London School of Hygiene & Tropical Medicine

Tara Beattie is deputy director of the Centre for Global Mental Health, and a member of MARCH and the Gender Violence and Health Centre.  Tara completed an immunology PhD in Nairobi back in 2004, and 15 years later she’s returned but this time as an epidemiologist working on global women’s health. Her current study, Maisha Fiti (which translates to ‘Life Perfect’ in Swahili), involves 1000 sex workers in Nairobi, evaluating whether social factors such as violence, mental health, and alcohol use, could be causing changes in women’s immune systems and leaving them more susceptible to HIV infection.

For mental health awareness week – where the theme is kindness – I caught up with Tara over an inspiring zoom call to discuss her journey to the current project, the innovative ways she’s including women who sell sex in her research, small acts of kindness in her study, and why we should all care about these women in the current pandemic.

Q. A tough question to start - if you had to describe your research in one sentence, what would you say?

I want to understand how upstream social factors such as violence and poor mental health impact physiologically and immunologically on a woman’s body, and then how that increases their risk of HIV acquisition.

Q. I'm interested in your background - can you tell me more about the journey that's led you to a project involving sex workers in Nairobi?

My PhD was on the immunology of HIV infection among female sex workers in Nairobi. I’d always wanted to work in international women’s health, and so after my PhD I studied epidemiology at LSHTM and have spent the last 14 years working in South India on HIV related projects -  looking at the drivers of risk and what can be done to prevent those. These projects were with sex workers but also with adolescent girls.

I’ve just finished two trials in south India. One was trying to prevent child marriage and entry into sex work by keeping girls in school, and the other was trying to prevent violence against sex workers by their lovers. So their husbands – their non-paying partners.

As part of all this and studying the global literature, I knew violence against women in the general population is strongly associated with an increased risk of HIV acquisition. And it’s also known that the main risk seems to be physical or emotional violence from an intimate partner. But there’s no evidence that sexual violence against women increases the risk of HIV. I started thinking:

‘If violence against women is putting them at an increased risk of HIV, but it’s not happening through rape, then what is causing this increase in risk?’

Some of it will be that that men who are violent towards women tend to have multiple overlapping risk factors. Men who are violent tend to have multiple sexual partners, tend to go to sex workers, tend to use drugs and alcohol, tend to have anal sex, and tend to not use condoms. Which means that then when they have consensual sex with their partners, they’re more likely to transmit HIV.  

But then I also wondered if there could be an immunological pathway. Where the women who experience a lot of violence, or ongoing violence, have higher levels of cortisol, which would cause changes in their immune systems – both in the blood and in their genital tract.

The theory being:  Violence increases cortisol levels (the stress hormone), cortisol increases inflammation, increased inflammation in the genital tract means more immune cells in the genital tract, and this makes a woman more likely to contract HIV as HIV infects immune cells.  There’s evidence already that violence does increase stress. Poor mental health, and alcohol consumption also increase cortisol production. But there weren’t any studies to link these factors to inflammation in the genital tract.

So I needed to work with a group of people who experience violence and experience poor mental health so I could study these risks over time. I went to my Nairobi colleagues from 15 years ago – and Joshua Kimani, my fantastic PI said they could make it work there.

And that’s my journey from being a very green doctoral student working in the labs to being a much more experienced epidemiologist now!

Q. You’re looking at a lot of social factors including violence, mental health problems, harmful drinking and poverty – how interlinked are these and what do we know already?

Violence, mental health, and poverty are three sides of the same triangle – they’re so interlinked.

The story of these women’s lives generally is that they’ve grown up in extreme poverty, and they’ve dropped out of school because there’s no money, or they’ve fallen in love as a teenager, got pregnant, left school married the guy and then the relationship breaks down for a variety of reasons including violence, infidelity and drinking.

So now she’s in a situation where she’s on her own with one or two children and no education. She moved to Nairobi to escape him – is living in an impoverished setting and someone suggests that she should try sex work. And that’s the way that she can have some autonomy in her life and earn a reasonable income to support her family.

