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Am J Public Health. 2009 May; 99(5): 811–819.
PMCID: PMC2667855

“… But Then He Became My Sipa”: The Implications of Relationship Fluidity for Condom Use Among Women Sex Workers in Antananarivo, Madagascar


Increasing evidence indicates that sex workers use condoms less consistently with regular (i.e., nonpaying) partners than with clients. Few studies have examined the extent to which these 2 categories are mutually exclusive. In an ethnographic study of women's sex work in Antananarivo, Madagascar, we examined how the meaning of women sex workers’ sexual relationships could shift among 3 different forms of sex work. Condom use was less likely in forms in which the distinction between client and lover (sipa in Malagasy) was fluid. For many sex workers, therefore, relationships they understood to be intimate imparted the greatest health vulnerability. It is important to examine the influence of the meaning of sexual relationships on condom use for HIV prevention. Policy implications for HIV prevention work with sex workers are considered.

In countries where the HIV epidemic is driven primarily by heterosexual intercourse, sex workers are typically considered a primary core group responsible for transmitting HIV to male clients who then pass HIV on to their wives and the general population.1 Many conventional HIV-prevention efforts involve campaigns for individual behavior change targeting high-risk groups and incorporating the so-called ABCs (abstinence, be faithful, and condom use). Combining the core group perspective with the ABC approach has resulted in programs that focus narrowly on individual behavior change to encourage consistent condom use among sex workers and their clients. Research conducted under this paradigm focuses on sexual behavior and examines the determinants and barriers to condom use.

These approaches, however, often rest on and reproduce oversimplified understandings of sex work and sex workers’ relationships. Behavioral studies have been criticized for failing to recognize the diversity of sex work present in a given setting, leaving an impression that sex workers are a homogenous population.2 In addition, these studies often assume that clients are sex workers’ only sexual partners—or their only risky partners.

Increasingly, studies are incorporating a distinction between sexual interactions with clients and sexual interactions with at least 1 other partner type, commonly described as a nonpaying partner (also described as boyfriend, regular partner, personal partner, or intimate partner). Condom use has been shown to be less consistent with nonpaying partners in a number of contexts in almost every region around the world, including Asia,3 sub-Saharan Africa,4 the West,5 and Central America.6

In most of these studies, sex workers’ multiple relationships are treated as belonging to separate, mutually exclusive categories. In the Western context, these categories do, in fact, appear to be largely mutually exclusive. Studies from Australia and Europe, for example, indicate that most sex workers distinguish clearly between clients and nonpaying partners.7 Women sex workers in Glasgow report almost 100% condom use with clients and nearly 0% condom use with regular partners.8

In other contexts, there is indication that these partnership categories are less distinct. Evidence suggests that women practicing more informal forms of sex work in sub-Saharan Africa do not easily differentiate between clients and nonpaying partners9; this pattern has been observed in Asia as well. A study from Cambodia describes how women practicing informal sex work within bars had difficulty distinguishing between “guests” (clients) and “sweethearts.”10 In a study from Kenya subtitled “Regular partners may contribute more to HIV transmission than clients,” Voeten et al. state that many women did not differentiate consistently between these groups, and perhaps this fact contributed to their increased vulnerability with regular partners.11

What some of these studies imply, without adequately addressing, is the important assertion that clients and nonpaying partners may not always represent distinct types of relationships. Rather, these are fluid relationships, distinguished from one another through the development of affective ties over time. We addressed this gap in the literature by using ethnographic data to explore how sex workers and the clients and partners of sex workers interpreted their relationships and the circumstances that led to relationship change. We also examined the implications of relationship fluidity for women's health vulnerabilities. This understanding is critical to the development of effective strategies to prevent HIV and other sexually transmitted infections.


A growing city of nearly 2 million people located in the central highlands of Madagascar, Antananarivo is still surprisingly ethnically homogenous.12 Women's employment opportunities in Antananarivo are concentrated in lower-paying jobs in the formal economy (e.g., textiles) or the informal economy (e.g., produce sales, embroidery).13 Sex work provides some women monthly earnings that far surpass what they could expect to earn through these other alternatives. Antananarivo is a globalizing city with Internet access on nearly every corner. Foreign media and clothing are ubiquitous. Western notions of love and romance are everywhere, reflected in Malagasy (as well as American and French) songs blasting tales of love and loss on the radio and in video.

Prevalence of HIV in Madagascar is still low, but rising—estimated at less than 1% in recent national surveillance studies.14 As elsewhere, HIV prevention efforts in Antananarivo are largely focused on individual behavior change targeted at high-risk groups—sex workers being first on the list. Sex workers and their clients are encouraged to use condoms for their sexual interactions.15 In addition, mass media campaigns encourage the general population to delay sexual debut, to be faithful to 1 partner, and to use condoms with nonregular partners (the ABC prevention strategy).16 Although a few studies indicate some diversity in sex work in Antananarivo17 and that condom use is lower among nonpaying partners than among clients,18 the meanings of sex work and sexual relationships within different forms of sex work remain relatively unexplored.


Women sex workers’ sexual relationships and condom use were explored within a broader project examining the social organization of women's sex work in Antananarivo. Data were collected by a small research team led by K. S. over the course of 14 months of fieldwork (January–December 2003; May–June 2004). As is the case in most of the world, sex work is highly stigmatized and sex workers are marginalized in Antananarivo. Therefore, the community perception of sex work has bearing on sex workers’ lives and opportunities.

The research team first conducted in-depth and informal interviews with experienced community informants (n = 24), and semistructured interviews with general community respondents (n = 60) to gain the community's perspective. Three forms of sex work were described by the community as ambany (low), antonony (middle, in-between), and ambony (high; the English is a direct translation of the community-generated terms). Women sex workers were purposively selected to capture the breadth of the social organization of sex work depicted by the community.

