"there is hunger in my community": A qualitative study of food security as a cyclical force in sex work in Swaziland

Background: Swaziland has the highest HIV prevalence in the world - 32% of adults are currently living with HIV - and many Swazis are chronically food insecure - in 2011 one in four Swazis required food aid from the World Food Programme. In southern Africa, food insecurity has been linked to high-risk sexual behaviors, difficulty with antiretroviral therapy (ART) adherence, higher rates of mother-to-child HIV transmission, and more rapid HIV progression. Sex workers in Swaziland are a population that is most at risk of HIV. Little is known about the context and needs of sex workers in Swaziland who are living with HIV, nor how food insecurity may affect these needs. Methods. In-depth interviews were conducted with 20 female sex workers who are living with HIV in Swaziland. Interviews took place in four different regions of the country, and were designed to learn about context, experiences, and health service needs of Swazi sex workers. Results: Hunger was a major and consistent theme in our informants' lives. Women cited their own hunger or that of their children as the impetus to begin sex work, and as a primary motivation to continue to sell sex. Informants used good nutrition and the ability to access "healthy" foods as a strategy to manage their HIV infection. Informants discussed difficulty in adhering to ART when faced with the prospect of taking pills on an empty stomach. Across interviews, discussions of CD4 counts and ART adherence intertwined with discussions of poverty, hunger and healthy foods. Some sex workers felt that they had greater trouble accessing food through social networks as result of both their HIV status and profession. Conclusions: Informants described a risk cycle of hunger, sex work, and HIV infection. The two latter drive an increased need for 'healthy foods' and an alienation from social networks that offer material and emotional support against hunger. Services and interventions for sex workers which address the pathways through which food insecurity generates vulnerability to HIV and social marginalization, build sex workers collective efficacy to mobilize, consider poverty alleviation, and address social and policy level changes are necessary and likely to have the greatest success.