Public Disclosure Authorized 45297 Europe and Central Asia Region and Global HIV/AIDS Program, World Bank Knowledge, Attitudes and Behavior Related to Public Disclosure Authorized 40 °E 4 2 °E 4 4 °E 44 °N HIV/AIDS among Transport Sector Workers 44 °N R U S S I A N F E D E R A T I O N A CASE STUDY OF GEORGIA To Soai C Gagra a u c a ABKHAZIA s Suhumi Mestia u To Vladikavkaz s K ol Tkvarceli k M Public Disclosure Authorized hi o Mqinvartsveri Mqinvar tsveri GEORGIA Dzvari da Ochamchira (5047 m) Ing uri u Kazbegi Oni n Lo w Zugdidi Ambrolauri t la nd ni South a Rio li Sachkhere Ossetia i ka isc Senaki Tkibuli ilk Kvir en Kutaisi n Tsk Black Sea Chinvali Ts'khinvali Iori Poti Rioni Samtredia s 42 °N Akhmeta 42 °N M tkv Gori Telavi Khashuri a r i (K Ozurgeti ura ) A la Lagodehi Mtskheta Kobuleti za ni AAD AA JJ RRAA T'BLISI Gurjaani Batumi Iori Akhaltsikhe To Rustavi Zagatala Marneuli Mar neuli Ahalkalaki Tsiteli- Kazreti Tskaro Ninocminda Public Disclosure Authorized Mt kva ri Io To ri Trabzon (Ku ra) T U R K E Y To Yevlax Mingechevir Reservoir To Erzurum To A R M E N I A AZERBAIJAN Erzurum To Armavir Lake Sevan 40 °E 42 °E 4 4 °E 46 °E June 24, 2008 Titles in this publication series available at: www.worldbank/aids > publications 1. Lessons from World Bank-Supported Initiatives to Fight HIV/AIDS in Countries with IBRD Loans and IDA Credits in Nonaccrual. May 2005. 2. Lessons Learned to date from HIV/AIDS Transport Corridor Projects. August 2005. 3. Accelerating the Education Sector Response to HIV/AIDS in Africa: A Review of World Bank Assistance. August 2005 4. Australia’s Successful Response to AIDS and the Role of Law Reform. June 2006. 5. Reducing HIV/AIDS Vulnerability in Central America. December 2006. (English, Spanish) 6. Reducing HIV/AIDS Vulnerability in Central America: Costa Rica: HIV/AIDS Situation and Response to the Epidemic. December 2006. (English, Spanish) 7. Reducing HIV/AIDS Vulnerability in Central America: El Salvador: HIV/AIDS Situation and Response to the Epidemic. December 2006. (English, Spanish) 8. Reducing HIV/AIDS Vulnerability in Central America: Guatemala: HIV/AIDS Situation and Response to the Epidemic. December 2006. (English, Spanish) 9. Reducing HIV/AIDS Vulnerability in Central America: Honduras: HIV/AIDS Situation and Response to the Epidemic. December 2006. (English, Spanish) 10. Reducing HIV/AIDS Vulnerability in Central America: Nicaragua: HIV/AIDS Situation and Response to the Epidemic. December 2006. (English, Spanish) 11. Reducing HIV/AIDS Vulnerability in Central America: Panama: HIV/AIDS Situation and Response to the Epidemic. December 2006. (English, Spanish) 12. Planning and Managing for HIV/AIDS Results – A Handbook September 2007 (English, Spanish, French, Russian) 13. Rapid analysis of HIV epidemiological and HIV response data about vulnerable populations in the Great Lakes Region of Africa. January 2008. (English, French) Published with the Great Lakes Initiative on AIDS. 14. HIV/AIDS in Ethiopia - an Epidemiological Synthesis. April 2008. Published with the Ethiopia HIV/AIDS Prevention and Control Office (HAPCO). 15. Blood Services in Central Asian Health Systems: A Clear and Present Danger of Spreading HIV/AIDS and Other Infectious Diseases. May 2008. (English, Russian) Published with World Bank Europe and Central Asia Region. 16. Knowledge, Attitudes and Behavior Related to HIV/AIDS among Transport Sector Workers A CASE STUDY OF GEORGIA. June 2008. Published with World Bank Europe and Central Asia Region. Europe and Central Asia Region The World Bank HIV/AIDS AND TRANSPORT IN EUROPE AND CENTRAL ASIA KNOWLEDGE, ATTITUDES AND BEHAVIOR RELATED TO HIV/AIDS AMONG TRANSPORT SECTOR WORKERS A CASE STUDY OF GEORGIA World Bank authors: Anne Bakilana, Shiyan Chao, Satoshi Ishihara, Owen Smith, Tamar Gotsadze, Zukhra Shaabdullaeva and Karumuna Kaijage. Euro Health Group authors: Kerry Richter, Christina Anderskov, Nana Morbedadze, Sofia Chanturishvili and Davit Tsabutashvili June 24, 2008 World Bank Global HIV/AIDS Program Reports This series, published by the Global HIV/AIDS Program of the World Bank's Human Development Network, makes interesting new work on HIV/AIDS widely available, quickly. Papers are posted at www.worldbank.org/AIDS (go to “publications”). For free print copies of reports in this series please contact the corresponding author whose name appears the bottom of page iii of the paper. Enquiries about the series and submissions should be made directly to Joy de Beyer (jdebeyer@worldbank). Cover photographs: Christina Anderskov of Euro Health Group © 2008 Euro Health Group © 2008 The International Bank for Reconstruction and Development / The World Bank 1818 H Street, NW Washington, DC 20433 All rights reserved. ii Knowledge, Attitudes and Behavior Related to HIV/AIDS among Transport Sector Workers - A Case Study of Georgia Europe and Central Asia Region, The World Bank This study is part of the work program on HIV/AIDS and Transport in Europe and Central Asia. The World Bank designed the study and commissioned the Euro Health Group to implement it, facilitated by the Georgian Ministry of Health, Labour and Social Affairs and the Ministry of Economy and Trade, and with help from The Georgian Seamen’s Medical Centre, The Georgian Seafarer’s Union, the Automobilist Garage in Batumi and the NGOs Tanadgoma (Batumi), Steps to the Future (Gori) and Association Mega (Poti). Funding was provided by the World Bank Global AIDS Program as part of the UNAIDS Unified Budget and Workplan. Abstract: This study reports on surveys that assessed attitudes and approaches toward HIV prevention and care among health sector institutions, transport sector institutions, non- governmental organizations (NGOs), transport sector workers (trucking and maritime) and sex workers. The aim was to provide country authorities and the World Bank with a better understanding of the unique needs of transport sector workers with respect to HIV prevention, determine how to foster an enabling environment for developing specific strategies and targeted HIV intervention programs within both the health and transport sectors, and offer recommendations for action. Keywords: HIV/AIDS, Transport, Georgia, Europe and Central Asia, HIV prevention, truckers, transport workers, seafarers, maritime, KAP, knowledge, attitudes and behaviors, sex workers, World Bank Correspondence Details: Anne Bakilana, MSN H11-1100, World Bank, 1818 H Street, NW, Washington DC, 20433. tel: (202) 473-458 5456 email: abakilana@worldbank.org. Human Development Sector Director, Tamar Manuelyan Atinc Europe and Central Asia Region Country Director for Armenia, Donna Dowsett-Coirolo Azerbaijan and Georgia Sector Manager, Health Nutrition and Armin Fidler Population Sector Manager, Transport Motoo Konishi iii iv CONTENTS ACKNOWLEDGMENTS ............................................................................................................. vii ABBREVIATIONS....................................................................................................................... viii EXECUTIVE SUMMARY ............................................................................................................. ix KEY RECOMMENDATIONS....................................................................................................................... xi HOW THIS REPORT IS ORGANIZED ...................................................................................................... xiii CHAPTER ONE: THE GROWING HIV/AIDS EPIDEMIC IN EUROPE AND CENTRAL ASIA ..................................................................................................................................................1 1.1 HIV/AIDS IN GEORGIA ......................................................................................................................... 2 1.2 WHY STUDY THE RISK OF HIV INFECTION AMONG TRANSPORT SECTOR WORKERS? ........... 4 1.3. GEORGIA’s EXPANDING TRANSPORT SECTOR: IS THERE INCREASED RISK FOR SECTOR STAFF? ......................................................................................................................................................... 7 1. 4. OBJECTIVES OF THE STUDY .......................................................................................................... 10 1. 5. METHODOLOGY ............................................................................................................................... 11 CHAPTER TWO: Risk of HIV Infection for Transport Sector Workers and their Partners.........14 PART I: FINDINGS FROM INTERVIEWS ..................................................................................................... 14 2.1 DEMOGRAPHIC PROFILE AND WORK CHARACTERISTICS......................................................... 14 2.2 TRUCKING SECTOR EMPLOYEE PROFILE ..................................................................................... 15 2.3 HIV/AIDS AWARENESS AND ATTITUDES IN THE TRUCKING SECTOR ....................................... 16 2.4 RISKY BEHAVIOR................................................................................................................................ 17 2.5 MARITIME SECTOR EMPLOYEE PROFILE...................................................................................... 18 2.6 HIV/AIDS AWARENESS AND ATTITUDES IN THE MARITIME SECTOR ........................................ 19 2.7 RISKY BEHAVIOR AMONG MARITIME SECTOR WORKERS .......................................................... 21 PART II: FINDINGS FROM THE QUESTIONNAIRE ......................................................................................... 23 2.8. KNOWLEDGE AND ATTITUDES TOWARD HIV/AIDS AMONG TRUCKERS................................. 23 2.9 PERCEPTION OF RISK ....................................................................................................................... 25 2.10 ALCOHOL AND DRUG USE ............................................................................................................. 26 2.11 SEXUAL BEHAVIOR .......................................................................................................................... 26 2.12 CONDOM USE ................................................................................................................................... 28 2.13 KNOWLEDGE OF SYMPTOMS OF SEXUALLY TRANSMITTED INFECTIONS ............................ 29 2.14 KNOWLEDGE AND HEALTH-SEEKING BEHAVIOR...................................................................... 29 2.15 REACHING TRANSPORT SECTOR WORKERS: MEDIA AND STOPPING/ RESTING PLACES ... 32 CHAPTER THREE: KNOWLEDGE, ATTITUDES AND SEXUAL BEHAVIOR AMONG SEX WORKERS .............................................................................................................................34 3.1 DEMOGRAPHIC PROFILE, MARITAL AND PARTNER STATUS AND SEXUAL HISTORY ............ 34 3.2 WORK CHARACTERISTICS AND SOCIO-ECONOMIC STATUS ...................................................... 34 3.3 KNOWLEDGE AND ATTITUDES TOWARD HIV/AIDS ..................................................................... 35 3.4 RISK PERCEPTION ............................................................................................................................. 36 3.5 ALCOHOL AND DRUG USE ............................................................................................................... 36 3.6 NUMBER OF PARTNERS AND CHARACTERISTICS OF CLIENTS.................................................. 37 3.7 CONDOM USE ..................................................................................................................................... 37 3.8 KNOWLEDGE OF STI SYMPTOMS .................................................................................................... 39 3.9 KNOWLEDGE OF AVAILABLE HEALTH SERVICES AND HEALTH-SEEKING BEHAVIOR ......... 39 3.10 REACHING SWs: MEDIA AND PLACES TO MEET TRANSPORT WORKER CLIENTS................. 41 CHAPTER FOUR: HIV PREVENTION AND CARE SERVICES FOR TRANSPORT SECTOR WORKERS .....................................................................................................................42 4.1 THE CHANGING ENVIRONMENT FOR HIV PREVENTION AND TREATMENT ............................ 42 4.2 HIV PREVENTION IN THE TRANSPORT SECTOR ........................................................................... 44 4.4 THE HEALTH SECTOR RESPONSE TO THE HIV/AIDS EPIDEMIC................................................ 45 4.5 RESPONSE to the RISKS OF HIV/AIDS IN THE TRANSPORT SECTOR........................................... 46 v CHAPTER FIVE: SUMMARY OF FINDINGS AND RECOMMENDATIONS .......................50 5. 1 SUMMARY OF FINDINGS.................................................................................................................. 50 5.2 THE TRANSPORT SECTOR AND RISK OF HIV INFECTION ........................................................... 50 5.3 RECOMMENDED INTERVENTIONS AND STRATEGIES.................................................................. 51 References.......................................................................................................................................55 BIBLIOGRAPHY...........................................................................................................................57 List of Tables Table 1-1: HIV Prevalence by City, Georgia ................................................................................3 Table 1-2: HIV testing in Georgia among maritime workers .......................................................3 Table 1-3: Number of Interviews by Site and Sector .................................................................11 Table 1-4: Transport Workers’ Sample, by Site ..........................................................................13 Table 1-5: Commercial Sex Worker Sample, by Site ..................................................................13 Table 2-1: Average Number of Correct HIV/AIDS Knowledge Answers (out of 7) .................24 Table 2-2: Average Number of Positive Attitudes toward PLHIV (out of 7) .............................24 Table 2-3: Sexual Behavior of Transport Workers (in percentages)............................................27 Table 2-4: Perceptions of Health Services among Transport Workers (in Percentages) .............30 Table 2-5: Experiences with HIV Testing among Transport Workers (in Percentages) ..............31 Table 3-1: Marital and Partner Status of Commercial Sex Workers (in Percentages) ..................34 Table 3-2: Work Characteristics of Commercial Sex Workers ....................................................35 Table 3-3: Condom Use by Type of Client ................................................................................38 Table 3-4: Condom Use by Transport Worker and Other Clients..............................................39 Table 3-5: Health-Seeking Behavior among Commercial Sex Workers (in Percentages) .............40 Table 3-6: Media Access of Commercial Sex Workers ...............................................................41 List of Maps and Figures Figure 1-1: New HIV Cases, Georgia ..........................................................................................3 Figure 2-1: Knowledge of HIV Transmission and Prevention among Transport Workers .........25 (Percentage who said “yes”) ......................................................................................................25 Figure 2-2: Condom Use with Occasional Partners (Georgian Truckers N=189; Foreign Truckers N=51; Georgian Sailors N=154; Foreign Sailors N=71) .....................................28 Figure 2-3: Where Truckers/Sailors Go for Relaxation (Truckers N=240; Sailors N=225) .......33 Figure 3-1: Knowledge of HIV Transmission and Prevention among Commercial Sex Workers (Percentage Answering “Yes”) (N=120) ............................................................................36 Figure 3-2: Number by type of Partners in Previous Seven Days, Sex Workers (N=120) ..........37 vi ACKNOWLEDGMENTS This report summarizes the findings of an exploratory study that reviews the risks of HIV for the transport sector in Georgia. The World Bank designed the study and commissioned the Euro Health Group to implement it. The study assessed current attitudes and approaches toward HIV prevention and care among health sector institutions, transport sector institutions, non- governmental organizations (NGOs), transport sector workers and SWs. The aim was to provide country authorities and the World Bank with a better understanding of the unique needs of transport sector workers with respect to HIV/AIDS and to determine how to foster an enabling environment for the development of specific strategies and targeted intervention programs within both the health and transport sectors. The study was funded by the UNAIDS Trust Fund from the World Bank Global AIDS Program as part of the UNAIDS Unified Budget and Workplan. The report was prepared by a research team led by Kerry Richter (EHG Team Leader), Christina Anderskov (EHG Deputy Team Leader), and Nana Morbedadze (IPM Project Director), Sofia Chanturishvili (IPM Qualitative Data Manager), Davit Tsabutashvili (IPM Quantitative Data Manager), Nana Tartarashvili (IPM Data Manager). Aleksandre Elbakidze (Data Manager), Lali Zaalishvili (Field Manager), Tamar Kinkladze (Field Manager), Liana Kovziridze (Data Manager), Tasso Tskhoidze (Regional Coordinator Batumi), Inga Gunia (Regional Coordinator Poti) and Nona Demetrashvili (Regional Coordinator Gori). The team also worked closely with Project Coordinator Jette Ramløse from the EHG headquarters in preparation and coordination. The Bank team was led by Anne Bakilana and included Shiyan Chao, Satoshi Ishihara, Owen Smith, and Tamar Gotsadze, together with a team of consultants including Zukhra Shaabdullaeva and Karumuna Kaijage. The work was supported by Armin Fidler, Sector Manager for Health Nutrition and Population, Motoo Konishi, Sector Manager for Transport, Donna Dowsett-Coirolo, Country Director for Armenia, Azerbaijan and Georgia and Tamar Manuelyan Atinc, Human Development Sector Director in the Europe and Central Asia Region of the World Bank. The team would like to recognize suggestions and comments received from peer reviewers of the study: Mary Mulusa, Senior Public Health Specialist, LAC; Siele Silue, Senior Transport Specialist, AFTTR; Peter Roberts, Lead Infrastructure Specialist, ETWTR; and Christopher Bennett, Senior Transport Specialist, EASTE. The team is also grateful for comments and suggestions received from Janet Leno, Global HIV/AIDS Program; Saumya Mitra, Lead Economist, ECSPE; Patricio Marquez, Lead Health Specialist, and Dominic S. Haazen, Acting Sector Manager, ECSHD. The team would like to thank the Georgian Ministry of Health, Labour and Social Affairs and the Ministry of Economy and Trade. In addition, we also thank all respondents who participated in this study. We are especially grateful for the support we received from The Georgian Seamen’s Medical Centre, The Georgian Seafarer’s Union, the Automobilist Garage in Batumi and the NGOs Tanadgoma (Batumi), Steps to the Future (Gori) and Association Mega (Poti). Their collaborative spirit and insights made access to a high number of respondents possible within the time and resources available. vii ABBREVIATIONS AIDS Acquired Immune Deficiency Syndrome BTC Baku-Tbilisi-Ceyhan pipeline BSS Behavioral Surveillance Survey CCM Country Coordinating Mechanism (Global Fund) SW Sex Worker ECA Europe and Central Asia GDP Gross Domestic Product GEL Georgian Lari GR Georgian Railways HIV Human Immunodeficiency Virus IDP Internally Displaced Person IDU Intravenous Drug User IEC Information, Education and Communications Material/Campaign ILO International Labor Organization IND Independent National Drivers IPM Institute for Polling and Marketing ITF International Transport Workers Federation ISO International Organization for Standardization M&E Monitoring and Evaluation MoLHSA Ministry of Labor, Health and Social Affairs MSM Men Who Have Sex with Men NCDC National Centre for Infectious Disease Control ND National Driver PLHIV People Living with HIV (includes people with AIDS) RH Reproductive Health SARS Severe Acute Respiratory Syndrome SCP South Caucasus Gas Pipeline STI Sexually Transmitted Infection TD Transit Driver TIR Transports Internationaux Routiers (International Transport System) TOR Terms of Reference USD United States Dollars WREP Western Route Export Pipeline viii EXECUTIVE SUMMARY The main objective of this exploratory study was to gain a better understanding of the risks of HIV for transport sector workers in Georgia and to outline the scope for policy response through prevention, care and treatment interventions. In particular, the aim was to identify the unique needs of transport sector workers with respect to HIV and to produce information that can be used to develop specific strategies and targeted intervention programs within both the health and transport sectors. The rationale for the study arose from both regional and Georgia-specific realities of HIV. The number of people living with HIV in the Europe and Central Asia (ECA) region more than doubled between 2001 and 2007. While injecting drug use remains the main mode of transmission, HIV cases through sexual transmission have been increasing. Georgia was selected as a case study because more than half (60%) of the 1,156 registered HIV cases to date have been reported in the last three years (2004–2006), and the annual number of newly registered HIV infections has risen each year (EuroHIV, 2007). Also, it is located in the Caucasus sub- region which has experienced rising HIV rates and is close to Russia and Ukraine – two countries with the highest prevalence of HIV in the region. The study focused on transport sector workers because research from other countries has shown that they tend to have many partners and often visit sex workers (SWs), and are therefore at increased risk of infecting themselves and their partners. Transport is also one of Georgia’s fastest growing sectors, and the study wanted to identify behaviors that, unless controlled, will put an increasing number of transport sector workers and their families and partners at risk over time. The study used both qualitative and quantitative methods. It assessed current attitudes and approaches toward HIV prevention and care among health sector institutions, transport sector institutions, non-governmental organizations (NGOs), transport sector workers and SWs. Two quantitative surveys were conducted with transport workers (truckers and sailors) and sex workers at study sites. Statistics on the transport sector, HIV/AIDS and other sexually transmitted infections (STIs), drug use, international trade, and other issues were also collected from secondary and official sources to give substance to the qualitative findings. The key findings from the study are as follows: Overall, awareness of HIV/AIDS among interviewed transport sector workers is high, however, knowledge on transmission and prevention varies. About 99% have heard of HIV/AIDS and nearly all knew that HIV could be transmitted by sharing needles. However, misconceptions and myths are common. Compared to maritime workers, truckers are less informed about HIV/AIDS issues and less knowledgeable about HIV transmission. For example, about 43% of Georgian truckers believe HIV can be transmitted by sharing food and nearly half of them believe it can be transmitted by a mosquito bite. HIV risk among transport workers is more likely through sexual transmission than through intravenous drug use. The study found minimal indications of intravenous drug use by transport sector workers or sexual or drug-use networking between transport workers and IDUs (the group with the highest prevalence of HIV in Georgia). Both qualitative and quantitative data indicate IDU is little known among sailors and truckers. It may be due partly to regular testing required by shipping companies for sailors and intolerance of drug use within the trucking sector. However, risk of HIV through sexual transmission is relatively high, particularly through unprotected paid sex. The study shows that about 70% of Georgian truckers and sailors and 97% of foreign sailors had paid sexual partners in the past 12 months. ix High level of awareness does not necessarily change risk behavior among transport workers and risky behavior is prevalent among both types of transport workers. Even though most informants knew about HIV/AIDS, only a few saw the link between the nature of their work and the risky behaviors many of them practice and the threat of either being infected with HIV or infecting their partners. They did not perceive transport workers in general as being at risk of transmitting HIV. The average frequency of visits to SWs was high, and the number who always used a condom was low. Among truckers, the study found that long hours spent on the road away from regular sexual partners and the easy availability of, and frequency of visits to, SWs along trucking routes result in a high HIV risk for truckers. Among maritime workers, the study identified a close link between sexual behavior and the use of alcohol. Sailors are more likely to have unprotected sex after alcohol use. There is easy access to SWs along transport routes, but condoms to prevent HIV transmission are not readily available. The sex worker survey found that SWs work an average of 10 hours a day, seven days a week, and average two clients per day. Their knowledge of HIV transmission and prevention and of STI symptoms was low. Only 64% knew that condom use in every sexual act can reduce the risk of HIV. Condom use among SWs was low: only 29% said that they always used condoms with their clients. Alcohol consumption is negatively related to condom use. Nearly one in four (23%) went to a public clinic or hospital to get condoms, and another 19% bought condoms at a drug store. Half of the SWs interviewed said that there were no condoms available at their place of work. Stigma and discrimination towards HIV/AIDS are still high in the transport sector. 