The 3 sex work forms identified by community respondents were examined through “key participant” women sex workers (n = 10) and matched non–sex worker comparison women (n = 8). Sex workers were either recruited by the research team or with the assistance of a nongovernmental organization and a sex work association. Because the “high” category of sex work was practiced in establishments patronized by tourists, K. S., who speaks Malagasy, was able to approach these women within these establishments. It was more difficult to establish relationships with women sex workers who practiced on the streets at night or in poor neighborhoods. The research team relied on a nongovernmental organization conducting outreach work and members of a sex work association for initial contacts.19

Key participant women's lives were examined via participant observation, life histories, in-depth interviews, and sexual relations diaries. Life histories and in-depth interviews were conducted by K. S. together with a research assistant in a quiet place of the participant's choosing (in 2 to 3 sessions over a total of 1.5 to 2.5 hours for life histories, and a 45-minute to 1-hour session for in-depth interviews).

Additional sex workers were included through participant observation (when possible) in sex work locales (n ≈ 50) and semistructured interviews (n = 13). Finally, semistructured interviews were conducted with a convenience sample of sex workers’ clients (n = 20) by P. G. R. in 4 different sex work locales. A detailed description of the study populations and methods used is presented in Table 1.

Study Populations, Survey Methods, and Data Gathered: Antananarivo, Madagascar, 2003

Interviews were transcribed, translated and then brought into Atlas/ti version 5.2 (Scientific Software Development, Berlin, Germany) along with field notes for data coding and analysis. Data were read for themes relevant to condom use, discussion and interpretation of sexual relationships, and description of health concerns. Condom-use reporting bias, a concern with many HIV prevention studies, was minimized through triangulation of methods and study populations, as well as through an extended period of data collection, which both built trust and provided opportunity for internal data checks.


The analysis of the social organization of sex work has been described in greater detail elsewhere.20 In general, women's sex work in Antananarivo during the study took place without the involvement of a third party of any kind; there were no brothels or pimps in Antananarivo. Women controlled their earnings and, for the most part, were their own managers.

Community respondents identified 3 forms of sex work (low, middle, and high) based on sex work location, price per client interaction, and women's ethnic and racial identity. Racial and ethnic identity formation in Antananarivo may be traced back to precolonial and colonial history and organizes the population of Antananarivo into 2 racial categories—those who self-identify as descendants of nobles or commoners (who are “white”) and those who are identified as descendants of slaves (who are “black”).21

The ethnic distinctions made in Antananarivo by the local ethnic group, the Merina, differentiate the Merina from those identified as non-Merina or côtier (coastal people).22 Women identified with the low form of sex work tend to be considered “black”; women identified with the middle form are more likely to self-identify as “white”; and those identified with the high form are often described as côtier.

The women practicing the low and the middle forms of sex work operated in poor neighborhoods and on main city streets, respectively, and described the sex work they practiced as mitady vola (looking for money). The women practicing the high form of sex work did so in bars and nightclubs and described what they did as mitady vady vazaha (looking for foreign husbands).23 A detailed description of the forms of sex work is presented in Table 2.

Characteristics of the Social Organization of Women's Sex Work: Antananarivo, Madagascar, 2003

Condom Use in Antananarivo

Condom use between sex workers and their sexual partners was structured by popular understandings of condoms within Antananarivo. Condom use has been influenced by a number of factors including, but not limited to, family planning communication efforts and HIV prevention efforts, which both began in the early 1990s.24 Evidence from other sub-Saharan African countries indicates that targeting strategies and the ABC approach to HIV prevention may be inadvertently symbolically associating condoms with immoral or commercial sexual encounters.25

Following this logic, couples wishing to understand their relationships as meaningful and moral may be less inclined to use condoms. Research participants described 2 relationships within which condoms were not necessary or not appropriate: sipa (lover, such as a boyfriend) and vady (spouse) relationships. As one key participant sex worker stated: “With the client you use a condom; with a sipa you don't use a condom.”

Sipa and vady relationships are ideally characterized by love and trust. Love, trust, and the fear of disease were the major themes raised by research participants in descriptions of condom nonuse within sipa and vady relationships compared with condom use in other sexual relationships—findings similar to those from studies in other regions of the world.26 As a 25-year-old man with nearly a completed high-school education explained:

With women who are “looking for money” [sex workers] I use a condom. With my sipa, when I trust her, and I'm certain, because she isn't a sex worker, then I can trust her and I don't use a condom.

Participants from all the sampled groups—sex workers, clients, non–sex workers—employed this same logic to describe any exceptions to expected condom-use practices. For example, some participants asserted lack of trust tied to concerns about disease to explain why they used condoms with their intimate partners.27 In other cases, condom nonuse between clients and sex workers was justified through emotional intimacy, or the anticipation of future emotional intimacy. The same man quoted previously, initially describing the clear distinctions between with whom it is and is not important to use a condom, went on to say, “Sometimes if I really like the woman [sex worker] I'm with, then I don't use a condom.”

Sipa relationships may be characterized by love and trust, but they are also unions that can be formed and severed quickly. For some women sex workers, the distinction between a client and sipa relationship was also highly fluid. We show how relationship fluidity contributed to women's health vulnerability given that condom use was deemed less appropriate with sipa or vady than with clients.

Fluidity in Women Sex Workers’ Sexual Relationships

Women practicing the low form of sex work.

The low form of sex work was practiced within slumlike neighborhoods throughout the city during the day.28 The women stood in areas of pedestrian traffic and accompanied the men they met to nearby small shacks rented by the half hour for the purpose of sexual intercourse. Women sex workers hoped that the men with whom they had intercourse would come to consider them as a sipa or vady (i.e., someone for whom a man should provide), so they could rely on the men in times of need. Men, in turn, have learned that women sex workers often make more money than they themselves can expect to earn. As a result, men and women each look to the other for some financial stability in their lives, fostered through romantic relationships that often begin as a sexual interaction with a client.

