THPE 267 Gatekeepers’ influence on female sex workers' HIV prevention behaviors in Ethiopia Authors: Mekuria Yilma1, Belayneh Dagnew1 and Woldemariam Girma1. Affiliates: 1Population Services International/Ethiopia(PSI/E) Peers: Some peers ,especially those who trained as peer educators, positively influence FSW to reduce HIV risk & to use health services. "As we are female sex workers the lessons from peer educators are important for us than any other community member. We have common issues such as HIV, and STI. Therefore, it is the life skill discussion among us that will bring about behavioral change." (FSW in Dessie, Ethiopia) Police : Commercial sex work is not a legally recognized ‘profession’ in Ethiopia* Some police tend to side with FSW’s clients during disputes about condom use or payment; and many also abuse FSWs physically and/or sexually. The negative influence of police is higher for street based FSWs than establishment/home based FSWs, as their ‘street’ worksite ‘is more prone to police patrol. Health Care Providers : Majority of FGD participants complained that they face stigma and discrimination from health care providers in public health facilities; which consequently adversely affects FSWs health seeking behavior. “Sometime ago, I had caught an STD and went to Sekeota hospital(Public health facility) for treatment. I paid 50 birr for the service. The health care provider was not treating me well; I was forced to frequently visit the facility to get the service. However, I couldn't be treated as the service was so poor. Then I went to a private clinic(Kal clinic) and I got treated.“ (FSW in Sekota, Ethiopia)   Background Type and level of influence : FSWs are surrounded by a complex web of gatekeeper influence The length of the arrow in figure1 shows the level of influence on FSWs by each gatekeeper. The shorter the arrow, the more the influence the gatekeeper has on FSWs . Boyfriend: Most FSWs have non-paying boyfriends. Boyfriends encourage FSWs to use condoms with other clients, but they insist not to use condoms with them. Most boyfriends share FSWs income and they provide protection service to FSWs in return. "Boyfriends are responsible for HIV transmission because they don’t use condom by justifying that love, duration of relationship and future potential marriage." (FSW in Gambella, Ethiopia) Bar/Hotel Owners/Managers: Owners and managers primarily support clients of FSWs when there is disagreement between FSWs & their clients. Owners/managers influence FSWs to drink excessive alcohol while clients invite FSWs to generate profit . Some male owners/managers seek free sex from FSWs; and threaten to fire them unless FSWs agree to do so. "There are managers and owners of bars/hotels who force new FSWs to have sex with them as a precondition to join their bars/hotels. Sometimes, whenever they need they also compel us to spend a night with them without payment.” (FSW in Addis Ababa, Ethiopia) Clients of FSWs: Some clients influence FSWs to not use condom in compensation for extra payment, or gift . Some clients Influence FSWs to drink excessive alcohol and then force them to not use a condom. "I have lots of clients working in nearby sugar project. They visit me at least once in a month. They drink and enjoy in group. They have lots of money. In the past, I was easily influenced and there were times that I practiced sex without condom for sake of extra payment. But now, I acquired good skill from peer education, I have the confidence to negotiate and convince my clients to use condom while we have sex." (FSW in Dessie, Ethiopia) MULU/MARPs is a five year combination HIV prevention project implemented by Population Services International/Ethiopia and supported by PEPFAR/USAID. The project is designed to contribute towards a 50% reduction in HIV infections among key populations, including female sex workers (FSWs), by the end of 2017. Gatekeepers are defined as persons who exercise control/influence over FSWs. It is hypothesized that they affect HIV prevention behavior among FSWs. However, limited studies have examined the FSW–gatekeeper relationship and its effect on HIV-related behaviors. This study explores FSWs’ perceptions and experience of gatekeepers’ influence as it pertains to HIV prevention. Methods A qualitative study design was employed. 53 FGDs were conducted in 51 towns in Ethiopia, each with a mix of 10-12 participants from homes, streets and establishments. All participants were 18 years and above. With the help of implementing partners, participants were purposively selected from the street, home and fixed establishments in areas where there is high concentration of female sex workers. The FGD explored FSW day to day experience with gatekeepers, including in-depth discussion of specific gatekeepers. All discussions were audio-taped and analyzed using thematic content analysis. Results conclusions Gatekeepers have vital role in the risk of HIV transmission among FSWs. The overall risk environment for FSWs can only be decreased through the inclusion of interventions that directly address gatekeepers. Key areas for intervention among gatekeepers shall include: prevention of gender-based violence, reduction of alcohol abuse, reduction of economic barriers to condom use, and stigma and discrimination towards FSWs. Figure 1 : Main Gatekeepers to FSWs Owner/manager Boyfriend Clients Literature cited *Ethiopian Demographic and health survey (EDHS,2011) **Save the Children, USA, 2010, Baseline Survey among Most at Risk Populations in Ethiopia Police Health care providers Peers Contact For any further information related with this study please contact Mr. Woldemariam Girma, email woldemariam@psi.org.et. PSI■■ 1120 19th Street, NW | Suite 600 Washington, DC 20036 psi.org