Dr Sean Cummings  
London, United Kingdom

Specialties: STD/STI HIV prevention

Interests: Hepatitis C, Men's Health, HIV Prevention
+44 (0) 20 7637 1600
London, United Kingdom
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South Africa, Prostitution and the World Cup 2010

Jun 22, 2010 - 16 comments

south africa




high risk hiv

The UN AIDS programme estimates that in excess of 5.7 million people are living with HIV in South Africa with around 3.2 million being women and 280,000 children up to the age of 14 years.

The prevalence of HIV in the general population in South Africa is over 18% compared with less than 0.2% in the UK.

There is a significant difference in HIV prevalence in South Africa between different provinces with KwaZulu-Natal having a rate of above 40% to approximately 15% in the Western Cape (Cape Town).

At Freedomhealth we have seen a large number of men who have returned recently from South Africa who have had unprotected sex with female commercial sex workers. This presents a significant hazard to the men themselves and their female partners they might return to. Significant numbers of these males have required either early intervention here in the UK with Post Exposure Prophylaxis (PEP) for HIV or have needed continuation of PEP already commenced in South Africa.

UNAIDS/WHO data (which is subject to time lag in terms of collection and reporting) suggests that in the major urban areas of South Africa the prevalence of HIV infections in female sex workers is in excess of 50%.

The generally stated and averaged risk of heterosexual transfer of HIV during heterosexual vaginal sex is approximately 0.1% or 1 in 1000 to 1 in 1200 "chance". However, this is an average and will vary quite markedly depending on both the "source" ie the infected patient's status and also the health of the non-infected participant. The figure is also taken from data obtained from industrialised Western countries irrespective of use of antiretrovirals.

We know that the rate of bacterial STD's in South Africa especially in the sex worker communities is very high indeed. We know also that other sexually transmitted diseases will facilitate the transfer of HIV. Sexual violence, poverty, underlying nutritional and health status and simultaneous presence of other, especially genitally ulcerating STD's will increase the chances of HIV transfer. Ulcerating genital disease caused by STD's such as herpes, syphilis, gonorrhoea, chancroid will increase the chances of transfer by up to approximately 6 times.

HIV transfer rates are up to 10 times higher in the early and late phase of HIV disease when the HIV viral load - the amount of virus in the blood stream and thus probably in genital secretions is markedly increased. In the quiet, asymptomatic phase a few months after infection, viral load will fall and so will potential infectivity.

Consequently, men having unprotected vaginal or anal sex with female sex workers in South Africa especially in some of the very high prevalence urban areas will expose themselves to an escalating lottery of risk depending on the circumstances of the women with whom they have sex. Uncontrolled HIV with high viral load, together with acquisition of STD's resulting in genital ulceration will expose them to an extremely high risk of contracting HIV. Unfortunately with upwards of 50,000 UK supporters in South Africa for the World Cup it is a certainty that some will return with a new HIV infection.

Condoms remain a thoroughly effective way of preventing HIV transfer and indeed are the only way to prevent transfer. The problem is not intact condom failure but failure to wear them in the first place and occasionally rupture or tear of the condom itself.

Men exposed to unprotected sex whilst in South Africa should seek medical attention whilst they are present there or return home for consideration of Post Exposure Prophylaxis and also screening for STD's and STI's prior to resuming sex with their regular partners.

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Avatar universal
by worriedguy278, Jun 25, 2010
it might be interesting to see why commercial sex workers in africa (and other developing countries) tend to do without condoms: is it because they given in to customer's requests, because of their poverty i.e. willing to take a bigger risk in exchange for more money? is it to decrease their costs (i.e. condoms?)

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by Dr Sean CummingsBlank, Jun 25, 2010
The sex workers who do not use condoms tend to do so because of a combination of at least a number of the factors below. Informed choice is rarely part of that equation. Female sex workers in South Africa represent a significant source of new HIV infections especially in the early stages of their disease. Condoms are not always used because

1) they may not be available

2) the sex worker may be subject to violence or intimidation and effectively subject to rape

3) the sex workers may agree to have unsafe sex because it will give them a greater fee

4) many are trafficked children or under-age girls who have little in the way of voice or ability to assert themselves in terms of demanding condom use

There are likely additional factors in terms of spread

1) poverty causing underling malnutrition, illness and poor education surrounding condom use

2) different cultural beliefs regarding use of condoms

3) religious interference and misinformation

4) other sexually transmitted diseases

5) many of the medications used need to be taken with food - in the absence of food patients may not take them. In addition whilst South Africa has an excellent free distribution of anti-HIV medications, there is not a parallel supply of cheap food - the medications if crushed and snorted or smoked have recreational properties. So HIV meds are available free but need to be taken with food. Food is not supplied. Patients sell the meds to others for them to use or sell on for recreational/hallucinogenic effects and use the money to buy food. A vicious circle.