Kara, a 22-year-old key participant with 3 years of education called home half a bed in one of the shacks used for sexual interactions during the day. Her relationships with men illustrate how the meaning of sexual relationships can shift. She described how her relationship began with a regular client:

He courted me. He took me for a passage [brief sexual interaction] and after that he bought me some toaka [local moonshine] and beer… . And he told me “I won't look for other women anymore. I will always go with you.” … Sometimes, he buys some clothes for me… . Sometimes, he comes even without going for any passage but just takes me to the bar, or asks me to go with him to buy some things.

Kara's description is more suggestive of a romantic relationship than a client interaction: He “courted” Kara, and he took her for a passage; he sometimes invited her out to the bar or to go shopping without any exchange of sexual activity. Kara also stated that he only paid her for a little less than half of their sexual interactions. She soon began to consider this man her sipa rather than her client:

Yes, he was a client, but then he became my sipa… . We went and had a picture taken together … it was then that he told me … “I love you, but I have a wife.”

He no longer paid her for sexual relations, but she did not mind because she loved him.

The following month Kara had a fat lip and a sore back—her sipa had beaten her with a piece of firewood. Kara explained: “When he sees that I have been with someone else … then he beats me, but he doesn't give me any money … and so I go with other men.”

This relationship, which began and ended within a little more than 2 months, illustrates the struggles faced by women in an extremely economically depressed setting. This man was not in a position to economically provide for Kara and Kara could not forgo her means of income generation to be only with this man. The cycle then repeated itself. Two months later, Kara was caught in another abusive relationship with a man whom she called a client, then a sipa, and then “a client who was together with me.” Client relationships could very quickly become understood as sipa or vady relationships, and often these categories of relationships were not clearly delineated.29

Women practicing this form of sex work frequently expressed (unsolicited) fears about acquiring HIV or other sexually transmitted infections. Most, however, also indicated that they did not insist on condom use with the men with whom they had sexual relations. It is generally found that a frequent explanation for condom nonuse is the pressure that immediate financial need creates, making women more likely to acquiesce to men's interests in having unprotected sexual intercourse. Condom nonuse could also be influenced by the shifting definition of relationships between client and lover or spouse. By failing to insist on condom use, a woman was inviting the sexual relationship to be understood as a relationship between trusting partners—in other words, as sipa or vady. As relationship meaning shifted, condom use became more and more unlikely.

Women practicing the middle form of sex work.

Women who practiced the middle form of sex work were more likely to self-identify as “white,” Merina (members of the dominant local ethnic group), and to have families who originate from the area and live nearby. As such, these women hold social capital that they would certainly lose if they were to be discovered as sex workers. Therefore, most hid this identity from their communities and families, and sometimes their own husbands.

To this end, most of these women practiced sex work on dark streets at night. This environment encouraged very formal transactions. Women awaited men on the street corner, they engaged in a discussion of the particulars of the sexual interaction, and then accompanied their client to a cheap hotel or back to his car to exchange sexual intercourse for immediate financial remuneration.

Most of these women made an effort to keep their romantic relationships distinct from their client relationships. Unmarried women pursued romantic relationships with men they met in other contexts. Unlike women practicing other forms of sex work, these women had a more pejorative view of those who allowed client relationships to transition into other kinds of relationships. They thought sex work should be about making money, not building relationships.

Compared with women in the low form, participants practicing the middle sex work form were much more likely to report consistent condom use with their clients. These women were also less likely to express concerns about sexually transmitted infections but more likely to express concerns about violence on the streets, as working on isolated streets at night made them easy targets for physical and sexual assault.30

Despite the formality, women who practiced the middle sex work form were sometimes pulled into more affective relationships with established “fixed” clients (regular clients). Some women described having a difficult time maintaining more formal client relationships, but that it was often the clients who encouraged such shifts.31

Women practicing the high form of sex work.

The high sex work form was practiced in bars and nightclubs, where women went to “look for foreign husbands.”32 These women made a conscious effort to maintain very informal interactions with the men they met, so that these interactions could be interpreted as a (Western construction of a) boy-meets-girl encounter in a bar or nightclub.

The women usually avoided discussion about money or the particulars of sexual intercourse before it took place. Participants described the importance of the woman's waiting for a man to approach her rather than trying to actively attract a man so as to ensure that he would be more receptive to any (financial) concerns she might communicate to him later (communicated as money needed for her family, e.g., a sick parent). In addition, they believed that there was an increased likelihood that if a man approached the woman first, his interest in her might extend beyond a 1-time sexual encounter.

Although women in clubs and bars insisted that they used condoms with their clients, they also explained that there were many women who did not always use condoms. Women were more likely to insist on using a condom if they knew they were not interested in the man as a potential husband. Alternatively, they were more likely to risk sexual intercourse without a condom if they were romantically interested in the man, or if they believed he might be romantically interested in them.

The result of these strategies was not only exposure to HIV and other sexually transmitted infections but also pregnancy. Women openly discussed abortions they carried out after learning that a potential husband was not in fact committed to their shared future.33 For example, Simone, a 24-year-old key participant with 7 years of education, explained that she had had to abort recently. The father was an older European man who had been sending her money between visits to Madagascar. She was led to believe he was interested in marriage. When he learned she was pregnant, instead of sending more money as promised, on his next visit he found another woman at the bar.

Soon after that, Simone met Pierre: a young, fit European tourist, he represented the ideal potential husband. Once he left Madagascar, he began financially supporting her and promised to return. Around her friends and family members she referred to him as her vady. However, in a formal interview, she referred to him as a fixed client, explaining that this was because they had not yet formalized their commitment (i.e., through formal marriage). Although he seemed committed, she hedged her bets by continuing to look for a foreign husband on weekends at the bar. She also explained that she was lonely when not going out and so she sought out Malagasy sipa for company.

