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AJPH First Look, published online ahead of print Mar 19, 2009
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May 2009, Vol 99, No. 5 | American Journal of Public Health 811-819
© 2009 American Public Health Association
DOI: 10.2105/AJPH.2007.118422

FRAMING HEALTH MATTERS

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

Kirsten Stoebenau, PhD, Michelle J. Hindin, PhD, Constance A. Nathanson, PhD, Paul Ghislain Rakotoarison, DEA and Violette Razafintsalama, MSc

Kirsten Stoebenau is with the Institute of Population Health of the University of Ottawa, Ottawa, Ontario. Michelle J. Hindin is with the Department of Population, Family and Reproductive Health at the Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Constance A. Nathanson is with the Department of Clinical Sociomedical Sciences at the Columbia University Mailman School of Public Health, New York, NY. Paul Ghislain Rakotoarison and Violette Razafintsalama are with the Université d'Antananarivo, Antananarivo, Madagascar.

Correspondence: Requests for reprints should be sent to Kirsten Stoebenau, PhD, Institute for Population Health, University of Ottawa, 1 Stewart St, Ottawa, ON K1N 6N5 Canada (e-mail: kstoeben{at}uottawa.ca).

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






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