‘Dirt just has to come down’: body perceptions and lived experiences of female sex workers in Côte d’Ivoire (ANRS 12361 PrEP-CI and ANRS 12381 PRINCESSE projects)

Valentine Becquet, Evelyne Kissi, Mélanie Plazy, Marcelin N'Zebo Nouaman, Patrick Coffie, Aline Agoua, Serge Eholié, Joseph Larmarange

► To cite this version:

Valentine Becquet, Evelyne Kissi, Mélanie Plazy, Marcelin N'Zebo Nouaman, Patrick Coffie, et al. 'Dirt just has to come down': body perceptions and lived experiences of female sex workers in Côte d'Ivoire (ANRS 12361 PrEP-CI and ANRS 12381 PRINCESSE projects). AIDS 2024, the 25th International AIDS Conference, Jul 2024, Munich, Germany. . [hal-04660389](https://hal.science/hal-04660389v1)

HAL Id: hal-04660389

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Submitted on 23 Jul 2024

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# "Dirt just has to come down": Body perceptions and lived experiences of female sex workers in Côte d'Ivoire (ANRS 12361 PrEP-CI and ANRS 12381 PRINCESSE projects)

Becquet V¹,², Kissi E³, Plazy M⁴, Nouaman M³,⁵, Coffie P³,⁶, Agoua A⁷, Eholie S³,⁶, Larmarange J²,¹

1. Ined - Aubervilliers (France) 2. Ceped, Université Paris Cité, IRD, Inserm - Paris (France) 3. PAC-CI - Abidjan (Côte d'Ivoire)

4. Bordeaux Population Health Research Center, Université de Bordeaux, Inserm, IRD - Bordeaux (France) 5. Département de Santé Publique, UFR d'Odonto-Stomatologie, Université Félix Houphouët-Boigny - Abidjan (Côte d'Ivoire)

6. Département de Dermatologie et Infectiologie, UFR des Sciences Médicales, Université Félix Houphouët-Boigny - Abidjan (Côte d'Ivoire) 7. ONG Aprosam - San-Pédro (Côte d'Ivoire)

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## Objective

To analyse the body perceptions of FSWs in Côte d'Ivoire. Their representations of their bodies, situated at the intersection of intimate and professional spheres, can shed light on their perceptions and acceptability of health services, including pre-exposure prophylaxis (PrEP).

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## Methods

Qualitative interviews were conducted among FSWs in multiple waves within two successive projects.

The first project (PrEP-CI ANRS 12361) was a cross-sectional study conducted in 2016-2017 to assess the relevance of PrEP in Abidjan and San Pedro.

It included **22 interviews** and **8 focus groups** in 2016.

The second project (PRINCESSE ANRS 12381) evaluated a comprehensive sexual and reproductive health program, including PrEP, on prostitution sites in the San Pedro region.

It included **16 interviews** and **4 focus groups** in 2019, **5 interviews** in 2021, **17 interviews** in 2022.

On-site observations at prostitution sites supplemented the interviews.

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Source: V. Becquet, prostitution site in San Pedro

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Source: cloth of the Akwaba Mousso association

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## Results

### In case of condom breakage

FSW explained that they “purged” themselves to cleanse their body. The term "purge" frequently arises in discussions, referring to drinking a liquid such as cola or using enemas made from perfume, salt, or even bleach.

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"Many times even the condom is broken. So I clean myself with bleach. (...) I tell myself that maybe if he's sick, maybe it will disinfect there because bleach removes dirt." (A. 48 years old, San Pedro, March 2022)

"When you finish [to have sex], you take coke to drink, it makes the dirt go down."

(A. 15 years old, Abidjan, December 2016)

<figure><img src="image_8.png" /></figure>

Along with semen, the risks of infection and pregnancy were expelled.

Many FSWs reported turning to these practices first, either because they were unaware of post-exposure HIV treatments or the morning-after pill, or because they believed these practices were more effective than taking pills, which was rarely done.

