Sex workers and men who have sex with men have both a higher risk of contracting HIV and a lower access to antiretroviral care due to stigma and discrimination as well as, in many instances, their illegal status and high mobility. In order to find innovative ways to increase not only access to life-saving ARVs but also to adherence to care and Pre-Exposure Prophylaxis (PreP) for key populations, we launched an ambitious “Corridor” project in January 2014 which spans Mozambique and Malawi, with recent extensions into Zimbabwe. Names of the sex workers have been changed.
Mary is from Zimbabwe, but she lives in Beira, Mozambique. On the morning we meet, she is sitting on the cement floor outside the guesthouse where she lodges with a dozen other Zimbabwean sex workers. Her arm is in a cast. “Who did that to you?” asks Edna, Médecins Sans Frontières peer educator. A shrug. “My boyfriend. We had an argument”. “You know you should go to the police, right? He can’t do that to you. That’s human rights”. Another shrug from Mary, “We’ll see.” Beira is a busy harbor city, the beginning and end of truckers’ routes distributing goods throughout Southern Africa. For the women, this is where the money is – not in their villages in impoverished Zimbabwe. Although “money” is a loose definition: when the intercourse is priced as little as 50 meticais (1 USD), they need many clients to be able to send money to their families back home. “It’s purely business, you know, no time for romance. The guy needs to be ready from the start. If he’s not done quickly, he pays more, or too bad for him”, explains Edna.
MSF counselor CeIarissivaia Deolinda Rodrigues Muassinle conducts an HIV pre-test and counseling with a truck driver inside the MSF car at a remote parking area outside Beira City.
It’s night time and we’re traveling throughout Beira’s hot spots. The first neighborhood looks quaint in the dark: a few shops of corrugated iron sheets, their feet in the sand, standing modestly under tall coconut trees. “It’s mostly the Mozambican girls who work here”, explains Sandrine Leymarie, Médecins Sans Frontières’ patient support officer. She points at an open room behind the shop, its ground littered. This is the place where paid sex work takes place, the grim reality behind the deceptive quaintness. More downtown, on Avenida Robert Mugabe, groups of women, short skirts and open shirts, wait for their clients; they’re mostly from Zimbabwe. A 2012 survey counted 714 professional sex workers in Beira – meaning women who have seven or more clients per month. Within the first 18 months of activity, Médecins Sans Frontières’ project in the city had enrolled over 600 sex workers, thanks to a group of peer educators actively engaging. However, adding those making ends meet with occasional sex work, the number of sex workers in Beira is likely to shoot upwards.
"Beira is a busy harbor city, the beginning and end of truckers’ routes distributing goods throughout Southern Africa. For the women, this is where the money is – not in their villages in impoverished Zimbabwe"
It’s Monday, a slow night, but prostitution is still everywhere. There are no condoms readily available and if Médecins Sans Frontières or another NGO doesn’t distribute it for free, sex workers would have to buy their only protection against HIV. 30% of the HIV negative women surveyed with us a year before, had contracted the virus within twelve months; the highest rate of seroconversion registered in Beira project. The lack of free condoms and the difficulty to impose it on a client, is but one obstacle to accessing HIV protection for women who are at a very high risk of infection. The many Zimbabwean sex workers are especially reluctant to go to health centers, knowing that most health workers there will automatically assume what their profession is and they will face stigma and discrimination. They also don’t have access to PreP medications that can prevent them from contracting HIV after unprotected intercourse. For this reason Gloria, a Zimbabwean who has been living with HIV for over ten years, regularly travels back home or has someone bring her ARVs to Beira. She’s proud to be virally suppressed, and therefore her 8 months old baby is HIV negative. But this is not sustainable for the hundreds of foreign women in need of protection against HIV.
There is wide consensus amongst HIV policy makers and donors that most-at-risk groups should be a target for ambitious projects against HIV as they are key to controlling the epidemic. It’s not only a matter of promoting condom use, but also to increase the low coverage of antiretrovirals as optimal treatment. Médecins Sans Frontières is testing ways to increase access and improve adherence to treatment through the “Corridor” project. Between the locations in Mozambique and Malawi, our projects support care for over 3800 sex workers and 4500 truck drivers (many of whom are their clients). The project has also started working with male sex workers; an extremely hard to reach group because of intense discrimination and criminalization of their way of life in Malawi and, until recently, Mozambique. It aims at reaching out to 200 male sex workers to offer early treatment and ensure adequate care. “Our dream is to find a way to ensure continuity of care for these vulnerable and highly mobile groups” explains Marc Biot, Médecins Sans Frontières’ coordinator of operations for Southern Africa.
The first hurdle came from our own local teams’ acceptance to working with highly stigmatized populations. In Beira, we enrolled nine sex workers as peer educators and also two men from Lambda, the only Mozambican association for men who have sex with men. Just as challenging was gaining the trust of these patients, who are sadly used to stigma and discrimination and wary of outside actors. “It’s tough, you know. At the beginning you get insulted a lot. The girls will call me at 4am with a question, and complain to my boss if I don’t pick up the phone. But now I have my techniques, I know how to handle them and it’s much better. They need us, you know?” says Patty Marume, Médecins Sans Frontières’ counsellor in Beira. Reaching out to the most vulnerable requires considerable investment in time and human resources. Who else but a peer educator, herself a former or active sex worker, can understand where they come from. “I’m proud of working as a peer educator: I feel like I’m a good example to the other sex workers,” says Cecilia Mondar Khanje, our peer educator in Zalewa, Malawi. “I’m always happy that I can help them because I know I’m part of them, I’m in their shoes. The girls know me, they see me with them every day, and as a result they trust me more than they would trust anybody else. And it’s a very difficult to gain their trust!”