Looking for Sex Workers in Suriname

Transcription

Anton de Kom University of Suriname
Institute of Graduate Studies and Research
“An Evaluation of methods to estimate the size of Sex Workers in Suriname”
Paper Submitted in fulfillment of the requirements for the degree of Master in Public Health
Deborah Stijnberg, M.D.
December 2012
i
Evaluation of Size Estimation Methods of Sex Workers in Suriname
Anton de Kom University of Suriname
Institute of Graduate Studies and Research
“An Evaluation of methods to estimate the size of Sex Workers in
Suriname”
Paper Submitted in fulfillment of the requirements for the degree of Master in Public Health
Deborah Stijnberg, M.D.
Mentors:
Willi Mc Farland, MD, PhD, MPH&TM
Julia Terborg, PhD
December 2012
Table of Contents
Abstract ....................................................................................................................................................................... iv
Acknowledgements ................................................................................................................................................. v
List of Abbreviations .............................................................................................................................................. vi
List of Figures........................................................................................................................................................... vii
List of tables ............................................................................................................................................................ viii
1. Introduction .......................................................................................................................... 9
1.1 HIV in the Caribbean ................................................................................................................................ 11
2.
Background .....................................................................................................................13
2.1 Sex workers in the Surinamese HIV epidemic ................................................................................ 15
2.2 Rational for the current study............................................................................................................... 16
3.
Literature Review ............................................................................................................18
3.1
Size estimation methods.................................................................................................................. 18
3.1.1 Methods based on data collected directly from population at risk ............................... 18
3.1.2 Methods based on data collected from general population............................................ 21
3.2 Review of country experiences with MARPS size estimations ................................................. 22
3.3 Theoretical requirements of the selected size estimation methods ...................................... 27
4.
Study design ....................................................................................................................28
4.1 Objectives ..................................................................................................................................................... 28
4.2 Operational definitions ........................................................................................................................... 28
4.3 Methodology .............................................................................................................................................. 29
4.3.1 Data sources and Estimation methods ..................................................................................... 29
4.4 Data analysis ............................................................................................................................................... 33
4.5 Ethical considerations .............................................................................................................................. 33
5. Results .................................................................................................................................34
ii
5.1 Estimated size of sex workers in Suriname ...................................................................................... 34
5.2 Assessment of adherence to theoretical requirements of estimation methods ............... 39
6.
Discussion ........................................................................................................................43
6.1 Data sources ................................................................................................................................................ 43
6.2 Methods used ............................................................................................................................................. 43
6.3 Adherence to theoretical requirements of estimation methods ............................................. 44
6.3.1 The Multiplier ...................................................................................................................................... 44
6.3.2 Mapping/Enumeration .................................................................................................................... 44
6.4 Results compared to international findings .................................................................................... 45
6.5 Limitation of the study ............................................................................................................................ 45
7.
Conclusions and Recommendations .............................................................................46
7.1 Conclusions.................................................................................................................................................. 46
7.2 Recommendations .................................................................................................................................... 47
References................................................................................................................................................................ 49
List of experts interviewed ................................................................................................................................. 51
ANNEX 1 Advantages and disadvantages different size estimation methods .............................. 52
ANNEX 2 Definitions of sex work in different Caribbean countries................................................... 53
ANNEX 3 Summary of the review of adherence to the theoretical requirements of size
estimation methods ............................................................................................................................................. 54
iii
Abstract
Knowing the number of sex workers in a population is a fundamental requirement of
understanding and addressing the health and social welfare problems facing this vulnerable
population. However, the severe stigma surrounding sex work challenges the standard
methodologies for obtaining accurate counts (e.g. censuses, probability-based household
surveys). Innovative methods for size estimation of hidden populations are currently being
implemented to try and get this data. The use of these methods require the target
populations to meet theoretical underpinnings and for field techniques to adhere to
methodological requirements.
After a literature review of available methods and experiences in other country, the multiplier
method, mapping and the enumeration method were chosen, also taking into account data
already available. Based on secondary analysis of data collected as part of a BSS done in
Paramaribo, Albina and Nickerie and data from a enumeration done in the goldmining areas,
in total expecting to hold 80% of sex workers in Suriname, an estimated size of sex workers
in Suriname was calculated. Furthermore, this thesis evaluated and compared the strengths
and weaknesses of three of these methodologies, while taking into account adherence to the
theoretical requirements of each method.
In the use of these three methods for the areas, expecting to hold 80% of sex workers in
Suriname, cumulated by the derived 20% for remaining areas, an estimated number of 2228
SW was calculated with in general good adherence to the theoretical requirements. A
limitation found with all 3 methods used, making this number a representation of the more
visible SW in this vulnerable group, is the fact that the more hidden and harder to reach
within the SW group such as those working in massage parlors, escort services or the women
in goldmining areas working in other professions but also doing sexual work for money or
goods, are excluded from this number.
While the estimated sex workers size in Suriname of 2228 in the period 2009/2010 is a good
start for intensifying, planning, monitoring and evaluation of health, including HIV, programs
for this vulnerable group, data collection through expansion of methods, intensifying
outreach and service data is necessary to keep numbers updated and come to more accurate
numbers.
iv
Acknowledgements
Dedicated to:
Charlo and Nita Stijnberg, my loving parents
With thanks to
My mentor Dr. Willi Mc Farland, who after being kidnapped by the Surinamese table in 2010,
stayed patiently with me, answering all thesis and non-thesis related emails, guiding me till
the end. I also have to thank Dr. Terborg, my second mentor, for her critical review, which
resulted in a much more scientifically sound report.
Rachel Eersel MD, for her suggestion to choose this subject for my thesis in a period where I
was so indecisive and for her review and valued suggestions
Wendy Emanuelson – Telgt for her help during the first size estimation report which is the
rudimentary basis for this final report and being there during the finalization for discussions
or just to talk.
Ansari Ameen for screening the text on the use of proper English
All persons involved in the work being done with Sex workers in Suriname, this being
outreach or research because without their efforts there would be no data to analyze and
use.
My fellow students for making this MPH-process still so fun. In this I have to mention Firoz
Abdoel Wahid, my friend, brother, colleague and distance sms -, email -, telephone study
partner in the late nights before exams or the handing in of papers.
Friends for their good examples, support, interest and always believing in me. You know who
you are.
My husband for his patience; I know I was not always easy to live with during the finalization
of this journey
And finally I am totally indebted to my parents for their love, support, guidance and giving
me every opportunity to grow. Always providing in all my needs; if that was a hug,
something to eat or running an errand. Thank you and Love you!
v
List of Abbreviations
ACD
Active Case Detection
AIDS
Acquired Immuno Deficiency Syndrome
ARV
Anti-retrovirals (medication)
BSS
Behaviour Surveillance Surveys
Derma
Dermatological Services
FSW
Female Sex Workers
GF
Global Fund
HIV
Human Immunodeficiency Virus
IDU
Intravenous Drug User
MARPS
Most-At-Risk-Populations
MOH
Ministry of Health
MSM
Men having Sex with Men
MSW
Male Sex workers
NGO
Non-Governmental Organization
PANCAP
Pan Caribbean Partnership Against HIV/AIDS
SMLA
Stichting Maxi Linder (Maxi Linder Association)
STI
Sexually Transmitted Infections
SW
Sex Workers
VCT
Voluntary Counseling and Testing
WHO
World Health Organization
PAHO
Pan American Health Organization
vi
List of Figures
FIGURE 1.1 GLOBAL HIV TREND 1990 - 2009.............................................................................................. 9
FIGURE 1.2 HIV AND AIDS STATISTICS BY REGION ........................................................................................ 9
FIGURE 1.3 HIV STATISTICS IN THE CARIBBEAN 2001 AND 2009 ............................................................ 11
FIGURE 2.1 NUMBER OF REGISTERED HIV POSITIVES BY SEX, 1983 – 2010 ........................................... 13
FIGURE 2.2 NUMBER OF HOSPITALIZATIONS FOR HIV/AIDS BY SEX, 2004 -2010 ............................... 13
FIGURE 2.3 NUMBER OF HIV RELATED DEATHS BY SEX, 1997 – 2009 .................................................... 14
FIGURE 3.1 CAPTURE - RECAPTURE METHOD ................................................................................................ 19
FIGURE 3.2 REASONING BEHIND THE MULTIPLIER METHOD ........................................................................ 20
FIGURE 7.1: PERCENTAGES OF SW BY GEOGRAPHICAL AREA ...................................................................... 46
vii
List of tables
TABLE 1: OVERVIEW OF HIV PREVALENCE AMONG MARPS IN SURINAME, 1986 – 2009 ................................ 15
TABLE 2 NUMBER OF SW AS A PERCENTAGE OF THE ADULT FEMALE POPULATION IN DIFFERENT COUNTRIES 24
TABLE 3 OVERVIEW OF THE LITERATURE REVIEW FINDINGS .................................................................................... 25
TABLE 4: DATA SOURCES PER SIZE ESTIMATION METHOD PER GEOGRAPHICAL AREA ........................................... 29
TABLE 5: NUMBER OF SW IN NICKERIE BY LOCATION ................................................................................................ 34
TABLE 6: NUMBER OF SW BY DATA SOURCE................................................................................................................ 35
TABLE 7: ESTIMATES FOR PARAMARIBO BASED ON THE MULTIPLIER METHOD ..................................................... 36
TABLE 8A, B,C EN D: CALCULATIONS FOR THE ESTIMATED NUMBER OF SW FOR RESP. PARAMARIBO, NICKERIE