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: only 22% thought an HIV-positive teacher should continue teaching and only 18% would buy food from a vendor with HIV. There are significant barriers to dialogue about prevention services for transport sector workers. Reaching transport workers with prevention messages is deterred by key stakeholders in the industry who harbor contradictory attitudes about sexual behaviors of transport workers (e.g., that they are family men) despite acknowledging that many drivers visit SWs. The enabling environment to fight the HIV/AIDS epidemic in Georgia is changing for the better. The policy on how to address HIV/AIDS issues has changed since the time when it was first diagnosed in Georgia. There is now free access to ARV drugs for all citizens, no more HIV testing of travelers, less police harassment of SWs, no more forced HIV testing of SWs, methadone treatment for selected injecting drug users (IDUs) and a higher level of openness toward men who have sex with men. However, much remains to be done. There is still a need to further develop a positive and enabling environment for HIV prevention and management of the AIDS epidemic in Georgia, including clarifying the mandate for HIV prevention, treatment and care; ending large scale imprisonment of IDUs; providing needle exchange programs and condoms in Georgian prisons; reevaluating the need for mandatory HIV testing in some sectors; and ending discrimination toward PLHIV. The Georgian health sector has initiated few programs or services to address the need for prevention services among transport sector workers. Some health officials did not perceive a link between the transport sector and the spread of HIV or dismissed it as a minor risk, while some saw it as one of the big challenges for the future. Some officials working at the central level dismissed the risks while health officials at the regional level were more inclined to see the link x and perceive HIV in the transport industry as a threat. This lack of response contrasts with the multi-level though somewhat uncoordinated response of the maritime sector. With regard to the NGO sector, the Global Fund provided funding for a small project on HIV awareness among truck drivers implemented by the NGO Tanadgoma. KEY RECOMMENDATIONS A key finding from this study is that a significant proportion of transport sector workers engage in unsafe sex with SWs and this calls for provision of specific information and prevention services for this highly mobile section of the population. While the risk of transport sector workers spreading HIV is still probably low, as the sexual mode of HIV transmission continues to grow, this section of the population is likely to face increasing risk of getting infected and infecting their partners. Despite lack of recognition of the direct link between transport sector and HIV risk, some limited information indicates that among tested maritime workers, the HIV rate is higher than the general HIV prevalence rate in Georgia (0.45% vs. 0.2 %) 1 and representatives of the various sectors, NGOs, health providers and transport and maritime industries reported that they would be interested in collaborating and joint work to address risky sexual behaviors and to reduce the risks of HIV among transport sector workers. The study identified the following recommendations for planning HIV prevention programs: Enhancing dialogue The lack of dialogue and interaction between public health institutions, NGOs and the private sector on transport and HIV/AIDS issues contributes to the inability to have a clear strategy and plan prevention programs in a coordinated, effective way. We recommend that the Bank facilitate dialogue on the importance of prevention services for transport sector workers. This could be done by: i) Disseminating study findings to key stakeholders, particularly to the private sector, industry leaders, NGOs and providing opportunities for various stakeholders to discuss the results, special needs and strategize the way forward. ii) Encouraging cross-sector collaboration among national transport companies, international transport companies, NGOs, the health sector and education sector to identify transport sector needs and develop a strategic plan for the transport sector within the framework of the national strategy for HIV/AIDS. iii) Engaging transport industry representatives in Country Coordination Mechanism (CCM) meetings and other HIV/AIDS-related activities in order for them to learn more about HIV/AIDS programming in Georgia and to raise awareness of transport issues for those working on programs funded by the Global Fund and encourage them to design programs to address the needs of transport workers in their HIV prevention. iv) Forging dialogue among central institutions, such as the AIDS Center, the National Center for Infectious Disease Control and the regional public health departments, and the transport sector, including the maritime sector. Cooperation among these sectors will lead to a more 1 EuroHIV. HIV/AIDS Surveillance in Europe, End-year report 2006 for maritime workers and UNAIDS for general prevalence rate (UNAIDS 2006 Report on the Global AIDS Epidemic). Please treat these numbers with caution as they are not strictly comparable and it was not possible to assess the reliability of the information on maritime workers. xi informed and inclusive approach, particularly as it will draw the transport sector into the national HIV/AIDS strategy. Raising awareness While transport sector officials feel that their workers are well educated and know how to protect themselves, their knowledge of HIV transmission and its potential danger is limited. Both transport workers and SWs lack knowledge of HIV and STIs and prevention methods. Further awareness-raising is recommended on HIV/AIDS, its mode of transmissions, the risks involved in having unprotected sex with multiple partners and various prevention measures. This could be accomplished through: i) Identifying champions and influential persons from the transport industry to talk to transport workers about HIV/AIDS. Engaging leaders in the industry to play a stronger role to support HIV responses. Improving leaders’ knowledge and attitude toward HIV/AIDS and their understanding of impact of AIDS on economy, industry and their workers and families. ii) Expanding information, education and communication (IEC) campaigns at sites identified by this study, including truckers’ rest stops, places where transport workers and sex workers meet and facilities where transport workers obtain health services. Written information, posters, and training to motivate medical personnel to raise these issues would help to improve knowledge levels among transport workers. The campaigns should be designed to target the high risk groups and settings based on the study findings. The information on prevention should include not sexual transmission, and also transmission through intravenous drug use, particularly for the trucking sector where potential risk for drug use is higher. iii) Introducing actions on transport and HIV/AIDS such as those advocated by the EU. The EU calls for targeting workers who are involved in building and maintaining transport infrastructure as well as those who operate transport services, many of whom, as this study has shown, engage in unprotected sex with SWs. Actions could include targeted health education, prevention, condoms, reducing time spent away from home, providing information and other services at rest stops and reducing time spent at border posts. Though the Government needs to support some of these initiatives, some programs could be initiated through private sector initiatives with NGOs. An excellent example is the partnership among the international Labor Organization, the International Transport Workers Federation and the International Road Transport Union which has produced a toolkit providing information on HIV/AIDS for transport workers. The toolkit contains a training of trainers manual; a training course for management personnel of road transport companies; and an awareness raising and advocacy course for transport workers. iv) Creating an enabling environment for transport workers and sex workers to conduct peer-to- peer education and share knowledge and experiences in HIV interventions. Peer educators could be a powerful force for communicating behavior change messages to these workers. Particularly on ships, where the audience is somewhat captive, programs could be implemented to raise the issues and break the ice. Engaging traditional healers in HIV/AIDS campaigns might also be useful since most SWs reported them as a source of care when they had STIs. v) Introducing media campaigns that convey health messages to transport sector workers and SWs. Advertising-type IEC campaigns, talk shows, soap operas and the like have been proven to be effective in communicating HIV prevention messages. xii Working towards behavior change The study shows that changing risk behavior is a challenge, and that knowledge is not enough to get people to change risk behaviors. Changing behavior will require persistent and intensified effort and interventions. Even though awareness of HIV/AIDS is high among transport workers, unprotected paid sex is common. Many transport officials said that condom use is strongly – and inversely – related to alcohol use. Survey respondents often said that they “didn’t think of” using a condom at the critical moment, even though many sex workers had them on hand. Therefore, it is important to provide means for prevention in addition to information. This could be done through: i) Moving beyond simply providing information and raising knowledge and awareness, making prevention services/means such as condoms readily available and accessible at a wide range of places. Leaflets on HIV prevention and care as well as condoms; could be made available in every transport worker’s travel kit. In addition, political and social leaders and health workers need to emphasize repeatedly that unprotected sex risks HIV infection and educate the public about the health benefits of condom use. Intensive work could be done with sex workers to encourage them to use condoms always. ii) Implementing voluntary counseling and testing programs. VCT is an opportunity to help people understand and reduce their risks. Recent studies find that people who test positive for HIV are likely to reduce risky behaviors. Looking towards the future The maritime sector in Georgia serves as a model of how modernization and reforms to meet international standards can improve awareness of health and human rights. There are opportunities to build on this model by continuing to move in the same direction to improve the health status of larger numbers of people by creating a program that aims to reduce HIV transmission among men who buy sex and their spouses, partners and sex workers. This should be a central focus of HIV prevention programs for the transport sector in the near future. HOW THIS REPORT IS ORGANIZED This report is organized as follows. Chapter 1 provides background and a summary of the report’s main findings. Chapter 2 presents findings from the qualitative and quantitative surveys, and Chapter 3 is on the sexual behavior, knowledge and practices among SWs. Chapter 4 is on NGO and health and transport sector responses to the epidemic. Chapter 5 summarizes findings and presents recommendations as well as next steps for the World Bank transport and health teams. xiii xiv CHAPTER ONE: THE GROWING HIV/AIDS EPIDEMIC IN EUROPE AND CENTRAL ASIA The number of people living with HIV in Europe and Central Asia (ECA) increased by 150% between 2001 and 2007. According to the 2007 AIDS Epidemic Update, 2 the number of people living with HIV in the region rose from 630,000 (490,000–1.1 million) in 2001 to 1.6 million (1.2 million–2.1 million) in 2007. An estimated 150,000 people (70,000–290,000) became newly infected in 2006. Injecting drug use remains the most common mode of HIV transmission; sexual transmission is the second most common and increasing. Of the new HIV cases reported in 2006 in Eastern Europe and Central Asia, nearly two-thirds (62%) were attributed to injecting drug use and more than a third (37%) to unprotected heterosexual intercourse (UNAIDS, WHO, 2007). Most people living with HIV (PLHIV) in this region are in the Russian Federation (66%) and Ukraine (21%), which together account for 90% of newly reported diagnoses in the region. In 2006, 39,000 new HIV diagnoses were officially recorded in Russia, bringing the total number of HIV cases registered in the country to about 370,000 (AIDS Foundation East-West, 2007; EuroHIV, 2007). Patterns of transmission are very similar to those prevailing region-wide as cited above. Women comprised about 44% of newly registered HIV cases in 2006, and national HIV prevalence among pregnant women was 0.4% in 2005 and 2006 (Russian Federal AIDS Centre, 2007). In Ukraine, the number of new annual HIV diagnoses has more than doubled since 2001, reaching 16,094 in 2006 and exceeding 8,700 in the first six months of 2007. South-eastern Ukraine continues to be the most affected area, especially the regions of Dnipropetrovsk, Donetsk, Mikolaiv and Odessa, as well as the Autonomous Republic of Crimea (UNAIDS, WHO, 2007). The annual numbers of newly reported HIV diagnoses are also rising in Azerbaijan, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Tajikistan and Uzbekistan (which now has the largest epidemic in Central Asia). The rates of HIV are increasing in the Caucasus in areas very close to the Russian Federation and Ukraine. Increasing numbers of new HIV cases are being reported in each of the Caucasian republics. In Georgia, more than half (60%) of the 1,156 registered HIV cases to date were reported in the last three years for which data are available (2004–2006), and the annual number of newly registered HIV infections has risen each year (EuroHIV, 2007). A similar trend is observed in Armenia where most reported HIV infections have been among injecting drug users (IDUs, almost all of them men). According to data from the Armenian National AIDS Foundation, HIV prevalence of about 9% was found among injecting drug users, whereas prevalence of less than 2% was found among female sex workers (UNAIDS, WHO, 2007). In Azerbaijan, almost half of the HIV cases registered by 2006 were in the capital, where 13% of injecting drug users tested HIV-positive in a 2003 survey (UNAIDS, WHO, 2007). Unsafe sex work is an important factor contributing to the growing epidemic in ECA. In Ukraine, HIV prevalence among sex workers ranged from 4% in Kiev to 24% in Donetsk and 27% in Mikolayev. Newly reported HIV cases in Moldova have more than doubled since 2003, to 621 in 2006. More than half (59%) of HIV infections reported in 2006 were attributed to unprotected sexual transmission. In Azerbaijan, high prevalence of HIV (9%) and other sexually transmitted infections (9% syphilis and 63% chlamydia) has been found among female sex workers, among whom condom use appears to be infrequent. In Tajikistan, where HIV 2 UNAIDS and WHO. 2007. AIDS Epidemic Update. 1 prevalence among injecting drug users increased in one year (2005–2006) from 16% to 24% in the cities of Dushanbe and Khujand, a coinciding sudden rise in prevalence among sex workers occurred in those same cities: from 0.7% to 3.7%. In Kyrgyzstan, the HIV epidemic is also concentrated among injecting drug users: sentinel surveys in Bishkek and Osh found HIV prevalence of 0.8% among injecting drug users, 3.5% among prisoners, 1.3% among female sex workers and 1% among men who have sex with men in 2006 (Ministry of Health Kyrgyzstan, 2007). (UNAIDS, WHO, 2007). 1.1 HIV/AIDS IN GEORGIA A number of papers review the recent history of the epidemic in Georgia and the current situation. The United Nations Educational Scientific and Cultural Organization (UNESCO) (2005) outlined how the traditionally low prevalence in the region contributes to stigma and ignorance about the disease. Lessons learned from countries with high prevalence and extensive research do not apply to the Georgian context, and little analysis has been done of the social and political factors that affect the potential for prevention. The study stresses the importance Georgian culture places on interpersonal relationships and short-term planning horizons, which affect such practices as shared needles, the low value accorded to long-term health practices, and lack of condom use based on trust, even with paid partners. Gender roles, including the tolerance of multiple partnering for men, as well as continued stigma for homosexuals are also barriers to preventive behavior. Gotsadze et al. (2004) outline the increase in HIV in Georgia since 1996. While overall prevalence remains low, the epidemic has reached every geographic area, and the percentage of new cases contracted through heterosexual contact has increased, indicating the potential for HIV to spread into the general population. The paper presents a national response analysis that delineates how political commitment, organizational structure, and the legal environment have positively and negatively contributed to the response to the epidemic. It concludes with recommendations for mitigating the impact of the epidemic on social and economic development. Dershem et al. (2004) conducted behavioral surveillance surveys in 2004 of IDUs and sex workers (SWs) in Tbilisi and Batumi. The sex workers in the Batumi SW study were older than in many parts of the world, and the average age at first commercial sex was 30.9 years. Fully 87% of these SWs said that they used a condom with their last client, and 54% said that they always use condoms. Only a very small percentage reported injecting drugs. In Tbilisi, reported condom use was even higher – 94% at last sex with a client and 84% consistent use. The study reported a significant increase in condom use between the two rounds of the surveys (2002–2004). The IDU studies found that, although there was a decline between the two survey rounds, a considerable proportion of the sample still shares needles and other injection equipment. Since nearly all know the connection between sharing injection equipment and HIV, the study concludes that sharing equipment is an important way of showing trust. According to data obtained from the AIDS Centre, 1582 cases of HIV infection had been registered in Georgia as of 2007 (Table 1-1). The distribution of transmission was 60.4% by injection drug use, 32.5% by heterosexual contact, 2.7% by homosexual or bisexual contact, 2.2% by vertical infection, 0.8% by blood transfusion, and 1.4% unknown. Data also show that there is a relatively high growth trend of new HIV cases. By November 2007, 285 new cases had been registered that year, compared to 259 new cases within the same time period in 2006. 2 Table 1-1: HIV Prevalence by City, Georgia City HIV cases City HIV cases Tbilisi 509 Kakheti 51 Samegrelo 226 Abkhazia 51 Zugdidi 165 Guria 34 Ajara 219 Shida Kartli 35 Imereti 186 Poti 27 Kvemo Kartli 53 Samtskhe-Javakheti 26 Total 1582 Source: Georgia AIDS Centre Figure 1-1: New HIV Cases, Georgia Source: Georgia AIDS Centre Official Georgian statistics on HIV follow the WHO format, so transport workers are not shown as an individual group. However, the Georgia Seamen’s Medical Centre in Batumi provided the statistics in Table 1-2, showing numbers of HIV tests performed and number of confirmed positive cases who are seamen. The total figure of 3277 people tested may include seamen’s family members and perhaps others; it may also include the same person being tested multiple times: Table 1-2: HIV testing in Georgia among maritime workers Year Number tested 2003 700 2004 608 2005 684 2006 719 2007 566 (2 confirmed positive cases) Total 3277 Total confirmed positive cases 17 (15 sailors and 2 others) Source: EuroHIV. HIV/AIDS Surveillance in Europe: End-year report 2006 3 The figures reveal an HIV-positive rate of 15/3277 or 0.45%. This compares to an HIV prevalence rate of 0.2% for Georgia as a whole. 3 However, these figures should be treated with caution as it was not possible to obtain further documentation on how many of the people tested were seamen and how many were tested multiple times. As mentioned above, similar statistics on truckers are not available. 1.2 WHY STUDY THE RISK OF HIV INFECTION AMONG TRANSPORT SECTOR WORKERS? Research in South Asia, Southeast Asia and Africa indicates that transport workers have many partners, often visit SWs, and may have sex with other men. Condom use has been found to be infrequent in most places studied. While few studies have found a link between transport workers and intravenous drug use, many find that truck drivers drink alcohol frequently and that there is a link between alcohol use and risky behavior. Research that collected biomarkers to test transport workers for HIV and other STIs have found a higher-than-average prevalence both for transport workers and those who live and work at transport hubs. Despite this, some studies have found that transport workers have a low perception of their risk of contracting HIV (Bwayo et al. 1991; Chaturvedi et al. 2006; Gibney et al. 2001, 2002, 2003; Majunath et al. 2002; Morris and Ferguson 2007; Podhisita et al. 1996; Singh and Malaiviya 1994; Thappa et al. 2002). Transport is linked to the spread of HIV because traffic routes facilitate the movement of people between areas of low and high HIV prevalence. 4 For example, UNOPS/UNDP (2001) showed that the land transport sector could contribute to the spread of HIV when roads and bridges are built, because then low and high HIV prevalence areas such as villages and cities are linked: this is not only true with domestic transport routes but also international ones. Hsu (2001) cites an example in which HIV prevalence rates changed following the construction or improvement of the Mandalay-Muse Highway in 1997 to link Mandalay, Myanmar, via Muse to Yunnan, China. Data show an overall increase in HIV prevalence among IDUs after completion of the highway. Similarly, three years after the highway linking Kunming (Yunnan) to Nanning (Guangxi) in China was completed, the number of documented HIV cases for Guangxi rose from 10 to 525. Another example is from the improved National Highway One in Vietnam, which may have facilitated the increase in HIV cases in the North (Ha Noi and Hai Phong): the rapid rise in HIV prevalence in the North is associated with better transport links with the already high HIV-prevalence area in the South, which includes Ho Chi Minh City. 3 UNAIDS 2006 Report on the Global AIDS Epidemic. 4 Reported in various studies, including: i) Marck. J. 1999. Long-distance truck drivers’ sexual cultures and attempts to reduce HIV risk behavior amongst them: A Review of the African and Asian literature. Pp. 91-100 in Caldwell, J. et al. (eds.), Resistances to Behavioural Change to Reduce HIV/AIDS Infection in Predominantly Heterosexual Epidemics in Third World Countries. Canberra ACT Australia: Health Transition Centre, National Centre for Epidemiology and Population Health, Australian National University. ii) Agha, S. 2000. Potential for HIV Transmission among Truck Drivers in Pakistan. AIDS: Volume 14. London: Lippincott Williams & Wilkins. iii) Bronfman et al., 2002; Mobile populations and HIV/AIDS in Central America and Mexico: Research for Action. AIDS: Volume 16, Supplement 3. London: Lippincott Williams & Wilkins.; iv) Profiling the Maritime Industry in the Port of Rarong, Thailand. Source: “http://siteresources.worldbank.org/INTTSR/Resources”; v) UNAIDS; UNDP; WHO; UNOPS. 2001. Assessing Population Mobility and HIV Vulnerability in Guangxi, People’s Republic of China; vi) UNAIDS; UNDP; WHO; UNOPS. 