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Factors associated with buying sex and the knowledge that condoms prevent HIV among long-distance truck drivers at Kazungula weighbridge terminal, Chobe District, Botswana

Factors associated with buying sex and the knowledge that condoms prevent HIV among long-distance... Copyright © The Authors African Journal of AIDS Research 2023: 1–11 Open Access article distributed in terms of the Creative Commons Attribution License AJAR [CC BY 4.0] (https://creativecommons.org/licenses/by/4.0) ISSN 1608-5906 EISSN 1727-9445 This is the final version of the article that is published https://doi.org/10.2989/16085906.2023.2176331 ahead of the print and online issue Research Article Factors associated with buying sex and the knowledge that condoms prevent HIV among long-distance truck drivers at Kazungula weighbridge terminal, Chobe District, Botswana 1 2 Wada Gaolaolwe * & Mathildah Mokgatle Department of Psychiatric Mental Health Nursing, Lobatse Institute of Health Sciences, Lobatse, Botswana Department of Public Health, Sefako Makgatho Health Sciences University, Pretoria, South Africa *Correspondence: wadagaolaolwe76@gmail.com Background: Long-distance truck drivers (LDTDs) have a higher rate of HIV infection compared to the general population. This is due to their living and working conditions which predispose them to riskier sexual behaviours. Inadequate knowledge of HIV and AIDS, coupled with risky sexual behaviours such as unprotected sex with commercial sex workers (CSWs), predisposes LDTDs to contract and propagate HIV. This study aims to determine the factors associated with buying sex and the knowledge that condoms prevent HIV transmission among long-distance truck drivers at Kazungula weighbridge terminal in the Chobe District of Botswana. Methods: A cross-sectional descriptive survey was employed and 399 LDTDs participated. A questionnaire was used to collect sociodemographic data and information on knowledge of HIV and AIDS and the sexual behaviours of the LDTDs. Results: The results reveal that more than half of the LDTDs (56.9%; n = 227) had paid for sex with CSWs at some point in their travels, and 27.1% (n = 108) reported having had unprotected sex with CSWs. The LDTDs who preferred to have sex with CSWs without a condom had about five times the odds of buying sex with CSWs than those who preferred to use a condom (AOR 4.9; 95% CI 2.85–8.46). Disliking condom use was a factor contributing to less knowledge of condom use preventing HIV among the LDTDs (AOR 0.4; CI 0.17–0.97). Conclusion: It can be concluded from the results of this study that the LDTDs engage in considerable risky sexual behaviours, and associated factors were found to be multidimensional. This population remains of concern in HIV acquisition and transmission. Therefore, there is a need for a robust public health response to deal with the problem of both new infection and re-infection with HIV in this population. Keywords: commercial sex workers, condom use, HIV knowledge, HIV transmission, risky sexual behaviour, truck terminals Introduction contribute to the risk of HIV infection among LDTDs: long-term separation from a regular partner, subject to Long-distance truck drivers (LDTDs) take protracted stress, attractive CSWs and their easy access in so-called periods away from their families and immediate hot spots (i.e. truck stops), and drivers usually not having environments, which exposes them to the temptation access to adequate medical services, including treatment of gratifying their sexual needs through buying sex with for sexually transmitted infections (IOM, 2005; Tiang et commercial sex workers (CSWs) at truck terminals. A al., 2010). Mobility is one of the significant drivers of the corpus of evidence is consistent in pointing out that LDTDs HIV epidemic, as it aids transmission by perpetuating pay a high amount of money to CSWs for unprotected sex, riskier sexual behaviours than that of the residents of which puts them at high risk of acquiring HIV (Sorensen et the countries travelled through, who have been found in al., 2007; Matovu and Ssebadduka, 2013). According to the some studies to have positive sexual behaviours (Deane literature, this problem is further heightened by the LDTDs’ et al., 2010; Nasir et al., 2015). A positive behaviour lack knowledge of the risks associated with unprotected change observed in local truckers can also be attributed sex, and either consider themselves invulnerable to to the implementation of HIV-prevention programmes HIV, or they believe that washing their genitals after for this population. For example, the North Star Alliance, unprotected sex prevents them from acquiring HIV (Agha, a non-governmental organisation formed to unite the 2010). Moreover, their living and working conditions transport sector in its response to the AIDS pandemic in put them at risk of infection and transmission of HIV. southern Africa, provide the LDTDs with access to primary The International Organization for Migration (IOM) has health care and HIV-related services through roadside identified the following working conditions as factors that wellness clinics (Lalla-Edward et al., 2017). African Journal of AIDS Research is co-published by NISC (Pty) Ltd and Informa UK Limited (trading as Taylor & Francis Group) 2 Gaolaolwe and Mokgatle According to the world-wide UNAIDS report, 690 000 of LDTDs such as literacy, current age and the specific people died of AIDS-related illnesses in 2020 compared to routes on which the LDTDs usually travel correlates 1.2 million in 2010, and the new HIV infections remain as with different levels of risky sexual behaviour and the high as 1.5 million, with a 30% decline since 2010 (UNAIDS, corresponding prevalence of HIV among this population 2020). A study conducted on groups that are at high risk (Mishra et al., 2012). However, no studies have been of contracting HIV indicates that LDTDs are one of those conducted in Botswana to establish if a connection exists groups. The risk for LDTDs is increased by their sexual between the sociodemographics of the LDTDs and buying practices, including regular sex with commercial sex workers sex, or knowledge that condoms prevent HIV transmission. (CSWs), with some reporting engaging in unprotected sex This study closes this gap. with CSWs, having multiple sexual partners, and with some Notwithstanding that some of the sociodemographic reporting as high as two or more sexual partners (Mishra et characteristics of LDTDs are factors that contribute to buying al., 2012; Sawal et al., 2016). In many parts of the world, sex and knowledge that condoms prevent HIV transmission, LDTDs are regarded as one key population that is at high there is evidence that LDTDs visit or get visited by CSWs, risk of acquiring and transmitting HIV, with buying sex from making them both vulnerable to HIV infection. Though there CSWs and a lack of knowledge that condoms prevent HIV is no study that investigates LDTDs’ exchange of money for transmission being ranked high as some of the main causes sex with CSWs in Botswana, there is evidence across the of the high prevalence rate of HIV among this population globe that LDTDs buy sex and truck terminals are common (Atilola et al., 2010; Azuonwu et al., 2011; Delany-Moretlwe places for them to have sex with CSWs in exchange for et al., 2014; Maarefvand et al., 2016; Ishtiaq et al., 2017). money; hence, it was important to conduct this study at This article presents findings from a study conducted Kazungula weighbridge terminal. A study conducted in Hong among a relatively large sample (N = 399) of LDTDs, the Kong reveals that one quarter of LDTDs visited CSWs and research site being a weighbridge terminal in Botswana 80.4% reported indulging in sexually risky behaviour (Wong located close to the country’s borders with Zambia and et al., 2007). These results connect well with those of a study Zimbabwe. The study was investigating factors associated conducted in India in which about one quarter of LDTDs with buying sex and the knowledge that condoms prevent visited CSWs and about 58% to 74% reported inconsistent HIV transmission among long-distance truck drivers at this condom use (Mishra et al., 2012). In other studies, some terminal. Kazungula weighbridge terminal is one of the LDTDs are reported to propose higher payments to be paid major truck junctions in southern Africa and it is important to for non-condom use with CSWs. For example, in a study compare the findings of this study to similar studies around conducted in South Africa, some LDTDs paid more for sex the world. Moreover, there is a lack of relatively large scale without a condom due to the CSWs’ desperate economic studies of this nature in southern Africa and none has been problems (Makhakhe et al., 2017). Nevertheless, literature conducted on this topic in Botswana. To this end, this study shows that in spite of the availability of condoms in the will add to the body of knowledge about this sub-population condom dispensers at the rest rooms at the truck stops, at Kazungula weighbridge terminal. their use is not necessarily associated with their availability, as demonstrated in a study that reveals that some LDTDs The sociodemographics and sexual behaviours of and make commercial sex workers choose between sex without condom use by LDTDs a condom or losing a sale. LDTDs constitute a heterogeneous population. Therefore, The attitude by LDTDs of disliking condom use is of great their sociodemographic characteristics such as age and public health concern as it increases the chance of HIV marital status provide an important relationship with the transmission (Sawal et al., 2016). It is clear from extant buying of sex and the knowledge that condoms prevent HIV literature that LDTDs have negative attitudes towards transmission (Yusuf et al., 2014). Studies carried out on condom use and thus indulge in riskier sexually encounters, LDTDs reveal that the significant demographic predictors which predisposes them to acquiring HIV and other sexual of condom use are educational and marital status and age. transmitted infections (Matovu and Ssebadduka, 2013). Sociodemographic factors such as the age at which one Their dislike of condom use has negative consequences started the trucking occupation also play a significant role in for their sexual behaviours. In some studies, LDTDs put their sexual behaviours, with adolescent entrants exhibiting the blame on condoms, saying that they destroy the mood higher risk sexual behaviours like buying sex compared to for sex (Sorensen et al., 2007; Matovu and Ssebadduka, the adult entrants (Mishra et al., 2012). A study conducted 2013). But generally, studies are inconsistent on the LDTDs’ in Nigeria found age as a demographic factor related to level of knowledge about HIV and there is less literature risky sexual behaviour, with younger truck drivers being that focuses on factors associated with the knowledge that more likely to use condoms; while, in a study conducted in condoms prevent HIV transmission. Moreover, no studies Bolivia, older truck drivers were found to use condoms less, have been conducted in Botswana on factors associated and those with a higher level of education had significantly with buying sex and the knowledge that condoms prevent higher levels of condom use (Sorensen et al., 2007; Aniebue HIV transmission among long-distance truck drivers at and Aniebue, 2009). Yaya et al. (2016) suggest that the link Kazungula weighbridge terminal. To this end, it was between education and risky sexual behaviour may indicate important to conduct a study on the factors associated with that education inspires an understanding of HIV-prevention buying sex and the knowledge that condoms prevent HIV information, which is provided as a form of risk reduction transmission among LDTDs at Kazungula weighbridge intervention for LDTDs. It can therefore be concluded with terminal to serve as a reference point in planning public evidence from the literature that demographic characteristics health programmes for LDTDs. African Journal of AIDS Research 2023: 1–11 3 Long-distance truck drivers’ knowledge of HIV and AIDS from the Botswanan and Zambian borders, and trucks stop A very important aspect to consider when taking into account at the weighbridge for customs duty and also for a break LDTDs’ sexual behaviours is their knowledge of HIV and from long-distance travel. Trucks remain at the weighbridge AIDS. In some studies conducted among truck drivers in Iran for long periods, making the place a lucrative rendezvous and Morocco, there was a low level of knowledge about HIV for commercial sex work. Approximately 3 000 LDTDs use and AIDS, and the HIV knowledge index was low among the Kazungula weighbridge in a month and most of them the semiliterate (Tehrani and