated that they regularly had sexual contacts while at work (travel), while 13 percent stated that they only occasionally had sexual contacts while traveling. Most sexual contacts took place in Poland and Russia. The most preferred sexual technique was coital (95 percent), though many respondents also indicated oral sex (47 percent) and anal intercourse (13 percent). Eighty percent of those who had casual sex while traveling stated that they used condoms, though only 8 percent could show a box of the condoms in their possession. In contrast, only 33 percent of the respondents indicated that they always used condoms at home, while 4 percent indicated they used condoms at home only sometimes. CHAPTER 5 DISCUSSION A notable feature of the two surveys was that despite the sensitive nature of many of the questions, a little over 57 percent of those approached agreed to participate in the exercise. Three-fourths of the 901 respondents who completed the questionnaire were between thirty and fifty years of age. Nine out of ten respondents were married, and almost all had completed secondary schooling, at the minimum. In many ways, therefore, the respondent group represented the population of truck drivers fairly well. Most respondents belonged to one of four countries (Poland, Belarus, Russia, and Ukraine), though many other nationalities were also represented. More than half of the respondents had been in the international transport driving profession for between six and twenty years, and most travelled abroad two to three times every month. On average, more than four-fifth of all respondents spent four or more months away from home in a year. Almost all truck drivers stopped at parking places for the night. An indisputable finding of the surveys was that a large number of truck drivers engaged in casual sex--thta is, sex with partners other than their regular partners--while traveling as part of their profession. Without doubt, frequent traveling, long absence away from home, and long waits at border crossings made the truck drivers particularly vulnerable to engage in casual sex, and the apparent abundant presence of commercial sex workers at these places provided the opportunity. This combination--of separation-induced vulnerability and ample opportunities-- resulted in the observed phenomenon of large incidence of casual sex among truck drivers at border crossings. Most truck drivers had only one regular sex partner at their place of residence, while some--particularly those under thirty years of age--had more than one. While traveling, however, two out of every five truck drivers engaged in casual sex with random partners. Most casual sex place took place in Poland and Russia; and Russian truck drivers were most likely to have casual sex compared to other nationalities. An interesting difference is observed in the use of condoms 17 18 WORLD BANK WORKING PAPER during sex with regular partners and during casual sex. Three-fifth of all truck drivers claimed not to use condoms with their regular partners, while two-thirds use condoms during casual sex. Most truck drivers seemed to be generally aware of the risk of HIV/AIDS transmission, but most felt that they themselves were not particularly in any danger. While most truck drivers identified heterosexual contacts, needles if used by drugs addicts and homosexual contacts between males were identified as causes of HIV/AIDS transmission, an overwhelming majority of respondents did not feel that they were in any danger of contracting HIV/AIDS despite their indulgence in casual sex. The correlation between the movement of populations and the propagation of disease and illness--particularly sexually-transmitted infections (STIs) and HIV/AIDS--is well recorded.7 A UNAIDS Technical Update (UNAIDS 2001b) cautions that: if you wanted to spread a sexually transmitted disease, you'd take thousands of young men away from their families, isolate them in single-sex hostels, and give them easy access to alcohol and commercial sex. Then, to spread the disease around the country, you'd send them home every once in a while to their wives and girlfriends. The movements of truck drivers across international borders in countries like Poland, Lithuania, Latvia, and Estonia represent a potential risk, as is also confirmed by the survey findings. The border towns serve as the points of entry for the truck drivers, and while the resident population of these towns is small, the mobile population is larger and includes the commercial sex workers and the truck drivers. Prevalence of HIV/AIDS among truck drivers is not recorded in any of these countries in the region, but the possibility of high levels and the risk that the mobile population represents cannot be ignored by any of these countries. Whereas some countries have made some efforts to raise awareness and provide support to HIV/AIDS activities in the transport sector, the border towns tend to be underserved because of the long distances from the capital city. Information dissemination efforts on HIV/AIDS in the border towns of Poland are virtually non-existent, and condom availability is limited. For all of these reasons, there