2000. Assessing Population Mobility and HIV Vulnerability in South East Asia. 4 Much of the previous research on the transport sector and HIV focused on measuring risks. Some studies have taken biomarkers – blood tests for HIV and other STIs – to measure the prevalence of these diseases in transport workers and those who come in contact with them. Most of these studies were conducted in South Asia and East Africa; the vast majority focused on truck drivers rather than seafarers. Previous studies on truckers in Africa and Asia Several review articles have been written about transport workers and HIV, including AIDSMark 2004; Marck 1999; and Broring and Van Duifhuizen 1993. Findings on risks from previous behavioral surveillance surveys, some of which included biomarkers, may be summarized as follows: Multi-partnering: Surveys of truck drivers show that they have multiple partners. A Bangladesh study found that each driver had an average of 4.57 partners in the previous year (Gibney et al. 2003); an India study showed that 45% had more than five partners in the previous year (Chaturvedi et al. 2006); and in Thailand the median number of partners over a lifetime was 29 (Podhisita 1996). Contact with SWs: Gibney et al. (2003) found that 54% had seen a sex worker in the past year; in two Indian studies Singh and Malaviya (1994) found this figure to be 78%, and Manjunath et al. (2002) found it to be 57%. In an East African study, Morris et al. (2007) found that half of the sexual acts of truckers were with SWs. Men who have sex with men (MSM): Most studies in South Asia find that sex with other men is not uncommon among truck drivers; a Bangladesh study found 7% had had sex with another man in the previous year, while an Indian study found 5% of truck drivers had sex with other men (Gibney et al. 2003; Singh and Malaviya 1994). In Pakistan qualitative research found that truckers were one of the groups of married men who said they had sex with other men when women were not available (Khan and Hyder 1998). Drug and alcohol use: While several studies have investigated a possible link between truckers and intravenous drug use, most do not find such evidence (Gibney et al. 2003; Singh and Malaviya 1994). Several studies have found that those who drink alcohol are more likely to visit SWs (Gibney et al. 2003; Chaturvedi et al. 2006; Manjunath et al. 2002). Condom use: Findings on truckers’ condom use with SWs have varied with the time of the study and nature of the epidemic. a recent study in East Africa found that 70% reported condom use with a casual partner (Morris et al. 2007), while a recent study in India found that only 7% used condoms every time with a SW (Chaturvedi et al. 2006). Risk perception: A Thai study (Podhisita et al. 1996) found minimal perception of HIV risk despite a high degree of risk behavior. Other STIs: Studies that collect biomarker as well as behavioral data found a high prevalence of various STIs. The Bangladesh study found 25.8% herpes simplex 2 and 7.0% syphilis (Gibney et al. 2002). Bwayo et al. (1991) found 5.0% syphilis. In Bangladesh the vast majority did not receive treatment for their symptoms (Gibney et al. 2003). Morris et al. (2007) found that while 77% of those with symptoms sought treatment, only 29% completed the course of treatment. HIV prevalence: For studies that tested truckers for HIV, results in India were 1.0% in 1994, 56.9% at an STD clinic in 1998-2000, and 15.9% in 2002 (Singh and Malaviya 1994; Manjunath 5 et al. 2002, Thappa et al. 2002); 2.3% in Thailand in 1996; and 18.0% at an STD clinic in Mombasa in 1991 (Bwayo et al. 1991). Spread of HIV to others: Gibney et al. (2001) tested women who lived near a truck stand in Bangladesh and found no cases of HIV but 6.3% had gonorrhea, 5.7% syphilis, and 32.0% herpes simplex 2. One study on HIV and the transport industry deserves mention due to its innovative methodology. Uhrig et al. (2000) mapped transport flows, passenger flows, services available and “hot spots,” stopping points where risk behavior occurs along Highway One in Vietnam. They found that most studies underestimate the numbers involved in the transport industry, as they exclude such workers as porters and taxi-drivers who serve the industry. These workers, besides buying sex themselves, are important as guides for others seeking sexual services. The Vietnam study found that opiate injecting was common at some hot spots and among some transport workers and the SWs who serve them. Several major multi-country intervention programs have been implemented targeting truckers and those who come in contact with them in Africa. These include the Corridor Project in West Africa, the Ethiopia Project and the Corridors of Hope peer education project in southern Africa (Lema et al. 2003; Martin 2004). Assessments of the effectiveness of these projects stress the need for multilevel involvement – including national and local leadership and the involvement of both government and industry. Previous Studies of Seafarers The literature on HIV and “seafarers” – sailors and fishermen – is much sparser than that on truckers. Kisslinga et al. (2005), in a review article of existing studies, concluded that fishermen’s high-risk occupations contributed to their risky sexual behavior. Their low social status was seen to contribute to “oppositional masculinity” that challenges norms of conventional or middle- class society, including multiple partnering and alcohol use. The limited health services available to fishing communities also contribute to their vulnerability. Gordon (2005) further states that in some communities where women compete for the fish catch against vendors or small-scale processors, they may trade sex for fish. A study conducted by HAIN (2003) in the Philippines maintained that seafarer’s macho values, including the belief that it is natural for men to pursue sex at every opportunity, put them at risk. The Thailand Seafarers’ Research Team (n.d.) studied Thailand, Vietnam, Cambodia and Myanmar and identified barriers preventing the government and industry entities from implementing prevention programs. This study did find that drug abuse, including injecting heroin, was a factor in increasing risk for seafarers. Previous Studies on Transport and HIV/AIDS in ECA Little attention has been paid to the role of transport in the spread of the epidemic in the ECA region, for reasons that include: (a) low prevalence rates (< 0.1% in many countries); (b) unlike other regions, the ECA epidemics have been to a large extent driven by IDUs, so the usual HIV- transmission pathways have not been explored; (c) HIV/AIDS is still seen as a health sector issue; and (d) lack of capacity in the transport sector to evaluate the role it could play in curbing the epidemic. Tomaszunas (1993) conducted a survey of Polish seafarers and deep-sea fishermen. He found that knowledge of HIV transmission and prevention was higher among the more educated respondents and that younger respondents expressed less stigmatizing attitudes about working with someone with HIV. Only about half said they used condoms for casual sexual encounters. 6 Kulis et al. (2004) conducted a study of truck drivers and SWs in the border areas of Poland and Lithuania. The truck drivers’ questionnaire included a self-administered module on sexual behavior and condom use. More than a third (37%) said they had casual sex while on the road, and two-thirds said that they always use condoms during casual sex. Regarding type of sex, 22% said they sometimes practiced oral sex and 5% anal sex. In Georgia, as in most of the ECA region, until recently HIV prevalence has been relatively low and linked closely with IDU. Yet in the past decade prevalence has climbed rapidly, and indications are that the epidemic is spreading to the general population through heterosexual sex (Gotsadze 2004). SWs have also been identified as a new high risk population. Most cases of HIV are in Tbilisi, but prevalence is increasing in the Black Sea coastal regions of Adjara and Samegrelo (Ikram and Kaijage 2007a). Although the transport sector is vitally important to Georgia’s economy and HIV risks in this industry have been studied extensively elsewhere, little research has been conducted to date on HIV/AIDS and transport in Georgia. In addition to the lack of basic information on knowledge, attitudes and practices in the industry, there are significant challenges facing prospects for incorporating prevention programs into existing transport projects and engaging the health sector on this issue. 1.3. GEORGIA’S EXPANDING TRANSPORT SECTOR: IS THERE INCREASED RISK FOR SECTOR STAFF? Georgia's location makes it an important transport link between East and West (the Black Sea and the Caspian Sea) and North and South (between Russia and Turkey). Trade with its neighbors, both transit and bilateral, is an important part of Georgia’s economy. Located at the crossroads of Europe and Central Asia, Georgia connects several economic regions with a total of 827 million people, including the European Union (495 million), the Commonwealth of Independent States (243 million), Turkey (73 million) and the Caucasus Region (16 million). The World Bank reports that Georgia’s transit activities generate a direct turnover of more that US$2 billion per year. 5 One of the government’s highest priorities is to develop Georgia’s comparative advantage as a transit country by improving its East-West transport corridor (World Bank, n.d.). Georgia’s economy is primarily driven by transit and imports and produces few products for export. The main destinations for exports and goods transiting Georgia are Austria, Armenia, Azerbaijan, the Czech Republic, France, Germany, Greece, Italy, Poland, the Russian Federation, Spain, Turkey, and Ukraine. Many projects rehabilitating the country’s infrastructure have been undertaken to facilitate development of Georgia as a transport corridor, and more will follow in the near future. Ministry of Finance Revenue Services data indicate that yearly turnover (in USD) from the transport sector has increased significantly: from $325,633,762 in 2002 to $388,380,273 in 2004 and $688,866,304 in 2006 (Georgia Ministry of Finance – Revenue Services). The World Bank (n.d.) reports that Georgia’s road network consists of 1,474 kilometers of main roads with about 70% in good to fair condition; 3,392 kilometers of secondary roads of which over 60% are in poor condition needing rehabilitation; and 15,429 kilometers of local roads most in very poor condition. The poor state of the highway network constrains travel of goods and persons between Georgia’s main cities and ports and along the transit corridor. Long transit 5World Bank (n.d.) It is unclear what is included in this figure, especially whether or not revenues from the oil and gas pipelines are included or only in the energy sector’s turnover 7 times and poor road conditions feed growing transport costs and deter use of the Georgian transit route. Since its election, the current Government has focused on improving road infrastructure. Funding provided to the transport sector has increased substantially: from GEL 51.4 million in 2003 to GEL 67.8 million in 2004 and GEL 121.4 million in 2005, the last year for which funding data are available; a further increase was expected in 2006. Road maintenance and construction in Georgia is fully privatized (World Bank n.d.). The main roads and highways cross Georgia from the Sarpi border to the Russian Federation along the Black Sea Coast via Batumi and Samtreda, forming a corridor from Sarpi via Samtreda, Kutaisi, Gori and Tbilisi to Armenia and Azerbaijan. The road links Tbilisi to the Russian border of Larsi, a short distance north of the capital. Land Transport The private transport sector is very young in Georgia and many companies, especially those engaged in international transport, were established only within the last ten years. The companies can be divided in two groups: international transport companies with new, modern trucks that can be used for international transport; and national transport companies with a fleet of old Soviet-style trucks that are allowed to be used only for regional transport (Georgia, Azerbaijan and Armenia). Companies are relatively small – international companies have fleets of 2–20 trucks. These trucks are “TIR marked” 6 and meet the standards of the 1975 TIR Convention. National transport companies have one or more trucks in their fleet, and often do not own the trucks but hire them from individuals or drivers. Data on the exact number of companies of each category in Georgia are not available. Information from the Georgian International Carriers Association and the Customs Control Department suggests that a fair estimate would be between 80 and 100 international transport companies. There are estimated to be at least twice as many national transport companies, based on the share numbers of such trucks on the Georgian highways, i.e., 160–200 companies. In addition, many truck drivers own their own Soviet-style truck and work as independent contractors. Consequently, there are many more national truck drivers contracted by national transport companies or working as independent contractors than international transit drivers contracted by international transport companies. Our informants reported that the vast majority of truck drivers on Georgian routes are not Georgian, but Turkish or Ukrainian. Data from the Sarpi border show that approximately 250 trucks cross the border daily: about 225 going from Turkey into Georgia and about 25 entering Turkey from Georgia. Most are Turkish and very few, according to the border police, are Georgian. Again it is not known how many transport companies are registered in Georgia or how many drivers there are in Georgia. Sea Transport Georgia has four ports: Batumi in the Adjara Region, Poti in the Samegrelo Region, Supsa in the Samegrelo Region (oil terminal) and Sukhumi, in the Abkhazia Region. Sukhumi Port has been affected by the conflict in Abkhazia and is not operating fully. Batumi and Poti are by far the largest ports and important contributors to the Georgian economy. They link Georgia directly to the Russian Federation, Ukraine, Turkey and Bulgaria via sea routes, mainly through rail ferries and “ro-ro” (“roll on–roll off” ships capable of transporting trucks). In addition, one port is under construction: Kulevi Oil Terminal in the Samegrelo Region. During the Soviet era, all vessels in the Georgian navy belonged to the state. Each port had its own medical clinic for 6TIR stands for the Transports Internationaux Routiers. The Customs Convention on the International Transport of Goods was established at the 1975 TIR Convention. 8 seamen, and each vessel had a medical doctor aboard (Source: interview #15 with a crewing company official). Our informants indicated that much has changed in the maritime sector since Georgia gained independence, including the privatization of Batumi Port; the ongoing privatization of Poti Port; the sale of the entire fleet of the Georgian Navy to privately held shipping companies; the closure of the Poti Seamen’s Medical Clinic; the elimination of medical doctors aboard vessels as it is not required by international standards; having to adjust the Georgian maritime sector to meet international standards, laws, regulations; and, last but not least, competitive markets in the global economy. Batumi Port was privatized in 1999. The total cargo turnover is 13 million tonnes per year, of which most (12 million tonnes) is liquid cargo (crude oil); only 1 million tonnes is dry cargo. During the privatization process, compensation was given to the port workers laid off by the administration, and social benefits are currently in place for port employees. Batumi Port has been certified in accordance with the International Organization for Standardization, which ensures that the port meets international standards. Poti Port is a dry cargo port with 1,284 employees, ranging from tugboat seamen to dockers and administrative personnel. Like Batumi Port, Poti Port has undergone a series of changes to adjust to the global market and standards. Poti Port is focusing on meeting ISO certification and other standards. Prospects for Further Growth Our informants indicated that existing Georgian infrastructure will see many improvements and developments in the near future. Some are already underway. In the maritime sector, three projects were highlighted: the Poti Port expansion, now underway; the new rail Ferry Poti– Kercher Strait connection to the Russian Federation, operating since June 2007; and the Kulevi Oil Terminal in Samegrelo, which is underway. For land transport the focus is on expanding and improving the current road, rail and border facilities. These include the Baku–Tbilisi–Karsi railway being constructed in 2007; the Tbilisi– Gori highway, which is being expanded and modernized; expansion and modernization of border crossings (at Sadakhlo, bordering Armenia; at Red Bridge, bordering Azerbaijan; and at Sarpi, bordering Turkey) and planned improvements of regional road infrastructure (Source: interview #2 with the Ministry of Economic Development, Transport Department). Smaller projects linked to transport infrastructure are also underway, stressing investors’ trust in an expanding market for Georgia’s transport sector. An example is the old, Soviet-style garage and truck-parking facility outside Batumi on the Sarpi highway; the facility is being developed with the help of private investors. The plan is that the new garage will meet international standards with parking security, hotel facilities and the right technical equipment to make mechanical repairs on modern, international trucks (Source: interview #17 with an official from “Avtomobilisti” company). The Georgian transport sector is expected to develop, grow stronger and count for a larger percentage of the GDP in the near future, given increasing investments in the sector, its prioritization by the government and international donors and its fast-rising contribution to the country’s Gross Domestic Product (GDP). With the increase in transport activities, some also expect an increased risk of communicable diseases, with particular concern over HIV/AIDS. 9 1. 4. OBJECTIVES OF THE STUDY This exploratory study has two main objectives: 1. To gain an understanding of the risks of HIV/AIDS for transport sector workers in Georgia, including a profile of their own knowledge, attitudes and behaviors regarding the disease and a profile of the workers’ surrounding environment; and 2. To identify the health resources available and the potential for prevention, care and treatment interventions in the sector. The ultimate objective of the study is to assist the World Bank in understanding the unique needs of the transport sector in Georgia and how to foster an enabling environment for the development of specific strategies and targeted intervention programs. Besides investigating how the health sector can best address the needs of the transport industry, the study examined how the industry itself can become involved. Despite the fact that sexually transmitted HIV cases now constitute an increasing share of new diagnoses in the ECA region, the Bank has not yet explored how different sectors could be contributing to the increasing spread of the disease or proposed a regional strategy or recommendation on how this new development can be addressed. The study therefore explored the role that the transport sector could be playing in the spread of HIV in the region. This was an exploratory study, which used the major port cities of the Black Sea; and the Baku–Tbilisi– Poti/Batumi corridor as a case study. The study sought to understand how the transport sector could be affecting the spread of the epidemic in the region through: i) risky sexual behaviors among transport sector workers and the role these behaviors could be playing in spreading HIV and ii) the potential for providing prevention, care and treatment interventions to transport sector workers, given that a significant proportion of this labor force works in jobs that take them away from their regular partners for long periods. Also, this study aims to inform the Bank’s policy dialogue and operational work on the role that the transport sector could play in the transmission of HIV. Recommendations informed by Bank-supported operations indicate that there is a need to understand the behaviors, beliefs and realities of people who live and work along transport routes and to use this information to design specific activities and strategies. Such activities could include prevention programs for transport sector workers who might face risk when they are away from home. Interventions could target workers at border crossings and rest stops and could include information, regional treatment/testing centers, etc. We recommend that transport sector companies and unions be involved in preventing the spread of HIV and that outreach to such companies include sensitization on the importance of a healthy workforce as contributing to business profits. These businesses can support and actively participate in HIV prevention, including providing information about the risks of infection to their employees. We also hope this study generates interest, encourages debate and fosters discussions about the HIV/AIDS epidemic in general and raises awareness among client countries on HIV and transport issues by providing not just research-based facts, but also recommendations that, if adopted, would mitigate real and potential risks. The expected outputs from this study were a report identifying interventions and recommendations that both the transport and health sectors could adopt. Both were to be based on: i) a literature review on the link between transport and HIV in the region and ii) a survey that, among other things, would provide information on behaviors such as unprotected sex and drug use that might put transport sector workers at risk of infection. 10 1. 5. METHODOLOGY The study used a mix of methods to examine HIV/AIDS issues facing Georgia’s transport sector. Qualitative methods were used to explore current attitudes and approaches towards HIV prevention and care among health sector institutions, NGOs and the transport sector. In-depth interviews were conducted with sex workers who have transport workers as clients. Statistics on the transport sector, HIV and other STIs, drug use, international trade, and other issues were collected from secondary and official sources to support the qualitative findings. Finally, our quantitative research included two surveys that were conducted with transport workers (truckers and sailors) and sex workers. A third survey of IDUs, proposed in the original terms of reference (TOR), was cancelled, both because a recent survey of IDUs had been conducted in Batumi and because the link between drug use and transport workers is unclear (Dershem et al. 2004). We explored drug use by examining reports in transport worker and sex worker surveys and by presenting the views of transport and health officials from the qualitative study. Qualitative Methods The Study’s qualitative component began by identifying the topics to be explored and developing a list of key informants to be interviewed. Participant observation and semi-structured, group and informal interview methods and techniques were used. Interviews and observations were conducted in Batumi, Poti, Gori and Tbilisi over five weeks, of which two weeks were spent in sites outside Tbilisi. We conducted 53 interviews with 68 informants, of which 15 interviewees were within the health sector, 15 in the land transport sector, 10 in the maritime sector, 7 in the NGO sector and 6 were other informants, including four SWs, a taxi driver and the Poti police chief. To enhance consistency and data quality, most interviews and observations were conducted by a two-person team consisting of the Deputy Team Leader and Qualitative Data Manager. The remaining qualitative data were collected by four IPM field researchers specially trained to conduct the interviews. Table 1-3: Number of Interviews by Site and Sector Health Land transport Maritime NGO Other Total sector sector sector sector Tiblisi 6 11 1 3 1 22 Batumi 5 1 8 2 0 16 Sarpi 0 1 0 0 0 1 Gori 2 1 0 1 4 8 Poti 2 1 1 1 1 6 Total 15 15 10 7 6 53 Source: Authors. The overall methodological approach to the qualitative part of this study was “hermeneutic,” meaning that the interviewers developed new guidelines and delved further into core issues until data satisfaction on a subject was reached. By using this ethnographic approach, interviewers were not limited to one set of questions throughout the study. The approach essentially helped the team learn while doing and take the newly obtained knowledge into consideration, which reduced having to ask questions already answered and the risk of missing relevant information. The interviews were written by hand by the interviewer in order to encourage frankness on the part of informants, who often become wary when recorded. Before ending each work day, the team met and inserted the notes into a matrix of key issues. Matrices were recorded in Georgian or English, depending on the informant’s preferred language. All interviews were later translated 11 into English by the Qualitative Data Manager and then coded by the Deputy Team Leader for further analysis. During the entire data collection process, the team discussed findings and revised the interview guidelines and lines of questioning in accordance with the knowledge gained. Quantitative Methods: Questionnaire Development and Pre-testing Both questionnaires were to a greater or lesser extent based on standard behavioral surveillance study (BSS) questionnaires and in particular on the Female Sex Worker Questionnaires used in the 2004 Tbilisi and Batumi surveys (Family Health International 2000; Dershem 2004). The transport worker questionnaire included the issues covered in the study’s TORs, including considerable information on routes and stopping places that can be used to design intervention programs. The HIV/AIDS knowledge, attitude and practice questions were adapted from the standard BSS questionnaire. The transport worker questionnaire was translated and pre-tested in Batumi with 10 sailors and 10 truck drivers. The SW questionnaire was not pre-tested as it closely resembled the 2004 questionnaire; questions were added about the behavior of transport workers as clients and on where SWs meet transport workers. The sampling methods for the surveys differed due to the difficulty in contacting sex workers directly. Sampling for Transport Worker Survey Where possible the transport workers survey used sampling methods adapted from previous surveys to systematically sample truckers and sailors (Family Health International 2000). When systematic sampling was not possible, respondent-driven sampling methods were used (Heckathorn 1997, 2002; Sagalnik and Heckathorn 2004), as follows: The study’s regional managers in Batumi and Poti identified key sites frequented by truck drivers and sailors. For truck drivers, these were mostly required stopping places: customs, registration, loading/unloading etc. The sites included the customs registration point near the Sarpi border, the Adii terminal where truckers load and unload, the Automobilist’s Garage on the road between Sarpi and Batumi, and two overnight-parking locations. For sailors, the sites included the seaports and the clubs nearby that foreign sailors visit. Gori was added as a site at the outset of fieldwork, as it is a major crossroads in the country’s interior. However, the regional manager had a difficult time finding truck drivers in Gori: they tend to pass through Gori and stop at nearby hubs such as Gomi, where several hotels and restaurants cater to drivers. The questionnaire asked where truckers stop near Gori so this area can be mapped and more research conducted in the area. For this study, the sample included 10 truck drivers who were contacted at a Gomi hotel that truck drivers visit to meet sex workers. The refusal rate was 20.4% (121 refusals). The main reasons given for refusing were being busy or simply not wanting to participate. Sampling for Sex Worker Survey As SWs are hard to reach, the study team worked with NGOs that have contacts with SWs in the three study sites. In Batumi, staff of the NGO Tanadgoma, who counsel many sex workers in the area, approached sex workers they knew and asked them to agree to an interview. In addition, sex workers who came into Tanadgoma during the fieldwork period were interviewed. Snowball sampling techniques were then used to expand the sample to sex workers working in the area. In Poti, the NGO Mega Association agreed to participate in the study by interviewing sex workers in the area. In Gori, the Regional Manager contacted key informants who said there was a group of sex workers who receive calls by truck drivers on their mobile phones and meet them at roadside hotels. 