Malek-Afzali, 2008; Himmich are from neighbouring South Africa. The study population et al., 2015). Some studies, however, reveal high levels of was comprised of both the international and local LDTDs knowledge about HIV and AIDS. For instance, in a study available at Kazungula weighbridge terminal, who were conducted in India, 95% of LDTDs knew that condom use can in transit and had stopped there. The LDTDs take a day reduce HIV transmission, but low levels of knowledge were or more, queuing to have their trucks weighed to pay the reported in relation to the importance of refraining from having required customs duty and also to have a break from a multiple concurrent sexual partners and avoiding high-risk long distance drive before proceeding to their various groups like CSWs (Singh and Joshi, 2012; Nasir et al., 2015). destinations. Most of them spend their nights in their trucks. In some studies, the level of knowledge that non-condom As for the road network, Kazungula village forms a vital use during sex is a mode of HIV transmission was as high as link with other SADC countries, which is why there is so 88.8% (Aniebue and Aniebue, 2009). The study by Aniebue much trucking activity in this area, making it one of the and Aniebue (2009) used a cross-sectional design and the major trucking corridors on the subcontinent, with a lot of questionnare was researcher administered, while Nasir et al. trucks parking at this terminal in transit. Nonetheless, there (2015) carried out a mixed methods analysis of descriptive are other routes that also service the north-south corridor, and inferential points, followed by interviews. From the for example, the Beitbridge route that passes between different study designs and methods used in different South Africa and Zimbabwe. Compared to the Kazungula studies, it is clear that even though LDTDs have high levels route, the Beitbridge route is relatively shorter for truckers of knowledge about HIV and its prevention, they harbour travelling from most SADC countries to more northern some misconceptions about the causes and transmission of sub-Saharan Africa, making it more favourable. However, HIV. Empirical evidence suggests that the misconceptions according to a report by Nkala (2021), the recently opened harboured by the LDTDs about the causes and transmission Kazungula bridge that crosses over the intersection of HIV include mosquito bites, shaking of hands and sharing of the Chobe and Zambezi rivers, replacing the ferry of rooms (Singh and Joshi, 2012; Poda and Sanon, 2015). crossing, gives the Kazungula route an advantage over With this in mind, it is necessary to examine LDTDs’ HIV the Beitbridge border crossing which regularly experiences knowledge as a component of information, attitudes towards transit bottlenecks and other problems on the Zimbabwe condoms, perceived vulnerability to HIV and AIDS and the side. These issues include the dilapidated road network, factors associated with sexual transactions in exchange many taxes and multiple vehicle inspection roadblocks. for money at critical points such as the weighbridge of Furthermore, Kazungula benefits from better infrastructural Kazungula terminal in the Chobe district of Botswana. development initiatives, such as the Botswana–Zambia one-stop border post, which now makes this route a better Methods alternative in facilitating intra-regional freight compared to other routes (Nkala, 2021). Study design and population The study employed a quantitative cross-sectional Sampling procedure descriptive approach to assess the level of HIV and AIDS A simple random sampling technique was used to select knowledge and related sexual behaviours among long the participants. The study opted to use a population of distance truck drivers. Cross-sectional descriptive design unknown size based on the transit nature of the border was suitable for this study as it involved collecting data from posts in Botswana. Nevertheless, the sampling relied on a large sample and subsequently describing, analysing the reported estimate of 3 000 LDTDs that pass through and interpreting factors associated with buying sex and the Kazungula weighbridge terminal each month as a basis for knowledge that condoms prevent HIV transmission among sampling. The sample size was calculated using the Raosoft LDTDs at a single point in time (Polit & Beck, 2017). This sample size calculator at a confidence level of 95% and a study was conducted at Kazungula weighbridge terminal 5% accepted margin of error at a response distribution of in the Chobe district of Botswana. Kazungula village is 50%. A 5% buffer of participants was included in the sample located on the northern side of Botswana. The village lies as a contingency and also to improve the extrapolation of to the south of the confluence of two big perennial rivers, the results, culminating in a sample size of 399 .Inclusion the Chobe and the Zambezi. Kazungula village has two criteria were: border posts, one for crossing into Zimbabwe and the other • Only truck drivers who understood either English or into Zambia. Trucks crossing through Botswana to Zambia Setswana were included in the study; use the north-south transport corridor, which forms part of • LDTDs who had truck driving as their occupation, who the Southern African Development Community (SADC) drove heavy trucks with three or more axles, and who regional truck network that passes through Kazungula, had registered for custom duty services at Kazungula thus providing an important link for regional economic weighbridge terminal; and integration, with voluminous trucking activity on this route. • Truck drivers that were a day or more away from home Kazungula weighbridge terminus lies about two kilometres and had stopped at Kazungula weighbridge terminal. 4 Gaolaolwe and Mokgatle All truck drivers who worked in Kazungula village or its Ministry of Health and Wellness IRB (Ref: HPDME 13/18/1 vicinity and those who had not been away from their homes X (855). Permission was also sought from the Kazungula for a day or more were excluded. weighbridge management to conduct the data collection at their facility (Ref: KR 5/20 III (149). Data was collected Data collection after the participants provided informed written consent. The data collection method was administered through Participation was voluntary, including the right to withdraw structured questionnaires. The questionnaires were from the study without any preconditions. For anonymity, administered by WG and a trained research assistant, no identifying information was collected and the data file using adapted validated questions from a previous was password protected, with access limited to both the study and it was prepared in English and translated into researchers in this study. Setswana (Madiba and Mokgatle, 2015). The questionnaire was composed of closed-ended questions to collect Results sociodemographic data of the LDTDs and their sexual behaviours such as exchange of money for sex with CSWs Characteristics of LDTDs and questions to ascertain the LDTDs’ knowledge that A sample of 399 LDTDs participated in this cross-sectional condoms prevent HIV transmission to allow a comparison study and 327 were international drivers. The ages of the of findings with previous studies which used such LDTDs who took part in the study ranged from 23 to 63 years, questions. On each day of data collection, the available with a mean age of 39.7 years (SD 8.89). The minimum LDTDs gathered at the weighbridge terminal offices age for becoming a long-distance driver was 19 and the in collaboration with the facility management for data maximum was 45. Most of the drivers (49.8%; n = 199) joined collection. The questionnaires were administered to the long-distance truck driving between the ages of 26 and 29 LDTDs who voluntarily consented to participate, and the years. The minimum period that a LDTD had spent on truck exercise took about 30 minutes per participant to complete. driving was one year, while the maximum was 33 years. Of The questionnaires were administered when the LDTDs the 399 participants, 9.5% (n = 24) did not have a formal were less busy and waiting for their turn to be assisted at education and of those who had a formal education, a high the weighbridge terminal. Data collection took about seven proportion of 63.4% (n = 253) had secondary education, with months, from February to August 2017. the remaining 30.6% (n = 146) consisting of those with tertiary and primary education at 15.0% and 15.5% respectively. Of Data analysis the 262 LDTDs who had intimate sexual partners, 53.1% Statistical analysis covered the sociodemographic profile of (n = 139) had had two or more in the past 12 months. The the study population, established the extent of the LDTDs’ remaining 34.3% (n = 137) had no committed intimate sexual knowledge about HIV and AIDS, the nature of their sexual partnerships, but had casual sex involving CSWs. Generally, behaviours and factors associated with buying sex and the the LDTDs who did not have committed sexual partners and knowledge that condoms prevent HIV transmission. Data those who had committed sexual partners all had casual sex was analysed using Stata 4.0 software (StataCorp). In involving CSWs. The sociodemographics of the participants the univariate analysis, sociodemographic profiles, sexual are sumarised in Table 1. behaviours and condom use of the LDTDs were calculated. The Pearson’s chi-square test was used in bivariate analysis LDTDs’ sexual behaviours for the relationship between knowledge that condoms prevent According to the results of this study (Table 2), more than HIV transmission, the sociodemographic characteristics half of the LDTDs (56.9%; n = 227) had paid for sex with and the sexual behaviours, and the relationship of sex in commercial sex workers at some point in their career, and exchange for money to sociodemographics and risky sexual 27.1% (n = 108) reported to have had unprotected sex with behaviours and condom use. Multivariable logistic regression CSWs. As many as 34.1% (n = 136) of the LDTDs reported analysis was performed to identify independent risk factors to have paid for sex with CSWs in the past 12 months. A for the dichotomous outcomes: sex with CSW in exchange for significantly high proportion of the LDTDs (97.2%; n = 388) money in the past 12 months (yes or no); and knowledge or knew where to get condoms when needed. Most LDTDs lack of knowledge that condoms prevent HIV transmission. had scores above 90% on the following: on their ability to The variables that were statistically significant during bivariate remember to carry a condom on their trips (93.2%; n = 372); analysis at a p-value less than 0.05 were then selected for their ability to buy condoms without feeling embarrassed the logistic regression model to assess among LDTDs the (90.5%; n = 361); their confidence in their ability to put on a variables’ contribution to sex in exchange for money among condom (93.5%; n = 373); their confidence in their ability to the LDTDs and to the knowledge that condoms prevent HIV remove and dispose of a condom after sexual intercourse transmission by estimating the adjusted odds ratios (ORs) at (93.2; n = 372); their ability to get a condom from a public 95% confidence intervals (CI). place without feeling embarrassed (91.5%; n = 365). The results also indicate that 29.1% (n = 116) of LDTDs indicated Ethical considerations that they would not feel confident to propose using a condom The Research Ethics Committee of Sefako Makgatho Health to a new intimate sexual partner because of the fear that the Sciences University (SMUREC) reviewed the protocol partner would think they have a sexually transmitted disease. and gave ethical clearance for the study to be conducted While 37.6% of the LDTDs (n = 150) in the study were of (SMUREC/H/286/2016 of 09/2016). The letter of clearance the view that a condom creates doubt between partners, from the SMUREC was used to get permission from the just above half of participants (51.4%; n = 205) had an African Journal of AIDS Research 2023: 1–11 5 Table 1: Sociodemographic characteristics of the long-distance Table 2: Long-distance truck drivers’ sexual behaviours and truck drivers condom use (N = 399) Sociodemographic variable Frequency (n) Per cent % Question/statement Response n % Type of commuter I have at some point paid for sex Agree 227 56.9 Local 72 18 with commercial sex workers in my Disagree 172 43.1 International 327 82 long-distance travels with a truck. Age (years) I have had sex with a commercial Agree 108 27.1 <25 4 1 sex worker without using a condom. Disagree 291 72.9 26–29 70 17.5 In the past 12 months I have paid Agree 136 34.1 >30 325 81.5 for sex. Disagree 263 65.9 Age started work as truck driver (years) I know where to get condoms when I Agree 388 97.2 <25 62 15.5 need