Pierre did return for a long visit, during which time they did not use condoms.34 He and Simone began compiling the paperwork toward a travel visa for her to visit him. Once he left the country Simone returned to going to the bar. Although she suggested that she was now more interested in money than in a potential husband, sex work practice in this setting was informally structured; therefore, shifts in relationship understanding and potential for condom nonuse would remain likely.

Key participant Denise had a Malagasy “spouse” off and on for 7 years who served as an emotional safety net while she looked for a foreign spouse. Denise said that they never used condoms, as they were spouses. However, they had separated on numerous occasions, always based on the same complaint. Denise explained: “He comes home with love-bites, but I didn't give them to him.”

Women who practiced the high form of sex work were therefore exposed to sexual health risk both through their relationships with potential foreign husbands and through romantic relationships with Malagasy men.


Our findings show that in Antananarivo the meaning of sexual relationships was highly fluid for women practicing certain forms of sex work. Once affective ties were introduced into a relationship between a client and a sex worker, condom use became less appealing, particularly if that relationship became understood as one with a sipa or vady. The result was that the health of many women sex workers was put at greater risk with men whom they understood to be sipa or vady rather than with men whom they understood to be clients.

Women practicing what the community respondents described as the middle form of sex work were more likely to maintain formal relationships with their clients, structured by their interest in discrete sex work practice. Women practicing the low and high forms, alternatively, either allowed or sought fluidity in the understanding of their relationships.

Such fluidity was integral to women's efforts to improve their situations through building intimate relationships with men who could provide stable economic support, and condom nonuse served toward building that intimacy. For these women, distinctions prevalent in conventional public health discourse between regular partners and clients did not exist.

This finding has implications for research and programs that assume that sex workers conceptualize 2 discrete groups (clients vs regular partners). Efforts to prevent HIV could benefit from more carefully accounting for the interpretation and fluidity of sexual relationships and condom use within those relationships. In addition, it is important to account for different contexts in which sexual relationships take place and to determine which relationships are most likely to increase health vulnerabilities for the individuals involved.

We found that significant health vulnerabilities were also generated through violence—whether structured as intimate partner violence, street violence, or sexual assault from relatively unknown perpetrators (such as formal clients). Prevention programs working with women sex workers should make efforts to address these women's pressing health concerns, such as violence, in addition to promoting condom use.

Not all of sex workers’ sexual relationships began as client relationships. Women practicing the high form of sex work, for example, took emotional refuge in relationships with Malagasy men while awaiting the ideal European husband. Women practicing the middle form were sometimes legally married to men they met outside of (or before) their sex work practice.

These relationships also contributed to women sex workers’ health vulnerability. Mounting evidence shows that marriage is a risk factor for HIV for women in sub-Saharan Africa (as well as other regions).35 This important finding affects any woman in Antananarivo who is married or in an intimate partnership (whether or not it began as a client relationship) through the cultural expectation that men have extramarital relationships that women should quietly tolerate.36

Women sex workers experience persistent gendered social, political, and economic inequalities that are fundamental to their disproportionate health vulnerabilities. Given the reality of these gendered power structures, interventions encouraging use of the male condom need to place more of the onus for condom use on men. In addition, continued encouragement of the development and distribution of women-controlled methods for HIV prevention is needed.37

In Antananarivo, the health vulnerability resulting from condom nonuse was structured, in part, by the general understanding of when it was and was not appropriate to use condoms. This understanding may result from HIV prevention messages grounded in idealized Western assumptions about sex work and sexual behavior in relationships.38

The ABC approach to HIV prevention has been criticized as overly reliant on a Western conception of marriage, assuming sexual monogamy with only rare episodes of infidelity (assumptions being tested by evidence that marriage is an HIV risk factor for women).39 In addition, within the current policy environment, the shift to strategies emphasizing abstinence and fidelity and away from condom use potentially exacerbates the association between condom use and immoral sexual interactions, further narrowing the description of with whom it is necessary to use condoms. Our findings indicate that the assumptions on which the ABC strategy is based do not correspond to the realities confronted by our study population.

The prevention and research community must find ways to take the symbolic power away from the condom. If prevention efforts continue to rely on categories such as client versus regular partner or primary versus occasional partner for the promotion of condom use, evidence suggests that a sizeable number of sexual interactions that should be protected will go on being unprotected (particularly in non-Western settings). The challenge becomes one of restructuring messages about condoms, moving away from promotion of population categories with whom to use them (and therefore implicitly with whom not to), and toward nonjudgmental encouragement of their use in sexual relationships more generally.

Inequalities ranging from a country's position within the global economy to local gender-based discrimination explain many (but not all) women sex workers’ participation in the sexual economy around the world. Until such inequalities are greatly diminished, sex work will remain a popular constrained choice for income generation. It is therefore imperative that the public health community be in a position to work with this population toward understanding their diverse needs and concerns.

However, this notion is incompatible with current funding restrictions tied to the US Global AIDS Act of 2003, which founded the President's Emergency Plan for AIDS Relief. Under this legislation, prostitution is equated to trafficking and in need of eradication, and both foreign and US organizations that receive US Agency for International Development funding toward HIV prevention are required to have a policy explicitly opposing prostitution.40 Our findings call into question the appropriateness of this interpretation of prostitution and suggest that these restrictions could seriously compromise HIV prevention efforts with sex workers, particularly efforts attempting to account for sex workers’ diverse health concerns. A bill reauthorizing the Global AIDS Act was passed in 2008. While the reauthorization bill relaxed earmarks on abstinence, it maintained the restrictions on funding applying to sex workers.