12 Table 1-4: Transport Workers’ Sample, by Site Target Site Target Sample Completed Total interviews Batumi Sailors (1) Georgian Sailors’ Union of Batumi 135 Georgian 45 135 (2) Georgia Seamen’s Medical Clinic 63 (3) Tanadgoma 27 Batumi (1) Automobilists’ Garage 26 Georgian 28 146 Truckers 50 foreign 50 (2) Truck parking 39 39 (3) Port entrance 8 9 (4) Near customs registration 6 6 (5) Bazaar 16 14 Poti sailors (1) By the port gate 25 Georgian 25 90 (2) At foreign sailors’ clubs 50 foreign 65 Poti truckers (1) Larnaka Street 31 31 90 (2) Terminal on Larnaka Street 28 28 (3) Kokaia Street 22 22 (4) Warehouse on Larnaka Street 9 9 Gori truckers Hotel 10 10 10 Total 455 471 471 Source: Authors Table 1-5: Commercial Sex Worker Sample, by Site Target Site Target Completed Total Sample interviews Batumi (1) Known to Tanadgoma, met outside the 41 SW NGO (2) Known to Tanadgoma; came into the NGO 75 16 75 (3) Not known to Tanadgoma, met in Batumi 11 (4) Not known to Tanadgoma, Gonio 7 Poti SW (1) Queue 5–7 6 (2) Clubs 18–25 35 16 35 (3) Mobile 10–15 13 Gori SW (1) Dormitory 10 10 10 Total 120 120 120 Source: Authors. Very few SWs refused an interview (10.4%), likely due to their previous acquaintance with the NGOs. Of those who refused, 28.6% indicated being busy, 28.6% indicated having to get back to work or having a strict boss, 14.3% said they did not want to, 14.3% that they wanted to relax and 14.3% provided no reason. 13 CHAPTER TWO: RISK OF HIV INFECTION FOR TRANSPORT SECTOR WORKERS AND THEIR PARTNERS PART I: FINDINGS FROM INTERVIEWS The section is based on interviews with transport sector employees, truckers and sailors in Batumi, Poti and Gori. This component of the study sought qualitative information on risky behaviors, such as unprotected sex and drug use. 2.1 DEMOGRAPHIC PROFILE AND WORK CHARACTERISTICS The sailors we interviewed were generally in their twenties or thirties, while truckers were in their thirties or forties. Over half the Georgian truckers were 40 years old or more, considerably older than their foreign counterparts. Georgian sailors also tend to be older than foreign sailors: 40% of the foreign sailors interviewed were 20-24. Interestingly, the Georgian transport workers were more educated than the foreign sample: 29% of interviewed Georgian truckers had some post- secondary education, compared to 10% of foreign truckers. Furthermore, 80% of the Georgian sailors had higher education, compared to 60% of foreign sailors. This last finding is likely due to the presence of the Maritime Academy in Batumi. Interviews revealed that the vast majority of transport workers were married, though due to the larger proportion of sailors in the younger age groups, twice as many of them are single. Correspondingly, 36% of sailors are childless, while only 20% of truckers are. Most (90%) of the foreign truckers were Turkish; the only other nationalities represented were Armenian (6%) and Bulgarian and Uzbek (2% each). The foreign sailors’ sample contained a wide range of nationalities, with the largest being Egyptians (28%), followed by Turkish (25%), Ukrainian (17%) and Filipino (13%). Only a few Georgian transport workers lived outside the country (1% of truckers and no sailors), and most foreign transport workers resided in their country of origin. The transport workers’ employee status varied greatly by their occupation and nationality: fully three-quarters of the Georgian truckers’ sample worked independently, while less than half (45%) of the foreign truckers did. Only a small percentage of sailors (5%) said that they work independently. Asked where their employer’s main office is located, most (85%) Georgian truckers who are employees said they worked for a Georgian company; most of the foreign truckers being Turkish said that their employer is based in Turkey (93%). In contrast, the sailors work for a wide variety of companies; only a third of Georgian sailors work for a Georgian company. Reflecting their largely independent status, a third of the Georgian trucker sample did not travel abroad at all. The rest traveled in various patterns, with a fairly even distribution by frequency of travel and days abroad. On average, Georgian truckers had spent 5.5 days in a foreign country in the previous month. Over 90% of the foreign truckers said that they went to a foreign country at least nine times a year, implying that they were on the road fairly constantly. Two-thirds of the foreign drivers had spent at least 4 months in a foreign country in the previous year; the entire sample had spent an average of 17 days abroad in the previous month. Sailors tend to take long voyages: most Georgian sailors reported going on only one trip per year, but the vast majority is gone for 4 months or more. The same is true for the foreign sailors. The majority of Georgian truckers who travel abroad make regional trips: 61% reported having been to Armenia, 51% had been to Azerbaijan, and 43% to Turkey. These destinations were also frequently mentioned by the foreign truck drivers, of whom 20% also said they went to the Russian Federation. While 14 Georgian sailors mainly go to Turkey (75%) and Ukraine (42%), foreign sailors visited a wider variety of destinations, including Bulgaria (42%), India (30%), Greece (29%) and the Russian Federation (26%). Most truckers (62%) had spent at least two months away from home in the past year and an average of 11 days away in the previous month. The question is less relevant for sailors, since they are usually able to go home when not at sea. Most truckers of all nationalities had worked in their profession at least six years. The same was true for sailors, who indicated they had many years experience in their profession. Earnings are generally lower for truckers than sailors, and they are particularly low for independent Georgian truckers who do not travel abroad. 7 Independent truckers who drive outside the region make nearly double the income of truckers who only drive nationally (700-799 versus 400-499 GEL) and make somewhat more than those who are employees as well. In general, Georgian truckers earn about half as much as their foreign counterparts. In contrast, Georgian sailors reported roughly the same income level as the foreign sailors. The average monthly household income in 2005 in Georgia was 303.5 GEL, indicating that while Georgian truckers’ income is somewhat above average, Georgian sailors earn more than five times the national average (Ministry of Economic Development 2006). 2.2 TRUCKING SECTOR EMPLOYEE PROFILE Transport companies whose workers were interviewed for the study included international transport companies with new, modern trucks and national transport companies with older trucks that can only be used for regional transport (Georgia, Azerbaijan and Armenia). It is important to keep in mind throughout this chapter that there are two categories of company – and equally important to know that there are at least three categories of Georgian truck drivers. In addition, there are many foreign, especially Turkish, truck drivers on Georgian roads. For the purposes of this report, we distinguish among three types of Georgian drivers: i) transit drivers (TDs) contracted by an international transport company, ii) national drivers (NDs) contracted by a national transport company, and iii) independent national drivers (IND) working as independent contractors. We found that drivers in all categories were likely to be married: companies prefer married drivers. None of the drivers had a permanent job; they were either hired on a yearly basis or on individual contracts. Individual day-to-day contracts are especially common among the INDs. They stand along the roads with their trucks on the outskirts of major cities and offer their services on a daily basis. In some places only a handful of trucks are seen at any time, whereas other places, such as the outskirts of Batumi toward the Sarpi border, as many as 30–50 trucks can be seen at a time. There is no transport union for drivers in the private transport sector, but some of the international transport companies are members of the Georgian International Road Carriers Association. Membership offers the benefit of truck and cargo insurance while on international roads, so if a TD is involved in a road accident abroad, he and the company will receive legal assistance. Some informants said that TDs have higher education than other categories of drivers and that many of them are engineers. The TDs have a relatively high income compared to the average income in Georgia, whereas other drivers, especially the INDs, struggle from day to day to find work. 7 There were no independent truckers in the sample who drove regionally (i.e., only to Armenia and Azerbaijan), and only 2 were employees but only drive within the country. 15 TDs must be 21 years old before they can drive on international roads, and the age span among TDs is relatively broad. Georgian law requires TDs and NDs to undergo a yearly medical check- up with special focus on eyesight. TDs have medical insurance when they go abroad as they are, by international standards, not permitted to enter Turkey or European Union (EU) countries without medical insurance. However, some company informants say that it is a “15 Lari insurance” of no use to the driver; its only purpose is to let the driver across the border. Other companies say that the insurance is genuine, suggesting that individual companies may get different types of insurance with differing levels of benefits for their drivers. For example, one transport company official reported: We pay 37 GEL to get insurance, which is necessary to get a visa. Basically, visa issues are the most problematic in our business... I did not have the chance to check how this insurance works, but my friend’s company’s driver who died abroad was repatriated to Georgia and the expenses were paid by the insurance company. (interview # 44) All categories of drivers spend long hours on the road. Most companies state that they try to keep the international standards for hours of driving and rest breaks. Both national and international Georgian transport companies make a point of explaining that their drivers mainly do not take rest breaks inside Georgia if they are en route to another country. With regards to risk behavior, this means that transit drivers and national drivers are more likely to encounter SWs in a foreign country: NDs in Armenia and Azerbaijan and TDs in Austria, the Czech Republic, France, Germany, Greece, Italy, Poland, Spain, Turkey and Ukraine. 2.3 HIV/AIDS AWARENESS AND ATTITUDES IN THE TRUCKING SECTOR Findings show that there is high awareness of HIV/AIDS among workers in the trucking sector in Georgia, but this awareness is coupled with a relatively uninformed attitude towards HIV/AIDS – at least compared to the maritime sector. Interviews with trucking informants revealed that all informants knew about HIV/AIDS and how HIV is transmitted. Some referred to high-risk behavior, such as intravenous drug use and men having sex with men (MSM) as the most likely way to become HIV infected; some also named high-risk countries. But only a few saw the link between the transport sector and the threat of HIV or perceived transport workers as being at risk of transmitting HIV. Uninformed attitudes, including misconceptions and myths, were common in the trucking sector, as described below. Few HIV/AIDS awareness-raising activities or preventive measures are in place in the transport sector. With regards to preventive measures instigated from an official level – among truck drivers of any category – there has been only one small project in Georgia, with another currently on the drawing table. The former project was funded by the Global Fund and implemented by the NGO Tanadgoma. It provides reproductive, sexual health and HIV/AIDS information and counseling to vulnerable groups such as IDUs, SWs and MSM. The project essentially focused on Georgian truck drivers with no distinction between national drivers and transit (mostly foreign) drivers. It conducted focus groups with Georgian truck drivers and used the findings to develop informational pamphlets. They then reached the drivers by handing out the pamphlets in sites where drivers congregate. Upon realization that the vast majority of transit drivers on Georgian roads are Turkish, the NGO translated the materials into Turkish. This project is described further in the section discussing the NGO sector’s response to HIV risk in the transport sector. A project titled “HIV/AIDS in the Private Sector” is planned for the near future and may affect the transport sector. It will be implemented by the Georgian Employer’s Association; 10 16 of its 200 member companies are transport companies. The main focus of the project is HIV/AIDS awareness in the workplace. It will be funded by either the International Labor Organization (ILO) or the Global Fund. Project planners hired a research company to conduct a survey in the workplaces and the report on “Employers' KAP Study Regarding HIV-Infected People" was published in February 2008. The reason that there are so few initiatives on HIV/AIDS in the transport sector can of course be manifold: some informants said that they or their institutions rejected linking HIV/AIDS and the transport sector. Others were simply puzzled as to why we wanted to talk to them about HIV/AIDS. For example, an official in the freight forwarding business responded as follows: I don’t think it is relevant to bind together these two – AIDS and the transport sector. Why is a driver different from a tourist, sportsman or students in an exchange program? I think it is an artificially created issue. Separating transport sector workers as a risk group is unnecessary detailing. (interview # 38) Respondents also explained that the Ministry of Economic Development and the Road Department see HIV prevention neither as their responsibility nor as their core competence. Not seeing HIV prevention as their core competence, they do not feel that they can be responsible for it. But beyond this, one informant went so far as to say that the government did not want to link the transport sector and HIV. This reaction is due to trucking’s prominent economic role and its priority focus by the government. One of the interviewees from the road carriers sub-sector responded as follows: There are no official, formal campaigns, but once again I want to say that the unofficial information exchange level is very high among the drivers. For example, the head of the parking spots (Zavgar), who are mostly experienced ex-drivers, often give advice to the younger drivers regarding risks connected to the SWs and STI. (interview # 1) 2.4 RISKY BEHAVIOR Most transport companies – national and international – did not perceive their employees as being at high risk of contracting HIV. The companies explained that they hired “family men” because of their maturity and the fact that they have responsibilities at home. According to the company representatives, maturity and responsibilities at home would prevent their drivers from having relationships with SWs, getting into driving accidents or committing crimes, such as drug trafficking across international borders. Altogether “family men” are simply less trouble according to the companies. One transport company official said: Drivers travel long distances, they cross several borders. Family men are more experienced and serious. They do not start running around going into each café (to find SWs). Besides, they have “hostages” back home – their families. Young men without families need money but do not want to work. Personally, for me the age is not as important as marital status. Of course, drivers above 50 can have different health problems, especially vision problems, and you cannot trust them with a very expensive vehicle and cargo. (interview # 44) According to most company informants, their own drivers do not have relationships with SWs – but drivers from other companies do. This means that the majority of company informants believe that truck drivers from all driver categories see SWs – just not the drivers they themselves have contracted. One company official reported: Georgian drivers who work in Europe don’t visit SWs very often. I exclude my drivers from this behavior, but I do not know about others. Foreign drivers tend to have more contacts with SWs. There are also so-called transit drivers who work individually, mainly transporting cars from abroad. They may have more active relationships with SWs, and they are maybe more “dangerous” regarding drug transportation. But I think that in general 99% of 17 Georgian drivers do not pose any danger from this point of view. They make 10–12 voyages per year. I have known them for years and if there were some disease, it would show up. (interview # 44) According to some informants, the drivers know how to protect themselves if they do have occasional sex with a SW. Drivers’ ability to protect themselves was connected to their high education level. All the informants we interviewed reported that intravenous drug use is not found among Georgian truck drivers, no matter which category they belong to. This view is supported by the Director of the Scientific Research Institute of Narcology. She explained that, while there was no research on this, in her opinion truck drivers might sell or transport drugs but were unlikely to use them (The Scientific Research Institute of Narcology Director (Interview 29). However, many of the informants had an anecdote involving drug use among drivers. They also consistently said that drug use is not unfamiliar, though drivers using drugs are fired because they cannot be trusted with vehicles or cargo, as the following official in the road carrier business explained: The minimum age of drivers in Georgia is 21 years; many are older. The elders teach the younger ones about good behavior and do’s and don’t’s in this business. There are few drugs but many use “Red Bull”-type drinks to stay awake at night. There are no injection drugs, no way, we are very firm on that! The drivers tell the company if someone is using injection drugs. It is easy to see from the marks on their arms – a person using these drugs is fired. They make trouble because they need so much money for their drugs. In Ukraine a Georgian driver was killed by another driver over some problem with injection drugs. (interview # 1) 2.5 MARITIME SECTOR EMPLOYEE PROFILE The profile that emerged of the average Georgian seaman shows that he is between 30 and 50, well-educated, married, living in Batumi and has an average income well above the Georgian standard. Most are union members, have internationally recognized health insurance while at sea, and above-average contact with the health system. Simultaneously, he is part of a very masculine maritime culture where sex with SWs worldwide is common and condom use is strongly and inversely related to alcohol use. Sex with other men and drug use are not unfamiliar in this culture. At the same time, the seaman is at risk of losing his livelihood if his medical certificates are not blue-stamped by the Georgian Seamen’s Medical Centre. We were unable determine the exact number of active Georgian seamen. However, a qualified estimate based on information from the Georgian Seafarers Union and triangulated with information from the crewing companies estimates 3,000 active Georgian seafarers. The vast majority live in Batumi and the Adjara region, but some live in Poti and the rest of Georgia. The active seamen have a wide age span, ranging from young new graduates of the Batumi Maritime School, to older high-ranking officers like captains, machine engineers and electricians. Study informants indicated that seamen are highly educated, and the lowest form of maritime certificate needed to go to sea requires minimum training of six months. There are indications that the group of active Georgian seamen may currently not be dominated by young new Batumi graduates, even though 120 graduate annually. Several informants explained that it was very hard for young, inexperienced seamen to get contracts, an international problem and not exclusive to the Georgian maritime sector. Since there are no Georgian vessels left, it is becoming increasingly hard for young seamen to gain the necessary experience to reach the higher ranks. 18 Crewing companies broker contracts between individual seamen and ships and shipping companies. When an agreement is reached, high-ranking officers get a four-month contract and low-ranking crew members a six-month contract. After finishing a contract, they are often home in Georgia the same amount of time they spent at sea: four to six months. If a company likes a certain seaman, he is often recruited to the same ship again. While at sea and in accordance with international maritime law, the seaman is fully insured as part of his contract. Our study found this type of insurance to be of a high quality and recognized globally, thus the seamen are very well secured, at least while at sea. The insurance covers all forms of injury while at sea plus disablement and death. In case of disablement the seamen receive a high insurance payment, and in case of death his family receives an insurance sum. In addition, seamen are beneficiaries of the government pension scheme and if they stay with one company over a longer period, there is an additional employer pension. In addition to health insurance while at sea, seamen receive a salary in accordance with international standards. Compared to the average Georgian wage, this salary makes seamen very highly paid. Some companies say the salaries are based on ITF recommendations whereas others admit that Georgian sailors are paid less than the ITF-recommended minimum wage. Nevertheless, the salaries are still relatively very high in the Georgian context. According to a crewing company interviewee, sailors’ salaries follow the international maritime union–set minimum for different categories of seamen: US$ 1,600 per month for low and US$ 6,000–8,000 for the highest levels. A high-level officer can make US$ 11,000 a month. Seamen can be paid only 10–15% of the whole salary – the rest is transferred to his bank account. Union members also pay a 2% membership fee through their employers. Thus, seamen have limited spending money while at sea and in foreign ports. In addition to relatively good insurance and high salaries, Georgian seamen have a high degree of contact with the health system. Before embarking on a voyage or starting employment with a new company, each seaman must undergo a medical exam at the Georgian Seamen’s Medical Centre (also called Batumi Maritime Hospital). The seaman finances it and is reimbursed by the crewing company. Each seaman has a book of certificates and vaccination cards: Some informants said it was at least 35 pages. For each new contract the seaman signs, he needs to get an up-dated set of certificates approved by the Georgian Seamen’s Medical Centre. If he is found “unhealthy,” the Centre will not approve his medical records, and he cannot go to sea again. A crewing company official reported: Every sailor is obliged to present the health certificate before going to the ship. This certificate is issued by Batumi Maritime Hospital where the general health examination takes place…. The list of examinations is affirmed and Maritime Hospital performs them, so if we get the certificate issued by this institution, we know that we can trust it. This hospital has all the sailors under supervision for years. The examination needed for getting the certificate includes a general health examination starting from oral cavity, including cardiology, psychological investigation, tests for HIV, 8 Hepatitis B and Hepatitis C. Different vaccinations are also necessary. (interview # 14) 2.6 HIV/AIDS AWARENESS AND ATTITUDES IN THE MARITIME SECTOR Georgia has been through and is still undergoing immense changes. These changes have unquestionably affected the working environment for maritime institutions and seamen. Yet despite facing rapid change and some institutional insecurity, qualitative evidence indicates that the maritime sector presents generally well-informed attitudes toward HIV/AIDS issues. 8 The issue of mandatory HIV testing is elaborated below. 