What do you do when one of the poorest nations in the world is battling an HIV pandemic while the country's poverty is forcing women to turn to sex work to earn a living?
Train sex workers to become health workers. This is what Médecins Sans Frontières (MSF/Doctors Without Borders) is doing in Malawi. In doing so, the organization hopes to start reversing some of the effects that HIV/AIDS has on communities in Malawi — especially on women who’ve been left vulnerable to sex work and exploitation due to a lack of jobs and economic opportunities.
According to HIV/AIDS non-governmental organisation Avert, Malawi is one of the countries that have been hit hardest by the pandemic. In 2017, 1 million people in Malawi were HIV-positive.
Even more troubling is that fact that there were 39,000 new infections in 2017, and around 50% of these affected people aged between 15 and 17 years old.
MSF says that even though huge strides have been made in the battle against HIV/AIDS — including 71% of infected adults being on antiretroviral treatment (ARVs) — “sex workers remain extremely exposed.”
Sex workers don’t have as much access to information and health care as the rest of the population, even though they are up to 13 times more likely to be infected with HIV, according to Avert. They also have a higher chance of being infected with other sexually transmitted infections (STIs) and unwanted pregnancies.
Violence and stigma from clients, partners, police, and health workers can prevent sex workers who have been exposed to risk of infection from going to clinics to get tested for HIV, and getting post-exposure prophylaxis (PEP) treatment, according to MSF.
“While these risks are seen by many as part of the job, empowering sex workers with knowledge and prevention methods is key to protecting their health,” according to a programme report from MSF.
PEP reduces the likelihood of being infected with HIV if taken within 72 hours of exposure, and then taken as instructed by a medical professional thereafter.
In the towns of Dedza, Mwanza, Zalewa, and Nsanje, the tides are turning.
A partnership between MSF and Malawi’s Ministry of Health has resulted in a programme that provides health services aimed specifically at sex workers, by training them to become community health workers.
MSF explains: “This shared experience enables them to discreetly link with other sex workers, understand their health situation, and explain the medical services they need.
“Medical staff in the project have also been given sensitivity training to provide friendly services for sex workers,” it adds.
For example, Margaret, whose name has been changed, is an MSF community health worker in Mwanza. Her job entails going to brothels and carrying out door-to-door visits sharing information about HIV testing, care, and treatment.
“For those who agree to be tested for HIV we set up a home visit,” she tells MSF.
Sex workers are also told about discreet one-stop clinics run by MSF in Ministry of Health facilities or in rented rooms in communities close to where they work or live.
The clinics provide HIV testing, treatment, and counselling; TB screening and referral for care; and an array of sexual and reproductive health care including contraception, cervical cancer screening, and treatment for sexual violence.
One of the women impacted by the programme, Bernadette (not her real name), lost both parents when she was 7 years old. Although she was taken in by her grandparents, they struggled financially.
“I started having sex in exchange for things as my grandparents were not able to provide me,” she tells MSF. “This is how I got pregnant and dropped out of school.”
She adds: “When I became a sex worker I didn’t know anything about condoms, or any other family planning methods. I had heard of HIV but never thought about contracting it myself.”
She only discovered information about HIV testing and sexual health through the MSF programme in Dedza.
“I saw it as an amazing opportunity that could help me to be healthy, no matter my circumstances ... With these services, I feel more empowered than before and I am able to negotiate protection with the clients,” she said.
Margaret added: “While some people used to look at us as animals, things have changed … Today, people understand that HIV affects everyone. And if we are to deal with HIV once and for all, the first step is to accept and recognise that, despite being different, we are all human beings.”