them. Disagree 11 2.8 26–29 199 49.8 I feel confident in my ability to put a Agree 373 93.5 >30 138 34.6 condom on myself. Disagree 26 6.5 Duration in trucking industry (years) I feel confident I could remove and Agree 372 93.2 <5 128 32.1 dispose of a condom after sexual 6–10 95 23.8 Disagree 27 6.8 intercourse. >11 176 44.1 I feel confident I could purchase Agree 361 90.5 Level of education condoms without feeling No formal education 24 9.5 Disagree 38 9.5 embarrassed. Primary school 62 15.5 Secondary education 253 63.4 I feel confident that I could go and Agree 365 91.5 Tertiary education 60 15.0 get condoms from a public place Disagree 34 8.5 without feeling embarrassed. Number of sexual partners None, but have casual sex 137 34.3 I feel confident I could remember to Agree 372 93.2 One 123 46.9 carry a condom. Disagree 27 6.8 Two 66 25.2 I would not feel confident suggesting Agree 116 29.1 More than two 73 27.9 using condoms with a new partner because I would be afraid they Disagree 283 70.9 would think I have a sexually transmitted disease. opposite view, and the rest (11.0%; n = 44) were not sure. A condom creates doubt between Agree 150 37.6 Table 2 also shows that 75.9% (n = 303) were worried about sexual partners. Disagree 205 51.4 contracting HIV, and 80.2% (n = 320) of the LDTDs indicated Not sure 44 11.0 that there was a high possibility that they might refuse How worried are you about getting Worried 303 75.9 coitus if their partner refused to let them use a condom. A HIV and/or AIDS? Not worried 96 24.1 significantly high number of 87.0% (n = 347) indicated that What are the chances you could ask High 347 87.0 there was a high chance that they might have an HIV test your partner to go for an HIV test Low 52 13.0 with their partners (Table 2). with you? What are the chances of you refusing High 320 80.2 Knowledge about HIV and AIDS sex if your partner does not want to Low 79 19.8 let you use a condom? The findings of this study shows that all the LDTD who participated in this study had heard about HIV and AIDS (100%; N = 399) (Table 3). The media was reported as the main source of information about HIV and AIDS at 65.9% Relationship between knowledge that condoms prevent (n = 263), while those who had learnt about HIV and AIDS at HIV transmission, sociodemographic characteristics school stood at 62.9% (n = 251). 53.6% (n = 214) had heard and sexual behaviours about it from a clinic, while 20% (n = 81) heard about HIV Table 4 presents a bivariate analysis of the knowledge that and AIDS at church. 5.0% (n = 20) had heard of it through condoms prevent HIV transmission and the participants’ unspecified ways. The overall results of the univariate sociodemographic characteristics. From the 90.2% (n = 360) analysis shows that the LDTDs had a high level of knowledge of the LDTDs who knew that HIV can be prevented using a about HIV and AIDS, with scores as high as 97.0% (n = 387) condom, those with a secondary education had the highest on the knowledge that HIV causes AIDS. Only 12.0% of the proportion with 58.7%, followed by tertiary with 14.5%, while LDTDs believed that HIV and AIDS is caused by witchcraft, those with no formal education or only primary education and most of the participants knew that currently there is no accounted for 5.8% and 11.3% respectively. This rendered cure for HIV (76.7%; n = 306). A high proportion of LDTDs a p-value of <0.001, which is statistically significant. The (97.0%; n = 387) had knowledge that having multiple analysis further reveals that age was not a predictor of partners increases the chance of contracting HIV, and that knowledge that condoms prevent HIV transmission, with HIV transmission can be prevented by using a condom p-value of 0.035. Knowledge that condoms can prevent during coitus (90.2%; n = 360). All the percentage scores for HIV transmission is associated with confidence to carry knowledge about HIV and AIDS were above 75% (Table 3). a condom on trips (p = 0.003), confidence to suggest a condom to a new partner (p < 0.001), attitude of disliking 6 Gaolaolwe and Mokgatle Table 3: Long-distance truck drivers’ sources and levels of knowledge about HIV and AIDS (N = 399) Questions/statements Response Frequency (n) Per cent % Have you ever heard about HIV and AIDS? Yes 399 100 Source of information Media Yes 263 65.9 Church Yes 81 20.3 School Yes 251 62.9 Clinic Yes 214 53.6 Other Yes 20 5.0 Knowledge levels Correct response HIV is the virus that causes AIDS. True 387 97.0 HIV and AIDS is caused by witchcraft. False 351 88.0 There is no cure for HIV and AIDS currently. True 306 76.7 Having a sexually transmitted disease can increase a person’s risk of getting HIV. True 380 95.2 A healthy-looking person can have HIV. True 375 94.0 Having multiple sexual partners increases the risk of getting HIV. True 387 97.0 HIV can be transmitted by sexual intercourse with an infected person. True 379 95.0 HIV can be prevented by using a condom during sexual intercourse. True 360 90.2 HIV can be transmitted by sharing needles or syringes. True 367 92.0 HIV can be transmitted by blood transfusion. True 374 93.7 HIV can be transmitted by sharing a glass or cup with an infected person. False 363 91.0 HIV can be transmitted by sharing a toilet with an HIV infected person. False 366 91.7 Infection with HIV can be prevented by washing one’s genitals with antiseptics or False 312 78.2 soap after sexual intercourse with an infected person. Table 4: Association between knowledge that a condom prevents HIV transmission and sociodemographics, sexual behaviour and condom use (N = 399) Knowledge that condoms prevent HIV transmission Sociodemographic variable p-value Yes No % (n) % (n) Age (years) <25 1.00 (4) 0.00 (0) 26–29 16.54 (66) 1.00 (4) 0.349 >30 72.68 (290) 8.77 (35) Level of education No formal education 5.76 (23) 0.75 (3) Primary 11.28 (45) 4.01 (16) <0.001 Secondary 58.65 (234) 4.51 (18) Tertiary 14.54 (58) 0.50 (2) Sexual behaviours and condom use Confident to carry condom on trips 85.21 (340) 8.02 (32) 0.003 Confident to suggest a condom to partner before intercourse 23.81 (95) 5.26 (21) <0.001 Worried about contracting HIV 69.42 (277) 6.52 (26) 0.154 Attitude of disliking condom use 10.03 (40) 2.76 (11) 0.002 Confident to refuse sex with a CSW using a condom 73.43 (293) 6.77 (27) 0.070 Not using a condom consistently because of unplanned sex 12.28 (49) 3.01 (12) 0.005 Perception that a condom kills the mood for sex 11.03 (44) 1.25 (5) 0.914 Have had sex with casual partner 18.55 (74) 3.01 (12) 0.141 condoms (p = 0.002) and not using a condom consistently (n = 12), and the association rendered a p-value of 0.001. because of unplanned sex (p = 0.005). Table 5 also shows that, though age was not a predictor in paying for sex with CSWs in the past 12 months during Relationship of sex in exchange for money to long-distance travels, the proportion of LDTDs paying for sociodemographics and risky sexual behaviours and sex with CSWs was 34.1% (n = 136). The number of sexual condom use partners that a LDTD had an association with buying sex in A bivariate analysis was conducted to establish the the past 12 months (p < 0.001). Paying for sex with CSWs association between paying for sex in the past 12 months in the past 12 months had an association to the reporting of and sociodemographics, sexual behaviour and condom being confident in the ability to wear a condom (p = 0.002), use (Table 5). Of the 136 drivers who paid for sex during confidence to refuse sex with a condom (p < 0.001), and an the past 12 months, 31.08% (n = 124) were international attitude of disliking condom use (p < 0.001). LDTDs, while the local LDTDs accounted for 3.01% African Journal of AIDS Research 2023: 1–11 7 Table 5: Association between paying for sex with commercial sex workers (CSW) in past 12 months and sociodemographics, sexual behaviour and condom use (N = 399) Paying for sex with a CSW in the past 12 months Sociodemographic variable p-value Yes No % (n) % (n) Type of traveller Local 3.0 (12) 15.0 (60) International 31.1 (124) 50.9 (203) 0.001 Age (years) <25 0.8 (3) 0.3 (1) 26–29 6.5 (26) 11.0 (44) 0.177 >30 26.8 (107) 54.6 (218) Level of education No formal education 2.0 (8) 4.0 (16 Primary 5.5 (22) 10.0 (40) Secondary 22.8 (91) 40.6 (162) 0.446 Tertiary 3.8 (15) 11.3 (45) Duration in trucking (years) <5 11.8 (47) 20.3 (81) 6–10 6.0 (24) 17.8 (71) 0.115 >11 16.3 (65) 27.8 (111) Number of sexual partners None, but have had casual sex 3.8 (15) 30.6 (122) One 10.3 (41) 31.3 (82) Two 12.2 (32) 13.0 (34) <0.001 More than two 18.3 (48) 9.5 (25) Sexual behaviours and condom use Confident about the ability to wear a condom 32.2 (120/373) 67.8 (253/373) 0.002 Confident to suggest a condom to partner before intercourse 37.1 (43/116) 62.9 (73/116) 0.648 Worried about contracting HIV 34.7 (105/303) 65.3 (198/303) 0.181 Confident to refuse sex with a CSW using a condom 64.8 (70/108) 35.2 (38/108) <0.001 Attitude of disliking condom use 56.9 (29/51) 43.1 (22/51) <0.001 Factors associated with the exchange of sex for money had less confidence (AOR 2.3; 95% CI 0.78–6.47). The with CSWs among LDTDs analysis further revealed the level of education as a factor Factors associated with sex in exchange for money with contributing to the knowledge that condom use prevents CSWs in the past 12 months were investigated using HIV transmission among LDTDs, with those who had no multivariable logistic regression analysis (Table 6). This formal education and those who had primary education indicated that international LDTDs were about three times being less likely to have knowledge that condoms use more likely to have bought sex in the past 12 months than prevents HIV transmission (AOR 0.5; 95% CI 0.65–3.24; the local ones (AOR 2.9; 95% CI 1.31–6.56). Furthermore, AOR 0.1; 95% CI 0.02–0.44 respectively). Disliking condom the multivariable logistic regression model analysis use was also a factor contributing to less knowledge that revealed that having more than two sexual partners had a condom use prevents HIV among the LDTDs (AOR 0.4; strong association with buying sex in the past 12 months, 95% CI 0.17–0.97). with a statistically significant p-value of 0.001 (AOR 3.2; 95% CI 1.65–6.33). In comparison, the LDTDs who had Discussion more than two sexual relationships had about three times the odds of buying sex in the adjusted odd ratio analysis This study took place at Kazungula weighbridge terminal than those with only two relationships or those who only to investigate factors associated with buying sex and the had casual sex with no committed relationship. The LDTDs knowledge that condoms prevent HIV transmission among who had high confidence in refusing sex with CSWs with a long-distance truck drivers. A number of factors including the condom had five times the odds of buying sex with CSWs sociodemographics such as the level of education, the number compared to those who lacked confidence (AOR 4.9; of committed sexual partners that the LDTDs had and having 95% CI 2.85–8.46). truck driving as an occupation especially an international LDTD were identified in this subpopulation group. Factors associated with the knowledge that condom use prevents HIV among the LDTDs Sociodemographics and LDTDs’ sexual behaviours The results of a logistic regression analysis in Table 7 shows This study shows that international LDTDs have a that the LDTDs who had confidence to carry condoms on significantly higher risk of contracting HIV than the local trips had about twice the odds of knowledge that condoms drivers. As indicated by Delany-Moretlwe et al. (2014) can prevent HIV transmission compared to those who on the topic of LDTDs and mobility, international LDTDs 8 Gaolaolwe and Mokgatle Table 6: Multivariate analysis — sex with a commercial sex worker (CSW) in exchange for money in the past 12 months (N = 399) Sex with CSW in exchange for money UOR AOR in past 12 months Variable p-value p-value (95% CI) (95% CI) Yes No % (n) % (n) Type of commuter Local (n = 72) 12 (16.7) 60 (83.3) Ref (0) Ref (0) International (n = 327) 124 (37.9) 203 (62.1) 3.1 (1.62–6.03) 0.001 2.9 (1.31–6.56) 0.009 Number of sexual partners in the past 12 months One 41 (30) 83 (31) Ref (0) Ref(0) Only have casual sex 15 (11) 122 (89) 0.3 (0.13–0.47) <0.001 0.2 (0.12–0.48) <0.001 Two 32 (48.5) 34 (51.5) 1.9 (1.02–3.47) 0.043 1.3 (0.68–2.63) 0.394 >2 48 (65.8) 25 (34.3) 3.84 (2.08–7.08) <0.001 3.2 (1.65–6.33) 0.001 Confidence to wear a condom Agree 120 (32.2) 25 (67.8) Ref (0) Ref (0) Disagree 16 (61.5) 10 (38.5) 0.3 (0.13–0.67) 0.004 0.5 (0.20–1.40) 0.200 Confidence to refuse sex with CSW without a condom Low chance 66 (22.7) 225 (77.3) Ref (0) Ref (0) High chance 70 (64.8) 38 (35.2) 6.3 (3.88–10.16) <0.001 4.9 (2.85–8.46) <0.001 Attitude of disliking condom use Yes 29 (56.9) 22 (43.1) Ref(0) Ref(0) No 107 (30.8) 241 (69.3) 3.0 (1.63–5.40) <0.001 1.3 (0.61–2.64) 0.526 Table 7: Multivariate analysis — long-distance truck drivers (LDTDs) with knowledge that condoms prevent HIV transmission and sociodemographics, sexual behaviour and condom use LDTDs with Variable UOR (95% CI) p-value AOR (95% CI) p-value knowledge n (%) Level of education Tertiary Ref (0) Ref (0) No formal education 23 (88.5) 0.3 (0.04–1.69) 0.159 0.5 (0.65–3.24) 0.435 Primary 45 (73.8) 0.1 (0.02–0.44) 0.003 0.1 (0.02–0.46) 0.003 Secondary 234 (92.9) 0.4 (0.10–1.99) 0.291 0.5 (0.97–2.14) 0.319 Confident to carry condom on trips Agree 340/372 (91.4) Ref (0) Ref (0) Disagree 20/27 (74.1) 3.7 (1.46–9.46) 0.006 2.3 (0.78–6.47) 0.132 Confident to suggest condom to new partner before sex Agree 265/283 (93.6) Ref (0) Ref (0) Disagree 95/116 (81.9) 0.3 (0.16–0.60) 0.001 0.3 (0.16–0.71) 0.004 Attitude of disliking condom use Yes 40/51 (78.4) Ref (0) Ref (0) No 320/348 (92.0) 0.3 (0.15–0.69) 0.004 0.4 (0.17–0.97) 0.043 Inconsistent condom use due to unplanned sex Yes 49/61 (80.3) Ref (0) Ref (0) No 311/338 (92.0) 0.4 (0.17–0.75) 0.006 0.4 (0.15–0.81) 0.014 generally spend more time on the road and this exposes Factors associated with sex in exchange for money and them to acquiring and transmitting HIV. This suggests the knowledge that condoms prevent HIV transmisison that cross-border long-distance trucking is one of the key The results of our study indicate that being an international drivers of the HIV epidemic and aids transmission through truck driver is a factor associated with sex in exchange risky sexual behaviours. The number of sexual partners for money. The higher vulnerability of international LDTDs that an LDTD has also exhibits a significant association compared with the local ones may also be explained, at with a higher proportion of paying for sex with CSWs in least partly, by their likelihood to engage in riskier sexual the past 12 months, especially among those who have behaviours, including sex in exchange for money with CSWs more than two committed sexual partners. This finding due to the environmental factors associated with the trucking is consistent with those of other research in various industry, such as high mobility and easy access to CSWs. settings that determined that the number of committed This study found that as high as 56.9% of the LDTDs had sexual partners that a LDTD has is linked to high-risk HIV paid for sex with CSWs at some point during their travels, behaviour (Nasir et al., 2015). 34.1% had paid for sex with CSWs in the past 12 months, African Journal of AIDS Research 2023: 1–11 9 and 27.1% of them engaged in unprotected sex with protected sex. Though the reasons for non-condom use CSWs. These findings are important because, to the best in some studies included their unavailability and having of our knowledge, there has not been any study previously to buy them for themselves, for this study, the reasons for conducted at weighbridge terminals in Botswana to assess non-condom use included the attitude of LDTDs of disliking the LDTDs’ sexual behaviours such as paying for sex with condoms and inconsistency in condom use because of CSWs. Nevertheless, other studies match the findings of unplanned sex (Aniebue and Aniebue, 2009). this study as demonstrated by the results of studies by both The number of sexual partners that the LDTDs have is Nasir et al. (2015) and Wong et al. (2007), in which 54% of also a cause for concern in the fight against HIV as it is the truck drivers paid for sex with CSWs. In comparison and a predictor of the exchange of money for sex with CSWs. as a matter of concern, this study shows that international This study reveals that the number of sexual partners LDTDs were three times more likely to buy sex with CSWs that the LDTDs had was positively associated with the than the local ones. In spite of this important finding, there exchange of sex for money with CSWs in the past 12 is a paucity of literature that compares the risky sexual months. The LDTDs who had more than two sexual behaviours such as sex in exchange for money with CSWs relationships had about three times the odds of buying sex between the international and local LDTDs in Botswana and with CSWs in the adjusted odd ratio analysis than those this study closes the gap. It can thus be concluded from with only two or those who only had casual sex with no empirical evidence from other studies that the international committed relationship. This finding is consistent with that LDTDs’ riskier sexual behaviours could be attributed to of a study conducted by Nasir et al. (2015) in Pakistan in staying away from their homes for lengthy periods (Nasir which a quarter of LDTDs had at least two sexual partners, et al., 2015; Atilola et al., 2010 ). This conclusion resonates and up to 54.2% had paid for sex with CSWs. well with the findings of a study conducted in South Africa Furthermore, the confidence to carry a condom is also in which international drivers generally spent more time on positively associated with the knowledge that a condom the road, getting exposed to acquiring and spreading HIV can prevent HIV transmission. This factor is important through paying for sex with CSWs (Delany-Moretlwe et al., and making condoms available at truck terminals is not 2014). enough because LDTDs could avoid using them for the It is evident from the results of this study that LDTDs same reasons that they do not carry the condoms, which use the desperate economic situation of the CSWs to could be from the lack of knowledge that condoms prevent exploit them into having unprotected sex with them in HIV transmission. In this study, the LDTDs who had the exchange for money (Ntseane, 2004). In this study, the confidence to carry condoms on trips had about twice the LDTDs who indicated that they would refuse sex with odds of having the knowledge that condoms can prevent HIV CSWs with a condom had five times the odds of buying transmission compared to those who had less confidence. sex with CSWs compared to their counterparts who would Even though this finding is important in the fight against not have unprotected sex with CSWs. Despite having HIV, there is a dearth of literature that supports it. But that such risky sexual behaviours, this sub-population has not still being the case, the available literature indicates that received the attention it deserves by other researchers LDTDs place the responsibility to carry condoms primarily or the government to embark on a national behavioural with CSWs, and/or do not carry condoms because they surveillance of the LDTDs. Even though some efforts at prefer to engage in unprotected sex. Due to their inadequate various governmental and non-governmental organisations knowledge of the importance of condoms as an HIV have been made to achieve behaviour change through preventive measure, they engage in unprotected sex and community sensitisation and mass-media exposure to use what they view as alternative safety measures such as promote safe sexual practices in the general population, washing their genitals with battery water or urine after sex the adoption of tailor-made preventive behaviours targeting (Makhakhe et al., 2017). The use of condoms during sex is a LDTDs is relatively low. LDTDs still engage in unprotected key preventive strategy since rates of HIV and other sexually sexual activities with CSWs. Public health initiatives geared transmitted infections continue to escalate. To this end, the towards the control of HIV and AIDS among LDTDs is a level of knowledge about condoms as a preventive measure challenge due to limited information on LDTDs’ sexual for HIV and their use is important to this sub-population. behaviours in Botswana and this consequently leads to a Literature shows that adults who have attained a higher failure to adequately reach out to this high-risk group as an education level have better health and longer lifespans important sub-population for intervention. Similar findings compared to their less-educated peers (Raghupath and on risky sexual behaviours have been reported in other Raghupath, 2020). So, there is no doubt that the level of studies, e.g. a study conducted in Uganda reveals that education that one has attained in life is a fundamental LDTDs had unprotected sex with CSWs in exchange for vehicle, not only in possessing knowledge, but also for money (Matovu & Ssebadduka, 2013). That study shows self-preservation (Bhardwaj, 2016). Thus, the level of that some LDTDs proposed a charge of 20 000 Ugandan education that the LDTDs attain can have a bearing shillings for non-condom use and 2 000 Ugandan shillings on how they comprehend and use the information for for condom use, with the former being the choice of the self-preservation against HIV. The results of our study also CSWs due to their desperate economic problems. These reveal the level of education as a factor that contributes to results are consistent with those of our study where LDTDs the knowledge that condom use prevents HIV transmission who indicated that they would refuse sex with CSWs with a among LDTDs. The LDTDs who had no formal education condom had five times the odds of buying sex with CSWs and those who had primary education were less likely to compared to those who lacked the confidence to refuse have knowledge that condom use prevents HIV transmission 10 Gaolaolwe and Mokgatle (AOR 0.5 and AOR 0.1 respectively). It can be concluded with sex in exchange for money. Factors associated with from the findings of this study that the LDTDs’ level of the knowledge that condoms prevent HIV transmission education has an influence on their knowledge about HIV among LDTDs include the confidence to carry condoms on and AIDS, with those with secondary and tertiary education trips. The results of our study further reveal that the level displaying more knowledge than those who had no formal of education is a factor contributing to the knowledge that or primary education, and this is consistent with the findings condom use prevents HIV transmission among LDTDs. It of a study conducted in Pakistan which produced similar can therefore be concluded with empirical evidence from results (Nasir et al., 2015). This finding can assist in aligning our study that LDTDs remain an at-risk group for acquiring health education activities to accommodate the LDTDs’ and propagating HIV, and the risk is more with international diverse levels of education for effectiveness in raising the LDTDs compared to those travelling locally. Other studies awareness about condoms as a preventive measure against ascribe the risky behaviour to being away from home for HIV. With the findings of this study, the government can protracted periods. The findings of our study demonstrate intensify mass media campaigns and other public health the need for HIV and AIDS control programmes to measures aimed at stimulating appropriate risk perception, strengthen HIV-prevention interventions among LDTDs. discouraging unsafe sex practices and promoting consistent Making condoms available at truck stops and the promotion condom use by LDTDs. of safe sex practices such as consistent condom use Although there are no studies that were conducted in requires policy decisions from those who wish to promote Botswana to gauge the historical progress made in regard safe sex among LDTDs. Furthermore, there is a need to LDTDs’ sexual behaviours, a comparison of the current to develop policies that embrace critical HIV-prevention study with similar ones conducted elsewhere shows strategies with high success rate for key populations, positive progress in their sexual behaviours. For instance, e.g. policies that support the provision of post-exposure a survey conducted by Singh and Malaviya in 1994 prophylaxis (PEP) and pre-exposure prophylaxis (PrEP) revealed that 78% of LDTDs reported CSW exposure and to vulnerable populations such as LDTDs, including the 77% occasionally engaged in unprotected sex. In 1998, non-citizen international truckers. a study by Mishra et al. (2012) found that 80% of truck drivers visited CSWs and 75% had either used a condom ORCID iDs inconsistently, or had never used a condom. The current study shows that 56.9% of the LDTDs visited CSWs at Wada Gaolaolwe – https://orcid.org/0000-0003-1014-2005 some point during their long-distance travels with a truck, Mathildah Mokgatle – https://orcid.org/0000-0001-5807-8212 and as little as 27.1% reported to have had sex with CSWs without a condom. That still being the case, more effort References needs to be geared towards changing LDTDs’ behaviours Agha, S. (2010). 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Factors associated with buying sex and the knowledge that condoms prevent HIV among long-distance truck drivers at Kazungula weighbridge terminal, Chobe District, Botswana

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Taylor & Francis