Our research underlines the recommendations of the Institute of Medicine's evaluation of the President's Emergency Plan for AIDS Relief in anticipation of the renewal and increased funding of this program.41 The Institute of Medicine's recommendations emphasized the need to allow regions to have flexibility in the substance and goals of their intervention efforts. Intervention efforts must be able to address the needs of each specific context, rather than apply the same strategy to every context on the basis of one assumption about sexual behavior and one assumption regarding the interpretation of the meaning of prostitution.


The study was funded by the Canadian Institutes for Health Research Initiative in Global Health Research Fellowship; The Hopkins Fogarty AIDS International Training & Research Program Competitive Awards for US New & Minority Investigators; The Gertman Fellowship in Gender and Women's Health; and The Andrew W. Mellon Foundation Award for Dissertation Data Collection with the Hopkins Population Center.

We are grateful for the insightful suggestions provided by 3 anonymous reviewers and would like to also thank Frieda Behets, Ronald Labonte, and Holly Wardlow for their very helpful comments on earlier drafts. We would like to thank Andriamahandrimanana Ramarozatovo for his help with translation, in addition to the others who assisted in interviewing, transcription, or translation. Finally, and most importantly, we wish to thank the participants for providing so much of their time and sharing so much of their lives with us.

Human Participation Protection

The study was approved by both the Committee on Human Research Subjects at Johns Hopkins University and the National Committee on Research Ethics in Antananarivo, Madagascar. All research subjects participated in an informed consent process prior to their inclusion in the research. All research participant names in this article are pseudonyms.