Avatar universal
by athinker, Jun 26, 2010
Yes, perhaps the cultural acceptance of condoms in the west, and the relative cheapness makes us forget that this may not be the case all around the world. it is indeed sad to see that people need to sell medicines which can prolong their lives on a long term basis, in order to be able to cope on a short term basis (food). Sex workers in these countries may be putting themselves at risk in order to earn more money to be able to feed their families.

Avatar universal
by landmire, Jun 27, 2010
Sir ,
i would just ask a quick question that bothers me a lot :
- does oral sex (cunnilingus) with a south African  girl would cause HIV ? Cuz i did it and i live in hell since 34 days ...

thanx for listening to my cares...

Avatar universal
by disturbed777, Jun 27, 2010
doesn`t matter where the girl is from ... Oral poses no risk ... one thing i got to add about South African prostitutes is that girls off the streets are more likely to be positive as opposed to girls in establishments and i believe this to be the case the world over ...

i am from South Africa ...

Avatar universal
by landmire, Jun 27, 2010
Deat Disturbed,

I didnt mean to insult South Africa ... and if i did , im sorry ! the problem is that i did cunnilingus to the gurl and we stayed together for a week together ... we did it twice.... its my 34 day and i already did HIV regular Antigen which i know thats worthless so i followed it with a P24 test and i will get the result in 15 days at max cuz i live in Egypt and they will send my blood sample to France !!! plz understand my cares cuz it really scares me to bits...

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by Dr Sean CummingsBlank, Jun 28, 2010
Mr Landmire

This isn't the Ask a Doctor area - if you want to do that then go to one of the Forums - such as HIV INTERNATIONAL FORUM and ask it there.

best wishes, Sean

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by Dr Sean CummingsBlank, Jun 28, 2010
Dear Athinker, and disturbed777,

Thanks for your comments on this.

The unexpected vicious circle of food needed for HIV meds but having to sell meds to get food is very toxic and it does mean uncontrolled HIV for many despite the apparent availability of medications.#

With respect to oral sex with female - it does carry a very very low risk - but again in circumstances where the female is suffering from uncontrolled HIV, might have other STD's, is nutritionally compromised and also perhaps there is menstrual blood in the vagina, then there are theoretical risks which begin to border on more likely.


Avatar universal
by disturbed777, Jun 28, 2010
one further point i would like to add without discrimination is that HIV is more prevalent in the black populace ...

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by Dr Sean CummingsBlank, Jun 28, 2010
Oh disturbed777 you need to be careful about that. Certainly in Sub Saharan Africa it is but then the bulk of the population there is coloured so thats a no-brainer. In Europe the bulk of HIV disease is in white men who have sex with other males. In the USA the situation is dire with HIV rates in the black populations in some areas - such as Washington DC actually EXCEEDING taht of Sub Saharan Africa - but again with poverty, social exclusion, crime, prostitution etc leading the epidemic in those populations.

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by alienshadow, Jun 28, 2010
I just want to add on this entry here.. I think the bottom line is no education here in the U.S. kids today are at great risk for all STDs due to there not being any kind of sex education classes.. I also see that women and men over the age of 50 seem to believe they made it this far in life so they arent prone to getting HIV or any other STD...Its a sad but true fact. You do see more commercials about getting tested know your status but what they leave out is the fear one goes through the anxiety one carries on these issues.. Many still believe HIV is a death sentence.. They also believe that they will lose family and friends if they test positive..  

I do agree with it being a routine thing at a drs office if he can get your blood for everything else why not test for HIV also...Bottom line is Education learning what the real risk factors are and learning what to do if you do have a risky exposure.. Hope this all makes since???

Avatar universal
by disturbed777, Jun 28, 2010
Dr.Cummings , i am talking in particular to South Africa , i do understand that Europe etc that it would be in the white populace , the point i was trying to make is that here in South Africa , the percentages are much higher amongst our black populace ...

it would be wise for someone travelling here to not pick up girls off our streets and even wiser that they are not black ...

if someone would like to be with a girl who is black rather go to a establishment  than picking up a girl from the streets ...


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by Dr Sean CummingsBlank, Jun 28, 2010
I understand - and understood! - just clarifying. Forgive me.

Avatar universal
by disturbed777, Jun 28, 2010
Dr.Cummings ...

nothing to forgive ...

i personally am indebted to you , you responded to me with my own issues with professionalism and tact , your words are helping me deal with my own anxiety and your mannerisms are exemplary  ...

i am forever indebted to you and for you taking time out now from your busy schedule to respond to me throughout this discussion ... i thank you

Avatar universal
by disturbed777, Jun 29, 2010

please feel free to post a comment in my thread if you think anything needs clarification...

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by Dr Sean CummingsBlank, Jun 29, 2010
No worries Mr Distrubed777 - I'll have a look later today. best regards, Sean

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