is a potential risk that insufficient HIV/AIDS prevention, care and support services at the border towns can be an opportunity for the spread of HIV/AIDS in all the countries along the transport corridor. Policy Implications There is no doubt that travel along the major transport routes in the region is an essential requirement for the socioeconomic well-being of the region; at the same time, however, it offers opportunities for faster transmission of HIV/AIDS among the people in the region. In the words of Dr. Lee Nah Hsu, Manager UNDP South East Asia HIV and Development project, mobility presents opportunities for improved connections between people. This can lead to benefits, as it enables opportunities for development and enlarges people's choices. However, it can also lead to threats, as it makes some people more vulnerable to HIV than they were before these connections were possible. While commercial vehicle drivers, commercial sex workers, and the local populations who live in border areas along the major transport routes are among the vulnerable groups that could be most adversely affected if HIV/AIDS prevention, care, and support services targeted at these transport routes are not provided, they also constitute the group that offers the most opportunities for 7. This has been discussed in detail in Chapter 2. TRUCK DRIVERS AND CASUAL SEX 19 dissemination of HIV/AIDS prevention messages. Well-designed HIV/AIDS prevention messages, if disseminated through these groups, can potentially be carried across boundaries, contributing to the fight against HIV/AIDS along the transport corridor. HIV/AIDS is a multisectoral challenge--cutting across many sectors and affecting many countries without being limited by national boundaries. In order to address this problem, the approach needs to be multisectoral and multi-country, and should target specific population groups without being restricted by political divisions. The target group includes providers of transport services (that is, truck drivers as well as the management of transport companies), users of transport services, the local population having contact with truck drivers, commercial sex workers at border crossings, and locally-based government employees (including police and immigration and customs). In Zimbabwe, for instance, the National Council of the Transport Operating Industry and National Railways of Zimbabwe have implemented several programs funded by USAID targeting HIV behavior change along major transport routes. Training programs were set up as early as 1992 for truck drivers, drivers' associates, bar attendants, waitresses, CSW, customs and police officers. In addition, a number of peer educators were trained in order to facilitate continued dissemination and sustainability of the program. In 1995 the National Railways of Zimbabwe introduced a program targeting its highly-mobile staff and their families through training and education. Programs addressed to the general population accompanied these programs (World Bank 2000). Tanzania initiated programs targeting truck drivers and transport sector employees as early as 1989. The programs were based on training, educational materials, and condom distribution. Peer education as well as involvement of the transport companies provided a high level of sustainability for the above programs (World Bank 2000). In 1998, Burkina Faso started targeting truck drivers, sex workers and seasonal migrant population through training and communication techniques, and developed groups of peer educators who disseminated the information further. A survey of truck drivers in Burkina Faso in 2000 reported condom use in 90 percent of the last sex act with an occasional partner, significantly higher than the 69 percent use reported three years earlier in 1997 (UNAIDS 2001b). In the Baltic region as well, an effective multisectoral, multi-country approach would need to rest on, besides treatment, care and support services for the affected population, measures such as increased coordination among countries, stronger alliance within communities and among stakeholders, and on-site provision of counseling and preventive services. The first and foremost pillar of such an approach is the development of a strong inter-country coordination and partnerships among the concerned governments in the implementation of transport sector policies specifically targeted toward driver education and to raising awareness of HIV/AIDS risks among the target population. The inter-country coordination should focus on developing and implementing policies to ensure smooth movement of commercial traffic along the transport corridor by adopting policies and actions that will expedite formal customs clearance and immigration procedures and address the informal barriers to the movement of people and goods across borders. The inter-country coordination activity should focus on setting up suitable monitoring and evaluation protocols that should constantly monitor biological and behavioral aspects of the targeted population. This will go a long way in helping to reduce the development of commercial sex markets at the border towns and