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© 2023 The Author(s). Co-published by NISC Pty (Ltd) and Informa UK Limited, trading as Taylor & Francis Group
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10.2989/16085906.2023.2176331
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Copyright © The Authors African Journal of AIDS Research 2023: 1–11 Open Access article distributed in terms of the Creative Commons Attribution License AJAR [CC BY 4.0] (https://creativecommons.org/licenses/by/4.0) ISSN 1608-5906 EISSN 1727-9445 This is the final version of the article that is published https://doi.org/10.2989/16085906.2023.2176331 ahead of the print and online issue Research Article Factors associated with buying sex and the knowledge that condoms prevent HIV among long-distance truck drivers at Kazungula weighbridge terminal, Chobe District, Botswana 1 2 Wada Gaolaolwe * & Mathildah Mokgatle Department of Psychiatric Mental Health Nursing, Lobatse Institute of Health Sciences, Lobatse, Botswana Department of Public Health, Sefako Makgatho Health Sciences University, Pretoria, South Africa *Correspondence: wadagaolaolwe76@gmail.com Background: Long-distance truck drivers (LDTDs) have a higher rate of HIV infection compared to the general population. This is due to their living and working conditions which predispose them to riskier sexual behaviours. Inadequate knowledge of HIV and AIDS, coupled with risky sexual behaviours such as unprotected sex with commercial sex workers (CSWs), predisposes LDTDs to contract and propagate HIV. This study aims to determine the factors associated with buying sex and the knowledge that condoms prevent HIV transmission among long-distance truck drivers at Kazungula weighbridge terminal in the Chobe District of Botswana. Methods: A cross-sectional descriptive survey was employed and 399 LDTDs participated. A questionnaire was used to collect sociodemographic data and information on knowledge of HIV and AIDS and the sexual behaviours of the LDTDs. Results: The results reveal that more than half of the LDTDs (56.9%; n = 227) had paid for sex with CSWs at some point in their travels, and 27.1% (n = 108) reported having had unprotected sex with CSWs. The LDTDs who preferred to have sex with CSWs without a condom had about five times the odds of buying sex with CSWs than those who preferred to use a condom (AOR 4.9; 95% CI 2.85–8.46). Disliking condom use was a factor contributing to less knowledge of condom use preventing HIV among the LDTDs (AOR 0.4; CI 0.17–0.97). Conclusion: It can be concluded from the results of this study that the LDTDs engage in considerable risky sexual behaviours, and associated factors were found to be multidimensional. This population remains of concern in HIV acquisition and transmission. Therefore, there is a need for a robust public health response to deal with the problem of both new infection and re-infection with HIV in this population. Keywords: commercial sex workers, condom use, HIV knowledge, HIV transmission, risky sexual behaviour, truck terminals Introduction contribute to the risk of HIV infection among LDTDs: long-term separation from a regular partner, subject to Long-distance truck drivers (LDTDs) take protracted stress, attractive CSWs and their easy access in so-called periods away from their families and immediate hot spots (i.e. truck stops), and drivers usually not having environments, which exposes them to the temptation access to adequate medical services, including treatment of gratifying their sexual needs through buying sex with for sexually transmitted infections (IOM, 2005; Tiang et commercial sex workers (CSWs) at truck terminals. A al., 2010). Mobility is one of the significant drivers of the corpus of evidence is consistent in pointing out that LDTDs HIV epidemic, as it aids transmission by perpetuating pay a high amount of money to CSWs for unprotected sex, riskier sexual behaviours than that of the residents of which puts them at high risk of acquiring HIV (Sorensen et the countries travelled through, who have been found in al., 2007; Matovu and Ssebadduka, 2013). According to the some studies to have positive sexual behaviours (Deane literature, this problem is further heightened by the LDTDs’ et al., 2010; Nasir et al., 2015). A positive behaviour lack knowledge of the risks associated with unprotected change observed in local truckers can also be attributed sex, and either consider themselves invulnerable to to the implementation of HIV-prevention programmes HIV, or they believe that washing their genitals after for this population. For example, the North Star Alliance, unprotected sex prevents them from acquiring HIV (Agha, a non-governmental organisation formed to unite the 2010). Moreover, their living and working conditions transport sector in its response to the AIDS pandemic in put them at risk of infection and transmission of HIV. southern Africa, provide the LDTDs with access to primary The International Organization for Migration (IOM) has health care and HIV-related services through roadside identified the following working conditions as factors that wellness clinics (Lalla-Edward et al., 2017). African Journal of AIDS Research is co-published by NISC (Pty) Ltd and Informa UK Limited (trading as Taylor & Francis Group) 2 Gaolaolwe and Mokgatle According to the world-wide UNAIDS report, 690 000 of LDTDs such as literacy, current age and the specific people died of AIDS-related illnesses in 2020 compared to routes on which the LDTDs usually travel correlates 1.2 million in 2010, and the new HIV infections remain as with different levels of risky sexual behaviour and the high as 1.5 million, with a 30% decline since 2010 (UNAIDS, corresponding prevalence of HIV among this population 2020). A study conducted on groups that are at high risk (Mishra et al., 2012). However, no studies have been of contracting HIV indicates that LDTDs are one of those conducted in Botswana to establish if a connection exists groups. The risk for LDTDs is increased by their sexual between the sociodemographics of the LDTDs and buying practices, including regular sex with commercial sex workers sex, or knowledge that condoms prevent HIV transmission. (CSWs), with some reporting engaging in unprotected sex This study closes this gap. with CSWs, having multiple sexual partners, and with some Notwithstanding that some of the sociodemographic reporting as high as two or more sexual partners (Mishra et characteristics of LDTDs are factors that contribute to buying al., 2012; Sawal et al., 2016). In many parts of the world, sex and knowledge that condoms prevent HIV transmission, LDTDs are regarded as one key population that is at high there is evidence that LDTDs visit or get visited by CSWs, risk of acquiring and transmitting HIV, with buying sex from making them both vulnerable to HIV infection. Though there CSWs and a lack of knowledge that condoms prevent HIV is no study that investigates LDTDs’ exchange of money for transmission being ranked high as some of the main causes sex with CSWs in Botswana, there is evidence across the of the high prevalence rate of HIV among this population globe that LDTDs buy sex and truck terminals are common (Atilola et al., 2010; Azuonwu et al., 2011; Delany-Moretlwe places for them to have sex with CSWs in exchange for et al., 2014; Maarefvand et al., 2016; Ishtiaq et al., 2017). money; hence, it was important to conduct this study at This article presents findings from a study conducted Kazungula weighbridge terminal. A study conducted in Hong among a relatively large sample (N = 399) of LDTDs, the Kong reveals that one quarter of LDTDs visited CSWs and research site being a weighbridge terminal in Botswana 80.4% reported indulging in sexually risky behaviour (Wong located close to the country’s borders with Zambia and et al., 2007). These results connect well with those of a study Zimbabwe. The study was investigating factors associated conducted in India in which about one quarter of LDTDs with buying sex and the knowledge that condoms prevent visited CSWs and about 58% to 74% reported inconsistent HIV transmission among long-distance truck drivers at this condom use (Mishra et al., 2012). In other studies, some terminal. Kazungula weighbridge terminal is one of the LDTDs are reported to propose higher payments to be paid major truck junctions in southern Africa and it is important to for non-condom use with CSWs. For example, in a study compare the findings of this study to similar studies around conducted in South Africa, some LDTDs paid more for sex the world. Moreover, there is a lack of relatively large scale without a condom due to the CSWs’ desperate economic studies of this nature in southern Africa and none has been problems (Makhakhe et al., 2017). Nevertheless, literature conducted on this topic in Botswana. To this end, this study shows that in spite of the availability of condoms in the will add to the body of knowledge about this sub-population condom dispensers at the rest rooms at the truck stops, at Kazungula weighbridge terminal. their use is not necessarily associated with their availability, as demonstrated in a study that reveals that some LDTDs The sociodemographics and sexual behaviours of and make commercial sex workers choose between sex without condom use by LDTDs a condom or losing a sale. LDTDs constitute a heterogeneous population. Therefore, The attitude by LDTDs of disliking condom use is of great their sociodemographic characteristics such as age and public health concern as it increases the chance of HIV marital status provide an important relationship with the transmission (Sawal et al., 2016). It is clear from extant buying of sex and the knowledge that condoms prevent HIV literature that LDTDs have negative attitudes towards transmission (Yusuf et al., 2014). Studies carried out on condom use and thus indulge in riskier sexually encounters, LDTDs reveal that the significant demographic predictors which predisposes them to acquiring HIV and other sexual of condom use are educational and marital status and age. transmitted infections (Matovu and Ssebadduka, 2013). Sociodemographic factors such as the age at which one Their dislike of condom use has negative consequences started the trucking occupation also play a significant role in for their sexual behaviours. In some studies, LDTDs put their sexual behaviours, with adolescent entrants exhibiting the blame on condoms, saying that they destroy the mood higher risk sexual behaviours like buying sex compared to for sex (Sorensen et al., 2007; Matovu and Ssebadduka, the adult entrants (Mishra et al., 2012). A study conducted 2013). But generally, studies are inconsistent on the LDTDs’ in Nigeria found age as a demographic factor related to level of knowledge about HIV and there is less literature risky sexual behaviour, with younger truck drivers being that focuses on factors associated with the knowledge that more likely to use condoms; while, in a study conducted in condoms prevent HIV transmission. Moreover, no studies Bolivia, older truck drivers were found to use condoms less, have been conducted in Botswana on factors associated and those with a higher level of education had significantly with buying sex and the knowledge that condoms prevent higher levels of condom use (Sorensen et al., 2007; Aniebue HIV transmission among long-distance truck drivers at and Aniebue, 2009). Yaya et al. (2016) suggest that the link Kazungula weighbridge terminal. To this end, it was between education and risky sexual behaviour may indicate important to conduct a study on the factors associated with that education inspires an understanding of HIV-prevention buying sex and the knowledge that condoms prevent HIV information, which is provided as a form of risk reduction transmission among LDTDs at Kazungula weighbridge intervention for LDTDs. It can therefore be concluded with terminal to serve as a reference point in planning public evidence from the literature that demographic characteristics health programmes for LDTDs. African Journal of AIDS Research 2023: 1–11 3 Long-distance truck drivers’ knowledge of HIV and AIDS from the Botswanan and Zambian borders, and trucks stop A very important aspect to consider when taking into account at the weighbridge for customs duty and also for a break LDTDs’ sexual behaviours is their knowledge of HIV and from long-distance travel. Trucks remain at the weighbridge AIDS. In some studies conducted among truck drivers in Iran for long periods, making the place a lucrative rendezvous and Morocco, there was a low level of knowledge about HIV for commercial sex work. Approximately 3 000 LDTDs use and AIDS, and the HIV knowledge index was low among the Kazungula weighbridge in a month and most of them the semiliterate (Tehrani and Malek-Afzali, 2008; Himmich