19 Awareness of the risks of HIV infection and the challenges of addressing the risks among sailors was acknowledged by a crewing company official: 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 do have to sign a statement saying they have been informed 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. (interview # 11) In addition to the risks of HIV infection, maritime officials and doctors, company managers, union representatives and directors who participated in this study also presented broad and insightful knowledge of other issues affecting workers’ health and social security and the rights of Georgian seafarers. These insights included: i) international safety laws and regulations regarding safety on ships and in port areas; ii) international human rights; iii) international medical standards and insurance; iv) international maritime law; v) international minimum wages for seamen; vi) International Transport Workers Federation (ITF) recommendations. This broad level of knowledge of international laws, standards and recommendations, though not the main focus of this study, is important to mention, as it provides the context for the Georgia maritime sector’s management of HIV/AIDS. All informants knew about HIV/AIDS, and the vast majority knew how HIV is transmitted. Some informants even had insights into the basic statistics on HIV infections in Georgia; many referred to high-risk behavior, such as intravenous drug use and men having sex with men as the most likely way to become infected. They perceived seamen as at risk of becoming infected via sexual transmission; all saw the use of condoms as a way of HIV prevention. None seemed puzzled about why we wanted to talk to them about these issues. Most informants who had some type of authority in the maritime industry took active part in some form of formal or informal HIV prevention exercise. A relatively high number of HIV awareness raising and preventive measures are in place in the maritime sector. Some are official and, according to our informants, dictated by international maritime standards; some are union based and influenced by the ITF; and some take place in collaboration between the Georgian Seamen’s Medical Centre and the maritime sector. Still others occur on a more informal and personal basis. Basic medical training with an HIV/AIDS component is conducted by staff of both the Georgian Seamen’s Medical Centre and the Batumi Maritime School; our informants reported that this training is mandatory for all seamen according to international standards. According to an interviewee: The level of awareness is quite high; AIDS is known well enough. At the Maritime Hospital there is a special training centre, where the sailors are taught about primary medical care. These courses are prepared by international organizations such as the ILO, and the sailors must pass these courses without failing and [earn a] certificate. By our inquiry the two themes – STI and HIV/AIDS – have been added to this training. These trainings have been conducted by the members of our office. This sort of training on the elementary level exists also at the Maritime Academy, but only these trainings meet the requirements of the international standards. (interview # 7) The Seafarers’ Unions in Poti and Batumi are also aware of the risk of HIV to their members, and both are or have been implementing projects with international partners, such as the ITF and the Danish Port Workers Union. Based in London, the ITF is implementing an HIV prevention campaign with transport unions worldwide. The Seafarers’ Union in Batumi reports being part of the campaign in that it distributes informational materials on the international ships in the Port of Batumi. Every autumn the Union also holds an 20 international sporting event in Batumi, inviting seamen of all nationalities from the ships there Port to participate in games such as basketball and soccer. The opportunity is taken to hand out HIV/AIDS information. As for more informal initiatives, many informants representing the crewing companies said that they inform their crews about the risk of HIV before going to sea. According to an interviewee from a crewing company: Meetings with the sailors are conducted before the voyage. We give them information regarding different issues, and about AIDS also. Besides, while being in the port, the captain informs the staff about diseases spread in that particular country. Earlier, I remember, the information books about AIDS and the ways of its transmission were distributed on the ships, but now it is not like this anymore. (interview # 13) The crewing companies, the union, the maritime administration of Georgia, the maritime school and the Seamen’s Medical Clinic have a strong degree of cooperation in combining efforts for HIV prevention education. Officially there is no coordinating body among these actors, so the “coordination” of these efforts appears to take place on an informal level within the maritime community as described by an interviewee from the Public Health Center: The Seamen’s Medical Centre belongs to the transport sector. They have an educational centre, which gives initial medical education to the sailors according to the international standards. With the initiative of the Georgian side, the courses on HIV/AIDS and hepatitis were included in this educational module. ( interview # 12) There is little sign of coordination between this tight maritime community and other parts of the health sector and the NGOs; our findings revealed no central level coordination of the efforts on HIV/AIDS in the maritime sector and very little knowledge at a central level of the measures being taken in the maritime sector. The maritime sector in Batumi, including the Georgian Seamen’s Medical Centre, is doing its “own thing” without central coordination and government interference. One informant remarked that the system is disorderly and that the government is no longer in control of measures being taken. The matter is complicated by the fact that the system is very chaotic. It used to be one general scheme before, but not today. Everything became private; the government is not able to control everything any more. Something can be done only with close cooperation with private companies, if they decide to help and cooperate on this serious matter. For example, we have agreement with four or five crewing companies, which direct their seamen to us. (interview # 7) 2.7 RISKY BEHAVIOR AMONG MARITIME SECTOR WORKERS Despite the high level of HIV/AIDS awareness in the maritime sector, certain perceptions remain regarding seamen’s risk behavior and not least a very “macho” maritime culture and attitude towards sexual behavior. Our findings do not question whether Georgian seamen have sex with SWs and casual partners, but how often, where and how. We found the maritime sector to have a very masculine, sexually open-minded and matter-of-fact attitude about sex with women. Simply put, the cultural discourse of the Georgian maritime sector is that sex with women who are not their permanent partner is normal, right, necessary and natural. One interviewee said: 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, 21 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 conduct these trainings used to be on board and know the psychology of the seamen. We know what they do when arriving at the ports… ( interview # 7) The official view on HIV/AIDS concerns seems to be that seamen are rational adults while absolving them of risky behavior due to inebriation. The study team was repeatedly informed that the seamen would not go anywhere perceived to be “places of high risk” and that they always used a condom. Unfortunately, a rational man does, according to this discourse, tend to lose his better judgment when he gets drunk, when he may go to a “risky” place or have unprotected sex. Alcohol, bars and drunkenness were often mentioned in connection to non- marital sex. The following views were expressed by interviewees: Yes, of course, me too, I used to (have sex with women in foreign ports) – but they (the seamen) are not stupid; they protect themselves and do not go to places where there is a high risk – only if they are really drunk.( interview # 15) These days everyone is aware of HIV/AIDS, but will they remember when they get to South Africa and the black girls come up to them in a bar? If you ask them they will all say they use condoms, but who really knows? (interview # 11) On the other hand some informants argue that Georgian seamen do not have quite as many sexual relationships as is generally thought. However, the issue has been known and addressed for a long time; it was also considered during the Soviet era: Georgian sailors are not really very fond of this kind of entertainment. Besides, it must be considered that these special institutions, which are in each port, are not cheap. There are a lot of temptations for the sailor, but they know that they must be careful. The fact is that prostitution is very widespread. The way of combating this problem in Soviet times was arranging a meeting of the sailors with their wives once in every one or one and a half months. (interview # 14) All informants referred to sexual relationships with SWs and the risk of HIV as something that can happen abroad and primarily in exotic destinations, such as Kenya or South Africa. That is of course a consequence of the fact that Georgian seamen travel worldwide, but it can also be interpreted as informants’ perceiving (correctly, for the time being) Georgia and the region as presenting less risk of contracting HIV than the more exotic destinations. As expected, seamen having sex with women is perceived as natural and normal. Men having sex with men on the other hand is perceived as a deviant, unnatural and immoral. The behavior is seen as occurring among seamen from other cultures but not Georgia or something that happened in the Soviet era. Some said, however, that seamen may resort to it if they are really needy. Several informants stated that a seaman would be fired if it was discovered that he had sex with a man. These views on MSM are consistent with general cultural perceptions in Georgia. Despite recent improvements, MSM are still highly stigmatized and discriminated against (UNESCO, 2005; and interview #36 with Inclusive Foundation). However, despite the rather harsh feelings and opinions toward MSM, none of the informants were unfamiliar with the concept of men having sex with men. They all see it as something that can occur on ships – whether in the past or not or among other cultures or not. The informants were also asked about use of intravenous drugs among seamen. The answers were highly consistent: no Georgian sailors use drugs. The primary reason given for this conviction is that it is much too dangerous to do drugs onboard a ship; and the 22 individual seamen using drugs would place the rest of the crew at risk. In addition, a very strict drug-testing system exists, and a seaman is fined or fired if discovered using drugs. Besides the general medical check-up before going to sea, the ship-owner can order random testing for drugs and alcohol of the entire crew at any time. According to transport company interviewee: Practically no (problem with intravenous drugs), we have no problems with that because we have annual testing, secondly, because the ship owners who are in charge can make random testing of the crew on the boat. If they have anything, they are fired. Also it is a small crew nowadays – and they can see if someone is not doing his job. The risk of accidents is too high on a ship for doing drugs. (interview # 15) I agree that commercial sex and addiction is a high risk in spreading HIV. I can tell you that now there are no drug-addicted sailors on our ships, as there is very tough control these days before going into sea. In the pervious 15 years, we have fired 200 sailors. There was a special committee in the past; it was called the “Black Police.” This committee was unexpectedly appearing on board and checking all the sailors for drug usage. I think that drug usage cannot be a high risk factor for HIV for sailors. (interview # 19) It is clear that despite the informants’ statements that there is no use of intravenous drugs among Georgian crews nowadays, there appears at least to have been a history of drug use, and there is a very strict drug testing system in place to prevent drug use on ships worldwide. If drug use weren’t an issue in the international maritime sector, it is difficult to see why such resource-demanding measures are required. One informant from a crewing company, who seemed to be less in agreement with the rest, may have the answer to that – namely, that drugs are widely available to international crews including Georgian seamen: Drugs are very cheap in the countries of Asia and Africa, and in Turkey. It is punished to use drugs on the ship, but it is still distributed, the main thing is not to be under the influence. The control mechanism is quite strict – checking before the voyage, unexpected checking in different ports initiated by companies…. If as a result of this checking drugs are found on the ship, a very serious fine is imposed and serious measures are undertaken. (interview # 14) In addition, the fact that 10–12% of Georgian seamen have contracted hepatitis C 9 reinforces the argument that drug use is not unfamiliar in the maritime sector. PART II: FINDINGS FROM THE QUESTIONNAIRE The qualitative component of the study revealed some differences between seamen and truckers and between Georgian transport workers and foreign transport workers. In addition to qualitative information, the survey obtained quantitative information on risky behaviors, such as unprotected sex and drug use, from 471 transport sector workers. Results are presented in four categories to illustrate the differences: Georgian truckers, foreign truckers, Georgian sailors and foreign sailors. Where appropriate, the text also presents differences between the subcategories of independent and employee Georgian truckers. 2.8. KNOWLEDGE AND ATTITUDES TOWARD HIV/AIDS AMONG TRUCKERS Nearly all of the transport workers (99%) had heard of AIDS, but what they knew about it varied. Nearly all knew that HIV could be transmitted by sharing needles, but almost half the 9Information based on interview with the Maritime Medical Service Ltd. Director Gocha Kuledjishvili, who also stated that that was the normal level in the global maritime sector. 23 foreign truckers did not know that a healthy-looking person could be infected, and nearly half of the Georgian truckers believed a mosquito bite could transmit HIV. There is no clear pattern of which group has the most misconceptions or lack of knowledge: foreign truckers were least likely to know that HIV can transmit from mother to child through breastfeeding (10%) or during pregnancy (20%) but were also least likely to say that one can become infected with HIV by sharing food (12%). Georgian truckers were most likely to say that one can become infected by sharing food (43%), but 72% of them knew that condoms can prevent HIV. When a summary index is created by counting the number of correct answers respondents gave out of 7 (Table 2.1), on average the truckers showed less knowledge than the sailors (F=4.1, p<.05), as might be expected from their lower educational status. The difference in knowledge by nationality was not significant. Table 2-1: Average Number of Correct HIV/AIDS Knowledge Answers (out of 7) Mean score (n) Truckers Georgian 3.96 186 Foreign 3.85 47 Sailors Georgian 4.18 153 Foreign 4.29 70 Source: Authors Results also showed that fully 60% think HIV/AIDS is a serious problem for Georgia now and in the future with an additional third thinking it is “somewhat” of a problem. Figure 2-1 examines attitudes towards persons living with HIV (PLHIV). As with knowledge, there is no clear pattern by group. Georgian truckers tended to express the most stigmatizing attitudes; only 22% think that an HIV-positive teacher should continue teaching and only 18% would buy food from an infected vendor. While foreign truckers are the least likely to say they would care for an infected relative in their home, they are more likely than Georgian truckers to say that a teacher could continue teaching. Sailors are less likely to discriminate against PLHIV than truckers, but again only a small percentage of foreign sailors would care for a relative in his home and fully 71% of Georgian sailors said that if a relative had HIV, they would keep it a secret. An index of positive attitudes (Table 2.2) reveals that the levels are fairly low for all transport workers. Sailors are significantly more likely to have positive attitudes than truckers, however (F=33.1 p<.000). Table 2-2: Average Number of Positive Attitudes toward PLHIV (out of 7) Mean score (N) Truckers Georgian 1.65 185 Foreign 1.28 47 Sailors Georgian 2.63 153 Foreign 2.72 71 Source: Authors. 24 Figure 2-1: Knowledge of HIV Transmission and Prevention among Transport Workers (Percentage who said “yes”) 1 G e o rg ia n tru c k e rs 2 F o re ig n tru c k e rs 3 G e o rg ia n s a ilo rs 4 F o re ig n s a ilo rs 66% D 8 . C a n a m o t h e r t r a n s f e r th e H IV /AID S 58% to h e r b a b y t h r o u g h b r e a s tf e e d in g ? 10% 51% D 7 D o yo u b e lie v e th a t a n H IV /AID S - 66% 69% in fe c te d p r e g n a n t w o m a n c a n t r a n s fe r 20% th e v ir u s to h e r f e tu s ? 62% D 6 .7 . D o yo u b e lie v e th a t a p e r s o n w h o 82% lo o k s h e a lt h y c a n b e in f e c te d w ith H IV , 75% 53% w h ic h c a u s e s AID S ? 60% D 6 .6 . D o yo u b e lie v e t h a t o n e m a y b e 96% in fe c t e d w it h H IV /AID S b y u s in g a 96% n e e d le /s yr in g e a lr e a d y u s e d b y 86% s o m e o n e e ls e ? 91% D 6 .5 . D o yo u b e lie v e t h a t o n e c a n g e t 25% 20% H IV /AID S b y ta k in g fo o d o r d r in k th a t 12% c o n ta in s s o m e o n e e ls e ’s s a liv a ? 43% D 6 .4 D o yo u b e lie v e th a t o n e c a n 27% p r o t e c t o n e s e lf f r o m H IV /AID S b y 37% k e e p in g a w a y fr o m ( a v o id in g ) s e x u a l 49% co n tact? 50% D 6 .3 . D o yo u b e lie v e t h a t o n e m a y 35% p r o te c t o n e s e lf fr o m H IV /AID S b y 54% h a v in g o n e u n in f e c t e d a n d r e lia b le 57% se xu al p artn e r? 66% 16% D 6 .2 . C a n o n e g e t H IV a s a r e s u lt o f a 29% m o s q u ito ' s b it e ? 25% 46% D 6 .1 C a n o n e r e d u c e th e H IV r is k if o n e 89% p r o p e r ly u s e s c o n d o m s d u r in g e v e r y 57% 53% s e x u a l c o n ta c t? 72% Source: Authors. 2.9 PERCEPTION OF RISK We asked the transport workers whether they felt personally at risk of contracting HIV. Between a third and a half said they felt no such risk, with foreign truckers being most likely to say this and foreign sailors least likely. Foreign sailors were also the most likely to say they were at high risk of contracting HIV (9%) and the most likely to say they don’t know their risk (24%). For those who said they were at no or low risk, their reasons for that belief was further examined. The most frequent answers were “I always use a condom” (42%), “I do not have suspicious partners” (39%), “I always use a condom with people I do not know very well” (21%) and “I trust my partner” (20%). For those who said they fear they have a moderate to high risk of catching HIV, the main reasons were precisely the opposite: not having always used a condom, having been to sex workers and having suspicious partners. 25 2.10 ALCOHOL AND DRUG USE Reports on alcohol use among transport workers indicated that while most do drink alcohol, only a very small percentage said they drink every day. Foreign truckers tended to say they drink the least, with 28% saying they do not drink at all. Foreign sailors tended to drink the most with half saying they drink once or twice a week. Georgian truckers indicated they drink somewhat more than Georgian sailors, with about a third saying they drink once or twice a week. The transport workers were also asked about their use of other stimulants and drugs. Only a small proportion said they took Red Bull or some other type of stimulant drink (7%); only 9% had ever taken some form of sleeping pills. The percentages for more serious drugs are low: amphetamines 1%, ecstasy 1% and heroin 1%. These figures are in line with the qualitative finding that drug use is not common but also not unknown. About 5% of the transport sample (21 respondents) said they had ever injected drugs. The percentage was fairly even for Georgian truck drivers (5% or 10 cases), Georgian sailors (5% or 8 cases) and foreign sailors (4% or 3 cases), but no foreign truckers said they had ever injected drugs. Only two respondents said that they had injected drugs within the month; 14 of them or two-thirds said that it had been a year or more since they injected. Only 29% of those who ever injected said that they had ever shared a needle. Only 19% (4 respondents) said that they ever received treatment for drug addiction. Of those who did not receive treatment, 71% said they stopped using drugs by themselves and 29% said they did not need treatment. Of the four who had received treatment, only one said he received methadone; two said they went through the “extreme need” treatment. 2.11 SEXUAL BEHAVIOR Table 2-3 presents various findings on transport workers’ sexual behavior. The median age at first sex was 16 to 17 with Georgian transport workers reporting sexual initiation at a younger age than the foreign workers. The vast majority (at least 97%) were sexually active in the past 12 months. The mean number of sexual partners in the past year was high for all groups—but varied by nationality and occupation. Foreign truckers and Georgian sailors had the “lowest” number of partners at an average of 6.1 and 5.9, respectively, in the past year. Georgian truckers reported an average of 8.5 while foreign sailors reported an average of 21.0 partners. If we eliminate the top 5% of cases to account for outliers, sailors still have a mean number of 15.7 partners. Looking at the type of partners reported by each group reveals that over 90% of the truckers and foreign sailors reported having a regular partner, but only 76% of Georgian sailors did. Regular partners included spouses and long-term, non-paid partners, so it is interesting that the truckers had an average of 1.5 regular partners in the past year. The percentage of transport workers who reported having a paid partner over the past year varied by group: over two-thirds (69%) of the Georgian truckers but only half (48%) of the foreign truckers did so, while fully 71% of Georgian sailors and 97% of foreign sailors had a paid partner. 10 Most of the groups said they had 3 or 4 paid partners in the previous year, while foreign sailors had an average of 15.8. The frequency of meeting paid partners is correspondingly higher for sailors than truckers. 10 Most of the foreign sailors we interviewed were contacted at the private clubs where they go to drink and relax. These were among the few sites where we could meet foreign sailors, as their access to the city is restricted. Hence, it is very likely that the sample is biased toward sailors who often go out to drink and meet sex workers; those who stay on the ship were not accessible to us. 26 Table 2-3: Sexual Behavior of Transport Workers (in percentages) Truckers Sailors Georgian Foreign Total Georgian Foreign Total (N=189) (N=51) (N=240) (N=154) (N=71) (N=225) All partners Median age at first sex 16 17 16 16 17 16 Sexually active in the past 12 96.7 98.0 97.0 96.7 100.0 97.7 months Mean number of sexual 8.5 6.2 8.0 5.9 21.0 10.1 partners in the past 12 months 11 Regular partners Regular sexual partner past 94.6 92.0 94.0 75.9 96.8 82.3 12 months Mean number of regular 1.5 1.3 1.5 1.0 1.3 1.1 sexual partners in the past 12 months Paid partners Had a paid sexual partner in 69.0 48.0 64.3 70.6 97.0 79.0 the past 12 months Mean number of paid sexual 4.3 3.0 4.0 4.2 15.8 7.5 partners in the past 12 months Frequency of having a paid sexual partner while traveling Several times a week 25.8 18.2 24.3 3.4 19.3 9.6 About once a week 29.0 22.7 27.8 9.0 22.8 14.4 2 or 3 times a month 23.7 22.7 23.5 19.1 36.8 26.0 Once a month or less 21.5 36.4 24.3 68.5 21.1 50.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 Had sexual intercourse the 97.8 100.0 98.3 100.0 100.0 100.0 last time they had sex with a paid partner Had oral sex the last time 19.6 33.3 22.4 11.3 48.4 26.1 they had sex with a paid partner Had anal sex the last time 10.9 8.3 10.3 19.6 14.1 17.4 they had sex with a paid partner Occasional partners Had an occasional sexual 45.9 46.0 45.9 27.5 78.9 44.1 partner in the past 12 months Mean number of occasional 2.7 2.1 2.6 0.9 4.5 1.9 sexual partners in the past 12 months Had anal sex with occasional 42.9 27.3 38.0 18.2 73.1 51.8 sex partners Source: Authors. In order to estimate the level of risk involved in sex between SWs and transport workers, we asked about the type of sex that the workers usually had with their paid partners. Nearly all 11 Includes those with no partners in the past 12 months. 