the associated HIV/AIDS risks. Time waiting at the borders particularly for the truck drivers crossing Polish eastern border varies from few hours to few days. Lengthy clearance procedures and inefficient processes extend the waiting time--time that truck drivers have to spend outside their homes. The combination of leisure time, long distance from home, and not particularly developed surrounding infrastructure potentially result in casual sexual contacts and visits to commercial sex establishments. Introducing measures to reduce waiting time will thus reduce transport workers' vulnerability to HIV/AIDS. Such measures require complex negotiations, but could significantly contribute to improving transport connectivity, productivity and profit, and the promotion of macroeconomic growth, while concurrently reducing HIV/AIDS vulnerability. 20 WORLD BANK WORKING PAPER A second pillar of such a multi-country and multisectoral approach is that of building an alliance of people who are in a position to make a difference. As indicated by Lee-Nah Hsu (2001): When new roads are built or road networks improved, the volume of traffic can be expected to rapidly increase. During the road construction phase, there will be an increasing number of construction-related vehicles coming through or stopping by certain communities. After the com- pletion of road construction, there will be more vehicles using the new roads. The communities at certain road transport relay points will feel the impact the most. These places usually expand into booming markets, rest stops, restaurants, entertainment facilities, vehicle repair stations, fuel sta- tions, and traffic congestion. It presents an opportunity for the community to work in partnership with the transport sector to organize arrangements that would benefit both the local communities and facilitate efficient operations of the transport sector. The transport sector is ideally positioned to spearhead this challenge and should support the organization of training and awareness seminars for truck drivers as a required curriculum to be provided by the managing transport company and association of international truck drivers The transport sector should also take this opportunity to liaise with the community in planning for preventive education and effecting policies aimed at influencing behaviors and habits. In doing this, the transport sector should form partnerships with local communities to ensure widespread awareness of the risks of transmission of HIV/AIDS if corrective actions are not taken immediately. A third pillar of such an approach is the provision of HIV/AIDS prevention services for the targeted population, which includes the formulation and implementation of an integrated HIV/AIDS policy along the transport corridor and the social marketing of condoms at border crossings along the entire corridor. In the design of an integrated HIV/AIDS policy, special attention needs to be given to improving information, education, and communication activities to be targeted at the identified groups at border crossings. Information should be provided in several languages and be related to HIV/AIDS preventions and safe sex. Condoms are known to be an effective prevention tool to fight HIV/AIDS, and all efforts must be made to increase their utilization. In marketing the use of condoms, adequately supported by procurement and distribution, special attention needs to be given to the most vulnerable populations along the corridor, which includes commercial sex workers and commercial vehicle drivers. In this context, possibilities of installing condom machines at toilets, gas stations, and small kiosks at border crossings need to be explored. APPENDIX A SURVEY INSTRUMENT 21 22 WORLD BANK WORKING PAPER QUESTIONNAIRE for INTERNATIONAL ROAD TRANSPORTATION WORKERS 1. How old are you? 2. What is your education? 1 below 21 1 primary 2 21­30 2 secondary professional 3 31­40 3 college 4 41­50 4 university 5 above 50 years old 3. What is your nationality? code ......................................................... 4. In what country were you born? ......................................................... 5. What is the country of your permanent residence? ......................................................... 6. In what country is your company's management located? State the country the employee is based in or his direct management is located in. In the case of supra-national companies, state the seat of ............................................................ the national office of the firm. 7. How many years have you been working as driver (driver- 1 shorted then 12 months mechanic) in international transport? 2 1­2 years 3 3­5 years 4 6­12 years 5 13­20 years 6 more than 20 years 8. How many times a year do you drive abroad 1 once a half of year (as a driver)? 2 once a quarter 3 once a two months 4 once a month 5 2­3 times a month 6 once a week or more often 9. How many of such trips have you made over the past month? (in May this year) .........................................times 10. Please estimate, how many days in a year do you spend on the 1 less then 7 days road? Estimate how many days over the past year you have spent 2 1­2 weeks travelling abroad, with the night outside the home (place of 3 3­5 weeks residence). 