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When Nalia* left her village for Addis Ababa, she expected to find a job and send money home to her family. She was looking for work as a maid, but says: "As I did not know anyone in the city, I lived in the streets. And I had to do this [sex work] to earn some money while finding a job. At 16, she is still a sex worker and her story is far from unusual.
Sex work was last mapped in Addis Ababa in 2002 where it was estimated that there were 8,134 establishment-based sex workers and 250 street-based sex workers. Sex work in Ethiopia is vast, diverse and conducted openly. Sex workers operate in virtually all hotels, bars and restaurants and there are street workers on most main roads of towns after sunset. Although the law does not prohibit sex work itself, the associated activities of brothel keeping, trafficking and public soliciting are illegal. Selling sex under the age of eighteen is a criminal offence in Ethiopia.
According to a report by the Federal HIV/AIDS Prevention and Control Office Ethiopia: "The size of the sex worker population in Ethiopia is not known. However, evidence suggests that sex work in Ethiopia is undergoing demographic and behavioral change. The number of sex workers is growing; much younger girls are joining the trade and the average number of clients they are seeing is increasing."
Ethiopia is signatory to the UN Convention of the Rights of the Child that commits to protect the human rights of people under 18 years of age. The convention also states that children have the right to life and health. This is contravened if they are excluded from effective HIV prevention and life-saving treatment, care and support services. And although Ethiopia's laws which criminalise sex work for those under 18 are intended to protect children, at the same time they are barriers to them seeking health services.
Abused, helpless and without health services
When I ask Nalia if she or her friends receive HIV prevention and family planning services, including HIV testing or free condoms, her answer is: "I heard about this [HIV] but I trust God. I don't use condoms because clients will say I have a disease."
Nalia, who started sex work aged 13 has been pregnant twice. The first time she mixed a soft drink and some antibiotics which induced a miscarriage. And the second time, she used a decoction (a method of extraction by boiling of dissolved chemicals from herbal or plant material) prepared by old women, which nearly killed her.
She told me: "I was very sick and I was bleeding a lot but I could not go to the hospital, because they would ask for my parents and ask many other questions and find out what I do. I didn't know what they would do to me then."
Nalia was afraid of being identified as a teenage sex worker by health officials and taken to a social centre. She said: "I thought I would be locked up for I do not know how long and then taken back to my family." As a result, she decided not to seek medical services.
Because she is young and living on the streets, she has also been a victim of physical and sexual violence. She explains sadly: "Sometimes street boys may beat you and take the money you've earned. They can sometimes rape you and clients may leave without paying you."
Reaching adolescents selling sex
According to UNAIDS, adolescents aged 10-19 are among the people most neglected by the HIV response. AIDS is the second biggest contributor to adolescent deaths globally and the main contributor in sub-Saharan Africa. And as sex workers and young girls, Nalia and her friends face an increased risk of HIV infection.
Although HIV risk reduction among adult female sex workers has been a major focus of HIV prevention around the globe, there are few HIV interventions for adolescents selling sex. Even reaching this extremely vulnerable population can be difficult.
One problem is the fact that there is no specific data. According to an inter-agency task team on HIV and young people worldwide, there is no accurate estimate of the number of adolescents who sell sex. This may be explained by the high mobility of this group, but also because sometimes adolescents are trafficked and are kept under close control by the adults who exploit them.
Human rights centred approach
Even if the Convention on the Rights of the Child clearly articulates that children younger than 18 have a right to "the enjoyment of the highest attainable standard of health" which justifies their right to access sexual health services, I personally think it is not morally acceptable to simply hand out condoms to teenage sex workers, treat their sexually transmitted infections and let them go back to the sex work. We cannot just stand by and watch children - because under the law adolescents are children - sell sex in the streets. Therefore in addition to providing them with sexual and reproductive health services, they should also be given opportunities to make a different choice if they don't want to do sex work.
However, interventions that focus exclusively on the immediate removal of the child from the sex trade sometimes violate their rights because they are generally detained in centres during rehabilitation. We must ensure that in seeking to protect one set of rights, we do not violate others.
On 17 February, UNICEF and UNAIDS launched the All In! Initiative, aiming to reach adolescents most at risk of HIV infection, but it is vital that the knowledge gap about adolescents who sell sex is filled. Reliable data is needed otherwise programmes and interventions will be designed based on assumptions.
We also need a synergy between different services and organisations. HIV and child protection activists should join forces and consult with the adolescents to design the best and most effective interventions. For example, adolescent friendly sexual and reproductive services could be combined with child protection services such as housing, rehabilitation and reunification with families.
All the girls who agreed to share their stories with me did it with shame and embarrassment. It made me realize they are not in sex work because they like it. We must follow a human-rights-centered approach to meet their needs and aspirations.
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