are from neighbouring South Africa. The study population et al., 2015). Some studies, however, reveal high levels of was comprised of both the international and local LDTDs knowledge about HIV and AIDS. For instance, in a study available at Kazungula weighbridge terminal, who were conducted in India, 95% of LDTDs knew that condom use can in transit and had stopped there. The LDTDs take a day reduce HIV transmission, but low levels of knowledge were or more, queuing to have their trucks weighed to pay the reported in relation to the importance of refraining from having required customs duty and also to have a break from a multiple concurrent sexual partners and avoiding high-risk long distance drive before proceeding to their various groups like CSWs (Singh and Joshi, 2012; Nasir et al., 2015). destinations. Most of them spend their nights in their trucks. In some studies, the level of knowledge that non-condom As for the road network, Kazungula village forms a vital use during sex is a mode of HIV transmission was as high as link with other SADC countries, which is why there is so 88.8% (Aniebue and Aniebue, 2009). The study by Aniebue much trucking activity in this area, making it one of the and Aniebue (2009) used a cross-sectional design and the major trucking corridors on the subcontinent, with a lot of questionnare was researcher administered, while Nasir et al. trucks parking at this terminal in transit. Nonetheless, there (2015) carried out a mixed methods analysis of descriptive are other routes that also service the north-south corridor, and inferential points, followed by interviews. From the for example, the Beitbridge route that passes between different study designs and methods used in different South Africa and Zimbabwe. Compared to the Kazungula studies, it is clear that even though LDTDs have high levels route, the Beitbridge route is relatively shorter for truckers of knowledge about HIV and its prevention, they harbour travelling from most SADC countries to more northern some misconceptions about the causes and transmission of sub-Saharan Africa, making it more favourable. However, HIV. Empirical evidence suggests that the misconceptions according to a report by Nkala (2021), the recently opened harboured by the LDTDs about the causes and transmission Kazungula bridge that crosses over the intersection of HIV include mosquito bites, shaking of hands and sharing of the Chobe and Zambezi rivers, replacing the ferry of rooms (Singh and Joshi, 2012; Poda and Sanon, 2015). crossing, gives the Kazungula route an advantage over With this in mind, it is necessary to examine LDTDs’ HIV the Beitbridge border crossing which regularly experiences knowledge as a component of information, attitudes towards transit bottlenecks and other problems on the Zimbabwe condoms, perceived vulnerability to HIV and AIDS and the side. These issues include the dilapidated road network, factors associated with sexual transactions in exchange many taxes and multiple vehicle inspection roadblocks. for money at critical points such as the weighbridge of Furthermore, Kazungula benefits from better infrastructural Kazungula terminal in the Chobe district of Botswana. development initiatives, such as the Botswana–Zambia one-stop border post, which now makes this route a better Methods alternative in facilitating intra-regional freight compared to other routes (Nkala, 2021). Study design and population The study employed a quantitative cross-sectional Sampling procedure descriptive approach to assess the level of HIV and AIDS A simple random sampling technique was used to select knowledge and related sexual behaviours among long the participants. The study opted to use a population of distance truck drivers. Cross-sectional descriptive design unknown size based on the transit nature of the border was suitable for this study as it involved collecting data from posts in Botswana. Nevertheless, the sampling relied on a large sample and subsequently describing, analysing the reported estimate of 3 000 LDTDs that pass through and interpreting factors associated with buying sex and the Kazungula weighbridge terminal each month as a basis for knowledge that condoms prevent HIV transmission among sampling. The sample size was calculated using the Raosoft LDTDs at a single point in time (Polit & Beck, 2017). This sample size calculator at a confidence level of 95% and a study was conducted at Kazungula weighbridge terminal 5% accepted margin of error at a response distribution of in the Chobe district of Botswana. Kazungula village is 50%. A 5% buffer of participants was included in the sample located on the northern side of Botswana. The village lies as a contingency and also to improve the extrapolation of to the south of the confluence of two big perennial rivers, the results, culminating in a sample size of 399 .Inclusion the Chobe and the Zambezi. Kazungula village has two criteria were: border posts, one for crossing into Zimbabwe and the other • Only truck drivers who understood either English or into Zambia. Trucks crossing through Botswana to Zambia Setswana were included in the study; use the north-south transport corridor, which forms part of • LDTDs who had truck driving as their occupation, who the Southern African Development Community (SADC) drove heavy trucks with three or more axles, and who regional truck network that passes through Kazungula, had registered for custom duty services at Kazungula thus providing an important link for regional economic weighbridge terminal; and integration, with voluminous trucking activity on this route. • Truck drivers that were a day or more away from home Kazungula weighbridge terminus lies about two kilometres and had stopped at Kazungula weighbridge terminal. 4 Gaolaolwe and Mokgatle All truck drivers who worked in Kazungula village or its Ministry of Health and Wellness IRB (Ref: HPDME 13/18/1 vicinity and those who had not been away from their homes X (855). Permission was also sought from the Kazungula for a day or more were excluded. weighbridge management to conduct the data collection at their facility (Ref: KR 5/20 III (149). Data was collected Data collection after the participants provided informed written consent. The data collection method was administered through Participation was voluntary, including the right to withdraw structured questionnaires. The questionnaires were from the study without any preconditions. For anonymity, administered by WG and a trained research assistant, no identifying information was collected and the data file using adapted validated questions from a previous was password protected, with access limited to both the study and it was prepared in English and translated into researchers in this study. Setswana (Madiba and Mokgatle, 2015). The questionnaire was composed of closed-ended questions to collect Results sociodemographic data of the LDTDs and their sexual behaviours such as exchange of money for sex with CSWs Characteristics of LDTDs and questions to ascertain the LDTDs’ knowledge that A sample of 399 LDTDs participated in this cross-sectional condoms prevent HIV transmission to allow a comparison study and 327 were international drivers. The ages of the of findings with previous studies which used such LDTDs who took part in the study ranged from 23 to 63 years, questions. On each day of data collection, the available with a mean age of 39.7 years (SD 8.89). The minimum LDTDs gathered at the weighbridge terminal offices age for becoming a long-distance driver was 19 and the in collaboration with the facility management for data maximum was 45. Most of the drivers (49.8%; n = 199) joined collection. The questionnaires were administered to the long-distance truck driving between the ages of 26 and 29 LDTDs who voluntarily consented to participate, and the years. The minimum period that a LDTD had spent on truck exercise took about 30 minutes per participant to complete. driving was one year, while the maximum was 33 years. Of The questionnaires were administered when the LDTDs the 399 participants, 9.5% (n = 24) did not have a formal were less busy and waiting for their turn to be assisted at education and of those who had a formal education, a high the weighbridge terminal. Data collection took about seven proportion of 63.4% (n = 253) had secondary education, with months, from February to August 2017. the remaining 30.6% (n = 146) consisting of those with tertiary and primary education at 15.0% and 15.5% respectively. Of Data analysis the 262 LDTDs who had intimate sexual partners, 53.1% Statistical analysis covered the sociodemographic profile of (n = 139) had had two or more in the past 12 months. The the study population, established the extent of the LDTDs’ remaining 34.3% (n = 137) had no committed intimate sexual knowledge about HIV and AIDS, the nature of their sexual partnerships, but had casual sex involving CSWs. Generally, behaviours and factors associated with buying sex and the the LDTDs who did not have committed sexual partners and knowledge that condoms prevent HIV transmission. Data those who had committed sexual partners all had casual sex was analysed using Stata 4.0 software (StataCorp). In involving CSWs. The sociodemographics of the participants the univariate analysis, sociodemographic profiles, sexual are sumarised in Table 1. behaviours and condom use of the LDTDs were calculated. The Pearson’s chi-square test was used in bivariate analysis LDTDs’ sexual behaviours for the relationship between knowledge that condoms prevent According to the results of this study (Table 2), more than HIV transmission, the sociodemographic characteristics half of the LDTDs (56.9%; n = 227) had paid for sex with and the sexual behaviours, and the relationship of sex in commercial sex workers at some point in their career, and exchange for money to sociodemographics and risky sexual 27.1% (n = 108) reported to have had unprotected sex with behaviours and condom use. Multivariable logistic regression CSWs. As many as 34.1% (n = 136) of the LDTDs reported analysis was performed to identify independent risk factors to have paid for sex with CSWs in the past 12 months. A for the dichotomous outcomes: sex with CSW in exchange for significantly high proportion of the LDTDs (97.2%; n = 388) money in the past 12 months (yes or no); and knowledge or knew where to get condoms when needed. Most LDTDs lack of knowledge that condoms prevent HIV transmission. had scores above 90% on the following: on their ability to The variables that were statistically significant during bivariate remember to carry a condom on their trips (93.2%; n = 372); analysis at a p-value less than 0.05 were then selected for their ability to buy condoms without feeling embarrassed the logistic regression model to assess among LDTDs the (90.5%; n = 361); their confidence in their ability to put on a variables’ contribution to sex in exchange for money among condom (93.5%; n = 373); their confidence in their ability to the LDTDs and to the knowledge that condoms prevent HIV remove and dispose of a condom after sexual intercourse transmission by estimating the adjusted odds ratios (ORs) at (93.2; n = 372); their ability to get a condom from a public 95% confidence intervals (CI). place without feeling embarrassed (91.5%; n = 365). The results also indicate that 29.1% (n = 116) of LDTDs indicated Ethical considerations that they would not feel confident to propose using a condom The Research Ethics Committee of Sefako Makgatho Health to a new intimate sexual partner because of the fear that the Sciences University (SMUREC) reviewed the protocol partner would think they have a sexually transmitted disease. and gave ethical clearance for the study to be conducted While 37.6% of the LDTDs (n = 150) in the study were of (SMUREC/H/286/2016 of 09/2016). The letter of clearance the view that a condom creates doubt between partners, from the SMUREC was used to get permission from the just above half of participants (51.4%; n = 205) had an African Journal of AIDS Research 2023: 1–11 5 Table 1: Sociodemographic characteristics of the long-distance Table 2: Long-distance truck drivers’ sexual behaviours and truck drivers condom use (N = 399) Sociodemographic variable Frequency (n) Per cent % Question/statement Response n % Type of commuter I have at some point paid for sex Agree 227 56.9 Local 72 18 with commercial sex workers in my Disagree 172 43.1 International 327 82 long-distance travels with a truck. Age (years) I have had sex with a commercial Agree 108 27.1 <25 4 1 sex worker without using a condom. Disagree 291 72.9 26–29 70 17.5 In the past 12 months I have paid Agree 136 34.1 >30 325 81.5 for sex. Disagree 263 65.9 Age started work as truck driver (years) I know where to get condoms when I Agree 388 97.2 <25 62 15.5 need them. Disagree 11 2.8 26–29 