4 2­3 months 5 4 months and more 11. How many days of the past month did you spend on the road? Estimate how many days over the past month you have spent .......................................days travelling abroad, with the night outside the home (place of residence). 12. Please state the directions of your travelling over the past code month?Indicate COUNTRIES of those trips ........................................................ ........................................................ TRUCK DRIVERS AND CASUAL SEX 23 ............................................................. ............................................................. 13. How long is the trip you return from/move on? Please, indicate number of days you are on road since you have left ........................................days home? 14. In what places do you usually stop for the night? 1 Parking ___ Please indicate according to frequency 2 Motels ___ 3 Hotels in cities ___ 4 Other (what?) ........................................... 15. Taking into account your present travel, how many times have you stopped until now? 1 Parking ___ times 2 Motels ___ times 3 Hotels in cities ___ times 4 Other (what?) ................... ___ times 5 Other (what?) ................... ___ times Give the questionnaire to self-completing by the respondent. 27. Are you aware how one may be infected by HIV/AIDS virus? 1 Needles when one uses intravenous drugs Please indicate according to frequency 2 Blood transfusion 3 Homosexual contacts with men 4 Sexual contacts with women 5 Other (what?) ........................................................................ ............................................................................ 6 Do not know 28. Do you feel personally in danger to be infected by HIV/AIDS 1 Yes virus? 2 Rather yes 3 Rather not 4 No 5 Hard to say 29. What way, in your opinion, one can limit a danger of HIV infections among truck drivers? Note opinion. Probe. ........................................................................................................................................................................ code ......................................................................................................................................................................... .......................................................................................................................................................................... 30. What is your civil status? 1 Single 2 Married 3 Divorced 4 Widowed 5 Living in free relation Thank you for your answers! We wish you a nice trip Date: No surveyor: ............... Length of surveying: .minutes Surveyor signature: ........................................... 24 WORLD BANK WORKING PAPER Border crossing: ........................................... No of questionnaire: .................... QUESTIONNAIRE for INTERNATIONAL ROAD TRANSPORTATION WORKERS to be completed by respondent 16. How often do you have your sexual contacts? Please, indicate how many contacts you have had last year average ........................... times a week in week or month. ........................... times a month 17. In your place of residence do you have your sexual contacts 1 Just one partner with one, single partner or with many partners? 2 With two partners 3 With three and more partners 4 No partners 18. How many sexual contacts you have had recent month? ........................... times 19. While travelling as part of your work, do you establish sexual 1 Yes, always contacts? 2 Yes, sometimes 3 No, never go to question 22 20. Have you had any such contacts over the past month? 1 Yes 2 No go to question 22 21. If during past month, while travelling you have had sexual code contact, in what countries it took place? ............................. ............................. ............................. ............................. ............................. ............................. ............................. ............................. 22. Do you use condoms in sexual contacts? At home Traveling 1 Yes, always 1 Yes, always 2 Yes, sometimes 2 Yes, sometimes 3 No, never 3 No, never 23. Have you used condoms over the past month? 1 Yes, in trip 2 Yes, at home 3 No 24. What brand and what production were these condoms? Can code you show a box from these condoms? Brand ..................... ........................ Note brand and production country Country of production........................... 25. What sexual techniques do you use? 1 Coital intercourse (vaginal, classical) 2 Anal intercourse 3 Oral intercourse 4 Other (what?) .......................... TRUCK DRIVERS AND CASUAL SEX 25 26. How often over the past month have you used the individual techniques? 1 Coital intercourse ........................ times 2 Anal intercourse ........................ times 3 Oral intercourse ........................ times 4 Other (what?) ........................ times Thank you very much for your help! REFERENCES Brown, J. and N. Rusinova. 