1. F. A. Plummer, et al., “The Importance of Core Groups in the Epidemiology and Control of HIV-1 Infection,” AIDS 5 (suppl), no. 1 (1991): S169–S176
2. Barbara de Zalduondo, “Prostitution Viewed Cross-Culturally: Toward Recontextualizing Sex Work in AIDS Intervention Research,” The Journal of Sex Research 28, no. 2 (1991): 223–248; Mauricio Hernandez Avila, Patricia Uribe Zuniga, and Barbara O. de Zalduondo, “Diversity in Commercial Sex Work Systems: Preliminary Findings From Mexico City and Their Implications for AIDS Interventions,” in AIDS and Women's Reproductive Health, ed. Judith Masslo Anderson, et al. (New York: Plenum Press, 1991), 179–194; Lois Jackson, Alexandra Highcrest, and Randall A. Coates, “Varied Potential Risks of HIV Infection Among Prostitutes,” Social Science & Medicine 35, no. 3 (1992): 281–286; International HIV/AIDS Alliance, Technical Review: Prevention and the Commercial Sex Industry, Concept Paper Annex 3, 2000; UK International HIV/AIDS Alliance, Prevention at the Frontiers of the HIV/AIDS Epidemic (2000); Graham Fordham, “Moral Panic and the Construction of National Order—HIV/AIDS Risk Groups and Moral Boundaries in the Creation of Modern Thailand,” Critique of Anthropology 21, no. 3 (2001): 259–316; Holly Wardlow, “Anger, Economy, and Female Agency: Problematizing ‘Prostitution’ and ‘Sex Work’ Among the Huli of Papua New Guinea,” Signs 29, no. 4 (2004): 1017–1040.
3. F. Amadora-Nolasco, et al., “Knowledge, Perception of Risk for HIV, and Condom Use: A Comparison of Registered and Freelance Women Sex Workers in Cebu City, Philippines,” AIDS and Behavior 5, no. 4 (2001): 319–330; E. Basuki, et al., “Reasons for Not Using Condoms Among Women Sex Workers in Indonesia,” AIDS Education and Prevention 14, no. 2 (2002): 102–116; D. K. S. Chan, et al., “Identifying the Psychosocial Correlates of Condom Use by Women Sex Workers in Hong Kong,” AIDS Care-Psychological and Socio-Medical Aspects of AIDS/HIV 16, no. 4 (2004): 530–539; L. T. Giang, et al., “Evaluation of STD/HIV Prevention Needs of Low- and Middle-Income Women Sex Workers in Ho Chi Minh City, Vietnam,” AIDS and Behavior 4, no. 1 (2000): 83–91
4. H. A. C. M. Voeten, et al., “Women Sex Workers and Unsafe Sex in Urban and Rural Nyanza, Kenya: Regular Partners May Contribute More to HIV Transmission Than Clients,” Tropical Medicine & International Health 12, no. 2 (2007): 174–182; M. Ntumbanzondo, et al., “Unprotected Intercourse for Extra Money Among Commercial Sex Workers in Kinshasa, Democratic Republic of Congo,” AIDS Care-Psychological and Socio-Medical Aspects of AIDS/HIV 18, no. 7 (2006): 777–785; Ilsa Pauw and Loren Brener, “‘You Are Just Whores—You Can't Be Raped’: Barriers to Safer Sex Practices Among Women Street Sex Workers in Cape Town,” Culture Health & Sexuality 5, no. 6 (2003): 465–481; S. Ray, et al., “Constraints Faced by Sex Workers in Use of Female and Male Condoms for Safer Sex in Urban Zimbabwe,” Journal of Urban Health–Bulletin of the New York Academy of Medicine 78, no. 4 (2001): 581–592; Vivien M. Walden, Kondwani Mwangulube, and Paul Makhumula-Nkhoma, “Measuring the Impact of a Behaviour Change Intervention for Commercial Sex Workers and Their Potential Clients in Malawi,” Health Education Research 14, no. 4 (1999): 545–554; Marjolein Gysels, Robert Pool, and Betty Nnalusiba, “Women Who Sell Sex in a Ugandan Trading Town: Life Histories, Survival Strategies and Risk,” Social Science & Medicine 54, no. 2 (2002): 179–192
5. Linda Cusick, “Non-Use of Condoms by Prostitute Women,” AIDS Care 10, no. 2 (1998): 133–146; J. Fox, et al., “Sex Work Practices and Condom Use in Women Sex Workers in Sydney,” International Journal of STD & AIDS 17, no. 5 (2006): 319–323; Priscilla Pyett and Deborah Warr, “Women at Risk in Sex Work: Strategies for Survival,” Journal of Sociology 35, no. 2 (1999): 183–197; Charles E. Waddell, “Women Sex Work, Non-Work Sex and HIV in Perth,” Australian Journal of Social Issues 31, no. 4 (1996): 410–424
6. B. Allen, et al., “Affection, Kisses and Condoms: The Basics of Sexual Practices of Women Sex Workers in Mexico City” [in Spanish], Salud Publica de Mexico 45, no. 5 (2003): S594–S607
7. Fox, “Sex Work Practices,” 319–323; Waddell, “Women Sex Work,” 410–424. Deborah J. Warr and Priscilla M. Pyett, “Difficult Relations: Sex Work, Love and Intimacy,” Sociology of Health & Illness 21, no. 3 (1999): 290–309; G. Gilchrist, et al., “Behavioural and Lifestyle Study of Women Using a Drop-In Centre for Female Street Sex Workers in Glasgow, Scotland: A 10 Year Comparative Study,” Addiction Research & Theory 9, no. 1 (2001): 43–58
8. Gilchrist, “Behavioural and Lifestyle Study,” 43–58.
9. Voeten, “Women Sex Workers,” 174–182; Sohail Agha and Mwaba C. Nchima, “Life-Circumstances, Working Conditions and HIV Risk Among Street and Nightclub-Based Sex Workers in Lusaka, Zambia,” Culture Health & Sexuality 6, no. 4 (2004): 283–299; Janet M. Wojcicki, “‘She Drank His Money’: Survival Sex and the Problem of Violence in Taverns in Gauteng Province, South Africa,” Medical Anthropology Quarterly 16, no. 3 (2002): 267–293
10. Kasumi Nishigaya, “Female Garment Factory Workers in Cambodia: Migration, Sex Work and HIV/AIDS,” Women & Health 35, no. 4 (2002): 27–42
11. Voeten, “Women Sex Workers,” 174–182. [PubMed]
12. François Roubaud, Identités et transition démocratique: l'exception Malgache? (Paris: L'Harmattan, 2000)
13. L'emploi, le chômage et les conditions d'activité des ménages dans les sept grandes villes de Madagascar (Antananarivo, Madagascar: INSTAT, Projet MADIO, 2001), 1–76.
14. Résultats préliminaires de l'enquête de surveillance biologique du VIH/SIDA et de la syphilis, année 2004–2005 (Antananarivo, Madagascar: Comité National de Lutte contre le VIH/SIDA and Ministère de la Santé et du Planning Familial, 2005), 1–20. Résultats préliminaires de l'enquête de surveillance biologique, année 2007 (Antananarivo, Madagascar: Ministère de la Santé et du Planning Familial et de la Protection Sociale, and Programme IST/VIH/SIDA, 2007)
15. La stratégie nationale en communication IST/IST/VIH/SIDA Madagascar 2001–2006, draft (Antananarivo, Madagascar: Comité National de Lutte contre le VIH/SIDA, 2003)
16. US Agency for International Development Madagascar, “Technical Profile HIV/AIDS, US Mission Madagascar USAID,” 2004. Additionally, among most recent (2007) campaigns aimed at youths is one encouraging abstinence that borrows a concept of the “red card” from soccer as a means of empowering youths to say no to sex. Another campaign, however, encourages condom use for prevention of both pregnancy and sexually transmitted infections, including AIDS, so that youths can remain “youthful.”
17. Gisele Maynard-Tucker, Étude qualitative des comportements sexuels des groupes à risque: prostituées non fichées et clients pour la prévention du SIDA à Antananarivo, Madagascar [expert consultant report, submitted to the World Bank and Futures Group] (1996); F. Behets, et al., “Sexually Transmitted Infections and Associated Socio-Demographic and Behavioural Factors in Women Seeking Primary Care Suggest Madagascar's Vulnerability to Rapid HIV Spread,” Tropical Medicine & International Health 6, no. 3 (2001): 202–211.
