In many contexts where Doctors Without Borders (MSF) works, key populations (also referred to as most-at-risk populations) such as sex workers and men who have sex with men have a higher risk of contracting HIV and are less likely to access antiretroviral (ARV) care due to stigma, discrimination, and their high mobility.
New HIV prevention methods like pre-exposure prophylaxis, or PreP, are a promising tool to curtail the progression of the HIV pandemic, but access remains limited in the most affected areas of Southern Africa. To find innovative ways to increase access to life-saving ARVs and PreP methods for key populations, in 2014 MSF launched an ambitious project in the “Corridor,” a busy trade route used by truckers hauling goods throughout Southern Africa. The project operates in Mozambique and Malawi, with recent extensions into Zimbabwe.
Few Options in Beira
Beira is a busy harbor city, the beginning and end of truckers’ routes throughout Southern Africa. For women, this is where the money is—not in their impoverished villages in Zimbabwe. When sex is sold for as little as 50 Mozambican meticais (about one dollar), 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,” explains Edna. “The guy needs to be ready from the start. If he’s not done quickly, he pays more, or too bad for him.”
At night in Beira’s hot spots, women stand modestly under tall coconut trees with their feet in the sand. “It’s mostly the Mozambican girls who work here,” explains Sandrine Leymarie, an MSF patient support officer. She points at an open room behind the shop, its ground littered with trash. This is the place where sex transactions take place, a grim reality behind the neighborhood’s deceptive quaintness.
Downtown, on Avenida Robert Mugabe, groups of women in short skirts and open shirts wait for their clients; they’re mostly from Zimbabwe. A 2012 survey counted 714 professional sex workers in Beira. Within the first 18 months of activity in the city, MSF’s “Corridor” project enrolled over 600 sex workers (about 90 percent of the number found in the survey), thanks to a group of peer educators who actively engaged with sex workers. However, if the number of individuals who only engage in sex work occasionally is added to those who do so regularly, the potential number of sex workers in Beira is likely to be as high as 7,000.
It’s Monday, but transactional sex is everywhere. If MSF or another humanitarian organisation doesn’t distribute condoms for free, sex workers need to use money from clients to purchase their only protection against HIV. It’s no wonder, then, that the virus is rampant: 30 percent of the women in Beira surveyed by MSF who were HIV negative had contracted the virus within 12 months.
The lack of free condoms, and the unwillingness of many clients to use them, is just one obstacle to accessing HIV protection for women who engage in sex work. Many Zimbabwean sex workers are reluctant to go to health centres out of fear of stigmatisation. Sex workers also don’t have access to post-exposure prophylaxis medication that can prevent them from contracting HIV after unprotected intercourse. For this reason, Gloria, a Zimbabwean woman who has been living with HIV for over 10 years, regularly travels back home or has someone bring her ARVs to Beira. . But this solution is not sustainable for the thousands of foreign women in need of HIV protection. “So, do we need to first treat a sick health system?”
A Holistic Approach
There is widespread consensus among HIV policy makers and donors that most-at-risk groups should be targeted for ambitious projects against HIV, as they are essential to controlling the epidemic. It’s not only about promoting condom use, but also increasing availability and access to ARVs for vulnerable groups. Combing these methods drastically reduces the risk of transmitting the virus.
MSF is testing ways to improve access and adherence to treatment through the “Corridor” project. Between locations in Mozambique and Malawi, MSF’s project supports care for over 3,800 sex workers and 4,500 truck drivers (many of whom are their clients). MSF also works with men who have sex with men, an extremely hard-to-reach group due to intense discrimination and criminalisation. MSF aims to offer early treatment and ensure adequate care to 200 of them. “Our dream is to find a way to ensure continuity of care for these vulnerable and highly mobile groups,” explains Marc Biot, MSF coordinator of operations for Southern Africa.
The first hurdle was assembling teams willing to work with highly stigmatised populations. In Beira, MSF made headway by enrolling nine peer educators who were former sex workers and 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 discrimination and wary of outsiders. “At the beginning you get insulted a lot,” Patty Marume, an MSF counselor in Beira. “The girls will call me at 4:00 a.m. with a question, and complain to my boss if I don’t pick up the phone. But now I have my techniques on how to handle them, and it’s much better.
Investing in People
Reaching out to the most vulnerable requires considerable investment in time and human resources. But who better than a former or active sex worker to understand the background and experiences of these patients and show them how to adapt HIV prevention methods to their situation?
“I’m proud of working as a peer educator,” says Cecilia Mondar Khanje, an MSF peer educator in Zalewa, Malawi. “I feel like I’m a good example to the other sex workers. As a peer educator, I help MSF teams contact the girls. If some girls default on their treatment, iI search for them and encourage them to go back to care. Every day I talk to the girls about hygiene, sexually transmitted diseases, tuberculosis testing, etc.
I work with the counselor: we get the girls to take an HIV test; if they are negative, we explain to them how to stay that way, and if they are positive we [send] them to the clinic to get on treatment. They’re willing to go there because everything is kept confidential and, unlike in most other clinics, they’re treated well by the staff. The services being free also helps quite a lot.
“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!”
*Patient names have been changed to protect anonymity.