Poverty, violence and mental health are interwoven throughout those stories.

Q. You already covered the theory behind how these social factors could be causing biological changes – but how do you actually measure them and  link one to the other?

The behavioural aspects are measured using validated questionnaires. For mental health we look at depression, anxiety, suicidal thoughts and suicide attempts, and self-harm, as well as harmful drinking and drug use. We build up a score for each person and consider confounding variables too such as vaginal washing practices, contraception use etc.

For biological factors we take samples, blood for HIV, HSV-2, and syphilis and hair for cortisol levels. And we ask women to wear a soft cup – it gets inserted into the vagina and collects vaginal fluids while they do the questionnaire. We use that to check for cytokines and chemokines than might indicate inflammation in the genital tract.

I actually asked the whole study team to try wearing a vaginal cup so we all knew what it felt like – and you can’t feel it at all!

Then we do baseline measurements and follow ups after 6 months. We look at, for instance, Woman 1, Woman 2, and Woman 3.  At the start Woman 1 had experienced violence and her cortisol levels were at a certain level. Then at follow up she hasn’t experienced any further violence and we look to see if her cortisol levels have gone down. And then we compare her to Woman 2 has who has experienced violence in the past 6 months – have her cortisol levels gone up, gone down or stayed the same? And what about Woman 3 who hadn’t experienced violence at either point? As you do this over several women, you can begin to build up the picture.

We also did 40 in depth interviews which helped us understand the context and build up a better conceptual pathway. For example, if we take a step backwards – the most impactful point of intervention might not be the violence against sex workers by clients etc, but instead the violence in interpersonal relationships that drive marriages to break down, and in turn causes women to turn to sex work.

It’s at that point where I’d be intervening – catching girls who have young children, who are young themselves and whose relationships are breaking down. I’d be providing them with financial support or some other type of intervention so that they don’t end up on that trajectory.

Q. And what’s the end outcome with this kind of study – what’s the bigger picture thinking?

In this study, if we do find that violence and poor mental health are increasing inflammation in the genital tract, we might start thinking – should we be giving anti-inflammatories to women who are experiencing violence?

And then, what big upstream interventions do we need to be doing to address violence? We need to be addressing violence anyway, regardless of whether there’s a risk of HIV. But it helps support the argument even more.

There haven’t been many interventions for sex workers like this to date. Most of the work has been on preventing HIV – proving clinics, ARTs, condoms. So this broader upstream thinking is quite new.

It helps us answer, ‘at what point do we want to intervene?’. And I think adolescence is a really key time – between the age of 15-25. Could we give them livelihood training or social support?

Q. I’m interested by how much involvement you’ve included from the sex workers themselves and included them as part of the research team. How much impact have they had on the study?

The first thing I did at our study site in Nairobi was holding a meeting with sex workers. I told them about our proposal and what we wanted to do and asked them how we could best make it work. They gave some really good input from the get-go – for instance making it clear we couldn’t discriminate based on HIV status, so we enrolled women regardless of HIV status, and it enabled me to do a sub-study related to HIV progression among HIV positive women.

Then my study team actually included 10 sex workers. We have people on the ground in each of the seven regions who act as peer educators, they help to address issues and concerns. For instance, we have to collect hair samples to measure cortisol levels, and some people were worried we were using hair samples for witchcraft. They helped to dispel those myths.

We invited the seven peer educators along to the first week of the training for the research team, and they asked to stay for the whole thing. I thought, ‘why not?’. And as we were planning the research design and questionnaires, they were constantly inputting and providing valuable insights – telling us when things didn’t make sense, helping us with translations. They’ve been really instrumental to the project’s success throughout.

Q. Speaking of kindness on mental health awareness week – you’ve also hired some of the women as beauticians in your clinic. What motivated that decision?

Yes -  two of the women work as beauticians within my clinic as I wanted to create a really nurturing environment. Women who sell sex have really hard lives, they spend all their time looking after other people, tending to their clients or to their children. We were asking them really hard questions about their lives, but I also wanted them to have a moment just for them, to feel nurtured.

