A Zambian sex worker living with HIV says efforts to reduce new HIV infections are being hampered by demand for unprotected sex, which comes at a higher price.
Mary B, from Mongu, west of Zambia's capital city Lusaka, said the situation is gaining in popularity as circumcised men believe they cannot contract sexually transmitted diseases.
The situation is being compounded by the fact that many of the lodges in Mongu do not stock condoms, resulting in many sex workers taking up the staggered pricing option.
Mary B added that many sex workers peg the rate for unprotected sex between 150 and 200 Zambian Kwacha (about US$25-30), while protected sexual intercourse was going for K50-K100 (about US$10-15).
"The male circumcision programme is somewhat being misunderstood by some men who think that it is a full protection against contracting HIV," Mary B said. "Others just say by looking at one's beauty that it is impossible that the woman could be HIV positive. Others simply say they don't enjoy sex with condoms and would rather pay more to have unprotected sex."
Many sex workers now offer unprotected sex as a first choice and settle for protected sex only when the man demands it and is unable to pay more.
However, another sex worker said increasingly women engaged in the trade were becoming more knowledgeable of their health rights and are not willing to engage in unsafe sex work simply for more money. The worker who spoke on condition of anonymity said clients were being asked if they have condoms and if they don't they provide one for their own safety.
"Most of the sex workers now carry extra pairs of condoms so that if the client hasn't got one it is easier to provide one instead of looking for a shop or bar which has some in stock. Not being armed with extra condoms has led to many women giving in to unsafe sexual intercourse," she said.
Strategies to prevent HIV
The Centre for Infectious Disease Research in Zambia states that male circumcision provides men with up to 60 per cent protection against HIV.
This is in line with the World Health Organization, who recommend voluntary medical male circumcision as a long-term HIV prevention strategy for countries like Zambia, which has low circumcision and high HIV infection. It also emphasises that male circumcision provides only partial protection and should be used with other prevention packages such as treatment of sexually transmitted infections, the promotion of safer sex practices, and the provision of male and female condoms.
Other health benefits of circumcision include prevention of phimosis in infants (a painful tightening of the foreskin), decreased urinary tract infections and risk of penile cancer, and reduced risk of infecting women with the human papilloma virus (HPV) - the cause of cancer of the cervix.
Efforts to reverse the trend of increased unsafe sex
Mary B, together with a few of her friends, has joined the Lifestyle Health Foundation which aims to sensitise sex workers about the dangers of unprotected sex.
The foundation is using data from a research study carried out in Livingstone from 2002-2010 by the University of Zambia's school of medicine in the department of public health and Norway's University of Bergen. The study found that 43 per cent of the places where people met new sexual partners in Livingstone never had condoms available.
Joseph Moyo, president of the Lifestyle Health Foundation, said his organisation has recently been working on gathering information from sex workers.
"We have so far met a lot of sex workers in Mongu and out of this number 68 have said they are HIV positive and are on antiretroviral treatment. The ages of those who have so far spoken freely range from 18 to 42," he said.
He went on to say that out of the residential areas covered, several sex workers have confirmed that despite their positive status, men who buy sex are not willing to use condoms and don't want to know their status. "These men are getting infected and later on pass the infection to their spouses," Moyo said.