52685 Sex and Drugs: Preventing HIV/AIDS among Truckers and Sailors in Georgia Anne Bakilana HIV/AIDS in ECA and Georgia Key Messages · Awareness of HIV/AIDS among transport This Knowledge Brief summarizes the results of a sector workers in Georgia is high; however, November 2007 study that examined attitudes and knowledge on transmission and prevention approaches toward HIV prevention and care among health varies and misconceptions are common. and transport sector institutions, non-governmental organizations (NGOs), transport sector workers, and sex · High level of awareness does not necessarily workers (SWs) in Georgia. The aim was to identify the change risky behavior which is prevalent among unique needs of transport sector workers with respect to both truckers and sailors. HIV so that specific strategies and targeted intervention programs within both the health and transport sectors can · According to a November 2007 study1, more be developed. The study was based on two quantitative than 50 percent of truckers and almost 80 surveys conducted with truckers, sailors and sex workers in percent of sailors in Georgia paid for sex in the Poti, Batumi and Gori in Georgia, and on qualitative preceding 12 months. There is easy access to sex surveys conducted with health and transport sector workers along transport routes but condoms to institutions and NGOs. prevent HIV transmission are not readily available. Sex workers had more than ten The number of people living with HIV in the Europe and different partners in a week but less than 50 Central Asia (ECA) region more than doubled between percent of Georgian truckers had always used 2001 and 2007. While injected drug use remains the main condoms in the preceding 12 months. mode of transmission, in some cases HIV infection through sexual transmission has been increasing. Georgia was · Some interviewed health officials did not selected as a case study because more than half (60 perceive a link between the transport sector and percent) of the 1,156 registered HIV cases so far were the spread of HIV or, at best, viewed it as a reported in the 2004-2006 period; and the annual number minor risk. Others saw it as one of the big of newly registered HIV infections has been rising each challenges for the future. Health officials at the year2. Its neighbors in the Caucasus sub-region, Russia and regional level were more inclined to see the link Ukraine, also have a high prevalence of HIV. Research and perceived HIV in the transport industry as from other countries around the world shows that transport an issue of concern. sector workers tend to have many sexual partners, often visit SWs, and are therefore at increased risk of infecting themselves and their partners. An understanding of the risks of HIV infection for transport sector workers in Georgia is essential so that an appropriate policy response 1 through prevention, care and treatment interventions can be Knowledge, Attitudes and Behavior Related to HIV/AIDS among Transport Sector Workers--A Case Study of Georgia, World Bank, initiated. 2007. The study was designed by the World Bank and was implemented by the Euro Health Group and IPM Georgia. 2 EuroHIV, 2007. ECA Knowledge Brief The Knowledge-Behavior Gap: HIV/AIDS Figure 1: A Large Proportion of Transport Sector Knowledge does not Guarantee Safer Sex Workers Pay for Sex Overall, awareness of HIV/AIDS among interviewed transport sector workers is high; however, knowledge on transmission and prevention varies, misconceptions and myths about HIV/AIDS are common, and stigma remains prevalent. About 99 percent of all interviewees in the study had heard of HIV/AIDS and nearly all knew that HIV could be transmitted by sharing needles. Compared to maritime workers, truckers were generally less informed about HIV/AIDS issues and less knowledgeable about HIV transmission. Almost half the foreign truckers interviewed did not know that a healthy-looking person could be infected, and nearly half of the Georgian truckers (43 percent) believed a mosquito bite could transmit HIV or that a person could become infected by sharing food. However, 72 percent of the Georgian truckers knew that condoms can prevent HIV. Foreign transport sector Source: Knowledge, Attitudes and Behavior Related to HIV/AIDS among Transport Sector Workers--A Case Study of Georgia, World Bank, 2007. workers were included in the study because estimates suggest that there are twice as many Georgian companies Figure 2: The Mean Number of Paid Sexual Partners is as foreign ones. They are an important part of transport High sector activities. Nationalities included Turkish, Armenian, Bulgarian and Uzbeks. On a summary index (created by counting the number of correct answers--out of seven-- given by respondents on HIV/AIDS), truckers on average showed less knowledge than sailors, as might be expected due to the formers' comparatively lower educational status. In addition, myths and misconceptions about HIV fuel the stigma and discrimination towards people living with HIV. Georgian truckers tended to express more stigmatizing attitudes towards people living with HIV--for example, only 22 percent thought an HIV-positive teacher should continue teaching and only 