Effective HIV Prevention Services Targeting Sex-Workers Include Their Voices in All Planning Stages

Magnitude, behavioural patterns, contributing factors, current interventions have an impact on participation by Sex workers in HIV prevention in Malawi.

This Report "captures the voices, perceptions, views and experiences of close to 950 sex workers, along with their clients and other stakeholders from 10 Districts in a situation analysis on the Magnitude, Behavioral Patterns, Contributing Factors, Current Interventions and Impact of Sex Work in HIV Prevention in Malawi.

The study was commissioned by the Family Planning Association of Malawi (FPAM) with funding from the United Nations Population Fund (UNFPA). Using participatory, quantitative and qualitative approaches, the study involved a counting of the sex workers; engagement of what the sex workers know about HIV and AIDS; the legal and policy issues surrounding sex work; and their problems, priorities, and experiences with service providers. The study also interrogated the sex workers on what could be done to ensure the effective implementation of interventions relating to sex work in the context of HIV prevention.

UNAIDS estimates that by the end of 2009, they were 33.3 million people living with HIV globally. In 2009 alone, there were 2.6 million new HIV infections (WHO, 2010). Sub Saharan Africa continues to experience high new infections. It is estimated that 1.8 million people in Sub Saharan Africa became infected in 2009 (WHO, 2010). UNAIDS further indicates that heterosexual intercourse is the main mode of HIV transmission in the region. For example, in Swaziland, transmission through heterosexual contact accounted for 94% of new infections. In Lesotho, between 35% and 62% of new infections in 2008 were noted among people who had at least a single heterosexual contact, and in 2006 heterosexual intercourse within a stable sexual relationship accounted for 44% of all new infections in Kenya (UNAIDS 2009). 

Sex workers are defined as: “Female, male or transgender adults and young people who receive money or goods in exchange for sexual services either regularly or occasionally, and who may or may not consciously define those activities as income generating,” (UNAIDS 2010). 

For purposes of this study, the operational definition adopted for a sex worker in the context of the study was: a female aged between 16-49 years, who has received money in exchange for sex either regularly or occasionally up to 12 months prior to the survey, and who may or may not consciously define those activities as income generating. 

There are two main legal approaches to sex work and these are: Criminalisation and decriminalization. The former approach is informed by the goals of: protection of health and safety; ancillary crime. prevention; protection from exploitation; preservation of society morals; achievement of eradication of the practice through deterrence; and realisation of human rights. This approach is largely grounded in feminist theory premised on the viewpoint that prostitution victimises women and objectifies women’s bodies and sexuality. This theory argues for the criminalisation of sex work on the grounds that it inherently perpetuates the patriarchal devaluation of women, while the other alternative of decriminalising and legalising it does not hold promise for affording women with safety. This viewpoint asserts that the criminalisation should only be with respect to the actions of the one providing the services, and that the criminal laws should not punish the one who procures. The theory is supported by other schools of thought such as the conservative moral school of thought, the paternalistic or protectionist approach and the abolitionist approach.

The public health approach converges with the human rights-based approach and argues that policy responses on sex work should reflect current knowledge of the social determinants of health, and move away from intensified repression to a comprehensive agenda of medical and social support to improve sex workers access to health care, reduce their social isolation and expand their economic options. This entails a multi-pronged approach that reinforces access to medical services for marginalized people, but also tackles the structural factors that expose vulnerable groups to disproportionate health risks in the first place. Prime areas for structural intervention include gender equity, education, and economic empowerment. This means pursuing two simultaneous, mutually reinforcing priorities, i.e. bringing health services and prevention interventions to sex workers in a participatory manner, advancing universal access to HIV prevention, care, and treatment, and protecting sex workers and the general population against HIV and STIs; while at the same time accelerating policies in appropriate sectors to address the structural issues of poverty and gender discrimination that currently leave female sex workers with few credible paths to alternative livelihoods.

Recommendations 

 There is an urgent need to build the capacity (knowledge and skills) of service providers working in sex work programming.

  There is an urgent need for outlining proper institutional set-ups for the steering, coordination and supervision of sex work interventions in Malawi. It is important that the mandates of relevant government institutions should be analysed in terms of their linkages with sex work in order to identify the lead institution.

  Sex work interventions should, wherever possible, be distinctly designed, planned, funded, implemented and monitored and evaluated. Currently most of them are implemented under the rubric of SRH thereby getting less attention in some institutions, particularly government.

  Collaboration among stakeholders is essential for the effective implementation of interventions given the constraints with resources, competing needs and capacity limitations. The limited collaboration that exists among stakeholders involved in sex work interventions is a major setback. There is a need for collaboration to be harnessed in order to have a platform for the identification of synergies, coherence and complementarities relating to sex work interventions in order to improve efficiency and effectiveness. 

 Livelihood services should be preceded with needs assessments. 

 The female condom provision programmes are not matching their utilization. There is an urgent need for a special study to critically analyze factors for the low utilization of female condoms notwithstanding their availability. The analysis should inform complementary initiatives to ensure increase in the utilization of female condoms by female sex workers. 

 Implementing and funding agencies need to effectively streamline sex work in their programmes by among other things adopting public health and human rights based approaches. 

 Sex workers need to be assisted so that they get organized and form an alliance which could be used as a platform to voice out their concerns for appropriate action from relevant authorities. The lack of such a network makes it impossible for sex workers to channel their concerns, thereby remaining a marginalized and neglected population, despite the availability of victim support units throughout the country.

 While it is clear that the debate on decriminalizing sex work in settings such as Malawi is far from settled, the legal complexities surrounding sex work derail the effective planning and implementing of interventions in sex work. This requires harnessing capacities on public health and human rights on the part of implementing institutions. 

 In future, population size estimation for hidden populations should be separated from social and behavioural related aspects in order to allow more time for each." For more follow this link please.