AND THE GOLDMINING AREAS ................................................................................................................................. 37
TABLE 9: ENUMERATION DATA COMPARED TO MALARIA TEST DATA, COLLECTED DURING ACD, IN GOLDMINING
AREAS .......................................................................................................................................................................... 41
viii
1. Introduction
HIV/AIDS is one of the biggest global health problems of the past several decades. Since the
first recognised cases of AIDS in the early 1980’s, the number of people living with HIV has
grown to an estimated 33.3 million in 2009 (UNAIDS, 2010) (see figure 1.1).
Figure 1.1 Global HIV trend 1990 - 2009
Source: (UNAIDS, 2010)
An estimated 34 million people are living with HIV, 70% of the global total, reside in subSahara. The second most affected region is the Caribbean region (see figure 1.2). In addition
to the high morbidity and mortality and consequent effects on the health care system, the
HIV epidemic also led to negative consequences on families, schools, workplaces and
economies of countries (AVERT, 2011)).
Figure 1.2 HIV and AIDS statistics by region
Source: (WHO, UNAIDS, & UNICEF, 2012)
9
In the past years, many strategies focusing on prevention, treatment, and reduction of
stigma and discrimination have been developed and implemented by countries to halt the
HIV epidemic and mitigate its impact. These actions have paid off and in the last UNAIDS
global report there is evidence of a decline in new infection from 3.1 million in 2001 to 2.6
million, nearly 20% fewer, in 2009. Also the number of deaths due to HIV has gone down
from a peak of 2.1 million in 2004 to an estimated 1.8 million in 2009 (UNAIDS, 2010)).
The decline in mortality is largely related to the increase of people with access to treatment,
care and support, which can be seen in the increase of people on treatment in the subSaharan region from 2% in 2002 to 37% of eligibles in 2009 ( (UNAIDS, 2010)
Still there are populations who, because of stigmatization and discrimination, have low
access to these services. These are also the populations who, because of either their
behaviors, social or environmental factors, have higher risk of contracting HIV. The groups
are variously identified as “most-at-risk-populations”, “at-risk populations”, or “key
populations”, for which biological and behavioral surveillance information is needed and yet
difficult to obtain. Principally, these populations are men who have sex with men (MSM), sex
workers (SW), injecting drug users (IDU) and clients of sex workers (Surveillance, Guidelines
on Estimating the Size of Populations Most at Risk to HIV, 2010). Besides these groups there
are others vulnerable to contracting and transmitting HIV on which different countries have
selected to focus their prevention, treatment and care programs, including:
•
Military and other uniformed services
•
Mobile populations (e.g., gold miners, migrant workers, truck drivers, fishermen)
•
Street youth
•
Incarcerated persons
•
Men and women engaging in transactional sex
•
Persons who engage in alcohol-associated HIV sexual risk behaviors
To halt the HIV epidemic it is important to put special focus and have strategies for
prevention, treatment and care for these populations as they comprise a disproportionate
burden of the epidemic.
10
1.1 HIV in the Caribbean
The HIV epidemic began in the Caribbean with the first case being identified in 1982 in Haiti.
By 1987 all Caribbean countries had reported at least one HIV case and in 2001 there were
already 210.000 people living with HIV. This number has increased to 240.000 in 2009 and
with a median adult prevalence of 1% (see figure 1.3). We are the region most effected in the
Western Hemisphere (UNAIDS, 2010)). Studies done by the Health Economics Unit of the
University of the West Indies (UWI) estimated the financial consequence at USD 20 million in
1995 and is projected to reach US 80 million by 2020, representing 6% of the region's Gross
Domestic Product (GDP) (CARICOM)
Figure 1.3 HIV statistics in the Caribbean 2001 and 2009
Source:(UNAIDS, 2010)
Sexual transmission has been the main mode of spread occurring in 75 of cases (CARICOM). In
many Caribbean countries, higher prevalence’s can be found among MSM and SW compared
to the general population. From 2006 - 2008 the prevalence found among SW ranged from
2.7% in the Dominican Republic to 27% in Guyana. There is much evidence to suggest that
these vulnerable groups function as a bridge for HIV to the general population and play an
important role in the wider spread of infection. In Jamaica, for instance, 25% of reported HIV
cases reported having sex with a female SW. Also, a study done in 2008 by UNAIDS looking
at the sex industry in 14 of the 15 Caribbean countries showed that Caribbean men from all
classes, ethnicities, professions, education levels and sexual orientations, are the main
clientele of SW (UNAIDS C. R., 2010)This is even the case in tourism-dominated countries and
includes men in steady heterosexual relations with women.
11
Focusing prevention strategies on SW is not easy because of issues of legality and stigma
and discrimination, but have already proven to be beneficial. For example, in the Dominican
Republic prevention programs promoting 100% condom use resulted in a decline of the
prevalence among SW from on average 9% in 2000 to 2.7% in 2007. Similar experiences are
found in other regions and are cost effective as shown in a study in India looking at targeted
prevention interventions for SW, which found a reduction of 47% of HIV cases (Shankar Prinja,
2011).
Thus in dealing with the HIV problem, implementation of intervention among MARP groups
remain very important, resulting in a need to know the size of these groups. Because they
are hard to reach, estimating the size remains very difficult in many countries and because of
illegal status often even impossible. Currently methods for estimating the size are being
implemented globally, necessitating adherence to theoretical requirements for calculating
confident and reliable numbers. In Suriname the estimated number of sex workers are also
unknown, making the selection of suitable methods and the calculation of a reliable estimate
through adherence to theoretical underpinnings, necessary.
Taking that into account this thesis in the background first looks at the evolvement of the
HIV epidemic in Suriname and the role SW play in it. In the next chapters the different
methods for size estimation, as described by the UNAIDS guidelines are explained, followed
by a review of size estimation studies done globally among different most-at-risk-groups.
The subsequent chapter mentions the objectives of this study and explains the methodology
followed to answer the research questions. Finally the discussion looks at feasibility,
applicability, and plausibility of results, resulting in some recommendations for improvement.
12
2. Background
With an estimated HIV prevalence of 1% in the last years (UNAIDS, 2010), Suriname has a
generalized epidemic, meaning HIV is prevalent in all layers of society. The first case of HIV
was registered in 1983 and since then with increasing availability of testing possibilities, there
has been steady increase in the number registered. The peak of cases registered yearly was
in 2006 when 740 new HIV cases were reported (Algoe & Stijnberg, 2010). In 2009, 596 newly
registered HIV patients were noted (see figure 2.1).
Number of registered HIV +, 1983 - 2010
Male
800
700
600
500
400
300
200
100
0
Female
Total
Figure 2.1 Number of registered HIV positives by sex, 1983 – 2010
Source: (M&E Unit, 2011)
Yearly there are on average 215 new people being hospitalized, excluding re-admittance
(Algoe, Jubithana, & Stijnberg, 2010).
(see figure 2.2).
300
V
250
M
200
150
Number
Jubithana, 2011)
The highest number was 255 admitted in 2004 (Algoe, Stijnberg, &
100
50
0
Year
Figure 2.2 Number of hospitalizations for HIV/AIDS by sex, 2004 -2010
Source: (Algoe, Jubithana, & Stijnberg, 2010)
13
From 1997 to 2009, the cumulative number of certified cases of AIDS is 1568 (Algoe, Stijnberg, &
Jubithana, 2011).
Due largely to many efforts in care and treatment, there is a decline in the
number of annual deaths. With a maximum number reported in 2005 of 181, HIV related
deaths have decreased to 106 in 2009 (see fig. 2.3). This is probably closely related to the
increase of early diagnostics and the wider availability of antiretroviral (ARV) drugs.
Number of HIV related deaths
200
Women
Men
150
100
50
0
Figure 2.3 Number of HIV related deaths by sex, 1997 – 2009
Source: (M&E Unit, 2011)
Although Suriname has made progress over the last years and has reduced the incidence by
25% (UNAIDS, 2010), like other Caribbean countries, there still is a high prevalence in most-atrisk populations (MARPs) (see table 1). This is why in the HIV National Strategic Plan
identifies different groups to focus prevention activities on.
These populations are (MOH, 2009):
-
Male and female sex workers (SW)
-
Clients of sex workers
-
Man having sex with men (MSM)
-
Prisoners
-
Armed forces
-
Gold miners
-
Clients of STI clinics
14
Table 1: Overview of HIV prevalence among MARPS in Suriname, 1986 – 2009
Year
SWs
1986
0.00
Street
SWs
Club SW
MSM
Prisoners
Military
STI Clinics
Clients
0.00
0.00
1989
0.01
0.60
1990
2.50
1991
1.03
1992
0.00
1996
22.00
1998
18.
1999
00
2004
24.10
6.7
0
2008
2009
1.40
7.2
2.8
15.7
Source: (Algoe, Jubithana, & Stijnberg, 2010)
2.1 Sex workers in the Surinamese HIV epidemic
Sex work is prohibited by law as the old colonial law states that “promotion of female
indecent behavior with obvious sexual provocation“ is prohibited (Wetgeving: politiestrafwet).
While soliciting is prohibited by law, sex work is nonetheless tolerated; clubs are used for sex
work under the condition that the SW are registered at the dermatology services and get
checked regularly for STI. For street workers such regular checks are not being done. In
addition to Suriname nationals, SW are typically from Brazil, Guyana, Colombia and the
Dominican Republic.
Since the establishment of the National AIDS Program (NAP) in Suriname in 1988, SW have
been identified as a sub-population at high risk to contract and transmit HIV. In 1989, after
an assessment of the needs of SW, there was a proposal by the NAP for the development of
outreach program for female SW. To institutionalize the SW outreach program, the Maxi
Linder Association (SMLA) was established in 19941. Outreach was primarily done in
1
At time of finalization of this thesis SMLA has changed the name to “Rachab”, with different goals and objectives
15
Paramaribo, the capital, also with a drop-in facility and provision of social services, vocational
training, HIV testing, and condom distribution (SMLA).
Previously, sex work was primarily employed by women; however, starting in the early years
2000 an increasing trend of young boys, transvestites and men in the commercial sex
business was noticed (CAREC/PAHO & SMLA, 2004). This is in line with the 2010 UNAIDS study
looking at sex work in the Caribbean (including Suriname), stating that although the majority
of sex workers are women, either biological or transgender, male SW also exists (UNAIDS C. R.,
2010).
Over the last years, SMLA has done many outreach activities among SW, especially street SW.
As most of these SW operated in the center of Paramaribo, most of their activities were done
in the city. Currently with the rise of gold mining activities, SW are migrating more towards
the gold mines in the interior, creating a need for intervention activities in these areas (Kembel,
2011).
Different behavioral surveillance surveys (BSS) and sero-prevalence studies have been
executed in the past years, illustrating that the need for HIV intervention programs among
SW is still strong. In the last sero-prevalence study done in Paramaribo in 2009, an overall
prevalence of 7.2% was found, with an even higher prevalence among the street SW subgroup (15.7%). In the border cities Albina and Nickerie a higher prevalence of HIV was also
found among SW compared to the general population, 4.9% vs. 2.1%, respectively (Schmeitz e.
a., 2008).
And although improvement in HIV knowledge and behavior appears evident in study results,
reduction of HIV infections is dependent on good coverage of intervention activities.
2.2 Rational for the current study
Starting in 2007, under the Global Fund (GF) prevention grant with SMLA being the
implementing NGO, the Ministry of Health started with outreach activities among SW. As
mentioned earlier though determining the coverage of outreach activities is important to
16
measure progress. For denominator values an estimation of the size of the SW population
was needed.
Furthermore, in the Surinamese context, reasons mentioned in the UNAIDS guidelines for
estimating the SW population size are also applicable (UNAIDS (. W., 2010):
 Setting the monitoring and evaluation framework by first identifying the problem and
its magnitude
 Increased understanding of surveillance data
 Projection of the likely course of the epidemic (in combination with behavioral and
sero-prevalence data)
 Understanding the response needed for positive change; thus resource requirements
to reach sufficient coverage
 For program planning, policy and advocacy
 For monitoring and evaluation purposes, population size estimates serve as
denominators in calculations of program reach and coverage
 Convince policy makers and funders of the magnitude of the public health problem
 Useful tool to lobby policy-makers and other stakeholders for appropriate
interventions and resources
 Plan appropriate prevention, care, and treatment programs