199 49.8 I feel confident in my ability to put a Agree 373 93.5 >30 138 34.6 condom on myself. Disagree 26 6.5 Duration in trucking industry (years) I feel confident I could remove and Agree 372 93.2 <5 128 32.1 dispose of a condom after sexual 6–10 95 23.8 Disagree 27 6.8 intercourse. >11 176 44.1 I feel confident I could purchase Agree 361 90.5 Level of education condoms without feeling No formal education 24 9.5 Disagree 38 9.5 embarrassed. Primary school 62 15.5 Secondary education 253 63.4 I feel confident that I could go and Agree 365 91.5 Tertiary education 60 15.0 get condoms from a public place Disagree 34 8.5 without feeling embarrassed. Number of sexual partners None, but have casual sex 137 34.3 I feel confident I could remember to Agree 372 93.2 One 123 46.9 carry a condom. Disagree 27 6.8 Two 66 25.2 I would not feel confident suggesting Agree 116 29.1 More than two 73 27.9 using condoms with a new partner because I would be afraid they Disagree 283 70.9 would think I have a sexually transmitted disease. opposite view, and the rest (11.0%; n = 44) were not sure. A condom creates doubt between Agree 150 37.6 Table 2 also shows that 75.9% (n = 303) were worried about sexual partners. Disagree 205 51.4 contracting HIV, and 80.2% (n = 320) of the LDTDs indicated Not sure 44 11.0 that there was a high possibility that they might refuse How worried are you about getting Worried 303 75.9 coitus if their partner refused to let them use a condom. A HIV and/or AIDS? Not worried 96 24.1 significantly high number of 87.0% (n = 347) indicated that What are the chances you could ask High 347 87.0 there was a high chance that they might have an HIV test your partner to go for an HIV test Low 52 13.0 with their partners (Table 2). with you? What are the chances of you refusing High 320 80.2 Knowledge about HIV and AIDS sex if your partner does not want to Low 79 19.8 let you use a condom? The findings of this study shows that all the LDTD who participated in this study had heard about HIV and AIDS (100%; N = 399) (Table 3). The media was reported as the main source of information about HIV and AIDS at 65.9% Relationship between knowledge that condoms prevent (n = 263), while those who had learnt about HIV and AIDS at HIV transmission, sociodemographic characteristics school stood at 62.9% (n = 251). 53.6% (n = 214) had heard and sexual behaviours about it from a clinic, while 20% (n = 81) heard about HIV Table 4 presents a bivariate analysis of the knowledge that and AIDS at church. 5.0% (n = 20) had heard of it through condoms prevent HIV transmission and the participants’ unspecified ways. The overall results of the univariate sociodemographic characteristics. From the 90.2% (n = 360) analysis shows that the LDTDs had a high level of knowledge of the LDTDs who knew that HIV can be prevented using a about HIV and AIDS, with scores as high as 97.0% (n = 387) condom, those with a secondary education had the highest on the knowledge that HIV causes AIDS. Only 12.0% of the proportion with 58.7%, followed by tertiary with 14.5%, while LDTDs believed that HIV and AIDS is caused by witchcraft, those with no formal education or only primary education and most of the participants knew that currently there is no accounted for 5.8% and 11.3% respectively. This rendered cure for HIV (76.7%; n = 306). A high proportion of LDTDs a p-value of <0.001, which is statistically significant. The (97.0%; n = 387) had knowledge that having multiple analysis further reveals that age was not a predictor of partners increases the chance of contracting HIV, and that knowledge that condoms prevent HIV transmission, with HIV transmission can be prevented by using a condom p-value of 0.035. Knowledge that condoms can prevent during coitus (90.2%; n = 360). All the percentage scores for HIV transmission is associated with confidence to carry knowledge about HIV and AIDS were above 75% (Table 3). a condom on trips (p = 0.003), confidence to suggest a condom to a new partner (p < 0.001), attitude of disliking 6 Gaolaolwe and Mokgatle Table 3: Long-distance truck drivers’ sources and levels of knowledge about HIV and AIDS (N = 399) Questions/statements Response Frequency (n) Per cent % Have you ever heard about HIV and AIDS? Yes 399 100 Source of information Media Yes 263 65.9 Church Yes 81 20.3 School Yes 251 62.9 Clinic Yes 214 53.6 Other Yes 20 5.0 Knowledge levels Correct response HIV is the virus that causes AIDS. True 387 97.0 HIV and AIDS is caused by witchcraft. False 351 88.0 There is no cure for HIV and AIDS currently. True 306 76.7 Having a sexually transmitted disease can increase a person’s risk of getting HIV. True 380 95.2 A healthy-looking person can have HIV. True 375 94.0 Having multiple sexual partners increases the risk of getting HIV. True 387 97.0 HIV can be transmitted by sexual intercourse with an infected person. True 379 95.0 HIV can be prevented by using a condom during sexual intercourse. True 360 90.2 HIV can be transmitted by sharing needles or syringes. True 367 92.0 HIV can be transmitted by blood transfusion. True 374 93.7 HIV can be transmitted by sharing a glass or cup with an infected person. False 363 91.0 HIV can be transmitted by sharing a toilet with an HIV infected person. False 366 91.7 Infection with HIV can be prevented by washing one’s genitals with antiseptics or False 312 78.2 soap after sexual intercourse with an infected person. Table 4: Association between knowledge that a condom prevents HIV transmission and sociodemographics, sexual behaviour and condom use (N = 399) Knowledge that condoms prevent HIV transmission Sociodemographic variable p-value Yes No % (n) % (n) Age (years) <25 1.00 (4) 0.00 (0) 26–29 16.54 (66) 1.00 (4) 0.349 >30 72.68 (290) 8.77 (35) Level of education No formal education 5.76 (23) 0.75 (3) Primary 11.28 (45) 4.01 (16) <0.001 Secondary 58.65 (234) 4.51 (18) Tertiary 14.54 (58) 0.50 (2) Sexual behaviours and condom use Confident to carry condom on trips 85.21 (340) 8.02 (32) 0.003 Confident to suggest a condom to partner before intercourse 23.81 (95) 5.26 (21) <0.001 Worried about contracting HIV 69.42 (277) 6.52 (26) 0.154 Attitude of disliking condom use 10.03 (40) 2.76 (11) 0.002 Confident to refuse sex with a CSW using a condom 73.43 (293) 6.77 (27) 0.070 Not using a condom consistently because of unplanned sex 12.28 (49) 3.01 (12) 0.005 Perception that a condom kills the mood for sex 11.03 (44) 1.25 (5) 0.914 Have had sex with casual partner 18.55 (74) 3.01 (12) 0.141 condoms (p = 0.002) and not using a condom consistently (n = 12), and the association rendered a p-value of 0.001. because of unplanned sex (p = 0.005). Table 5 also shows that, though age was not a predictor in paying for sex with CSWs in the past 12 months during Relationship of sex in exchange for money to long-distance travels, the proportion of LDTDs paying for sociodemographics and risky sexual behaviours and sex with CSWs was 34.1% (n = 136). The number of sexual condom use partners that a LDTD had an association with buying sex in A bivariate analysis was conducted to establish the the past 12 months (p < 0.001). Paying for sex with CSWs association between paying for sex in the past 12 months in the past 12 months had an association to the reporting of and sociodemographics, sexual behaviour and condom being confident in the ability to wear a condom (p = 0.002), use (Table 5). Of the 136 drivers who paid for sex during confidence to refuse sex with a condom (p < 0.001), and an the past 12 months, 31.08% (n = 124) were international attitude of disliking condom use (p < 0.001). LDTDs, while the local LDTDs accounted for 3.01% African Journal of AIDS Research 2023: 1–11 7 Table 5: Association between paying for sex with commercial sex workers (CSW) in past 12 months and sociodemographics, sexual behaviour and condom use (N = 399) Paying for sex with a CSW in the past 12 months Sociodemographic variable p-value Yes No % (n) % (n) Type of traveller Local 3.0 (12) 15.0 (60) International 31.1 (124) 50.9 (203) 0.001 Age (years) <25 0.8 (3) 0.3 (1) 26–29 6.5 (26) 11.0 (44) 0.177 >30 26.8 (107) 54.6 (218) Level of education No formal education 2.0 (8) 4.0 (16 Primary 5.5 (22) 10.0 (40) Secondary 22.8 (91) 40.6 (162) 0.446 Tertiary 3.8 (15) 11.3 (45) Duration in trucking (years) <5 11.8 (47) 20.3 (81) 6–10 6.0 (24) 17.8 (71) 0.115 >11 16.3 (65) 27.8 (111) Number of sexual partners None, but have had casual sex 3.8 (15) 30.6 (122) One 10.3 (41) 31.3 (82) Two 12.2 (32) 13.0 (34) <0.001 More than two 18.3 (48) 9.5 (25) Sexual behaviours and condom use Confident about the ability to wear a condom 32.2 (120/373) 67.8 (253/373) 0.002 Confident to suggest a condom to partner before intercourse 37.1 (43/116) 62.9 (73/116) 0.648 Worried about contracting HIV 34.7 (105/303) 65.3 (198/303) 0.181 Confident to refuse sex with a CSW using a condom 64.8 (70/108) 35.2 (38/108) <0.001 Attitude of disliking condom use 56.9 (29/51) 43.1 (22/51) <0.001 Factors associated with the exchange of sex for money had less confidence (AOR 2.3; 95% CI 0.78–6.47). The with CSWs among LDTDs analysis further revealed the level of education as a factor Factors associated with sex in exchange for money with contributing to the knowledge that condom use prevents CSWs in the past 12 months were investigated using HIV transmission among LDTDs, with those who had no multivariable logistic regression analysis (Table 6). This formal education and those who had primary education indicated that international LDTDs were about three times being less likely to have knowledge that condoms use more likely to have bought sex in the past 12 months than prevents HIV transmission (AOR 0.5; 95% CI 0.65–3.24; the local ones (AOR 2.9; 95% CI 1.31–6.56). Furthermore, AOR 0.1; 95% CI 0.02–0.44 respectively). Disliking condom the multivariable logistic regression model analysis use was also a factor contributing to less knowledge that revealed that having more than two sexual partners had a condom use prevents HIV among the LDTDs (AOR 0.4; strong association with buying sex in the past 12 months, 95% CI 0.17–0.97). with a statistically significant p-value of 0.001 (AOR 3.2; 95% CI 1.65–6.33). In comparison, the LDTDs who had Discussion more than two sexual relationships had about three times the odds of buying sex in the adjusted odd ratio analysis This study took place at Kazungula weighbridge terminal than those with only two relationships or those who only to investigate factors associated with buying sex and the had casual sex with no committed relationship. The LDTDs knowledge that condoms prevent HIV transmission among who had high confidence in refusing sex with CSWs with a long-distance truck drivers. A number of factors including the condom had five times the odds of buying sex with CSWs sociodemographics such as the level of education, the number compared to those who lacked confidence (AOR 4.9; of committed sexual partners that the LDTDs had and having 95% CI 2.85–8.46). truck driving as an occupation especially an international LDTD were identified in this subpopulation group. Factors associated with the knowledge that condom use prevents HIV among the LDTDs Sociodemographics and LDTDs’ sexual behaviours The results of a logistic regression analysis in Table 7 shows This study shows that international LDTDs have a that the LDTDs who had confidence to carry condoms on significantly higher risk of contracting HIV than the local trips had about twice the odds of knowledge that condoms drivers. As indicated by Delany-Moretlwe et al. (2014) can prevent HIV transmission compared to those who on the topic of LDTDs and mobility, international LDTDs 8 Gaolaolwe and Mokgatle Table 6: Multivariate analysis — sex with a commercial sex worker (CSW) in exchange for money in the past 12 months (N = 399) Sex with CSW in exchange for money UOR AOR in past 12 months Variable p-value p-value (95% CI) (95% CI) Yes No % (n) % (n) Type of commuter Local (n = 72) 12 (16.7) 60 (83.3) Ref (0) Ref (0) International (n = 327) 124 (37.9) 203 (62.1) 3.1 (1.62–6.03) 0.001 2.9 (1.31–6.56) 0.009 Number of sexual partners in the past 12 months One 41 (30) 83 (31) Ref (0) Ref(0) Only have casual sex 15 (11) 122 (89) 0.3 (0.13–0.47) <0.001 0.2 (0.12–0.48) <0.001 Two 32 (48.5) 34 (51.5) 1.9 (1.02–3.47) 0.043 1.3 (0.68–2.63) 0.394 >2 48 (65.8) 25 (34.3) 3.84 (2.08–7.08) <0.001 3.2 (1.65–6.33) 0.001 Confidence to wear a condom Agree 120 (32.2) 25 (67.8) Ref (0) Ref (0) Disagree 16 (61.5) 10 (38.5) 0.3 (0.13–0.67) 0.004 0.5 (0.20–1.40) 0.200 Confidence to refuse sex with CSW without a condom Low chance 66 (22.7) 225 (77.3) Ref (0) Ref (0) High chance 70 (64.8) 38 (35.2) 6.3 (3.88–10.16) <0.001 4.9 (2.85–8.46) <0.001 Attitude of disliking condom use Yes 29 (56.9) 22 (43.1) Ref(0) Ref(0) No 107 (30.8) 241 (69.3) 3.0 (1.63–5.40) <0.001 1.3 (0.61–2.64) 0.526 Table 