18. P. J. Feldblum, et al., “Results of a Randomised Trial of Male Condom Promotion Among Madagascar Sex Workers,” Sexually Transmitted Infections 81, no. 2 (2005): 166–172 [PMC free article] [PubMed]
19. There was concern that both the nongovernmental organization and the sex work association would introduce bias by associating the research team with these groups and by selecting participants with certain characteristics deemed preferable by either organization. Without these connections, however, meeting women would have been nearly impossible. We minimized these biases to the extent possible. The research team made only 1 initial contact to a peer-educator sex worker through members of a nongovernmental organization outreach team. The sex work association president went on to be a research team member, and assisted the first author in interviews with key participant sex workers. She and another sex worker association member helped locate participants (n = 5) whom they had met only once before when conducting an informal survey of sex work in Antananarivo funded by the Ministry of Health. We asked the president not to discuss her affiliation to this sex worker association to key participants who were not already aware of it. We did not include association members in our key-participant study population.
20. Kirsten Stoebenau, “From Those Who ‘Have to Carry Men’ to Those Who ‘Look to Marry Men’: The Social Organization of Women's Sex Work in Antananarivo, Madagascar” (Ph.D. diss., Johns Hopkins University, 2006): 1–367.
21. François Rajaoson, “Séquelles et résurgences de l'esclavage en Imerina,” in L'esclavage à Madagascar: Aspects historiques et résurgences contemporaines: Actes du Colloque International sur l'Esclavage, Antananarivo (September 24–28, 1996) (Antananarivo, Madagascar: Institut de Civilisations–Musée d'Art et d'Archéologie, 1997), 347–355; Gerald M. Berg, “The Myth of Racial Strife and Merina Kinglists: The Transformation of Texts,” History in Africa 4 (1977): 1–30
22. Françoise Raison-Jourde and Solofo Randrianja, “Introduction,” in La Nation Malgache au Défi de L'Ethnicité, ed. Françoise Raison-Jourde and Solofo Randrianja (Paris: Karthala, 2002), 7–36.
23. Sex work forms are socially ranked by the community, but describing them as social categories would imply a level of boundedness that they do not possess. Sex work forms are loose, analytic categories with the possibility of movement between them—this movement is more likely between some forms than others. For example, women who practice what the community called the low form of sex work can sometimes move into the high form, or to the middle form. There is much less movement between the middle and high forms of sex work. The distinctions between the middle and the high form are based upon a woman's constructed ethnic identity and her preferences in how and why she practices sex work attached to that identity (i.e., a good Merina woman should not flaunt her body and go to nightclubs—women who valued that identity preferred to practice on the street). Preferences attached to a woman's identity do not factor as strongly into possible movement out of the low form of sex work.
24. Centre National de Recherches sur l'Environnement and Macro International Inc, “Enquête National Démographique et Sanitaire 1992” (Calverton, MD: Macro International Inc, 1994); Jocelyne Andriamiadana (physician with US Agency for International Development in the Health, Population and Nutrition Division, Antananarivo, Madagascar), conversation with author in Antananarivo, 2004.
25. Shanti A. Parikh, “The Political Economy of Marriage and HIV: The ABC Approach, ‘Safe’ Infidelity, and Managing Moral Risk in Uganda,” American Journal of Public Health 97, no. 7 (2007): 1198–1208; Agnes M. Chimbiri, “The Condom Is an ‘Intruder’ in Marriage: Evidence From Rural Malawi,” Social Science & Medicine 64, no. 5 (2007): 1102–1115; Sandra Manuel, “Obstacles to Condom Use Among Secondary School Students in Maputo City, Mozambique,” Culture Health & Sexuality 7, no. 3 (2005): 293–302
26. Cusick, “Non-Use of Condoms,” 133–146; Warr and Pyett, “Difficult Relations” 290–309; Rachel Jones, “Sex Scripts and Power: A Framework to Explain Urban Women's HIV Sexual Risk With Male Partners,” Nursing Clinics of North America 41, no. 3 (2006): 425–436, vii; Manuel, “Obstacles to Condom Use,” 293–302; Cicely Marston and Eleanor King, “Factors That Shape Young People's Sexual Behaviour: a Systematic Review,” Lancet 368, no. 9547 (2006): 1581–1586; L. Murray, et al., “The Role of Relationship Intimacy in Consistent Condom Use Among Women Sex Workers and Their Regular Paying Partners in the Dominican Republic,” AIDS and Behavior 11, no. 3 (2007): 463–470; Ndola Prata, Farnaz Vahidnia, and Ashley Fraser, “Gender and Relationship Differences in Condom Use Among 15–24-Year-Olds in Angola,” International Family Planning Perspectives 31, no. 4 (2005): 192–199; M. J. Wawer, et al., “Origins and Working Conditions of Women Sex Workers in Urban Thailand: Consequences of Social Context for HIV Transmission,” Social Science & Medicine 42, no. 3 (1996): 453–462
27. Condoms were sometimes used within sipa and vady relationships, and those trying to insist on condom use were sometimes men. One client described using condoms with his wife because he knew she had other lovers; and one key-participant comparison woman described her husband trying to insist on condom use, but she refused (she explained spouses should not have to use condoms). Another example was a key participant comparison woman who insisted that her husband, whom she knew to have other lovers, use a condom with her (however, she may be somewhat unique—this key participant lived next to a health educator for sex workers who encouraged her to insist on condom use)
28. These women and the clients they attract are very poor, and as many of these women are discriminated against as “black,” opportunities for other work are very limited.
29. Other examples of the fuzzy definition of a client include Kara's description of an outing she had with a client that involved going for a picnic in the countryside. Another key participant, Paty, recounted her most recent client interaction as going to see a video and being given some money for food without any exchange of sexual relations.
30. These concerns were substantiated. Most women the research team encountered practicing this form (approximately 30) reported acts of violence such as rape or assault (for example, when the lead author attended an outreach session with 12 women on the street at night, all 12 reported having experienced client rape). In semistructured interviews, 6 out of 10 women on the street spontaneously reported having experienced violence. Violence in the other forms was less pervasive and structured differently (more often as intimate partner violence). Both key participants who worked at night in the middle form reported having experienced client rape, although this was the case in one 1 of 3 key participants in the high form and 0 of 3 key participants in the low form. It is because women in the middle form feel that they must hide their practice that they place themselves at such high risk of violence.