➤ **The aim was to expel the "dirt" (this is how semen or menstrual blood is often defined)**

### Enemas: a common practice

The "purge" can associate drinks and enemas; it also helps to avoid unwanted pregnancies.

<figure><img src="image_9.png" /></figure>

"I take salt with water, put it in, then drink it. (...) They say if you sleep with a boy and don't want to get pregnant, you have to wash the sperm out, then you drink and pee."

(L. 29 years old, San Pedro, March 2022)

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## Conclusions

* Female sex workers have a perspective on their **health** and **self-care** that may not necessarily align with the project team's thinking.

* Their **body perceptions** highlight the **reservations** they may express regarding **various healthcare services**, particularly contraception, which they do not always perceive as suitable. It helps to understand the **barriers** that prevent them from accessing and remaining in care.

* **Unresolved challenges** in PRINCESSE include low uptake of contraception despite it being offered, and no observed effect from providing menstrual cup.

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## Results (following)

### Maintaining body cleanliness

Menstruations were also often considered something dirty that was preferable to be regularly flushed out. Consequently, some of the sex workers interviewed appeared reluctant, when aware of their existence, to use injections or contraceptive implants because this could have interrupted their periods, causing them to "remain" in the body rather than being expelled.

"Maybe the injections or there are others that block the menstruation. But I would prefer that if I do it, the menstruation comes down, the dirt comes down." (S. 18 years old, Abidjan, November 2016)

<figure><img src="image_12.png" /></figure>

➤ **Hormones dirty the blood**

Other testimonies also emphasize this idea of keeping one's body clean, particularly in relation to hormonal contraceptives.

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"But you have placed the implant, you have placed it, and you are there! If it's not on its annual day, the date will come to remove it to wash the blood." (T. 45 years old, San Pedro, March 2022)

The same notions of dirtiness and toxicity are therefore associated with bodily fluids as well as synthetic hormones.

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### These perceptions influence the use of the care offered in the PRINCESSE project

#### Use of contraception

At the inclusion in the Princesse project, out of the 348 sex workers who did not plan to have a child in the next 3 months, 66% reported using at least one contraceptive method.

Contraceptive methods used (multiple methods possible):

* Male condoms: 44%

* Implant: 14%

* Female condoms: 13%

* Injections: 5%

* Pill: 5%

➤ **No significant changes during the project**

### Menstrual management

The FSWs having menstruation (not menopausal, not pregnant, or breastfeeding) used:

* Cotton / cloth / toilet paper / lotus / foam: 62%

* Sanitary pads (Vania): 44%

* Limited use of the menstrual cup

Because menstruations are considered dirty, menstrual cups were not always appreciated, since they involved touching blood.

<figure><img src="image_15.png" /></figure>

"It's not that I can't use it, I don't like it, I prefer cotton. Because when you use it, you have to take it out, rinse it, and put it back in, whereas with cotton you finish using it, you throw it away, you put it in the toilet, you put water in, and it goes away instead of rinsing, touching, touching the blood and all that."

(L. 29 years old, San Pedro, March 2022)

### Working During Menstruation

62% work during their periods. The flow of menstruation can be temporarily suspended, using:

* Cotton / fabric / toilet paper / foam: 88%

* Menstrual cup: <1%

"Now if I want to manage, I pay for Lotus at the shop, I do this... I fold, fold it. I make it into a ball, I put shea butter on it. I push it inside me to go plug the hole! And then I manage on top of it! I go out with it... Even when I have intercourse with it, you don't even feel that I'm on my period."

(A. 15 years old, Abidjan, December 2016)

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Thus, many women interviewed describe similar practices, involving various materials inserted into the vagina and left in place for several sexual encounters.

### The case of PrEP: a medication taken preventatively, without being ill

PrEP, a medication taken when not ill, is seen by some as "burdensome" and "unnecessary" with the risk of causing imbalance in a healthy body.

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