18 percent said they would buy food from a vendor with HIV. High level of awareness does not necessarily change risky behavior among transport workers; risky behavior is prevalent among both truckers and sailors. Even though Source: Knowledge, Attitudes and Behavior Related to HIV/AIDS among Transport Sector Workers--A Case Study of Georgia, World Bank, 2007. most interviewees knew about HIV/AIDS, only a few saw the link between the nature of their work, the risky behaviors many of them practice, and the threat of either There is easy access to SWs along transport routes but being infected with HIV or infecting their partners. They condoms to prevent HIV transmission are not readily did not perceive transport workers in general as being at available. The Survey found that sex workers work an risk of being infected and transmitting HIV to their average of 10 hours a day, seven days a week, and have sex partners. At the same time, their average frequency of with an average of two clients per day (Figure 4). Their visits to SWs was high and the number of transport knowledge of HIV transmission and prevention, and of the workers who always used condoms was low (Figures 1 and symptoms of sexually transmitted infections (STI), is low. 2). Among truckers, the study found that long hours spent Only 64 percent of them knew that condom use in every on the road away from regular sexual partners and the easy sexual act can reduce the risk of HIV. Condom use among availability of and frequency of visits to SWs along the SWs was low: only 29 percent said that they always trucking routes, resulted in a high HIV risk. Among used condoms with their clients. Nearly one in four sex maritime workers, the study identified a close link between workers (23 percent) went to public clinics or hospitals to sexual behavior and the use of alcohol, especially among get condoms, and another 19 percent bought condoms at sailors who were more likely to have unprotected sex after drug stores. Half of the SWs interviewed said that there alcohol use (Figure 3). were no condoms available at their place of work. ECA Knowledge Brief Figure 3: Transport Sector Workers put themselves at HIV transmission among transport workers is more likely Risk of Sexually Transmitted Infections to take place through sex than through intravenous drug use. The Study found minimal indications of intravenous drug use among transport sector workers, or sexual and drug-use networking between transport workers and intravenous drug-users (IDUs)--the group with the highest prevalence of HIV in Georgia. Both qualitative and quantitative data indicate that IDU is little known among sailors and truckers. This may be partly due to the regular testing required by shipping companies for sailors and intolerance of drug use within the trucking sector. Box 1 Mixed Views on HIV Infection Risks Faced by Transport Sector Workers when they are Away from Home Source: Knowledge, Attitudes and Behavior Related to HIV/AIDS among Transport Sector Workers--A Case Study of Georgia, World Bank, 2007. "Sometimes our seamen have to go to Kenya or South Africa; then I give them a little talk before they go to sea. I tell them [to] remember about HIV/AIDS. For malaria they Figure 4: Commercial Sex Workers Host a Large do have to sign a statement saying they have been informed Number of Clients that there is malaria and they know what to do about it. But there is no such international rule on HIV/AIDS prevention. It is my own idea to talk to them about it. But they are grown men; it is up to them to protect themselves." Member of a crewing company "The seamen are well-informed about the risk, but it seems they forget everything as soon as they reach the port. Just imagine how long they are at sea, separated from other people and suddenly they arrive in a big city, with a lot of money in their pockets... drugs, alcohol, casual sexual relations... In almost every port there are a lot of so-called `interclubs,' where the sailor can easily meet SWs. Such clubs were established by trade unions with quite different reasons. In Batumi such interclubs were recently opened on the right side of the entrance of the Boulevard, close to the fountain....All the sailors agree that while having relations with prostitutes they should always be protected. But it is one thing to say something and another to do it. We, doctors, who Source: Knowledge, Attitudes and Behavior Related to HIV/AIDS among conduct these trainings used to be on board and know the Transport Sector Workers--A Case Study of Georgia, World Bank, 2007. psychology of the seamen. We know what they do when arriving at the ports..." Medical services personnel Some interviewed health officials did not perceive a link member between the transport sector and the spread of HIV. In "Georgian drivers who work in Europe do not visit SWs very addition, according to most transport company often. I exclude my drivers from this behavior, but I do not respondents, their own drivers do not have relationships know about others. Foreign drivers tend to have more with sex workers but drivers from other companies do (see contacts with SWs. There are also so-called transit drivers Box 1). Other officials in the