International and national donors expect measurable progress
17
3. Literature Review
Knowing the difficulties with size estimation of vulnerable groups in this chapter the different
possibilities for size estimation as advised by the UNAIDS guidelines are explained.
Furthermore looking at experiences globally, some studies done under different MARPS are
presented looking at methods used, advantages and disadvantages.
3.1 Size estimation methods
(UNAIDS (. W., 2010)
Methods to determine the size estimate of MARPs fall into two categories:
1. Methods based on data collected directly from population at risk
2. Methods based on data collected from the general population
3.1.1 Methods based on data collected directly from population at risk
Census and Enumeration Methods
The census and enumeration methods essentially count members of a population or
community. Broadly, the census method attempts to count every individual of population at
risk whereas enumeration counts only a sample of populations and extrapolates to the
whole.
These methods generally start with a list or “sampling frame” of locations where the
population in question is visible. For SW, the sampling frame might be a list of all sites where
SW are known to be working, inside venues or in streets and outside areas. Following the
census method, all known sites would be visited and all sex workers there are counted. The
different sites need to be visited in short time period to avoid double counting of SW due to
migration or mobility between sites. With enumeration, a sample of sites would be selected
and only sex workers at the selected site are counted and the numbers are scaled up
according to size and structure of sample frame. To be sure that you have a complete list
before enumeration or census, thorough ethnographic mapping needs to be done.
18
Capture-recapture method
The technique used in this method has been used since earlier centuries. It was first
described in 1662 to estimate the population of London and has been applied to different
fields such as estimating wildlife populations.
In the capture-recapture method the targeted population is encountered at two points in
time. The list of people captured the first time is compared to the list of people encountered
second time and people that overlap is determined (see figure 3.1).
Figure 3.1 Capture - recapture method
Source: (Surveillance, 2010)
The size of the total population is estimated using the amount of overlap as follow:
MC
S=
R
S = Estimated population size
M = Total number of persons captured at first visit
C = Total number of persons captured at second visit
R = Number of people overlapping; included at both visits
For estimates of at-risk populations there are 2 approaches that can be followed for this
method:
a. Direct contact approach, in which the targeted population is contacted directly, e.g.,
through doing a survey at point 1 and then at another point 2
b. Indirect approach, in which existing lists from certain services/programs of the
targeted population are used to look at people on both list. For example, comparing
lists from an STI clinic giving services to SW with list of SW registered at brothels.
19
Multiplier Methods
The basic principle behind multiplier methods is that the number of people in the population
of interest who access services at a specific institution during a certain time period (e.g., SW
at VCT sites) is equal to the total size of the population of SW multiplied by the ratio of the
population who do not: do attend the service (see figure 3.2). Thus, an existing count (e.g.,
the service) and a direct contact with the population (e.g., survey) are used.
Figure 3.2 Reasoning behind the multiplier method
Source: (UNAIDS (. W., 2010)
Therefore, the data sources needed for the multiplier method is:
1. Service/program data of the number of the targeted population accessing the
organization (e.g., the number sex workers coming for STI screening at clinic), and
2. Representative survey data giving the percentage of respondents who reported
making use of that same service at the same institution in the same time period
The estimated population size can then be expressed as:
# of key population accessing services
S=
% population reported being registered
In the absence of service data, the multiplier still can be carried out by creating a count. For
example, a “unique object multiplier” approach can be carried out. In this case, distinctive
objects are given to members of targeted population and this count replaces the service
data count. The second part, the survey measuring the proportion receiving the unique
object originates from a subsequent survey in which people are asked if they received object.
20
3.1.2 Methods based on data collected from general population
Population Surveys
Surveys of the general population are done at a certain time in countries and are often
administered to persons living in a sampled number of households, representative of the
nation. Depending on the situation in the country there are different ways of executing these
kind of surveys, e.g. by telephone or door-to-door.
To estimate the size of the hidden population, respondents would be asked questions
identifying them as part of that population; in this case, for example, asking them if they are
a SW. Because these MARPs are often stigmatized, discriminated and engage in illegal
activities, the truthfulness of answers in these settings is uncertain. The circumstances
surrounding the interview such as wording of questions, rapport with interviewers, location
of interview, may determine the truthfulness of answers.
Network Scale-up method
This method is still “under development” for estimating the size of MARPs. The estimated
size, using the network scale-up method, is derived from the general population based on
the average number of hidden population that respondents know and the average personal
network size of respondents. That is in broad strokes, if the average person knows 300
people and 3 are SW, then the proportion of the adult population who are SW would be
estimated as 1%.
The 3 steps followed:
1. Estimating the average personal network size of the general population (C)
This can be done by using either the Summation Method or the Known Population
Method (see Annex 1 for more information on these 2 methods).
2. Asking the general population, the number of individuals they know belonging to the
specific population and taking that average(M)
3. Calculating the estimated population size as the average proportion of the network
who are members of the population
21
T= Total population in specific area of research (e.g. country, region, etc.)
M
MARPS population size=
x
T
C
All these different methods for arriving at the estimated size of hidden populations such as
SW have their advantages and disadvantages that need to be taken into account. For more
information on advantages and disadvantages see ANNEX 2.
3.2 Review of country experiences with MARPS size estimations
The different MARPs who are targeted within HIV prevention efforts are similar in that they
are hard to reach, complicating the implementation of studies. For this reason, this literature
review includes not only size estimates conducted among SW but studies done among
various hard to reach populations. An overview of the studies reviewed can be found in table
3.
In general looking at studies done for determining the size of MARPs, the most frequently
used method is the multiplier. In different studies this method is described as easy to
execute. In the study done by Zheng (Zheng, Lu, wang, & al, 2006) and others, they found it
straightforward and cost effective as it required the addition of a few questions to a BSS
already planned. Further, mathematical skills needed are relatively easy and no matching of
individuals is required.
The theoretical concerns with multiplier methods are that the correctness of the size
estimate is dependent on the representaviness of the survey for the researched population
as mentioned by Ning, Pan and others (Ning, Pan, Zheng, Zhang, Lv, & Kang, 2007) and that
participation in the survey is independent of use of the services used as the count.
Although in most instances, as explained in the article by Salganik et al (Salganik, Fazito,
Bertoni, Alexandre Abdo, & Bastos, 2011), indirect methods such as the multiplier are thought
to produce an underestimation. The reason for this is that users of services are also likely to
be those accessible for research. The calculation above shows that such non-independence
22
would reduce the total population size calculation. Thus in using the multiplier it also is
important to think about the probability for a biased amount of overlap between the data
sources.
Two other methods found in the literature were mapping based on key informants within
“hotspots” done in 7 cities in Pakistan and a more advanced one, making use of a telephone
survey among men to come to the estimated number of MSM in Germany. The mapping
done in Pakistan cities in 2005 was done in two stages (Blanchard, Khan, & Bokhari, 2008).
First through interviews with key informants, locations were identified where sex workers
could be found. The locations which were mentioned by multiple sources or those who were
said to hold many SW were visited and sex workers on the spot were counted, corroborated
against the key informant estimates for the specific locations, and sex workers were further
categorized by the type of sex work.