But they’ve provided so much more than that. When I told the clinician that he’d have to cut women’s hair to collect our hair samples, he went white. And the two beauticians were like, ‘Why don’t we do it, we’re hairdressers so we can fix their hair too?’.  

So now they give hand massages, paint nails and style hair whilst collecting the samples.

And one great example where they’ve added value. It got to a point in November/December where recruitment had really slowed to only two or three women a day, and I was starting to worry. Then one of our hairdressers said, ‘let me make the phone calls and have a go’.  She went out to the clinics and started making phone calls. Suddenly we were getting around 30 women a day – and the labs were working until the early hours of the morning.

That wouldn’t have happened if I hadn’t have included her in all of the training and as part of the study team.

Q. You started with a video called ‘Be Your Sister’s Keeper’, which provided an insight into these women’s lives. Why was that important for the project?

To me, in this film, I wanted to communicate that these are women first and foremost. And one of the things they do in their lives to earn money is sell sex. And that’s the major thing that differentiates them from me. I go to work in my office and when something adverse happens to me it’s really small. But when they go to work, they are at huge risks of all these adverse outcomes for them, it’s really stressful work. I wanted to communicate that – sex work is NOT very sexy, and people who don’t understand it don’t always get that.

It was important to me to destigmatise who a sex worker is and why it’s important to care about the things they experience. It’s a powerful way to communicate to students, to fellow academics, and to policy makers – a four-minute film can set the context far better than a two-hour presentation.

Q. What impact is the current pandemic having on women in Nairobi?

It’s having a really awful impact. The main impact has been on their ability to fund themselves economically. One of the most remarkable things I’ve found about the women there is that they’ll take in children who aren’t their own and look after them. They have a large number of co-dependents, some biologically related, some not. And they support these children financially through the money they earn from selling sex.

Lockdown has meant that they can’t earn money which means that they are starving and their children are starving. Because they’re looking for money, those who are still trying to sell sex are having to choose clients who are much riskier. Riskier sex, with riskier men, in riskier places.

For instance, going with men they might normally think, ‘no not him’, and getting in people’s cars or going back to houses where they don’t know what’s waiting for them. Or agreeing to sex without a condom or anal sex when they wouldn’t normally. And probably for much less money than usual. We’ve already seen three women murdered since the beginning of lockdown and we’re seeing increased rates of violence.

Then trying to protect themselves from Covid-19 whilst having sex is impossible. I think they’ve been trying to do it with both of them wearing masks and doing it doggy style. And that is not going to protect anyone from Covid-19.

Mental health is going to become a huge issue because of financial stress. And HIV prognosis will be worse because they need food to take medication, and they don’t have food. I feel like all of these risks are going up at the moment – poverty, violence, HIV transmission, COVID-19 transmission, poor mental health.

Q. How can we ensure vulnerable populations are protected at this time?

Financial and social support would be the most powerful thing. Regular secure income of £10-£15 a week. There’s no social support system in place there – there’s nothing to help protect them or pick them up.

If I could wave a magic wand right now, I’d create a social support system for sex workers so that they don’t have to sell sex. To make sure they have money to buy food – and that immediately reduces their risk of violence, increases their ability to adhere to ART therapies, reduces their risk of HIV, and reduces their risk of COVID-19. Its not a “sexy topic” but it’s a really important one and it’s what I’d do.

Q. It’s mental health awareness week and the theme is kindness. What act of kindness would you ask people reading this to take?

Donate £15 to our fund! This would be enough to support one woman and her family for one week.  If people aren’t in the position and many people aren’t – just sharing the link would be amazing.

More locally – let’s look out for people with pre-existing mental health problems and try to protect them. If you have a friend who has an underlying condition such as anxiety, bipolar or whatever it is. Just pick up the phone and have a wee chat and check in with them. That small act of kindness can make all the difference.

You can find out more about the Maisha Fiti project here and if you want to donate to Tara’s fund, the link is here.