27 reported having sexual intercourse the last time they had sex with a paid partner. Foreign truckers (33%) and sailors (48%) were the most likely to say they had oral sex the last time they were with a paid partner. Anal sex was most common among Georgian sailors (20%) and foreign sailors (14%). It should be noted that anal and oral sex are usually practiced in addition to sexual intercourse; only 24% said they had only oral sex and no one had anal sex without also having sexual intercourse. Finally, a substantial proportion of transport workers said they also have occasional partners who they do not pay for sex: about 45% of truckers; 28% of Georgian sailors and 79% of foreign sailors. The much lower rate among Georgian sailors is probably due to the fact that they spend more time at home than foreign sailors. The sample had an average of about two occasional partners per year and many had anal sex with these partners as well. 2.12 CONDOM USE The survey asked about condom use with paid partners and occasional partners, using several different questions to facilitate estimating the transport workers’ level of use and self-efficacy for use. In Figure 2-2 we see that condom use at last sex with a SW varied by sector and nationality: fully 90% of the foreign sailors said they had used a condom, while only a third of the foreign truckers did. Georgian truckers were nearly twice as likely to use condoms as their foreign counterparts (62% versus 33%). The percentage who said they “always” used a condom with SWs over the past year was dramatically lower than the percentage reporting use last time: only about half of sailors and 43% of the truckers reported consistent use. It may be that transport workers exercise varying degrees of caution depending on where they are. Figure 2-2: Condom Use with Occasional Partners (Georgian Truckers N=189; Foreign Truckers N=51; Georgian Sailors N=154; Foreign Sailors N=71) Georgian truckers Foreign truckers Georgian Sailors Foreign sailors 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 77% 65% Used condom last time 83% 84% 97% 100% Initiated conmod use (Mine +mutual) 100% 96% 49% 9% Always used condom in the past year 56% 62% 66% 64% Could ask to use condom 67% 59% Source: Authors. The percentage of foreign truckers always using condoms was 30%, low but nearly the same as their last use. Nearly all of those who used a condom said that they did so under their own initiative or that it was a mutual decision with the SW. Only 66% of the foreign sailors said that they felt that they could ask a sex worker to use a condom. Somewhat surprisingly, truckers were more likely to say they used condoms with their last occasional partner than with paid partners; 65% of foreign truckers and 77% of Georgian 28 truckers did so (Figure 2-2). Consistent condom use with occasional partners fell to a lower level, especially for foreign truckers. While the decision to use condoms was again nearly universally the man’s or mutual, an even lower proportion of the transport workers said that they felt they could ask an occasional partner to use a condom than was true for a paid partner. 2.13 KNOWLEDGE OF SYMPTOMS OF SEXUALLY TRANSMITTED INFECTIONS Transport workers were asked if they could name STI symptoms in women and in men. The questions were open-ended, and very few could name an STI symptom for women; most frequently mentioned were vaginal discharge (13%), abdominal pain (13%) and itching (9%). Knowledge of symptoms in men was better but still not high: one in four named burning while urinating (28%) or genital discharge (27%) with one in eight mentioning a genital ulcer (13%). Swollen lower abdomen, named by 12% of the sample, is not a common STI symptom for men. Only a small percentage of transport workers reported STI symptoms in the past 12 months: 5% reported genital discharge or burning upon urination, less than 1% reported genital ulcer or rash. 2.14 KNOWLEDGE AND HEALTH-SEEKING BEHAVIOR Table 2-4 presents findings on availability and use of services reported by the transport workers. As expected from the qualitative findings, a high percentage of sailors and of foreign truckers who are employees report that medical services are provided by their company (94–96%), while only 17% of Georgian truckers who are employees have such services. Medical check-ups are the most frequently mentioned service; most workers also have health insurance, except for the Georgian truckers. While 89% of foreign truckers and nearly all sailors report that their company has mandatory medical check-ups, only a third of Georgian truckers reported so. As indicated in the qualitative study, this group is likely to be truckers who are able to travel abroad. The transport workers were asked where they would get information about HIV/AIDS if they needed it. Most Georgian drivers mentioned a clinic (66%) with “friends” being the second most frequent answer (17%). Foreign drivers were more likely to say they would go to a private doctor (57%) with “clinic” being the second choice (48%). While Georgian sailors also mentioned a private doctor first (58%) with clinic as the second choice (29%), foreign sailors were most likely to turn to the internet (56%) before a doctor (29%). More than two-thirds of the sailors said there was information about HIV available at their workplace, but only a very few truckers so reported. Only a minority of the transport workers thought there was treatment available for those with HIV, with about half thinking that care was available. A majority of foreign sailors and truckers (100% and 79%, respectively) thought that their employer was required to provide HIV care services; none of the Georgian truckers and only half of the Georgian sailors thought so. Finally, most transport workers thought that they could get a confidential HIV test (95% or more). 29 Table 2-4: Perceptions of Health Services among Transport Workers (in Percentages) Truckers Sailors Georgian Foreign Total Georgian Foreign Total Employees only (N=47) (N=28) (N=75) (N=143) (N=70) (N=213) Percentage who say their 17.0 96.4 46.7 94.4 100.0 96.2 company provides medical services Types of services Health insurance 25.0 70.4 60.0 74.1 100.0 82.9 Medical check-ups 100.0 63.0 71.4 91.9 100.0 94.6 Doctor on boat - - - 23.7 1.4 16.1 Nurse on boat - - - 14.1 18.6 15.6 Percentage who say their 33.3 89.3 54.8 99.3 100.0 99.5 company has mandatory medical check-ups (N=189) (N=51) (N=240) (N=154) (N=71) (N=225) Sources of information about HIV/AIDS Sexual partner 4.6 2.4 4.2 2.6 1.5 2.3 Friends 16.8 9.5 15.3 11.8 19.7 14.2 Family 1.2 2.4 1.4 5.9 1.5 4.1 Private doctor 12.1 57.1 20.9 19.1 13.6 17.4 Clinic 65.9 47.6 62.3 56.6 28.8 48.2 Internet 4.0 0.0 3.3 28.9 56.1 37.2 TV 6.4 7.1 6.5 13.8 15.2 14.2 Radio 0.6 2.4 0.9 2.0 1.5 1.8 Booklets 0.0 0.0 0.0 2.0 0.0 1.4 Consultations with Tanadgoma 0.0 0.0 0.0 0.7 0.0 0.5 Total 100.0 100.0 100.0 100.0 100.0 100.0 Percentage who said there is 7.5 12.2 8.6 72.3 69.2 71.4 information about HIV available at their workplace Percentage who thought 16.3 14.7 16.0 18.6 25.0 21.0 treatment is available for those infected with HIV Percentage who thought care 61.5 37.5 57.1 54.5 94.7 66.7 is available for those infected with HIV Percentage who thought their 0.0 100.0 23.5 50.0 79.0 72.2 employer is required to provide HIV care services Percentage who think it is 95.2 95.3 95.2 97.3 98.6 97.7 possible to get a confidential HIV test Source: Authors. The study also collected information about health-seeking behavior. Asked how they would handle a health problem while on a trip, respondents’ answers varied a great deal by occupation and nationality. Half of the Georgian truckers said that they would wait to see a doctor when they returned home, and a quarter said they would go to a public clinic when they stopped for the night (recall that most Georgian drivers travel short distances). However, fully three-quarters of the foreign drivers also said that they would not see a doctor until they returned home. While a third of the Georgian sailors said they would see the doctor on ship, the highest percentage of the foreign sailors (38%) said that they would see a private doctor in the next city they visited. 12 12 As discussed above, only a very small number of transport workers reported experiencing STI symptoms and so there is not enough information about their health-seeking behavior to present here. 30 Sailors were much more likely than truckers to say that they had ever sought information on HIV/AIDS. Fully 55% of foreign sailors and 32% of Georgian sailors had done so, but only about one in five truckers reported having done so. Truckers said that they sought out information from TV and friends, while sailors were likely to mention the internet or a clinic. This last finding is likely related to the fact that sailors regularly go to clinics for check-ups, including HIV testing. About half of respondents in these groups said they had discussed HIV/AIDS with someone, especially foreign sailors (97%). “Friends” was the most common answer when asked who they discussed the issue with. Table 2-5 presents the findings on HIV testing among transport workers. As discussed in the qualitative section, testing is closely tied to employee status. Most Georgian and foreign sailors said they had been tested (92% and 75%, respectively), while 48% of foreign drivers said so and only 5% of Georgian drivers did. Most of this testing was mandatory (required by the employer). Nearly all of those who had been tested knew their test results; about two-thirds of Georgian truckers and all sailors told someone their test result, although only 26% of foreign truckers did so. Spouses, friends and family members were told the results most frequently. Table 2-5: Experiences with HIV Testing among Transport Workers (in Percentages) Truckers Sailors Georgian Foreign Total Georgian Foreign Total (N=189) (N=51) (N=240) (N=154) (N=71) (N=225) Percentage ever tested 4.9 44.9 13.2 92.1 75.4 87.5 Whether test was voluntary Voluntary 44.4 27.3 32.3 3.6 0.0 2.7 Not voluntary 55.6 72.7 67.7 96.4 100.0 97.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 Who required the test Employer 80.0 100.0 95.2 99.3 97.7 98.9 To get permission for 20.0 0.0 4.8 0.7 2.3 1.1 blood donation Percentage who knew 100.0 86.4 90.3 96.4 100.0 97.3 their test result Percentage who told 66.7 26.3 39.3 73.9 67.4 72.3 anyone their test result Who they told Spouse 44.4 33.3 37.5 38.5 23.8 35.0 Regular partner 0.0 20.0 12.5 2.2 16.7 5.6 Family members 44.4 33.3 37.5 38.5 61.9 57.6 Friends 33.3 13.3 20.8 38.5 26.2 37.3 Nobody 11.1 26.7 20.8 38.5 14.3 7.9 Doctor 0.0 0.0 0.0 2.2 0.0 1.7 Everyone 0.0 0.0 0.0 1.5 0.0 1.1 Source: Authors. The survey asked drivers (only) some specific additional questions about health. When asked if they had a medical kit in their truck, most said yes; about 45% of Georgian drivers and 20% of foreign drivers said they kept condoms in their kit. A very small percentage (4–8%) said they had ever been asked whether they had condoms in their medical kit by the border police. The survey also asked sailors about the services available on their ships: 24% of Georgian sailors but only 4% of foreign sailors said they had a doctor on board; nurses were reported by a 31 minority of respondents (14% and 20%, respectively). Safety officers were commonly reported, however: by 86% of Georgian and 99% of foreign sailors. Finally, all transport workers were asked about the safety information and programs available at their workplace. A third (35%) reported that written information about health and safety was available; 81% reported safety training; 53% reported that their company held safety meetings. 2.15 REACHING TRANSPORT SECTOR WORKERS: MEDIA AND STOPPING/ RESTING PLACES The survey also asked about the transport workers’ exposure to media and where they stopped to relax or sleep for the night. About 82% of Georgian truckers and all of the foreign truckers had a radio, tape player or CD player; the same was true for 95% of the sailors. About two in three Georgian truckers had a radio, with the same percentage having a tape player. CD player ownership was much less common for Georgian truckers (7%). Over half of Georgian truckers (58%) and two in three foreign truckers said that they listened to the radio while driving (65%). Ar daidardo was by far the most popular station for Georgian truckers (52%) while the foreign drivers (mostly Turkish) listened to Turkish radio. For the most part, truckers stay on their trucks at truck parking facilities. About a fifth said they sometimes stay in hotels. The survey collected information on the exact location of these places that will be mapped in the next stage of the research. Almost all sailors stay on the ship, with 20% sometimes staying in hotels. About half of the workers say that they go to bars to relax (Figure 2-3). Sailors also tended to say that they go to nightclubs, as there are special clubs where foreign sailors are allowed to go at the ports. 13 A third of truckers and nearly half the sailors said they go to relatives’ houses to relax. Restaurants were mentioned by about one in five respondents; casinos, saunas, brothels and discothèques were also mentioned but only by a few. As noted earlier, the survey collected abundant information on where truckers stop for the night, where they go to relax and where they meet sex workers. This information was collected for cities, by type of place (such as hotel, bar and restaurant) and by the exact name of the place. It can be used to make detailed maps of different cities and rest stops. Although the team has not yet fully exploited all of this information or included it all in this report, the team hopes to produce a series of maps for a national seminar where they can be used for planning intervention programs for transport workers. 13 Again, it should be noted that much of the sampling for the foreign sailors was done at these clubs. 32 Figure 2-3: Where Truckers/Sailors Go for Relaxation (Truckers N=240; Sailors N=225) Truckers Sailors 0% 20% 40% Bar 53% 48% Nightclub 12% 42% Restaurant 21% 16% Casino 3% 6% Brothel 5% 7% Sauna 7% 5% Canteen 2% 0% Relatives 35% 46% Hotel 0% 1% Discotheque 0% Source: Authors. 33 CHAPTER THREE: KNOWLEDGE, ATTITUDES AND SEXUAL BEHAVIOR AMONG SEX WORKERS The study also interviewed sex workers who frequented the same locations as transport sector workers. Our aim was to gain knowledge of their understanding of the epidemic, ways to prevent infections, and risky behaviors. Combined with other information from the study, we found that transport workers have many sexual partners who are mainly sex workers, but include occasional non-paid partners as well. Condom use is not universal, and from the answers on reasons for condom non-use, it is clear that transport workers make judgments about which partners are risky. These workers often said “I trust my partner” even when talking about a sex worker who on average has nine paying clients in seven days. 3.1 DEMOGRAPHIC PROFILE, MARITAL AND PARTNER STATUS AND SEXUAL HISTORY Our sample of sex workers was somewhat older than generally found in research on sex workers internationally. However, the age distribution is slightly younger than found in a 2004 sex worker survey in Batumi (Dershem et al. 2004). In our survey, 38% of SWs were aged 20–25, while in the earlier study 43% were aged 30–39 years. Our study found a similar percentage with some post-secondary education as the earlier study (19% vs. 22%). The two studies differ greatly in SWs’ marital status: 54% of the earlier survey sample was married compared to only 9% in our survey. We asked about age at major life events: age at first sex was on average 17.1 years, age at first marriage 17.4. Average age at first commercial sex was 25.3; corresponding to the younger age of the sample, this is also somewhat younger than the 2004 study of Batumi. Table 3-1 presents data on their sexual relationships. Table 3-1: Marital and Partner Status of Commercial Sex Workers (in Percentages) Total (N-120) Currently married, having sex with husband 4.5 Currently married, not having sex with husband, sex 1.8 with partner Currently married, not having sex with husband or 0.9 partner Married; have both a husband and a lover- boyfriend- 1.8 man Not married, but having sex with a partner-lover-man 36.0 Not married, not having sex with a partner 55.0 Total 100.0 Source: Authors. 3.2 WORK CHARACTERISTICS AND SOCIO-ECONOMIC STATUS Table 3-2 shows information about the amount of time worked and earnings of the sex workers. Most work long (10-hour) days and most work seven days a week. The average earnings are 70 GEL per day and 1800 GEL per month. This is considerably higher than average household earnings in Georgia of 304 GEL per month (Ministry of Economic Development 2006). The median amount the last client paid was 35 GEL, and SWs had two clients per day on average. 34 Table 3-2: Work Characteristics of Commercial Sex Workers Total (N=120) Mean Median Average number of hours worked per day 9.9 10 Average number of days worked per week 6.3 7 Average amount earned per working day 76 70 Average monthly income from sex work 2599 1806 Average amount last client paid 44 35 Average number of clients last working day 2.2 2 Source: Authors. We find that 75% of the SWs report providing some support to dependents. These include children (72%), a husband (6%), parents (40%) and other relatives (19%). For those providing for dependents, the mean number of dependents is 2.5 (N=90). Only about 14% of the respondents said that they had another job besides sex work. These jobs are mostly in the service industry, such as waitress, bar maid, etc. SWs who had second jobs made very little from this other work: 65% made from 100–199 GEL per month. For the very small number (N=8) of respondents who were married and living with their husband, half said that their husband worked in the transport industry. Of the sample, 78% was Georgian, 13% was Russian, and the rest were from nearby countries in the region. About 13% said they were internally displaced persons (IDPs). Only about half said they had lived in their current city for 10 years or more and a third had lived there for 1–4 years. Half of the women said they had worked as SWs in another city and a third that they had worked abroad on their own initiative (not through trafficking). Most (88%) had worked in Turkey. Additionally, 10% said they had been a victim of trafficking. 3.3 KNOWLEDGE AND ATTITUDES TOWARD HIV/AIDS The questions on knowledge and attitudes regarding HIV/AIDS were the same as those asked of transport workers. Figure 3-1 shows that a substantial proportion of the SWs had misconceptions about HIV/AIDS; only 61% knew that a healthy-looking person can be infected, and 44% thought one can get HIV from a mosquito bite. Only 64% think that using condoms for every sexual act can reduce the risk of HIV. In sum SWs had very similar knowledge levels to Georgian truckers, with a mean score of 3.96 answers correct out of 7. The sex workers interviewed were somewhat more optimistic about the future prospects for Georgia in combating the HIV/AIDS epidemic. While 61% think the disease is a very serious problem now, only 49% think it will be very serious in the future. This is in contrast to the transport workers, who gave very similar answers for now and the future. The SWs had fairly negative attitudes towards PLHIV. Only 25% thought a teacher who is HIV-positive should be allowed to continue teaching, and only 25% would buy food from an infected vendor. On average the SWs had 1.68 positive attitudes out of 7; again very similar to the average for Georgian truckers. 35 Figure 3-1: Knowledge of HIV Transmission and Prevention among Commercial Sex Workers (Percentage Answering “Yes”) (N=120) 0% 20% 40% 60% 80% 100% J 4 .1 . C a n o n e re d u c e th e H IV ris k if o n e p ro p e rly u s e s c o n d o m s d u rin g e v e ry s e x u a l 64% c o n ta c t? J 4 .2 . C a n o n e g e t H IV a s a re s u lt o f a m o s q u ito 's b ite ? 44% J 4 .3 . D o yo u b e lie v e th a t o n e m a y p ro te c t o n e s e lf fro m H IV /A ID S b y h a v in g o n e 59% u n in fe c te d a n d re lia b le s e x u a l p a rtn e r? J 4 .4 . D o yo u b e lie v e th a t o n e c a n p ro te c t o n e s e lf fro m H IV /A ID S b y k e e p in g a w a y fro m 50% (a v o id in g ) s e x u a l c o n ta c t? J 4 .5 . D o yo u b e lie v e th a t o n e c a n g e t H IV /A ID S b y ta k in g fo o d o r d rin k th a t c o n ta in s 30% s o m e o n e e ls e ’s s a liv a ? J 4 .6 . D o yo u b e lie v e th a t o n e m a y b e in fe c te d w ith H IV /A ID S b y u s in g a n e e d le /s yrin g e 92% a lre a d y u s e d b y s o m e o n e e ls e ? J 4 .7 . D o y o u b e lie v e th a t a p e rs o n w h o lo o k s h e a lth y c a n b e in fe c te d w ith H IV , w h ic h 61% c a u s e s A ID S ? D o yo u b e lie v e th a t a n H IV /A ID S -in fe c te d p re g n a n t w o m a n c a n tra n s fe r v iru s to fe tu s ? 89% C a n a m o th e r tra n s fe r th e H IV /A ID S to h e r b a b y th ro u g h b re a s tfe e d in g ? 70% Source: Authors. 3.4 RISK PERCEPTION When asked about their personal risk of contracting HIV, one in four SWs thought they were at high risk, 20% said they had “no risk”, 20% said “little risk”, another 20% “some risk,” and 10% said they did not know. Those who thought they were at no or low risk said that they trust their partner(s) (27%), that they do not have suspicious partners (25%), that they avoid intravenous injections (22%) and that they use condoms when they are with partners they do not know well (20%). It may be said that these are naïve answers, especially as more respondents mentioned partner trust than condom use. 14 Those who did consider themselves at some or high risk of contracting HIV said that they have many partners (74%), that they do not always use condoms (56%) and that their partners have other partners (54%). 3.5 ALCOHOL AND DRUG USE Our sex worker sample also exhibited a range of alcohol use patterns. Nearly one in four (23%) said that they do not drink alcohol at all, but nearly a third (30%) said they drink every day. 14It should be remembered also that many of the respondents in the sample had previous contact with NGOs that provide HIV prevention education and counseling. 36 Alcohol use affects the likelihood of condom use: fully 82% of those who said they do not drink reported that they used a condom with their last client, while only 32% of those who drink every day said that they had done so. Reported drug use was quite low. The most frequently used drug was sleeping pills/sedatives, reported by 15%. Only three respondents reported ever using heroin; only one reported using ecstasy, poppy or opium. Five said they had ever injected drugs; four reported injecting during the past week and one declined to answer this question. Two of the five respondents who had ever injected said that they had ever shared a needle. Four of these respondents said they had never received medical treatment for drug addiction while one declined to answer this question. 3.6 NUMBER OF PARTNERS AND CHARACTERISTICS OF CLIENTS Figure 3.2 shows the reported average number of partners in the previous seven days: 11.5, which corresponds to the average of two per day reported above. The average number of paying clients was 9.4. The average number of regular/permanent clients—defined as a regular client who might not pay for sex every time—was 1.7. Only 38% of the SWs reported having a spouse, boyfriend or lover as a partner in the past seven days (average 0.4). Figure 3-2: Number by type of Partners in Previous Seven Days, Sex Workers (N=120) c2.1 Over the last 7 days (a w eek) how many 9.4 paying clients did you have? c2.2 Over the last 7 days (a w eek) how many 1.7 regular/perm anent clients did you have? c2.3 Over the last 7 days (a w eek) how m any permanent partners did you have - husband, lover, 0.4 boyfriend? c3 Over the last 7 days (a w eek) how m any different partners did you have? Include husband, 11.5 lover, regular/perm anent client Source: Authors. The SWs were asked if they had transport workers as clients, and the majority did: 64% reported Georgian truck drivers as clients, 49% reported foreign sailor clients, 44% reported foreign truck drivers and 37% said they had Georgian sailors as clients. We also asked about customs officials (27%) and border guards (20%) as they have important ties to the transport industry in the area. Finally, since the Black Sea area is a major tourist destination, we also asked about Georgian tourists (33%) and foreign tourists (24%). Transport workers were also often permanent/regular clients of the SWs. Georgian truck drivers again ranked first (49%), followed by Georgian sailors (23%), foreign truck drivers (23%), border guards (19%) and foreign sailors (14%). 3.7 CONDOM USE The questionnaire asked about condom use with different types of clients and non-paying partners, about who initiated condom use, and the reasons for not using a condom if one was not used. In Table 3-3, we see that 62% of the SWs reported using condoms with their last client 37 and nearly the same percentage, 56%, with their last regular client. Only 6% used a condom the last time they had sex with their permanent partner (spouse or boyfriend). Table 3-3: Condom Use by Type of Client Last Client Regular Client Permanent Partner Used a condom last time 61.7 56.1 5.6 Who offered to use condom My initiative 51.4 54.0 -* Client's initiative 21.6 12.0 - Mutual initiative 27.0 32.0 - Total 100.0 100.0 - Paid a higher price not to use condom 11.1 n.a. n.a. Reason for not using condom Partner refused 2.9 3.6 3.9 Don't like it 5.9 14.3 3.9 Didn't think of it 91.2 32.1 11.8 Was not available/Didn't have it - 7.1 - Too expensive - 14.3 - Didn't think needed/Trust partner - 57.1 90.2 He looked healthy - 7.1 11.8 Do not use with my regular clients - 42.9 - Take contraception - - 2.0 Client doesn’t go to others - - 3.9 Not offered by a client - - 2.0 Don't use with my husband - - 2.0 Total 100.0 100.0 100.0 Usual frequency of condom use Always 26.9 29.2 1.9 Often 30.3 19.8 1.9 Sometimes 37.8 39.6 16.7 Never 5.0 11.5 79.6 Total 100.0 100.0 100.0 Source: Authors. Note: * Too few cases to estimate. When asked who initiated condom use, for both paying and regular clients, about half the women said they did and another third said the decision was mutual. Only 11% of the SWs who did not use a condom said that their client paid them extra to not use a condom. The number one answer by far for non-use was “didn’t think of it”—implying that this group of SWs is unaware of the risks of unsafe sex and not in the habit of using condoms. For regular clients, the top answers were “trust partner” (57%) and “do not use with my regular clients” (47%), with another large percentage saying “didn’t think of it” (32%). For permanent partners, fully 90% gave “trust my partner” as the reason. Only one in four of the SWs—27%—said that they always use a condom with their paying clients, with another 30% saying that they often do. Condom use is substantially less frequent for regular clients, and fully 80% said that they never use condoms with their permanent partner. As shown in Table 3-4, we also asked the SWs about the condom use habits of different transport workers, border officials and tourists. Foreign tourists received the highest ratings from the SWs, who said that 86% of them always suggested using a condom. The lowest ratings—with the highest percentage of SWs saying they never suggested condom use—were foreign sailors (34%), customs officials (25%), foreign truck drivers (23%) and Georgian truck drivers (22%). Georgian sailors landed firmly in the middle of the pack with 55% said to “sometimes” suggest condom use. When asked what groups were willing to use condoms if asked, foreign tourists again scored highly with 93% said to be “always willing” to use a condom; percentages were 38 similar among Georgian tourists (79%), Georgian sailors (77%) and foreign sailors (71%). The worst-rated groups in willingness to use condoms were foreign truck drivers (13% never willing) and regular clients (10% never willing). These findings mesh somewhat with the findings on condom use reported by the transport workers themselves. Table 3-4: Condom Use by Transport Worker and Other Clients Type of client Suggest using condom Willing to use condom Always Sometimes Never Always Sometimes Never Foreign sailor 35.6 30.5 33.9 71.2 25.4 3.4 Georgian sailor 43.2 54.5 2.3 77.3 20.5 2.3 Foreign truck driver 20.8 56.6 22.6 47.2 39.6 13.2 Georgian truck driver 13.0 64.9 22.1 48.1 42.9 9.1 Border guards 45.8 37.5 16.7 58.3 37.5 4.2 Customs officials 34.4 40.6 25.0 62.5 28.1 9.4 Georgian tourists 46.2 51.3 2.6 79.5 17.9 2.6 Foreign tourists 86.2 10.3 3.4 93.1 3.4 3.4 Usual clients 7.0 69.6 23.5 35.7 53.9 10.4 Source: Authors. All the SWs said they knew where to obtain condoms, and 97% said they could buy condoms at a drug store. Not surprisingly, 42% knew they could get condoms at Tanadgoma. The other most frequent sources were from women they work with (12%) and clients (11%). Three out of four respondents said they could get condoms within 15 minutes of where they worked. The interviewers also asked if the SW had condoms with them at that moment; 43% said yes, with half of those (22%) only having one or two condoms. 