In Germany the size of MSM population was determined by taking the percentage of men
confirming that they were a MSM during a telephone survey among men, and applying it to
the general population of men aged 20 – 59 years (Marcus, Schmidt, Kollan, & Hamouda, 2009).
Concerns raised by researchers with this method were the possible underestimated reporting
of being a MSM because of stigma. Also the representativeness sample of the telephone
survey which could lead to overestimated size estimates.
The article by Salganik and others, makes use of different methods to determine the size of
heavy drug users in Brazil. In this study there is mention of expected underestimation using
the indirect methods because the general population surveyed will often underreport drug
use because it is not well accepted behavior in most communities (Salganik, Fazito, Bertoni,
Alexandre Abdo, & Bastos, 2011). The estimates found with the network scale-up method were
much higher than expected compared to those found using the direct method. The higher
than expected difference could be explained by the order in which questions were asked,
possible deviation by interviewers of study protocol, inflation of substance use by others (
“drug use inflation”) by interviewed persons and biases in the sampling frame. Researchers
tried to validate the results found with the network scale-up method by calculating the size
23
of 20 other known populations (e.g. non-stigmatized populations for which there is a census,
doctors, teachers, priests, for example) and found their calculations approximating the range
of the real census numbers. Nonetheless, the authors still call for more research to decide on
the use of the network scale-up method compared to the multiplier and direct estimation
methods.
Vanderpitte et. al. looked at estimates of FSW in different regions in the world (J Vanderpitte,
2006).
These researchers defined FSW as women having sex in exchange for money or goods
and used estimates to calculate the proportion of women in the population engaging in sex
work among the female population aged 15-49 years. Most estimates were obtained from
mapping with census and the multiplier method; one capture-recapture study and several
surveys in general populations were also reviewed. Researchers found the most plausible
estimates to be produced through mapping with census and capture-recapture methods. An
overview of some of the percentages found in countries, closely related to Suriname, either
historically, culturally or sex work related, are mentioned in table 2.
Table 2 Number of SW as a percentage of the adult female population in different countries
Country
Percentage of women 15 to 49
engaging in sex work
0.6%
2000
Belize
7.4%
2001
Dominican Republic
1.8%
2001
Colombia
0.7%
2001
Haiti
2.0%
2001
Netherlands
Year
Source:(J Vanderpitte, 2006)
Review of the different size estimation studies done among hard to reach populations such
as sex workers show that the reliability and achievability of a size estimation method is
dependent on the target group, situation of that group in the country, and availability of
resources.
24
Table 3 Overview of the literature review findings
Place
Lit1 (PazBailey, Jacobson,
Guardado, & al.,
2011)
San
Salvador, El
Salvador
Lit2
Lit3
Lit4 (Ning, Pan,
((Zheng, Lu,
wang, & al,
2006)
Xingyi and
Guiyang,
China
(Blanchard,
Khan, & Bokhari,
2008)
Seven
cities in
Pakistan
Zheng, Zhang, Lv,
& Kang, 2007)
Lit5 (Marcus,
Schmidt, Kollan, &
Hamouda, 2009)
Shanghai
Germany
Year
2008
2003
2005
2007
2008
Target
group
MSM and FSW
FSW
FSW
MSM
MSM
Multiplier
Applying
proportion
reported MSM
during
telephone
survey to
number of men
Method
Data
Sources
Size
estimate
Proporti
on to
relevant
general
populati
on
Capture RecaptureMethod
Lit6 (Salganik,
Fazito, Bertoni,
Alexandre Abdo, &
Bastos, 2011)
Curitiba,
Brazil
2011; using
data from
2004, 2009
and 2010
Heavy drug
users
1. Direct
estimation 2.
Network
Scale-up 3.
Generalized
network
Scale-up 4.
Multiplier
1. Survey of
general
population
Multiplier
Mapping
1. Chains
distributed
through NGO
2. IBBS
survey
participants
1. Female
attendees
STI clinic
2.
Participan
ts BSS
Mapping for
size,
distributio
n and type
of FSW
through
interviews
key
informants
and counts
1. Number of
MSM visiting
2 popular MSM
websites 2.
Survey among
MSM
1. Telephone
survey done
as part
evaluation
HIV
prevention
activities 2.
Country
Demographics
FSW:5765
Guiyang:
17500 (95%
CI 1030031900)
Xingyi:
2500 (CI
2000-3400)
34480 for 7
cities
(57.5%
home-based,
40% public
places, 2%
club-based)
Based on
website A:
398433 2.
Based on
website B:
370755
575,000 to
785,000
Multiplier:
11,459
2.5% - 3.4%
Direct 2004:
0.3% (CI95 0,
0.7)
Direct 2010:
0.6% (CI95 0,
1.6)
Multiplier:
0.6% (CI95:
0.3, 3.2)
Network
Scale-up:
Guiyang:
3.4% of
urban
adult
female pop
Xingyi:
3.6%
6.9 FSW per
1000 men
Resp. 7.1%
and 6.6% of
male
population
aged 15-49
years of
Shanghai
25
(2004, 2010)
2. Survey of
heavy drug
users (2009)
3.
Administrative
records from
drug
treatment
program
(2009)
3.3% (CI95
2.7, 4.1)
Generalized
network
scale-up:
6.3% (CI95
4.5, 8.0)
Advantag
es
Concerns
low costs,
easy data
collection
Limitations
of RDS
sampling;
question of
representati
veness
survey
sample
1.
Straight
forward
and Cost
effective
2.
Combined
with BSS a
trend over
time of
size SW
can be
obtained
1. Little
deviation
of
definition
of FSW in
both
sources 2.
Small SS
of 200 3.
Other STI
clinics in
catchment
area
Consistent
use of
method make
differences
between
cities
realistic
Mapping was
done in
context of
limited
prevention
programmes
and
comprehensi
veness
cannot be
assured
Feasible
1.Easy, no
statistical
skills needed
2.no extra
costs
Using
different
methods it is
possible to
verify
results
Representativ
eness
Underestimati
on with selfreporting due
to stigma
related to
MSM;
representativ
eness
telephone
survey
Underestimati
on using
direct method
and
multiplier
Overall, methods using information directly from the population such as capture-recapture,
multiplier, and census appeared the most reliable. The use of multiple methods, as was done among
drug users in Brazil, gives the advantage of comparing results and reaching a more data-supported
estimated size of target group in country.
26
3.3 Theoretical requirements of the selected size estimation methods
All methods used have some assumptions, which set the theoretical basis a researcher needs
to adhere to when choosing to use these methods. As mentioned earlier, not adhering to the
theoretical underpinnings can greatly influence the size estimate of researched population.
In this section of the report the theoretical requirements of the most frequently used
methods, based on the literature and the methods selected for Suriname given the available
data namely the multiplier, the mapping with census and enumeration are summarized.
Requirements for the multiplier method (UNAIDS (. W., 2010):
1. The two populations for the sources are equivalent, but independent
2. The data sources need to be overlapping
3. The theoretical population being counted must have non-zero probability of inclusion in
both sources
4. The survey must be random and encompass the group at the institution, but can include
others as well
5. Institution data source need not be random but must be specific to the population being
estimated. That is, the institution/venue data must identify and distinguish researched
population from other groups.
Requirements for mapping and enumeration (UNAIDS (. W., 2010)
1. The total population has an equal or known probability of appearing within your map.
2. The population can be counted
27
4. Study design
Based on the literature review, providing an overview of available methods and the
applications of them globally, this chapter presents the objectives and research questions of
this thesis. To answer these questions, the process followed is further elaborated on.
4.1 Objectives
The objectives for this study are:
1) To estimate the size of sex workers in Suriname
2) To assess adherence of collected data to the theoretical requirements of the selected
size estimate methods
The accompanied research questions are:
(a) Which size estimate methods are feasible to be performed in Suriname based on the
available data
(b) What is the estimated size of sex workers, calculated based on application of the
methods
(c) To which extent did the size estimation methods used provide a reliable result, taking
into account definitions, data quality and other requirements related to the chosen
methods
4.2 Operational definitions
One of the key findings of the 2008 UNAIDS research on the sex industry of the Caribbean
was that there is no single standardized operational definition for SW (UNAIDS C. R., 2010). In
the literature a range of activities are mentioned in regards to sex work, including full-time
sex work which is more visible and the less visible part-time sex work such as sex for
exchange for goods, cash, drugs or other benefits (Ward & Oral, 2006; UNAIDS C. R., 2010).
In the PANCAP 2009 report of research done about sex work in the Caribbean (Kempadoo,
2009) different definitions used by countries are mentioned (see annex 2). In line with the
28
definition from the 2008 BSS study in Suriname, the following definition will be used (Schmeitz
e. a., 2008):
“Women or men engaging in sexual acts in exchange for cash, goods or services with
someone you have no further partner relation with”
Subgroups of SW will be distincted based on:

Location of work: brothel-, street-based, bars and saloons

Geographical location: capital, border districts, gold mining areas

Gender: male and female
4.3 Methodology
4.3.1 Data sources and Estimation methods
After deciding on the objectives for this study, all data available was reviewed looking for
information regarding the estimation of the size of SW. An overview of the data sources
found and that will be used in the application of the chosen methods can be found in table
4.
Table 4: Data sources per size estimation method per geographical area
Method
Mapping
Data sources
Mapping report 2008 (Pre BSS)
Location
Border Districts
Mapping report 2009 (Pre BSS)
Paramaribo
Expert
estimation
BSS report 2009
Paramaribo
Multiplier
method
BSS report 2009
Service data SMLA and
Dermatological Services 2009
Enumeration study in the gold
mining areas 2010
Paramaribo
Enumeration
Gold mining areas
Based on an inventory of data available in Suriname and the commonly used methods found
during the literature review, following methods were selected:
i.
Multiplier
ii.
Mapping with census
iii.
Enumeration
29
Additional to these methods, mentioned in the UNAIDS guidelines, an estimate by SMLA,
seen at that time as the expert organisation working with SW, was taken into account. In
many instances the only source available.
Applied methods in estimating the number of sex workers
Estimating the number of sex workers in Suriname, these methods were applied to areas
suspected to hold the majority of the SW and then extrapolating the found number for the
remaining areas.
Mapping/census
Mapping was done in Paramaribo, Albina and Nickerie. These were done in the
preparation phase of doing the BSS in 2008 and 2009. In all three mapping exercises,
key informants were used to identify locations that were visited at different times for
counting of all SW at the spots.
Multiplier
The multiplier method was used for Paramaribo by using data collected during the
BSS in 2009. This under the assumption that Dermatological Services (Derma) and
the Maxi Linder Foundation (SMLA) provide the following services regarding HIV to
respectively club and street SW, registered at their institution:

HIV testing

Condom distribution

HIV education
The service data with the number of registered SW at these 2 institutions thus form the first
source. The second source, needed for the multiplier, looked at the percentage of street and
club SW interviewed in the 2009 BSS study done in Paramaribo (Heemskerk, BSS among CSW, 2009),
30
who stated accessing any of the services at respectively SMLA or Derma, when asked the
following questions:
1. Where do you usually get your condoms
2. In the past 12 months, have you received information about HIV and AIDS? If yes
from where?
3. In the last 12 months, have you received condoms from an outreach program activity
or clinic? If yes which one?
4. Do you know where to go for an HIV test? If yes, please state where?
Adhering to the multiplier formula the number from the service data will be divided by the
percentage out of the BSS to get an estimate for street- and club SW in Paramaribo.
Enumeration (Nieuwendam, 2010)
With the gold rush, more SW went to work in goldmines. To get an idea of how many SW
works in the goldmines, 11 “hotspots” were selected based on the goldminers population
density; more miners means often more SW. A rapid ethnographic mapping guided by key
informants and gatekeepers was done in the selected areas in 2010. Every location was
visited by 2 interviewers, accompanied by a “resource person” (someone familiar with the
population at the site and trusted by them). To all person identified as a Sex Worker on site,
a questionnaire was administered to gather basic information such as gender, age,
education, nationality but also migration, condom use and HIV testing. These were all
counted.
For extrapolation of results to include the remaining goldmining areas experts familiar with
the situation in the goldmining areas, were interviewed. The number of SW found with the
application of the enumeration method was also validated by combining information from
the interviews with these experts and data from the GF malaria program “ Looking for gold,
finding malaria”, collected during Active Case Detection (ACD) missions.
31
Applied methods for assessing the adherence to the theoretical requirements
The data sources and the population specificities were assessed for their adherence to the
theoretical requirements of the size estimation methods taking into account the following
points.
Theoretical requirements for multiplier method:
1. The two populations for the sources are equivalent, but independent
 Review the definitions of SW used in the various sources for comparability;
looking at the formal and informal definitions, “on paper” versus operationalized
“in the field”
 Assess the degree to which being at the institution/venue/service does or does
not influence being in the survey or vice versa
2. The data sources need to be overlapping
 Do they overlap geographically?
 Do they overlap in time?
3. The theoretical population being counted must have non-zero probability of inclusion in
both sources
 Are some parts of the population excluded from one data source or the other?
4. The survey must be random and encompass the group at the institution, but can include
others as well
 Looking into the representativeness of survey used to come to estimate
5. Institution data source need not be random but must be specific to the population being
estimated. That is, the institution/venue data must identify and distinguish researched
population from other groups.
32
Theoretical requirements for mapping and enumeration
1.
The total population has an equal or known probability of appearing within your map.
 Are there parts of the population that do not congregate in areas included in the
mapping?
2.
The population can be counted
 Is the process followed in counting valid: looking into frequency, identification,
procedures for avoiding duplicates or missing certain SW
4.4 Data analysis
For the multiplier, secondary analysis from data collected in 2009 was done using SPSS 13.
Further calculations were done in accordance with guidelines for the method.
The second part of the analysis consisted of a review of data used, looking for example at
quality, definitions, sample representaviness and other elements against the theoretical
underpinnings of the chosen methods.
4.5 Ethical considerations
This Study was executed under the umbrella of the Ministry of Health. The procedures for
ethical approval for research with human subjects lie with the Director of Health who
approved this study. Also, all the studies of which the results were used in this study, had
been separately approved by the Director of Health, advised by her ethical review board.
33
5. Results
After implementation of this study as explained in the previous chapter, in this chapter the
found results are presented
5.1 Estimated size of sex workers in Suriname
1st step: Results for mapping, multiplier and enumeration
Nickerie and Albina
In April 2008 a 4 days mapping was done in New Nickerie based on information of
key informants.
Table 5: Number of SW in Nickerie by location
Sex Work Type
Units
Number per Unit
Club-based
5
10-12
50-60
Bar-based
3
1-3
3-9
Street-based
Total
10-12
Total
63-81
Three types of SW were found, resulting in a count of 63 - 81 (see table 5). Most of these SW
were foreigners from Santo Domingo, Brazil, Colombia and Guyana. Observations and key
informant information excluded male SW in this district from the counts.
Using the same method of key informants, a mapping was also done in Albina, the border
city of Marowijne. This resulted in 3 groups:
-
Heterosexual club-based: mobile groups of foreigners, travelling from Paramaribo to
goldmines
-
Heterosexual street-based: consisting of local maroon girls
-
Homosexual street-based: Indigenous and Maroon men, serving clients from French
Guyana
34
The local street-based SW did not openly call themselves SW and therefore could not be
reached and counted. 63 SW were counted.
Table 6: Number of SW by data source
Source
Data of interest
Result
BSS 2008
Albina & Nickerie
Mapping Nickerie
63 – 81
Mapping Albina
63
BSS 2009
Size estimation through mapping
325 - 375
BSS 2009
Paramaribo
NGO size estimate for Paramaribo
and Nickerie
2000 SW
Enumeration 2010
gold mining areas
11 hot spots
192
Paramaribo
Paramaribo
For Paramaribo different estimates regarding the number of SW are available. In 2009, prior
to the execution of the BSS, mapping was done. After information from key informants,
different sites known for their sex workers were visited and sex workers were counted taking
also into account age, sex, and nationalities. They were stratified by place of work as follows
(Heemskerk & Uiterloo, 2009):