7: Multivariate analysis — long-distance truck drivers (LDTDs) with knowledge that condoms prevent HIV transmission and sociodemographics, sexual behaviour and condom use LDTDs with Variable UOR (95% CI) p-value AOR (95% CI) p-value knowledge n (%) Level of education Tertiary Ref (0) Ref (0) No formal education 23 (88.5) 0.3 (0.04–1.69) 0.159 0.5 (0.65–3.24) 0.435 Primary 45 (73.8) 0.1 (0.02–0.44) 0.003 0.1 (0.02–0.46) 0.003 Secondary 234 (92.9) 0.4 (0.10–1.99) 0.291 0.5 (0.97–2.14) 0.319 Confident to carry condom on trips Agree 340/372 (91.4) Ref (0) Ref (0) Disagree 20/27 (74.1) 3.7 (1.46–9.46) 0.006 2.3 (0.78–6.47) 0.132 Confident to suggest condom to new partner before sex Agree 265/283 (93.6) Ref (0) Ref (0) Disagree 95/116 (81.9) 0.3 (0.16–0.60) 0.001 0.3 (0.16–0.71) 0.004 Attitude of disliking condom use Yes 40/51 (78.4) Ref (0) Ref (0) No 320/348 (92.0) 0.3 (0.15–0.69) 0.004 0.4 (0.17–0.97) 0.043 Inconsistent condom use due to unplanned sex Yes 49/61 (80.3) Ref (0) Ref (0) No 311/338 (92.0) 0.4 (0.17–0.75) 0.006 0.4 (0.15–0.81) 0.014 generally spend more time on the road and this exposes Factors associated with sex in exchange for money and them to acquiring and transmitting HIV. This suggests the knowledge that condoms prevent HIV transmisison that cross-border long-distance trucking is one of the key The results of our study indicate that being an international drivers of the HIV epidemic and aids transmission through truck driver is a factor associated with sex in exchange risky sexual behaviours. The number of sexual partners for money. The higher vulnerability of international LDTDs that an LDTD has also exhibits a significant association compared with the local ones may also be explained, at with a higher proportion of paying for sex with CSWs in least partly, by their likelihood to engage in riskier sexual the past 12 months, especially among those who have behaviours, including sex in exchange for money with CSWs more than two committed sexual partners. This finding due to the environmental factors associated with the trucking is consistent with those of other research in various industry, such as high mobility and easy access to CSWs. settings that determined that the number of committed This study found that as high as 56.9% of the LDTDs had sexual partners that a LDTD has is linked to high-risk HIV paid for sex with CSWs at some point during their travels, behaviour (Nasir et al., 2015). 34.1% had paid for sex with CSWs in the past 12 months, African Journal of AIDS Research 2023: 1–11 9 and 27.1% of them engaged in unprotected sex with protected sex. Though the reasons for non-condom use CSWs. These findings are important because, to the best in some studies included their unavailability and having of our knowledge, there has not been any study previously to buy them for themselves, for this study, the reasons for conducted at weighbridge terminals in Botswana to assess non-condom use included the attitude of LDTDs of disliking the LDTDs’ sexual behaviours such as paying for sex with condoms and inconsistency in condom use because of CSWs. Nevertheless, other studies match the findings of unplanned sex (Aniebue and Aniebue, 2009). this study as demonstrated by the results of studies by both The number of sexual partners that the LDTDs have is Nasir et al. (2015) and Wong et al. (2007), in which 54% of also a cause for concern in the fight against HIV as it is the truck drivers paid for sex with CSWs. In comparison and a predictor of the exchange of money for sex with CSWs. as a matter of concern, this study shows that international This study reveals that the number of sexual partners LDTDs were three times more likely to buy sex with CSWs that the LDTDs had was positively associated with the than the local ones. In spite of this important finding, there exchange of sex for money with CSWs in the past 12 is a paucity of literature that compares the risky sexual months. The LDTDs who had more than two sexual behaviours such as sex in exchange for money with CSWs relationships had about three times the odds of buying sex between the international and local LDTDs in Botswana and with CSWs in the adjusted odd ratio analysis than those this study closes the gap. It can thus be concluded from with only two or those who only had casual sex with no empirical evidence from other studies that the international committed relationship. This finding is consistent with that LDTDs’ riskier sexual behaviours could be attributed to of a study conducted by Nasir et al. (2015) in Pakistan in staying away from their homes for lengthy periods (Nasir which a quarter of LDTDs had at least two sexual partners, et al., 2015; Atilola et al., 2010 ). This conclusion resonates and up to 54.2% had paid for sex with CSWs. well with the findings of a study conducted in South Africa Furthermore, the confidence to carry a condom is also in which international drivers generally spent more time on positively associated with the knowledge that a condom the road, getting exposed to acquiring and spreading HIV can prevent HIV transmission. This factor is important through paying for sex with CSWs (Delany-Moretlwe et al., and making condoms available at truck terminals is not 2014). enough because LDTDs could avoid using them for the It is evident from the results of this study that LDTDs same reasons that they do not carry the condoms, which use the desperate economic situation of the CSWs to could be from the lack of knowledge that condoms prevent exploit them into having unprotected sex with them in HIV transmission. In this study, the LDTDs who had the exchange for money (Ntseane, 2004). In this study, the confidence to carry condoms on trips had about twice the LDTDs who indicated that they would refuse sex with odds of having the knowledge that condoms can prevent HIV CSWs with a condom had five times the odds of buying transmission compared to those who had less confidence. sex with CSWs compared to their counterparts who would Even though this finding is important in the fight against not have unprotected sex with CSWs. Despite having HIV, there is a dearth of literature that supports it. But that such risky sexual behaviours, this sub-population has not still being the case, the available literature indicates that received the attention it deserves by other researchers LDTDs place the responsibility to carry condoms primarily or the government to embark on a national behavioural with CSWs, and/or do not carry condoms because they surveillance of the LDTDs. Even though some efforts at prefer to engage in unprotected sex. Due to their inadequate various governmental and non-governmental organisations knowledge of the importance of condoms as an HIV have been made to achieve behaviour change through preventive measure, they engage in unprotected sex and community sensitisation and mass-media exposure to use what they view as alternative safety measures such as promote safe sexual practices in the general population, washing their genitals with battery water or urine after sex the adoption of tailor-made preventive behaviours targeting (Makhakhe et al., 2017). The use of condoms during sex is a LDTDs is relatively low. LDTDs still engage in unprotected key preventive strategy since rates of HIV and other sexually sexual activities with CSWs. Public health initiatives geared transmitted infections continue to escalate. To this end, the towards the control of HIV and AIDS among LDTDs is a level of knowledge about condoms as a preventive measure challenge due to limited information on LDTDs’ sexual for HIV and their use is important to this sub-population. behaviours in Botswana and this consequently leads to a Literature shows that adults who have attained a higher failure to adequately reach out to this high-risk group as an education level have better health and longer lifespans important sub-population for intervention. Similar findings compared to their less-educated peers (Raghupath and on risky sexual behaviours have been reported in other Raghupath, 2020). So, there is no doubt that the level of studies, e.g. a study conducted in Uganda reveals that education that one has attained in life is a fundamental LDTDs had unprotected sex with CSWs in exchange for vehicle, not only in possessing knowledge, but also for money (Matovu & Ssebadduka, 2013). That study shows self-preservation (Bhardwaj, 2016). Thus, the level of that some LDTDs proposed a charge of 20 000 Ugandan education that the LDTDs attain can have a bearing shillings for non-condom use and 2 000 Ugandan shillings on how they comprehend and use the information for for condom use, with the former being the choice of the self-preservation against HIV. The results of our study also CSWs due to their desperate economic problems. These reveal the level of education as a factor that contributes to results are consistent with those of our study where LDTDs the knowledge that condom use prevents HIV transmission who indicated that they would refuse sex with CSWs with a among LDTDs. The LDTDs who had no formal education condom had five times the odds of buying sex with CSWs and those who had primary education were less likely to compared to those who lacked the confidence to refuse have knowledge that condom use prevents HIV transmission 10 Gaolaolwe and Mokgatle (AOR 0.5 and AOR 0.1 respectively). It can be concluded with sex in exchange for money. Factors associated with from the findings of this study that the LDTDs’ level of the knowledge that condoms prevent HIV transmission education has an influence on their knowledge about HIV among LDTDs include the confidence to carry condoms on and AIDS, with those with secondary and tertiary education trips. The results of our study further reveal that the level displaying more knowledge than those who had no formal of education is a factor contributing to the knowledge that or primary education, and this is consistent with the findings condom use prevents HIV transmission among LDTDs. It of a study conducted in Pakistan which produced similar can therefore be concluded with empirical evidence from results (Nasir et al., 2015). This finding can assist in aligning our study that LDTDs remain an at-risk group for acquiring health education activities to accommodate the LDTDs’ and propagating HIV, and the risk is more with international diverse levels of education for effectiveness in raising the LDTDs compared to those travelling locally. Other studies awareness about condoms as a preventive measure against ascribe the risky behaviour to being away from home for HIV. With the findings of this study, the government can protracted periods. The findings of our study demonstrate intensify mass media campaigns and other public health the need for HIV and AIDS control programmes to measures aimed at stimulating appropriate risk perception, strengthen HIV-prevention interventions among LDTDs. discouraging unsafe sex practices and promoting consistent Making condoms available at truck stops and the promotion condom use by LDTDs. of safe sex practices such as consistent condom use Although there are no studies that were conducted in requires policy decisions from those who wish to promote Botswana to gauge the historical progress made in regard safe sex among LDTDs. Furthermore, there is a need to LDTDs’ sexual behaviours, a comparison of the current to develop policies that embrace critical HIV-prevention study with similar ones conducted elsewhere shows strategies with high success rate for key populations, positive progress in their sexual behaviours. For instance, e.g. policies that support the provision of post-exposure a survey conducted by Singh and Malaviya in 1994 prophylaxis (PEP) and pre-exposure prophylaxis (PrEP) revealed that 78% of LDTDs reported CSW exposure and to vulnerable populations such as LDTDs, including the 77% occasionally engaged in unprotected sex. In 1998, non-citizen international truckers. a study by Mishra et al. (2012) found that 80% of truck drivers visited CSWs and 75% had either used a condom ORCID iDs inconsistently, or had never used a condom. The current study shows that 56.9% of the LDTDs visited CSWs at Wada Gaolaolwe – https://orcid.org/0000-0003-1014-2005 some point during their long-distance travels with a truck, Mathildah Mokgatle – https://orcid.org/0000-0001-5807-8212 and as little as 27.1% reported to have had sex with CSWs without a condom. That still being the case, more effort References needs to be geared towards changing LDTDs’ behaviours Agha, S. (2010). 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Journal

African Journal of AIDS ResearchTaylor & Francis

Published: Jan 2, 2023

Keywords: commercial sex workers; condom use; HIV knowledge; HIV transmission; risky sexual behaviour; truck terminals

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