31. One example cited by women in every sex work category was a relationship with a maty-gauche or jaombilo. These terms describe men who attach themselves as “boyfriends” to women they know to be sex workers and are then financially supported by the woman's sex work. Some younger clients on the streets at night outside a nightclub discussed the advantage of gaining monetary support from women sex workers who fall for them (see also: Jennifer Cole, “The Jaombilo of Tamatave [Madagascar], 1992–2004: Reflections on Youth and Globalization,” Journal of Social History 38, no. 4 [2005]: 891–914, on jaombilo in an east coast city of Madagascar)
32. Women practicing this form are often discriminated against as côtier who are expected to be more promiscuous than Merina women. Chaste “white” Merina women would be looked down upon for going to nightclubs and bars, particularly if they were unaccompanied and dressed in trendy, revealing clothes. This form of sex work is similar to that explored in studies of sex tourism elsewhere. See for example: Denise Brennan, What's Love Got to Do With It? Transnational Desires and Sex Tourism in the Dominican Republic, Latin America Otherwise: Languages, Empires, Nations (Durham, NC, and London: Duke University Press, 2004); Kamala Kempadoo, “Freelancers, Temporary Wives, and Beach-Boys: Researching Sex Work in the Caribbean,” Feminist Review, no. 67 (2001): 39–62
33. Most key participants were not using family planning methods other than the male condom, although a few reported use of the calendar method with stable, intimate partners. Some key participants were interested in getting pregnant and were not using methods with intimate partners for that reason. Many women cited concerns (e.g., hair loss, cancer, weight gain) they had with pills or injectable methods of contraception.
34. Simone's explanation of why they no longer used condoms demonstrates that an association between condom use and immorality may be quite relevant to this study site. We were discussing why it is difficult to use condoms with sipa or vady and she explained:. It's difficult because, for example, Pierre won't use them at all anymore … he said “I don't consider you as a sex worker, and my family doesn't know that either … they know you as a well-behaved person” and so he won't use them at all! It is the association between condom nonuse and “a well-behaved person” that is particularly revealing.
35. Shelley Clark, Judith Bruce, and Annie Dude, “Protecting Young Women From HIV/AIDS: The Case Against Child and Adolescent Marriage,” International Family Planning Perspectives 32, no. 2 (2006): 79–88; J. S. Hirsch, et al., “The Social Constructions of Sexuality: Marital Infidelity and Sexually Transmitted Disease–HIV Risk in a Mexican Migrant Community,” American Journal of Public Health 92, no. 8 (2002): 1227–1237; S. Newmann, et al., “Marriage, Monogamy and HIV: A Profile of HIV-Infected Women in South India,” International Journal of STD & AIDS 11, no. 4 (2000): 250–253; M. Urassa, et al., “HIV Prevalence and Sexual Behaviour Changes Measured in an Antenatal Clinic Setting in Northern Tanzania,” Sexually Transmitted Infections 82, no. 4 (2006): 301–306. For detailed examinations of how extramarital sexual relations are socially organized to generate such vulnerability to women as wives in various contexts, see Daniel J. Smith, “Modern Marriage, Men's Extramarital Sex, and HIV Risk in Southeastern Nigeria,” American Journal of Public Health 97, no. 6 (2007): 997–1005; J. S. Hirsch, et al., “The Inevitability of Infidelity: Sexual Reputation, Social Geographies, and Marital HIV Risk in Rural Mexico,” American Journal of Public Health 97, no. 6 (2007): 986–996; Parikh, “The Political Economy,” 1198–1208; Chimbiri, “The Condom Is an ‘Intruder,’” 1102–1115; Holly Wardlow, “Men's Extramarital Sexuality in Rural Papua New Guinea,” American Journal of Public Health 97, no. 6 (2007): 1006–1014
36. Among key participant sex workers, 6 of 10 described being in a relationship in which their partner or husband cheated, as did every key participant comparison woman (8 out of 8). Further evidence of this issue in Madagascar is provided by the most recent Demographic and Health Survey, in which only 1% of sexually active women in Antananarivo reported having had more than 1 sexual partner in the past year compared with 23% of men (“Enquête démographique et de santé de Madagascar 2003–2004” [Calverton, MD: INSTAT and ORC Macro, 2005]). Although this may reflect culturally inscribed under- and overreporting by women and men, respectively, the perception of acceptability is as important as the reality.
37. However, as a word of caution, these methods must be introduced with care as they too are at risk of being associated with immoral sexual activity, lack of trust between partners, and other concerns we have described associated with the male condom. Evidence of such concerns was recently detailed in a study examining diaphragm use in Mombasa, Kenya. (See: J. Okal, et al., “Secrecy, Disclosure and Accidental Discovery: Perspectives of Diaphragm Users in Mombasa, Kenya,” Culture, Health & Sexuality 10, no. 1 [2008]: 13–26.)
38. A study of sexual relationships among youths in urban Mozambique argues this very point suggesting that the nonuse of condoms in steady relationships results from HIV prevention messages that only emphasized condom use between occasional sexual partners. (See: Manuel, “Obstacles to Condom Use,” 293–302.) A number of scholars have criticized HIV prevention efforts in general, and specifically with regard to sex work as being overly reliant on Western moral assumptions about sexuality and sexual behavior (See: Framing the Sexual Subject: The Politics of Gender, Sexuality, and Power, ed. Richard Parker, Regina M. Barbosa, and Peter Aggleton [Berkeley, CA: University of California Press, 2000]; Mark Hunter, “The Materiality of Everyday Sex: Thinking Beyond ‘Prostitution’,” African Studies 61, no. 1 [2002]: 99–120; Fordham, “Moral Panic,” 259–316)
39. Wardlow, “Men's Extramarital Sexuality,” 1006–1014; Parikh, “The Political Economy of Marriage,” 1198–1208.
40. “Implications of U.S. Policy Restrictions for Programs Aimed at Commercial Sex Workers and Victims of Trafficking Worldwide; Policy Brief: Legal and Policy Restrictions on U.S. Global AIDS and Trafficking Funding” (Takoma Park, MD: Center for Health and Gender Equity, 2005), 1–5.
41. See: “PEPFAR Implementation: Progress and Promise. Report Brief, March 2007” (Washington, DC: Institute of Medicine, 2007), 1–3; R. Feingold, et al., “PEPFAR Reauthorization: Looking Forward,” Center for Strategic and International Studies, The Henry J. Kaiser Family Foundation, Meeting Transcript. http://www.kaisernetwork.org/health_cast/hcast_index.cfm?display=detail&hc=214 (accessed November 29, 2007)

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