Street sites (street corners, squares, or specific spots),

Clubs where sex workers live in-house,

Clubs that are renting rooms to sex workers but where they do not live,

Bar / dancing’s, including a pool café and karaoke bars, and

‘Hidden’ SW providers, among which regular neighborhood houses and massage and
hair salons.
During this mapping 325 – 375 SW were counted of which 30 – 40 were men.
The next estimated size was from SMLA which can be seen as an expert organization
regarding SW. As mentioned in the BSS report, the organization estimated that there are
2000 SW in Paramaribo and Nickerie (Heemskerk & Uiterloo, 2009).
35
A third method used for Paramaribo was the multiplier method. With the assumption that
registered SW can access either one of the services, the percentage of the street and club
based SW reporting making use of at least one of above mentioned services from SMLA and
Dermatological Services, respectively, in the BSS in 2009 in Paramaribo (Heemskerk & Uiterloo,
2009)
was calculated.
Table 7: Estimates for Paramaribo based on the multiplier method
Source
Result
Service data
Estimated number
BSS
Street: 75.6%
SMLA: 344 SW
344/0.756
= 455
Derma: 232
SW
232/0.56
= 414
SW
SMLA
Club: Derma 56%
2009
869
In 2009, 344 SW were registered at SMLA and 232 at Dermatological Services. Of the street
SW, 75.6% mentioned getting at least one of the services (HIV testing, education or condom
distribution) from SMLA. Looking at the club-based SW for the same services, 56% answered
getting at least one service at Derma. Putting these percentages to the registered SW at
SMLA and Derma, respectively, a total estimate of 869 SW for Paramaribo was calculated
(see table 7).
Besides Paramaribo and the 2 border districts, data were also collected for the gold mining
areas. With the growing gold sector, an increase of sex workers in these areas is noted. An
enumeration was done in 11 hotspots, selected based on their large gold miner population
and associated with the presence of SW. With the help of key persons in the camps, SW were
identified, approached and counted looking at demographics such as age, ethnicity and
country of origin. 192 sex workers were counted (table 6).
2nd Step: Calculate the mean
For places where one method produced more than one estimate, the mean was calculated
(table 8 a-d).
36
3rd Step: Multiply results from mapping by 2 or 3
Based
on
literature
(Mc
Farland,
stating
2011)
that
numbers
gathered
through
mapping/enumeration are usually 2 to 3 times lower than the actual number of SW, a lower
and upper bound was calculated by multiplying mapping data from Paramaribo, Albina and
Nickerie, 2 and 3 times.
For the gold mining areas, which are in the middle of the hinterlands and people stay in
camps together, the counted numbers were used as is, based on the high probability that all
SW at the study locations were found. Based on a interview with the coordinator diagnosis
and treatment of the malaria Global Fund malaria project, estimating that the areas covered
by the enumeration study contain about 80% of SW in gold mining areas (Cairo, 2011), the
estimated number for SW in gold mining areas came to 240 (see table 8d)
Table 8a, b,c en d: Calculations for the estimated number of SW for resp. Paramaribo, Nickerie and the
goldmining areas
a. Paramaribo
Method
Step 1
Step 2
MP
869
Mapping 2009
325-375
SMLA estimate
2000-74= 1926
350
Mean total
Step 3a
lower
Step 3b
Upper
700
1050
1165
1282
b. Nickerie
Method
Map 2008
Step 1
Step 2
66 - 81
Step 3a
lower
74
148
Step 3b
Upper
222
c. Albina
Method
Map 2008
Step 1
Step 2
63
37
Step 3a
lower
126
Step 3b
Upper
189
d. Gold mining areas
Method
Step 1
Enumeration 2010
192
Step 2
Step 3a
lower
Step 3b
Upper
192
240
4th Step: Sum of all methods
For a total amount of SW for Paramaribo, Nickerie and Albina, the sum of the lower and the
upper bound numbers was calculated
Lower
Total
Upper
1165+148+126+192=1631
1282+222+189+240=1933
5th Step: 80/20% rule
With these estimates for Paramaribo, the border districts and the gold mining areas, the
assumption can be made that the data currently available is data from the areas where most
of the SW from Suriname can be found. Using these numbers, an estimate for the country is
calculated based on the experience of China with size estimation. In their NCAIDS 2007
estimate report it is stated that the high-density areas of CSW cover about 80% of the total
amount of sex workers in the country (China, 2007). This 80/20% rule was applied to the lower
and upper bound numbers.
Lower
Upper
Step 4 (=80%)
1631
1933
Step 5 (=100%)
2039
2416
Based on the lower and upper bound of 2039 and 2416, there are an estimated 2228
Commercial Sex workers in Suriname.
38
5.2 Assessment of adherence to theoretical requirements of estimation
methods
Looking at the adherence to the theoretical requirements of the 3 main size estimate
methods gives the following results.
Theoretical requirements Multiplier Method:
The sources used for this method are the BSS done in Paramaribo, which was compared with
service data from SMLA and Dermatological Services.
The two populations for the sources are equivalent, but independent
The definition for SW used in the BSS is “Men and women engaging in sexual acts in
exchange for cash, goods, or services, with someone you have no further partnership
relation with”. This is in line with the definition of this research.
It is a very broad
definition but looking at the report of the survey, in practice the following groups within
this definition were excluded (Heemskerk & Uiterloo, 2009) :
(a) People who maintain sexual relationship(s) in exchange for randomly provided cash or
goods.
(b) SW working with escort services. Escort girls and boys do not work from one location
and, when calling the number listed in one of the various advertisements, they typically
refused to collaborate because of fear to reveal their identity.
Comparing the definition of the BSS with the registered club- and street- based SW from
respectively Derma and SMLA, there is overlap. In the BSS a clear distinction between
street- and club- SW was made.
As researchers executing the BSS used SMLA and Derma as resource institutions, the
probability of registered SW of Derma and SMLA being included in the sample is high.
The data sources need to be overlapping
 All sources overlap geographically. SMLA and Derma have SW from Paramaribo
registered and the BSS covered Paramaribo only.
39
 Time overlap: BSS was executed from April to July 2009 and it was set against the
2009 registered SW
The theoretical population being counted must have non-zero probability of
inclusion in both sources
Using the multiplier as was done during this study, only an estimate for the club- and
street- based SW was calculated. Excluded from this calculation were SW from other
places such as massage salons, houses, etc. These are usually not registered at either
SMLA or derma and during the BSS there were also difficulties in including them.
The survey must be random and encompass the group at the institution, but can
include others as well
The intended sample strategy of the BSS was interviewing half of SW found during the
mapping at different sites to reach a sample of 250 female SW and 40 male SW. In
practice this was not possible because of mobility of SW resulting in not finding the same
amount of people at different sites and having to deal with refusal especially from male
SW. Contrary in clubs, all wanted to participate and denying them would be difficult. The
owners of some undercover places (e.g., Chinese massage salons) refused to participate.
Despite these constraints, making the sample not random, researchers tried to include
SW from all different sites, still resulting in a representative sample of SW in Paramaribo,
except for the MSW.
Institution data source need not be random but must be specific to the
population being estimated.
SMLA is non-governmental organization that specifically works with street sex workers so
for registration one definitely needs to be a sex worker. For Derma, SW are clearly
separated from other people that visit Derma. The registration for SW is kept separate.
40
Theoretical requirements for mapping and enumeration
The total population has an equal or known probability of appearing within
your map.
The mapping studies in Paramaribo, Albina and Nickerie tried to recognize all spots
where SW could be found and prevent from excluding certain groups. Still all 3 mapping
reports make mention of not being able to reach certain hidden groups, for example in
Paramaribo the Chinese parlors, massage houses and in Albina the local maroon street
SW who because of stigma deny being SW.
For the enumeration done in the goldmines, SW were identified by key persons from the
camps, giving the expectation that groups or persons would not be missed. Contrary to this,
anecdotal data makes mention of women in the gold mining areas who are not primary sex
workers but have other jobs, e.g. shopkeeper, cook etc. and at night still perform sexual
duties for money or gold. Because this group also fits in our definition of SW, to get an idea
of the magnitude of this group we compared our estimate with data from the malaria
program of the Ministry of Health. Speaking to 3 experts, familiar with the situation in the
gold mining areas, the estimate is that about 50% of women in gold mining areas perform
sex work (Heemskerk, 2012) (Cairo, 2011) (Baltus, 2012).
Table 9: Enumeration data compared to malaria test data, collected during ACD, in goldmining areas
ACD Place
ACD
Period
Number
screened
50% of
screened
Number found during
enumeration
Victoria
Jan-10
139
69.5
3
Benzdorp
Dec-09
308
154
28
Macu
Sep-09
225
112.5
63
Grankreek
Aug-10
201
100.5
26
Nov-10
177
88.5
11
Sep-10
79
39.5
38
Villa Brazil
Selakreek
41
The Global Fund Malaria Program does ACD (=Active Case Detection) activities in the gold
mining areas in which everybody is tested for malaria; thus serving as a census. Using data
from ACD’s done in some of the same areas where the enumeration was done, the 50% of
women present estimate was applied (see table 10), which resulted in an average increased
number of 7 times (minimum=1, maximum=23) that of the other estimates.
As for all the mapping/enumerations studies, the locations were first identified and then
visited at different times; thus making every attempt to count all possible SW and avoid
double counting through recognition of women previously seen.
42
6. Discussion
6.1 Data sources
Suriname has a growing availability of data regarding sex workers. In the last decennia,
regular research has been conducted among this group. This results in more information for
planning of interventions but also in availability of data to conduct this size estimation
research. Fortunately, studies among sex workers in the border districts and Paramaribo were
recently conducted when this research was started. The enumeration study was thus the only
study that was specifically conducted with size estimation in mind.
6.2 Methods used
In line with methods used internationally, the direct methods multiplier, mapping and
enumeration were chosen in this study. As Suriname is a small community where it seems
most people know each other, indirect methods such as population survey probably would
not work; people would not be eager to admit that they are sex workers because of stigma.
Also the network scale up method is not expected to give a true estimate as sex workers
usually do not mix with general population or people do not know that acquaintances do sex
work. Taken all this into account, the methods used, although chosen based on available
data, seem the best choices for Suriname at present.
Also the fact that different methods could be combined to arrive at the estimate of 2228 Sex
workers in Suriname increases the confidence that this estimate is in line with reality.
Paramaribo is the capital city, with 60% of the population of Suriname. Together with
Nickerie, the second city, Albina and the gold mining areas, it is very reasonable to expect
80% of SW being in these areas and applying the 80/20 rule.
All methods used were relatively easy, did not require difficult statistical analyses and are
easy to repeat in the future to follow the trend.
43
6.3 Adherence to theoretical requirements of estimation methods
6.3.1 The Multiplier
The multiplier was an obvious choice, looking at data that was available. An important
requirement for results produced by the multiplier is the representativeness of the sample
from the survey data used. Looking at the method used in the survey, the relatively easy to
reach sex workers are properly represented. The more undercover sex workers such as those
in massage parlors, with escort services etc. will not be captured. This related to difficulties
including them in surveys and also the lack of service data for these groups.
As researchers executing the BSS used SMLA and Derma as resource institutions, the