2000. "Negotiating the Post-Soviet Medical Marketplace: Growing Gaps in the Safety Net. Russia's Torn Safety Nets: Health and Social Welfare during the Transition." In M. G. Field and J. L. Twigg, Russia's Torn Safety Nets: Health and Social Welfare During the Transition. New York: St. Martin's Press. Burke, J. 2000. "Internal Migration: A Civil Society Challenge. Russia's Torn Safety Nets: Health and Social Welfare during the Transition." In M. G. Field and J. L. Twigg, Russia's Torn Safety Nets: Health and Social Welfare During the Transition. New York: St. Martin's Press. Chaplinskas S. and I. Mittiene. 2001. "Behavioral peculiarities of Intravenous Drug Users and their Vulnerability to HIV Infection." Acta Medica Lituanica (Supplement 6):42­47. Dehne, K. and Y. Kobyscha. 2000. "The HIV epidemic in Central and Eastern Europe: Update 2000. A Report to a Second Strategy Meeting to Better Coordinate Regional Support to National Responses to HIV/AIDS in Central and Eastern Europe." Copenhagen: World Health Organization. Garrett, L. 2000. "Betrayal of Trust: The Collapse of Global Public Health." New York: Hyperion. Grund, Jean Paul. 2001. "A Candle Lit from Both Sides: The epidemic of HIV Infection in Central and Eastern Europe." In Karen McElrath, ed., HIV and AIDS: A Global VIEW. Wesport, Connecticut: Grenwoood Press. Hsu, Lee-Nah. 2001. "Building an Alliance with Transport Sector in HIV Vulnerability Reduction." UNDP South East Asia HIV and Development Project, March. Kramer, John M. 2000. "Drug Abuse in Post-Communist Russia." In M.G. Field and J.L. Twigg, Russia's Torn Safety Nets: Health and Social Welfare During the Transition. New York: St. Martin's Press. Kriksciukaityte, R. 2002. "Services for Street Sex Workers who use Drugs in Vilnius." Thirteenth International Conference on the Reduction of Drug Related Harm, Ljublijana, March 3­7. 27 28 WORLD BANK WORKING PAPER Lacerda, Regina, Neide Gravato, William McFarland, George Rutherford, Katherine Iskrant, Ron Stall, and Norman Hearst. 1997. "Truck drivers in Brazil: prevalence of HIV and other sexually transmitted diseases, risk behavior and potential spread of infection." AIDS 11(Supplement 1). Study by ASPPE Associacao Santista de Pesquisa Prevencao e Educacao em DST/AIDS and Secretaria de Higiene Saude de Santos, Brazil. Marcinkeviciene, Dalia. 2002. "Lithuanian women's NGO `Praeities Pedos.'" A Resource Book for Working Against Trafficking in Women and Girls, Baltic Sea Region, Kvinnoforum, Stockholm, 3rd Edition, February. Murauskiene L., and S. Chaplinskas. 2001. "Economic Evaluation for Drug Addiction and HIV/AIDS Prevention in Lithuania." Acta Medica Lituanica (Supplement 6). Nzyuko, Solomon, Peter Lurie, William McFarland, Wendy Leyden, David Nyamwaya, Jeffrey S. Mandel. 1997. "Adolescent sexual behavior along the Trans-Africa Highway in Kenya." AIDS 11(Supplement 1). Ramjee G. and E.E. Gouws. 2002. "Prevalence of HIV among truck drivers visiting sex workers in KwaZulu-Natal, South Africa." Rodolph, Michelle. 2001. "HIV Policy Formulation and Strategic Planning For the Communication, Transportation, Post, Construction and Tourism sectors Lao People's Democratic Republic." UNDP. Stratford, D., T.V. Ellerbrock, and J.K. Akins. 2002. "Highway cowboys, old hands, and Christian truckers: Risk behavior for HIV infection among long-haul truckers in Florida." Hall HL, March. Subata E., and J. Tsukanov. 1999. "The Work of General Practitioners Among Lithuanian Roma in Vilnius: Incorporating Harm Reduction in Primary Medical Practice." 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While the threat of an HIV/AIDS epidemic cannot be taken lightly in any country of the Europe and Central Asia region, four countries--Poland, Latvia, Lithuania, and Estonia--stand out as being particularly vulnerable. First, the prevalence of HIV/AIDS is relatively high and is rapidly increasing in loca- tions neighboring these countries to the east, like Ukraine, Kaliningrad, Belarus, and Moldova, where public health condi- tions are also rapidly deteriorating. Second, because of their geographical location, Poland, Estonia, Latvia, and Lithuania stand at the crossroads of the main east-west and north-south transport corridors, and represent the link between countries of the former Soviet Union and western Europe.The open borders and rapid transit threatens to broaden the sweep of the HIV epidemic, from Russia, Ukraine, and Belarus to Poland, Estonia, Latvia, and Lithuania, as drug injectors and sex workers come into contact with other population groups in these countries. This report is based on a survey that explores the practice of casual sex among truck drivers and commerical sex workers in the border areas of Poland and Lithuania at a point in time, and uses this evidence to extrapolate the potential impact on the spread of HIV/AIDS in these countries. World Bank Working Papers are available individually or by subscription, both in print and online. ISBN 0-8213-5894-4 TMxHSKIMBy358948zv":&:>:^:% THE WORLD BANK 1818 H Street, NW Washington, DC 20433 USA Telephone: 202 473-1000 Internet: www.worldbank.org E-mail: feedback@worldbank.org