15 Surprisingly fully half of the SWs said there were no condoms available at their place of work. 3.8 KNOWLEDGE OF STI SYMPTOMS SWs have some knowledge of STI symptoms in women; 73% mentioned vaginal discharge, and about 45% mentioned itching, burning urination and abdominal pain. The women knew less about symptoms that men experience; 47% mentioned genital discharge, 30% burning urination and 23% itching. Fully 50% of the SWs had experienced vaginal discharge themselves in the past 12 months and 11% had experienced a vaginal ulcer. 3.9 KNOWLEDGE OF AVAILABLE HEALTH SERVICES AND HEALTH- SEEKING BEHAVIOR The SWs were asked where they would get information about HIV/AIDS if they wanted it, and the top answer at 40% was private doctor. Another 22% mentioned clinics, 19% friends and 19% Tanadgoma. Only 31% of the SWs thought it was possible to get treatment for HIV/AIDS and 36% that there are care services available. Most respondents—78%—thought it was possible to get a confidential HIV test. Table 3-5 examines the SWs’ health-seeking behavior. For those who had experienced STI symptoms, the top answer—for nearly half the sample (48%)—was to consult a traditional healer or wise man. Nearly one in four (23%) went to a public clinic or hospital, and another 19% bought treatment at a drug store. Only a minority of those with 15 Since the CSWs only reported having an average of two clients a night, this supply may be suffice for most. 39 symptoms used condoms during the symptoms (20%), stopped having intercourse (15%) or told their partner they had symptoms (13%). Table 3-5: Health-Seeking Behavior among Commercial Sex Workers (in Percentages) Total (N=120) Treatment for STI Symptoms Consulted or received treatment at state-owned health clinic or hospital? 23.3 Consulted or received treatment at a private health clinic or hospital? 4.2 Consulted or received treatment at a drugstore 19.2 Consulted or received treatment from a traditional healer or a wise man? 46.7 Applied self-treatment? 20.8 Told your sexual partner about your symptom or STD? 13.3 Stopped intercourse when the symptoms appeared? 15.0 Did you use the condoms during the symptomatic period? 20.0 Percent who ever sought information about HIV/AIDS 39.2 Source of information Friends 10.9 Private doctor 10.9 Clinic 6.5 Internet 15.2 TV 45.7 Radio 10.9 Provided information at Mega Association 4.3 Brochures in "Tanadgoma" 37.0 Flyers from an organization 17.4 Percent who had ever discussed HIV/AIDS with anyone 53.3 Whom discussed with Sexual partner 32.8 Friends 68.8 Family 14.1 Private doctor 10.9 Clinic 1.6 Mega Association 3.1 Colleagues 17.2 Tanadgoma worker 6.3 Source: Authors. Only 39% of the SWs said they had sought out information about HIV/AIDS; 45% said that their source of information was TV, with 37% getting brochures from Tanadgoma. Only about half of the respondents said that they had discussed HIV/AIDS with anyone; most (69%) had discussed it with their friends and one in three (33%) with a sexual partner. The study also examined HIV testing experiences of the SW sample. Half of the women said they had been tested. In contrast to the transport workers, fully 92% said that the testing was voluntary. For the small percentage who said the test was required, 60% said that a doctor required the test along with other testing. Most had been tested within the past two years. Only 86% said they knew their test result, implying that some who decided to take a test did not go back to get the results. Asked whom they would tell if they tested positive, most said they would tell their SW colleagues (57%), and some said they would tell their friends (33%). 40 3.10 REACHING SWS: MEDIA AND PLACES TO MEET TRANSPORT WORKER CLIENTS Findings on media access by SWs showed mixed results for radio: a third said they listened daily, another third said they never listened. A large majority of the sample (83%) said that they watched TV every day. Table 3-6: Media Access of Commercial Sex Workers Total (N=120) Frequency of listening to radio in the past 4 weeks Everyday 31.7 No less than once a week 16.7 Less than once a week 15.8 Never 35.8 Total 100.0 Frequency of watching TV in the past 4 weeks Everyday 83.3 No less than once a week 10.0 Less than once a week 4.2 Never 2.5 Total 100.0 Source: Authors. 41 CHAPTER FOUR: HIV PREVENTION AND CARE SERVICES FOR TRANSPORT SECTOR WORKERS 4.1 THE CHANGING ENVIRONMENT FOR HIV PREVENTION AND TREATMENT From the time that the first case of HIV was discovered in Georgia in 1989 and throughout the 1990s, HIV testing was mandatory for a wide range of Georgian citizens (UNESCO 2005). When entering Georgia, all travelers were HIV tested. It was reported that groups perceived as high risk, such as SWs, were gathered by the police and forced to undergo testing. This “closed door” approach to HIV prevention, combined with a traditional and discriminatory view toward MSM restricted open discussion about HIV/AIDS and its prevention until recently (UNESCO 2005; World Bank 2004). Many developments over the last few years contribute to a more enabling environment to fight the epidemic, including free access to ARV drugs for all citizens, no HIV testing of travelers, less police harassment of SWs, no forced HIV testing of SWs, methadone treatment for selected IDUs, and more openness toward MSM. Many NGOs and health sector institutions working with SWs say that that over recent years their cooperation with the police has become more positive. A small number of IDUs are receiving methadone treatment, which can be seen as a positive change in both legislation and attitudes toward this population segment. Despite continued discrimination towards homosexuals, there appears to be a more open approach toward the subject of homosexual sex in the general population – especially among young people. The first gay and lesbian rights organization, Inclusive Foundation, was established in Georgia in 2006 to fight discrimination and raise awareness in Georgian society. That said, there are still a number of issues hindering further development of a positive and enabling environment for HIV prevention and management of the AIDS epidemic in Georgia. These factors include: institutional insecurity and confusion on the mandate for HIV prevention, treatment and care; a legal environment that results in large-scale imprisonment of IDUs; lack of needle exchange programs and condoms in Georgian prisons; and discrimination toward MSM and PLHIV. The study attempted to map the structure of the Georgian health care system to understand its response to the epidemic and found that there appears to be some confusion within the health sector on who is doing what and why. Informants could not answer questions about which institutions are in charge of what parts of HIV prevention, treatment and care in Georgia and indeed, what their own institution’s mandate is. The health system is under reform and over the last year has changed from a vertical structure to a more horizontal one. An example of the confusion over the health sector’s mandate for HIV services is the way that HIV testing is handled. Any medical facility, public or private, can do an HIV test. The test is sent to one of several regional laboratories. If the test is found to be positive, the regional laboratory sends the blood sample to the Tblisi-based AIDS Centre for confirmation. The HIV- positive patient is then informed of the result by the doctor or facility that conducted the test, and the patient is referred to one of the three regional AIDS centers situated in infectious disease hospitals in Batumi, Zugdidi and Kutaisi. 16 While until recently care was given only in Tblisi, now the regional AIDS Centres also offer care and treatment. The personnel at these Centres are carefully trained in HIV/AIDS counseling, care and treatment under various international training standards, and they receive refresher training yearly at the AIDS Centre in Tblisi. In addition, many central level health officials have received HIV/AIDS training abroad, for 16 The Kutaisi Centre opened in December 2007. 42 example, in the US. In the meantime, after confirming the HIV test, the AIDS Centre in Tblisi starts an epidemiological survey (if granted permission by the patient) to find out how the patient was infected. Both the AIDS Centre and the National Centre for Infectious Disease Control (NCDC) lay claim to currently being in charge of keeping national statistics on HIV (interviews #49 and 32 with the NCDC and the Tblisi AIDS Centre). Uncertainty about the statistics mandate was also evident at regional levels. One informant told us that the NCDC would get some of the AIDS Centre’s mandate and that it was planned to unite the two institutions in the near future (interview #12). In addition to role confusion among the national AIDS Centre, NCDC and the regional centers, there are inconsistencies about who is actually providing testing, care and treatment. Some services that are supposed to be provided by trained staff at the regional centers have been outsourced: NGOs and their volunteers provide all forms of psychosocial care to PLHIVs. Also, some of the health institutions in contact with HIV patients or in charge of conducting HIV tests are not part of the above-outlined structure, and their staff receives no HIV/AIDS training or education. As an example of this, a private medical facility in Poti has been contracted by the government to conduct a series of medical tests on an army base, including HIV testing. Some informants commented that there are too many “players” and that the government is no longer “in charge” of HIV prevention after privatizing the health system. Whether or not such statements are true, interviews made clear that health care professionals in charge of implementing HIV prevention, treatment and care are uncertain about their own current and future mandate. The second factor with a negative impact on the enabling environment for HIV prevention is that Georgian laws continue to hinder full provision of services. For example, the law on IDUs essentially labels all IDUs as criminals. Second-time offenders are automatically sentenced to prison (UNDP, 2006), resulting in a large number of IDUs in prisons. HIV prevalence in prisons is high, and there is no doubt among Georgian health officials about the severity of the problem, yet condoms are not easily available nor are clean needles, despite reported cases of sex between men, sexual abuse and drug use. In addition, according to current Georgian law, only blood and tissue donors are subject to mandatory HIV testing; high-risk groups such as IDUs and SWs can get free and anonymous HIV testing (UNESCO 2005). 17 While this is the current law and the policy that most health professionals refer to when discussing HIV testing in a Georgian context, in practice there are many exceptions. Some Georgian citizens still undergo mandatory HIV testing, including seamen. This is not just an employment policy of private companies but is covered under Order 218 issued by MoLHSA on January 30, 2006, which states that seamen should undergo HIV testing along with other medical tests and checks. The order provides a long list of professions, with specifications of which medical checks each should undergo and how often in order to stay in their profession. Whether or not this order is legally binding, it is carried out in practice; if seamen refuse to be tested or if the test is positive, they cannot go to sea and therefore lose their livelihoods. We also received information that the military and all service personnel on military 17 The law was adopted in 1995 and amendments were adopted in 2001. The 1995 version envisioned mandatory HIV/AIDS screening of every individual coming from a foreign country, as well as Georgian citizens returning from long business trips (World Bank 2004). With the 2001 amendments, HIV testing of travelers was abandoned. A working group under the Global Fund is currently working on revising the law, as it is perceived to have inherent legal flaws and does not live up to international standards (interview 35). 43 bases were subject to mandatory testing and that port workers at Batumi Port were HIV tested before being hired. 18 4.2 HIV PREVENTION IN THE TRANSPORT SECTOR As described in previous chapters, all categories of drivers spend long hours on the road away from their families, have job insecurity (as they are hired from contract to contract), little or no medical insurance and varying income levels. Drug use is not unfamiliar in the transport sector. On top of this, contradictory attitudes are presented on sexual issues: the same informants who acknowledge that many drivers go to SWs maintained that their drivers are hired because they are “family men” perceived to be stable, responsible, and not likely to visit SWs. This pervasive viewpoint poses a barrier to dialogue on risk behavior in the driver’s workplace. At the same time, drivers are continually surrounded by the availability of SWs. They are present wherever the driver is likely to spend the night (in Georgia or abroad), in the restaurants along his routes, at the gas stations, at the parking garages, near the borders and near the places where the INDs stand and wait for work. Altogether these elements of life as a truck driver in Georgia create a potentially risky environment for the spread of HIV. We also found certain pervasive misconceptions about HIV/AIDS in the transport sector and a general reluctance of those in authority to see drivers as at risk. HIV is seen as someone else’s problem and unlikely to touch those in the transport sector, who are well-educated family men. As one informant from a transport company explained, even if a driver were to contract HIV through heterosexual sex, he is unlikely to develop AIDS for decades: AIDS? Well, they are quite educated. They know about it and call it SPID [Russian abbreviation for AIDS]. By the way, it is a problem as there are a lot of women “hunting” for truck drivers. But the drivers know that they are dangerous…. Of course, you are right – the more transport moves to and from the country, the higher is the risk. But it is not the main risk – the main thing is that the country is full of drug users and homosexuals – from 100 infected all will be either one or the other and the AIDS is punishment for this [behavior]. Very few are infected through occasional sexual contacts. And even less, only very occasionally, through blood transfusions or from mother to child. There are a lot of interesting things about that – the person infected the [hetero-]sexual way can live for decades and not develop AIDS, but those ones infected through needles or homosexual contacts, they will for 100% sure develop AIDS. (interview # 51) Most informants in the transport sector assumed that truckers use condoms, because they are well-informed about HIV/AIDS. One maintained that all truckers keep two condoms in their medical kit and that the border police consistently check that the condoms are there. The difference between being required to have condoms and actually using them was not seen as an issue. These attitudes consistently present an environment where the risks faced by transport workers are not taken seriously, as other groups are perceived to be the real “problem,” not the drivers. As noted above, it is not only private companies that refuse to link the transport sector to HIV. The Ministries and some of the interest organizations at a central level are also hesitant to accept a link between transport and HIV and to take any action. Seeing the link and accepting 18 The 2005 “Drug Situation in Georgia” report by the UNDP marks in a footnote a similar finding: “Within the framework of the HIV/AIDS prevention state programme, testing of HIV antibodies is provided free to the populations at risk. Before employing an individual or issuing him/her with a visa, some institutions and services in Georgia require a HIV test certificate. Testing is charged in cases like this.” (UNDP, 2005. p. 27), the footnote then refers to “i.e. police, military etc.” as being subject to HIV testing. Thus it appears that people working in the police, military, some port workers and seamen undergo mandatory (non-volunteer) HIV testing, which is not in accordance with Georgian law. 44 it is the first step toward creating an enabling environment for HIV prevention in the Georgian transport sector. Certain cultural perceptions and behaviors found among sailors – especially their perceptions of sexual relationships with women and the close link between sexual behavior and alcohol consumption – contribute to an environment of risk for Georgian sailors. On the other hand, the matter-of-fact attitude and openness regarding sexual relations can also be seen as enabling Georgian seamen to talk about and express themselves on issues that may be hard to talk about in other parts of Georgian society. That at least has the potential of forming the basis of an enabling environment for HIV prevention. As described above, there are also many small initiatives in the maritime sector, formal and informal, that further openness, awareness and direct HIV prevention. Most of these efforts, perhaps remarkably, are initiatives of the Georgian maritime community itself and not outsiders. Other initiatives are being implemented in collaboration with the health sector (the Georgian Seamen’s Medical Centre) and international organizations such as the International Transport Workers Federation (ITF). Some of the formal structures surrounding the seamen are, however, disturbing from the point of view of international standards on HIV/AIDS. We thought we had misunderstood an informant the first time we heard that Georgian seamen were subject to mandatory, involuntary HIV testing, so we pursued the issue. This study has found that all seamen undergo mandatory HIV testing before they go to sea. If they test positive, they do not receive a blue stamp on their health certificates. The information is kept confidential; only the practicing doctor and the seaman know the result, and the information is not conveyed to the company that wanted to hire the seaman, but of course the seaman loses his livelihood as he is barred from going to sea (interview # 7). In conclusion, there are several factors that would contribute to a positive environment for HIV prevention for Georgian seamen. Not the least of these is the generally enlightened attitudes and proactive stance of the support services in the maritime sector. On the other hand, there is a series of practices (mandatory HIV testing and a lack of coordination of the health care system at both the central and industry level) and attitudes (a generally machismo attitude towards sexual partnering) that remain a cause for concern. 4.4 THE HEALTH SECTOR RESPONSE TO THE HIV/AIDS EPIDEMIC Georgia’s first national HIV/AIDS program, launched in 1994, mainly implemented four interventions: i) the National AIDS Prevention Program, ii) National Safe Blood Program, iii) National AIDS Treatment Program, and iv) VCT for the most-at-risk groups. Another program became operational in 2005 to prevent mother-to-child transmission. Until 2007, the National AIDS Prevention Program was implemented by the Public Health Department in the Ministry of Labour, Health and Social Affairs through the National AIDS Centre (Infectious Diseases, AIDS and Clinical Immunology Research Center) and other partner organizations. Ongoing health sector reforms since 2007 resulted in the closing of the National AIDS Prevention Program, and its activities (mainly VCT services) were incorporated in the National AIDS Treatment Program administered by the State Health and Social Insurance Fund. Georgia’s response to the HIV/AIDS epidemic is guided by the 2006–2010 National Strategic Plan of Action. The plan aims to ensure universal access to HIV/AIDS prevention, treatment, care and support services to the whole nation by end 2010. The plan focuses on four major strategic directions: i) surveillance; ii) prevention; iii) treatment, care and support; and iv) national 45 commitment. The overall goal is to reduce the HIV/AIDS risk, vulnerability and impact of the HIV/AIDS epidemic in the country. The aim is to reduce HIV/AIDS prevalence, related illnesses and mortality by ensuring that i) HIV prevalence is kept at levels of 5% or below among most-at-risk group (IDUs, SWs and MSM); ii) prevalence among pregnant women is maintained at levels below 1%; iii) prevalence is maintained below 5% among 15–24 year olds; iv) survival rates of people on ARV treatment improve; v) the number of children orphaned by AIDS each year remains below the level in 2003; vi) infection among TB patients is kept at low levels and vii) a strong monitoring and evaluation (M&E) system that is consistent with the Three Ones principles is developed. Georgia receives strong support for its HIV/AIDS response from, among others, the Global Fund, which has been supporting the national response to HIV in Georgia since 2003. The Global Fund is the largest financier of interventions; in the period 2004-2006 it allocated about US$ 7 million. In addition, a number of partners, including UNFPA, WFP, IOM, UNDP, WHO and UNICEF provide support that has included technical assistance in HIV/AIDS care and treatment and costing; development of the national PMTCT policy and action plan; campaigns for children and youth, capacity building in peer education; capacity building and information, education and communication (IEC) among military personnel, reproductive health capacity building on HIV/AIDS and PMTCT, condom supply, public IEC and advocacy; food for education; labor migrant HIV prevention through IEC; and anti-drug programs. Although a multi-sector Country Coordination Mechanism (CCM) for HIV/AIDS – attended by senior officials of the line ministries, UN and international partners, PLHIV and NGOs – has existed since 1996, the HIV prevention strategy has remained very much focused on health sector interventions. 4.5 RESPONSE TO THE RISKS OF HIV/AIDS IN THE TRANSPORT SECTOR Our findings indicate there has been no response – in the form of programs or services from the Georgian health sector – to the risks of HIV infection among transport sector workers. As seen in previous chapters, health officials we spoke to were divided on the subject: some didn’t perceive a link between the transport sector and the spread of HIV or viewed it as a minor risk; others saw it as one of the big challenges for the future. We observed a tendency for officials working at the central level to fall into the first group – dismissing transport work as a risk factor: I don’t understand the link between transport and HIV. There are other diseases linked to international travel like different strains of flu and SARS….