probability of registered SW of Derma and SMLA being included in the sample is high. This
could lead to an underestimation of estimated number because of the higher probability of
overlap.
6.3.2 Mapping/Enumeration
One of the known disadvantages of these methods is that hidden parts of the population
cannot be found and therefore cannot be counted. This is also a disadvantage found while
using these methods. Hidden parts of the sex workers populations could not be counted. In
Paramaribo these were the SW working in massage saloons, escort services and in Albina the
local male and female SW. This limitation probably was compensated by the 2 – 3 times
calculation of the found number.
Another factor that should be taken into account with this method is double counting due to
migration of sex workers between different areas. This especially applies for movement
between Albina and Paramaribo and Paramaribo and gold mining areas. Also sex workers
going through Albina are usually on their way to the gold mining areas. To know the
magnitude of the over or under estimation due to this migration, further research needs to
be executed.
In the goldmines, the issue of only the “real” SW being included in the enumeration study
and so excluding the women for which sex work is not their primary job, could increase the
found number of SW in gold mining area as much at 7 times.
44
6.4 Results compared to international findings
As verification of the calculated number of SW, the estimate was compared against the
UNAIDS workbook (UNAIDS/WHO, 2009), which states that it is unusual for a country to have
more than 0.8% of the female adult population being SWs. Based on this, Suriname with a
female population older 15 years of 182,398, is expected to have less than 1459 SW. The
difference found between the expected and the number found, could be explained by the
fact that studies indicate that most SW are not of Surinamese origin. In studies done in
Paramaribo, Albina, Nickerie and the gold mining areas, only 20, 13, 13 and 24% respectively
of SWs were of Surinamese origin. Applying the percentage of 20% to the estimate of 2643,
would give 529 Surinamese SWs; this is about 0.4% of the female adult population, which is
line with percentages mentioned in the literature.
6.5 Limitation of the study
The major limitation of this study, as mentioned before, is the exclusion of the more hidden
SW groups. For these groups at the moment there seems to be no data available.
In calculating these estimates a factor that was not taken into account was the mobility of
SWs between the different areas in Suriname. It is therefore necessary to have a closer look
at available data and review international literature and experiences in size estimation for
SW.
As more research is being done and more intervention activities are undertaken for this
group, the availability of data increases with in the future an expectation for more accurate
estimations.
45
7. Conclusions and Recommendations
7.1 Conclusions
Having no data for the number of sex workers in Suriname and needing this to plan HIV
prevention activities within this MARP group, this estimation research was initiated. Primarily
based on data already available, the multiplier, mapping and enumeration size estimation
methods were used, coming to an estimated number of 2228 (minimum 2039, maximum
2416) sex workers in Suriname for the period 2009 -2010. Taking into account that the data
suggest that 80% of SW in Suriname are foreigners, the remaining 20% of Surinamese SW
fall well within the international percentage of 0.8% adult females being SW.
Looking at geographical areas, 55% of SW were estimated to be in Paramaribo (see figure
7.1) and together with Nickerie, Albina and the goldmining areas, it was estimated to hold
80% of SW.
20%
Marowijne
Paramaribo
Nickerie
Goldmines
Remaining areas
7%
10%
8%
55%
Figure 7.1: Percentages of SW by geographical area
Disaggregation of the number of sex workers by gender has proven to be very difficult
because in both Paramaribo and Albina, where there was mention of male sex workers, the
MSW were underrepresented in the data available. Although this makes an explicit estimate
of the number of male SW within this vulnerable group impossible it is obvious that MSW
are just a small proportion of the sex workers community.
During the mapping exercise, clearly the number of sex workers per location, were
mentioned which provides good information to plan for prevention interventions for specific
46
locations such as clubs, the streets, bars etc. Still the problem of the more hidden among
these populations came up for all methods used and sub-populations such as the SW from
massage - , beauty parlors in Paramaribo and the women in the gold mining area who have
other primary jobs but also exchange sex for money or goods, are excluded from this size
estimate.
Having reviewed the theoretical underpinnings (see annex 3 for summary), it can be
concluded that there was a very good adherence to the theoretical requirements of these
methods. The biggest gap found during the review is the underrepresentation of the more
hidden parts of these groups. Still confidence can be found in the size estimate of 2228 sex
workers in Suriname and the number can be used to strengthen HIV prevention activities
through good planning, monitoring and evaluation.
7.2 Recommendations
This size estimate is for the period 2009 – 2010. With this population being very mobile it is
important to keep repeating this research to get a better idea of the evolution of sex work in
Suriname. Some recommendations for the future in this regard, taking into account gaps
identified in this study are:
 Include size estimate efforts in the regular Behavioral Surveillance Surveys done every
2-3 years. The Ministry of Health currently has a plan to repeat surveys. By simply
adding some simple actions size estimation can be part of these surveys.
 Expand methods used:
 Expand the use of the multiplier method through exploration of different type
of multipliers e.g. instead of comparing survey answers with service data it
could be compared with data about having received a present, having
attended a party etc. (so called object multiplier, event multiplier)
 Expand Delphi method: do a complete Delphi method through consultation
with experts, discussion and coming to consensus
47
 Inclusion of “wisdom of the crowd” method in which the target population
themselves for example during a survey will be asked to estimate a number.
This method lives by the assumption that more are smarter than one.
 Upgrade data collection during outreach activities by obtaining data about migration,
numbers per location, etc.
 Improve service data by getting information about e.g. number SW getting HIV tests,
on treatment or coming for any other health services. For the goldmining areas the
percentage of women, not being perceived as SW, but still doing sexwork can be
obtained for example through the malaria Tourtonne laboratory.
 Strengthen collaboration with other ministries for intervention and information
gathering of the more hidden groups. By working together e.g. with the Ministry of
Justice and Police maybe policies regarding sex work in the massage parlors, hair
salons, escort etc can be established and implemented.
Implementation of ways for gathering additional information could improve the accuracy of
the estimated number of sex workers in Suriname, resulting in more intensified and focused
HIV interventions. With the intensification of focused, scaled up interventions hopefully a
decrease of new HIV cases among Sex workers and their clients will be achieved leading
ultimately to a decrease of Surinamese cases in general.
48
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51
ANNEX 1 Advantages and disadvantages different size
estimation methods
52
ANNEX 2 Definitions of sex work in different Caribbean
countries
“commercial sex workers are here defind as
men or women who provide sexual services in
exchange for money as their main method of
income” (Campbell and Campbell 2001:10).
e
Similarly, Maggie Schmeitz et al. defin com mercial sex work as “Engaging in sexual acts
in exchange for cash, goods or services with
someone you have no further partner relation ship with” (2009:6).
• Barbados: “beach boy”, “beach bum”, “gigolos” (Phillips 1999, 2002).
• Belize: “muchachas” (female sex worker),
“prostitutas or mujeres malas”, “freelancers”
(part time, independent sex workers) (Rags dale and Anders 1999).
• French Guyana: “prostitutes” (Celse and Dixneuf 2008).
“Prostitution and related activities” is used
by Leith Dunn in her study of child prostitu tion in Jamaica to refer to “various forms of
pornography and sexual activities for income
or other reasons” (Dunn 2001:39). In relation
to young people Sian Williams describes sex
work as “sexual activity for economic gain” or
“sex for gain,” “utilization of sex for economic
independence,” and “sex in return for goods”
(2000: 3-4).
• Haiti: “Brasez” (one seeking a living, make
money anyway one can), prostitutes (Rolfe et
al. 2006).
• Jamaica: “beach girls”, “beach boys”, “beach
hustlers”, “gigolos” (Campbell et al. 1999):
“Rent-a-Dreads” or “rentals (Kempadoo
2004); “business girl”, “professional dancer”,
“entertainer”, “lady of the night” (Campbell
and Campbell 2001); “sketel” (Earle & Phil lips 2002).
The PSI study in Antigua
s
identifie sex wo r k
as “sex in exchange for money and gifts”
(Joseph and Faura 2008:2). In French Guyana,
“sexual relations for remuneration” is the definition used (Entr ’aides 2008).
• Suriname: “Temporary wife”, “freelance and
part time sex worker” and “opportunity sex
worker” (who may be saleswomen and cooks)
in Suriname (Antonius-Smits 1999).
For Guyana, Red Thread understands sex work
as a “highly mobile and part-time incomes
generating strategy” (Red Thread 2002:2).
Likewise the study in Haiti identifie sex wo r k
as an “incoming-generating dactivity” (Rolfe et
al. 2006:13).
• Tobago: “beach bums” (CAFRA 2004);
“beach boys” and “studmen” who solicit visi tors for a fee (Dunn 2002c).
Sex workers are identifie in soci al and HI V
studies in a number of other ways. Apart from
“commercial sex workers”
a or “CSWs”, some
examples of identifict ions ar e:
• Trinidad: “street prostitutes”, “escorts”,
“beach boys”, “entertainment workers”, “mo bile sex workers” and “foreign and high school
students as CSWs” (CAFRA 2004); “Drag
Queens”, “male prostitutes”, and “girls of the
night” (Hunte and Lewis 2002).
• Antigua: “amigos” or “friends” as those
partners whom one has sex with in exchange
for money or gifts (The Population Services
International (PSI) 2008).
Moreover, sex work in the English-speaking
Caribbean may be referred to as “hooking”,
“hustling”, “mekkin’ heights”, “picking fares”,
“whoring work”, or “sexing for money”.
11
53
ANNEX 3 Summary of the review of adherence to the theoretical
requirements of size estimation methods
Multiplier
Theoretical requirement
The two populations for the
sources are equivalent, but
independent
a.
Comparability definitions
Result
Adherence
theoretical
requirement
a. Both sources same definitions
b. High probability inclusion survey
of registered SW as SMLA and derma
are being used as resource
institutions for execution survey
b. Probability of being in one source
influence falling in the other
The data sources need to be
overlapping
a.
b.
Geographically,
time
The theoretical population being
counted must have non-zero
probability of inclusion in both
sources
a. Exclusion out of one of the sources
The survey must be random and
encompass the group at the
institution, but can include
others as well
a.
Exclusion others e.g. escort, working
massage parlors etc.
Good inclusion from different SW
working sites. Under representation
MSW, SW undercover places
Representaviness survey sample
Institution data source need not
be random but must be specific to
the population being estimated
a.
a. SMLA and Derma cover Paramaribo and
Survey done in Paramaribo
b. Survey: April-July 2009, set
against 2009 registry data SMLA and
derma
Only taking into account street – and
club SW
Clear distinction at derma between SW
and non-SW. SMLA register only SW
Clear distinction between target
population and others
Mapping with census and enumeration
Theoretical requirement
Result
The total population has an equal
or known probability of appearing
within your map
a.
Exclusion parts of group?
a.
Valid counting: frequency,
identification, avoiding duplicates or
missing
Met
Reasonably Met
Excluded: 1. women not perceiving
themselves as SW in goldmining areas
(about 7 times more). Secundary work
is sexwork. 2. More undercover SW e.g
escort, SW in massage saloons,
hairdressing etc.
SW could and can be counted. As much
as possible avoid double counts and go
to all sites. With migration between
areas still some double counting
possible.
Unmet
54
Remarks

Looking for Sex Workers in Suriname

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