transport sector that were who work individually, mainly transporting cars from interviewed saw HIV prevention as the responsibility of the abroad. They may have more active relationships with SWs Ministry of Health and said that it was not one of their own and they are maybe more `dangerous' regarding drug core competences. On the other hand, the need for transportation. But I think that in general 99 percent of awareness on the risks of HIV infection and the challenges Georgian drivers do not pose any danger from this point of view. They make 10-12 voyages per year. I have known them of addressing the risks among sailors were acknowledged for years and if there was some disease, it would show up." as being necessary by some of the interviewed health and Transport company member transport sector officials. ECA Knowledge Brief Recommendations for Reducing HIV Infection accomplished through identifying champions and Risks in the Transport Sector influential persons from the transport industry to talk to transport workers about HIV/AIDS. In the transport sector, there are barriers towards better dialogue about prevention services for sector workers. Introduce actions on transport and HIV/AIDS, such as Prevention messages might be hindered by contradictory those advocated by the EU, which call for targeting attitudes about sexual behaviors of transport workers, workers who are involved in building and maintaining despite acknowledging that many drivers visit sex workers transport infrastructure as well as those who operate (Box 1). transport services. Actions could include targeted health education, prevention services, distribution of condoms, While the enabling environment to fight the HIV/AIDS reducing time spent away from home, providing epidemic in Georgia is changing for the better, there is still information and other services at rest stops, and reducing need to further develop it by: time spent at border posts. Though the Government needs to support some of these initiatives, some programs could · Clarifying the mandate for HIV prevention, be initiated through private sector initiatives with NGOs. treatment and care An excellent example is the partnership among the · Ending large scale imprisonment of IDUs International Labor Organization, the International · Providing needle exchange programs and condoms Transport Workers Federation and the International Road in prisons Transport Union: they have produced a toolkit providing · Reevaluating the need for mandatory HIV testing information on HIV/AIDS for transport workers which in some sectors includes a `training of trainers' manual, a training course · Ending discrimination toward people living with for management personnel of road transport companies, HIV (PLHIV) and an awareness raising and advocacy course for transport workers. Actions to be Taken Work towards behavior change through persistent and intensified efforts and interventions. Even though Enhance the dialogue and interaction between public awareness of HIV/AIDS is high among transport workers, health institutions, NGOs and the private sector on unprotected paid sex is common. Many transport officials transport and HIV/AIDS issues. This might encourage said that condom use is strongly, and inversely, related to cross-sector collaboration among national transport alcohol use. Survey respondents often said that they "didn't companies, international transport companies, NGOs, the think of" using condoms at the critical moment even health sector, and the education sector to identify transport though many sex workers had them on hand. Therefore, it sector needs and develop a strategic plan within the is important to provide both condoms and information framework of the National Strategy for HIV/AIDS. about the risks of HIV at truckers' rest stops, places where Engaging transport industry representatives in Country transport workers and sex workers meet, and facilities Coordination Mechanism (CCM) meetings and other where transport workers obtain health services. HIV/AIDS-related activities would expose them to issues around HIV/AIDS programs in Georgia and raise awareness on transport issues for those working on Lastly, the maritime sector in Georgia serves as a model of programs provided for by the Global Fund. how modernization and reforms that meet international standards can improve awareness of health. There are Raise HIV/AIDS awareness among transport sector opportunities to build on this model by creating a program officials. While transport sector officials feel that their that aims to reduce HIV transmission among men who buy workers are well-educated and know how to protect sex, as well as their spouses, partners and sex workers. themselves, their knowledge of HIV transmission and its potential dangers is limited. Further awareness-raising is recommended on HIV/AIDS, its modes of transmission, the risks involved in having unprotected sex with multiple partners, and various prevention measures. This could be "ECA Knowledge Brief" is a regular series of notes highlighting recent analyses, good practices and lessons learned from the development work program of the World Bank's Europe and Central Asia Region http://www.worldbank.org/eca