(interview # 49) – while health officials at the regional level were more inclined to see the link and perceive HIV in the transport industry as a threat. Responses from the National Centre for Disease Control suggest that responsibility for HIV prevention lies in the hands of Georgian SWs, who are perceived as highly trained and knowledgeable. The respondent in interview 49 cited above did, however, think that training truck drivers is important in combating HIV transmission as demonstrated by this response to the follow-up question about truck drivers having sex with SWs on their routes: Yes, if we think about the truck drivers and their sex with prostitutes, then, yes, there is a link. But I don’t think it is of very big importance from an epidemiological perspective, because the Georgian prostitutes are trained and knowledgeable. Then we will have to train the Georgian drivers. What the prostitutes in other countries do, we cannot be responsible for. 46 Health officials in the regional sites of Batumi, Poti and Gori seem to be more inclined to perceive the expanding transport sector as a threat to the spread of HIV as demonstrated by this response to the same question: Yes, what you said [Does the expanding transport sector pose a risk to the spread of HIV?] really increases the risk of AIDS. Due to the fact that our town is a port city, the region is territorially close to the border, where the number of people having AIDS is high. Considering the total size of the Adjara population, this number is really very high. There are 220 people infected with AIDS….We would like to collaborate with people if our collaboration will be helpful for the population. As for prevention activities, from health structures, that is of course acceptable. But I think it will be really very difficult to consult transport sector employees. I mean, these people are moving all the time. But I think if the collaboration between health and the transport sector will be executed, it will be splendid. (interview # 9). This informant was not alone in calling for heightened collaboration between the transport sector and the health sector. Many health sector informants, especially at a regional level, made similar comments and observations. One informant from the health sector compared HIV to bird flu and the tight collaboration between Turkey and Georgia and cross-sector collaboration to that threat. She believed that a similar approach should be taken to the threat of spreading HIV: Infectious diseases do not have borders. The issue is that any migration process is connected to the risk.…The collaboration must take place on governmental level. For example, collaboration with Turkey must be very intensive. When the thread of bird flu appeared, all the institutions were prepared: health systems, veterinary control and the emergency departments of the hospitals. Individual self-protection instruments were created. To conduct all these measures is mainly a public health sector responsibility. The important thing from the transport sector is not to make obstacles, but on the contrary to support the initiatives. The private transport sector is also an interesting sphere – they need to be worked with. Today, they are too much involved in income generation, not paying any attention to social issues. They need to be motivated to invest money in educational and social spheres. Special work must be conducted so that they understand not only the necessity of this, but also get the idea that a healthy worker is the face of the company, it is more beneficial to care about employees’ health. (interview # 12) Overall a majority of informants thought there was a link between HIV and the transport sector – both land transport and sea transport. The main reasons given for not taking any action on this threat was lack of leadership and funding. Plus as the above quote shows several health institutions had little faith in the transport sector itself - the health sector may be putting up barriers for collaboration where there may be none. The health sector – through the Georgian Seamen’s Medical Centre – is responding strongly to the threat of spreading HIV via the maritime sector. As already mentioned, seamen undergo various trainings, including an HIV/AIDS component at the Georgian Seamen’s Medical Centre. However, it is not known at which level of the health sector this step has been taken or if it is in fact the medical centre taking the lead in collaboration with several crewing companies and the Batumi Maritime School. As already explained, there exists strong cross-sectoral collaboration in the maritime sector. And the Georgian Seamen’s Medical Centre and the rest of the maritime sector may be operating separately from the rest of the health sector. The exception is of course mandatory HIV testing of seamen, which is the only “preventive measure” taken from a central level and comes from the MoLHSA. This is worth noting, because it demonstrates that someone somewhere at a central level must have perceived the threat of transmitting HIV via the maritime sector as real. Otherwise this measure would not be in place. The fact is that many health officials outside the Georgian Seamen’s Medical Clinic see the maritime sector and seamen in particular as at risk of contracting HIV. They also refer to the maritime sector as being a “closed community” and say that they know very little of what is going on in that community and the 47 risk behaviors present there. Thus some informants call for more research on the subject before they will be able to address to issue properly: There should be some specific risk behavior among sailors, but I do not know. This is quite a closed society. I hope, that there [abroad], women are “educated,” and sailors themselves have more information on the issue. Earlier, the risk behavior among sailors was more connected to drug use, but now there are very strict regulations. But even now, we can guess that the seaman who came to us for consultation is a drug user. As for training on other diseases, I know that before going on a voyage to countries like those in Africa or Latin America, the crew members are specially consulted. Anyway, I think that to reveal the risk behavior of the sailors, a survey must be conducted among them.(interview # 12) On the other hand the NGO sector has been active in responding to the epidemic. The Global Fund funded a small project, implemented by Tanadgoma, on HIV awareness among truck drivers. The project started in 2004 and will, according to the Project Manger of the Global Fund, end in 2009. According to Tanadgoma, however, the project is no longer running. Both parties say that it was a very small project and no monitoring and evaluation has been conducted. Therefore, very little knowledge resulted about the first HIV prevention and transport sector project in Georgia. Tanadgoma provided the following information about the project: In 2005 a social worker from Tanadgoma conducted a series of focus group interviews with Georgian truck drivers. Some of the drivers were identified with the help of some of the largest transport companies in Georgia, and some were identified at rest stops in Georgia. No consideration was made of whether the drivers were international or restricted to driving in Georgia/the region. According to the social worker conducting the interviews the truck drivers’ knowledge of HIV/AIDS was very low: The little information they do have on AIDS they get from Russian speakers. They didn’t even know the word for AIDS in Georgian. They have no idea about transmission, epidemiology but they know STIs. If someone has told you that the drivers know, it is misinformation – how can they say that? They may have higher education, but that doesn’t mean that they know [about AIDS]. They don’t know! They didn’t think about the risks before they were interviewed; some were surprised to learn that MSM sex was dangerous, and they didn’t know about oral sex and blood contact as risks. Their knowledge is low, very low. They judge whether a person is safe to have sex with by his/her appearance, their condom use is low, very low, and they don’t perceive that condoms can protect them. (interview # 4) Based on the information gained from the focus group interviews, informational pamphlets in Georgian and Russian were prepared by Tanadgoma and targeted specifically at this group. However, it soon became clear that the vast majority of truck drivers in Georgia are Turkish – not Georgian – so the materials were translated into Turkish. There seems to be disagreement on whether the pamphlets were given to transport unions, companies and border police or if they were handed out to drivers at rest stops and for which period of time (Interviews 4, 6 and 28). None of the other NGOs we interviewed had done any work in the transport sector, and Tanadgoma is clearly the largest actor on the Georgian NGO scene and most likely to be involved in such projects. In their opinion much more research is needed in Georgia before solutions can be found and appropriate targeted preventive measure aimed at the Georgian transport sector: That would take months. I am not an expert, I cannot say. I need to think about it, but we definitely need more research…in a Georgian context; the countries and cultures are different; that should all be taken into consideration. There is a lot to be done on cross-sector cooperation in this country, on cross-cutting issues. We do not have the resources to work more on this issue, but we would like to: for now our knowledge is low. (interview # 4) 48 According to our findings, there has been one direct response to HIV risks facing the maritime sector. Tanadgoma in Batumi is currently doing training sessions on drugs and HIV/AIDS at the Batumi Maritime Academy. At the same time, several informants from the maritime sector in Batumi said that they have been visited by Tanadgoma staff handing out information. There is, however, no response directed to active seamen, the seamen in Poti and the foreign seamen in both ports, and Tanadgoma stresses the importance of cooperation between the NGOs and the maritime sector: Of course the collaboration is possible and even necessary. It would be good if transport companies could organize the meeting places for truck drivers or sailors, for giving them information in an organized way. Spreading the information is of course the most important. (interview # 6) 49 CHAPTER FIVE: SUMMARY OF FINDINGS AND RECOMMENDATIONS 5. 1 SUMMARY OF FINDINGS The importance of the transport sector to the Georgian economy cannot be exaggerated. Infrastructure investments to improve the East-West transport routes have been a priority of the current government. Privatization of seaports has brought immense changes to the maritime industry, including modernization and standardization. Transport is an important contributor to the GDP and a major employer in present-day Georgia. For this reason, it is vital that specific needs of transport sector employees be addressed, that their risk of HIV be evaluated and that the prospects for HIV prevention programs targeted to transport workers be planned in a coordinated way. The study found that the health sector response to needs in the transport sector varied. In general the public health system in Georgia is undergoing a period of transition, with changing responsibilities for HIV testing, record-keeping on HIV cases, and planning for HIV treatment. Roles of various agents responsible for aspects of HIV/AIDS care are somewhat confused, as are policies toward anonymous and confidential testing. While the maritime sector offers an impressive combination of training, health care and insurance for its employees, these services are not well coordinated at the central level. HIV testing is mandatory for sailors. A positive HIV test forces a seaman to abandon his primary livelihood – seafaring – as he can no longer obtain the health certification required by Georgia’s maritime industry. A key insight for understanding the situation of transport sector workers in Georgia is that they are not a homogenous group. Sailors are among the highest paid workers in Georgia; they are well educated, receive health education with their maritime training, have excellent health insurance and receive regular check-ups. Truckers who travel internationally also receive health check-ups and have insurance, but only a minority of truckers fall into this category. Many Georgian truckers, whether independent or working for a Georgian company, make only an average income, face job insecurity as they work from contract to contract and have no health insurance. We found that the differences in job profiles are to some degree reflected in the transport workers’ knowledge, attitudes and behavior regarding HIV/AIDS. Sailors were somewhat more knowledgeable about HIV transmission and prevention and had slightly more positive attitudes toward PLHIV than truckers. Yet sailors had the greatest degree of risk with the highest number of paid and occasional partners; few reported that they used condoms consistently. 5.2 THE TRANSPORT SECTOR AND RISK OF HIV INFECTION This study’s design called for “an evaluation of the potential or real risk of transmission of HIV from these high-risk people to the general public”; the study found minimal indications of a bridge between the transport sector workers and IDUs who currently have the highest prevalence of HIV in Georgia. Regarding intravenous drug use, while sailors can afford drugs and travel in many areas where drugs are common, it is likely that regular testing by shipping companies keeps intravenous drug use among sailors to a minimum. For truckers, the risk is somewhat higher: a few informants mentioned that some international truckers are involved in drug trafficking, and that it is not a far step from trafficking to use (interview# 29). 50 Still, both the qualitative and quantitative data indicate that injecting drug use is little known among truckers and that it is not tolerated within the industry. Interviews inquired about the prevalence of men having sex with men in the transport industry. While some informants indicated that this was not unknown on ships, especially in the past, all maintained that men having sex with men is not part of Georgian culture. The pre-test questionnaire had a question on whether respondents had ever had sex with a man, but the reaction was so negative (almost to the point of raising respondents’ anger toward the interviewers) that it was omitted from the final questionnaire. A qualitative study, involving male sex workers and other MSM in the Poti and Batumi area, would be needed to thoroughly investigate this issue. The major risk for transport workers and for their potential to spread HIV to the general population is through heterosexual sex. Transport workers have many sexual partners, mainly sex workers but occasionally non-paid partners. Condom use certainly is not universal, especially for some sub-groups: while 90% of foreign sailors said that they used a condom with their last paid partner, only 33% of foreign truckers did so. And only 52% of foreign sailors said that they “always” use condoms with paid partners. From the answers on reasons for condom non-use, it is clear that transport workers make judgments about what partners are risky; many said “I trust my partner” even when talking about a sex worker. Besides inconsistent condom use, two other factors contribute to heightened risk of HIV through commercial and casual sex for transport workers: one is that these men are not very knowledgeable about STIs, and the second is the prevalence of higher-risk sexual acts reported by the sample. Less than a third of the transport workers could name a single symptom of STIs for men. Plus, most said they deal with their health problems only after returning home from a trip. It should be recognized that the likelihood of other sexually transmitted infections in this group can contribute to a higher risk of their contracting HIV as well. Anal sex is quite common: 8–20% had anal sex with their last paid partner, and 18–70% said that they had anal sex with their occasional partners. Additionally, few respondents said they had only oral sex—a safer alternative—the last time they paid for sex. The SW survey provides further insight into the risks facing transport workers: few SWs reported injecting drug use, but condom use among the SWs was low: only 29% said that they always used condoms with their clients. The most often-given reason for not using a condom was “didn’t think of it,” and it should be remembered that 30% of SWs said that they drink every day. Alcohol use affects the likelihood of condom use: fully 82% of the SWs who said they do not drink reported that they used a condom with their last client, while only 32% of those who drink every day said that they did. The sex worker sample reported that many transport workers are unlikely to suggest using condoms and that some are unwilling to use a condom if asked. The SWs were not very knowledgeable about condom use and STIs and had generally negative attitudes toward PLHIV. 5.3 RECOMMENDED INTERVENTIONS AND STRATEGIES The key finding from this study is that a significant proportion of transport sector workers engage in unsafe sex with SWs and this calls for specific provision of information and prevention services for this highly mobile section of the population. The risks identified in this study lead to many potential strategies for HIV prevention programs. We found that most of the groups interviewed—NGOs, the health sector, and members of the 51 transport and maritime industries—stated that they would be interested in working together on these issues. For some, greater awareness, and perhaps recognition, of the link between the transport sector and HIV risks are needed. Our recommended strategies fall into four major areas: enhancing dialogue; raising awareness; working toward behavior change; and looking towards the future. Enhancing dialogue: We found that the various sectors involved in this issue—public health agencies, NGOs and the private sector—currently have little opportunity to interact with each other. Their isolation contributes to an inability to plan prevention programs in a coordinated and effective way. We offer four suggestions to change this: Ö Hold a dissemination seminar for key stakeholders to present the findings of this study. Give opportunities for stakeholders from the various sectors, including transport workers themselves, to present their needs and what they see as the best way forward. Ö Invite representatives from the transport industry to attend Global Fund CCM meetings, both to learn about HIV/AIDS programming in Georgia and to raise the awareness of transport issues for those working on Global Fund programs. Ö Central institutions such as the AIDS Centre, the NCDC and the regional public health departments can begin a dialogue with the maritime sector to gain insight into how the Georgian Seamen’s Medical Centre and other entities are currently combating HIV/AIDS. This cooperation could lead to a more informed and inclusive approach, particularly if it draws the maritime sector into the national HIV/AIDS strategy. Ö Cross-sector cooperation among transport companies, NGOs and the health sector begins within the framework of the national strategy for HIV/AIDS. Raising awareness: While transport sector officials feel that their workers are well educated and know how to protect themselves, we find that workers’ knowledge of HIV transmission and prevention is lacking and that their condom use is inconsistent. The sex workers interviewed— even though contacted through NGOs that do HIV education—also lack knowledge on HIV and particularly on other STIs. Ö The study identified many sites with potential for IEC campaigns: rest stops for truckers, places where transport workers and sex workers meet, and facilities where transport workers obtain health services. Many of the transport workers and sex workers said they sought out information from doctors and clinics, indicating that these are the most comfortable and credible sources; truck drivers also go for eye check-ups. Written information, posters, and training to motivate medical personnel to raise these issues would help improve knowledge levels. Ö Solicit influential persons from within the transport industry to talk to transport workers about HIV/AIDS and STIs. As we have noted, the machismo and family-man image of transport workers—though somewhat contradictory—makes it difficult to create a dialogue within the industry. Yet peer educators could be a powerful force for communicating behavior change messages to other transport workers. Particularly on ships, where the audience is somewhat captive, programs could be implemented to raise the issues and break the ice. Ö The study identified the media forms most accessed by transport workers and sex workers. Both groups said that they sought out HIV/AIDS information from television, which can be a powerful medium for conveying health messages. Advertising-type IEC campaigns, 52 talk shows, soap operas and the like have been proven to be effective in communicating HIV prevention messages (Singhal and Rogers 1999; Tufte 2001). Working towards behavior change: It is a lesson well learned that raising knowledge and awareness is not sufficient to change behavior. Transport officials in our survey said that condom use is strongly—and inversely—related to alcohol use, consistent with evidence from other countries. Many survey respondents said that they “didn’t think of” using a condom at the critical moment, even though sex workers often had condoms on hand. Ö Implement programs that make condoms readily available and less stigmatized so that they become a habit. Programs that emphasize contact with condoms, giving people practice at opening the package, unrolling them onto models, blowing them up, etc. have been very successful at de-stigmatizing attitudes. Given the frequency of anal sex in this population, it would be useful to promote the use of water-based lubricants with the condoms during anal sex. 19 Ö Develop and implement a 100% condom use program with SWs, adapting the successful Thailand experience. Ö Given the difficulty of achieving behavior change through public policy interventions, new programs should have a strong M&E component to determine whether desired outcomes are being realized. Looking towards the future: The maritime sector in Georgia serves as a model of how modernization and reforms to meet international standards can improve awareness of health and human rights. We suggest building on this model by continuing to move in the same direction to improve the health status of larger numbers of people. This should include implementing voluntary counseling and testing programs: VCT enables people to learn their status and to be counseled on how to reduce their risk and, if HIV-positive, how to reduce the risks of transmitting the virus to others. Next steps for the World Bank team: Operationalizing recommendations of the study: The World Bank began lending for HIV/AIDS in 1988; in recent years the Bank increased dramatically its support for HIV/AIDS programs and started to apply the full range of its tools and talents to confronting the epidemic. Analysis led by the Bank has identified the broader development dimensions of the epidemic, and identified tools that can help in response to HIV/AIDS. The Transport sector already acknowledges that HIV/AIDS is not simply a medical issue, but a broader development challenge; and that the sector can play a role in preventing its spread. The Transport Sector is already mainstreaming AIDS in transport projects in some regions and developing some free standing HIV projects, such as the Abidjan-Lagos Transport Corridor Project, whose objectives are to increase access along the Abidjan-Lagos transport corridor to HIV/AIDS prevention, basic treatment, and support and care services by underserved groups especially transport sector workers, migrants; sex workers and local populations living along the corridor, especially at the border towns. Examples of activities that are funded in these efforts include: i) HIV prevention services for the targeted population; ii) 19Note: oil-based lubricants should not be used with condoms, as the oil can weaken the latex and increase the risk of breakage 53 HIV/AIDS treatment, care and support services for the targeted population; and iii) Capacity building and policy development. Next steps: 1. Harness the multisectoral strengths of the Bank: Bring together the Bank’s Health and Transport teams for dialogue on the results of the report; have a joint lunch-time seminar; hold a brainstorming session to discuss the recommendations of the report and come to an understanding of the most effective way to operate in multi-sectoral teams. 2. Conduct a Dissemination Workshop to initiate dialogue with stakeholders within the Transport and Health Sectors, trucking companies – local, national, or international trucking associations, trade unions, and training institutions; health providers (treating STIs and other illnesses); community members. 3. Present results of this study to members of the AIDS Country Coordinating Mechanism in order to sensitize members about the risks that transport sector workers might face. Seek to leverage study findings to enhance political commitment to take action. 4. Use examples from countries in the European Union to demonstrate how the region is already addressing HIV and assist countries in the region to act on some of the recommendations of the study. This includes providing examples of cooperation between the private sector and the ILO which has resulted in information and prevention programs targeting the transport industry. 5. 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The impact of voluntary counselling and testing: a global review of the benefits and challenges. Geneva, Switzerland UNDP. Programme of Assistance for the Prevention of Drug Abuse and Drug Trafficking in the Southern Caucasus (SCAD), Annual Report, 2006. Drug Situation in Georgia. Tbilisi UNESCO. 2005. HIV and AIDS in Georgia: A socio-cultural approach. World Bank. Undated. Georgia, Retrieved December 14, 2007 from http://web.worldbank.org/WBSITE/EXTERNAL/COUNTRIES/ECAEXT/EXTECAREG TOPTRANSPORT/0,,contentMDK:20647622~pagePK:34004173~piPK:34003707~theSitePK: 571121,00.html 59 W WW. WO RL DB AN K . O RG /AI DS For more information, please contact: The Global HIV/AIDS Program Europe and Central Asia Region World Bank Group Human Development Unit 1818 H St. NW The World Bank Washington, DC 20433 1818 H Street NW Tel:   +1 202 458 4946 Washington DC 20433 Fax: +1 202 522 1252 Tel: +1 202 473 0163 wbglobalHIVAIDS@worldbank.org Fax: + 1 202 477 0574