Sex workers and clients

After years, their wait is over. The Association des Femmes Amazones Zen (AFAZ) has opened a drop-in centre in Lomé, the capital of Togo, where female sex workers can find refuge and help.

Funded by the United States President’s Emergency Plan for AIDS Relief through the Ending AIDS in West Africa project implemented by FHI 360, the centre opened last October, providing HIV prevention and testing services, the treatment of sexually transmitted infections, care for people living with HIV and assistance to survivors of gender-based violence.

Honorine Têlé Mensah, the coordinator of AFAZ, said that such drop-in centres bring many benefits for the community. The centre provides people with a place where they can listen, receive information and training and meet and share with others. It is a place where they can feel safe and free from discrimination and stigma. “By helping women to speak out and feel confident, we help them set an example for the community. In this way, the centre has an impact on the entire community,” she said.

But she has encountered difficulties. “Some people don’t want to get tested, and we sometimes lack nutritional kits to assist people living with HIV to stay on treatment and items such as reagents for HIV testing. Restrictions due to the COVID-19 pandemic have not helped either.” According to her, funding should be reviewed and the provision of items such as nutritional kits should be taken into account.

“I would like all AFAZ members in Togo to be able to benefit from drop-in centres and care centres like in Lomé,” she said. In the future, she would like the centre to grow. “It would be great if members could benefit from training in entrepreneurship or income-generating activities,” she said.

“Drop-in centers are often the only places where sex workers can access health care, legal advice and other services. They also provide a safe space for sex workers to gather, document abuses and mobilize for their rights,” said Eric Verschueren, UNAIDS Country Director for Togo. “UNAIDS supports the opening of more across the country.”

Located in Bole sub-city, the Bole drop-in centre is one of 12 such centres established in Addis Ababa, Ethiopia, to provide community-based comprehensive HIV services. It provides critical services and support for clients, including female sex workers, and has been a lifeline during the COVID-19 outbreak.

The centre offers a full range of integrated clinical services, including HIV testing and self-testing kits, the provision of oral pre-exposure prophylaxis (PrEP), antiretroviral therapy, the diagnosis and treatment of sexually transmitted infections, screening and referral for the treatment of tuberculosis, cervical cancer screening and treatment, and programmes to prevent and respond to gender-based violence, including access to post-exposure prophylaxis.

The drop-in centre is strategically located in one of the city’s hotspots to cater primarily for female sex workers and their children, young women and adolescent girls who are out of school, and men at higher risk of HIV infection.

It also offers consultations by mobile phone, with 31 cyber-educators trained to provide 15-minute counselling sessions with an accent on the prevention of both HIV and COVID-19. The programme has proved to be invaluable during the COVID-19 pandemic.

“I am truly inspired by the work being carried out at the Bole drop-in centre,” said UNAIDS Executive Director, Winnie Byanyima, when she met staff and clients during her recent visit to Ethiopia. “It is a great example of integrated community-led service delivery and is exactly the kind of programme that is key to ending AIDS as a public health threat by 2030.”

The centre is primarily funded by the United States President’s Emergency Plan for AIDS Relief, through the United States Agency for International Development, while UNAIDS has provided catalytic funding for the cyber-education programme, the promotion of PrEP among vulnerable groups of people and mental health counselling. This support will help to generate the uptake and continuation of needed services during the COVID-19 pandemic. Partners include Population Services International and a local nongovernmental organization called Integrated Service on Health and Development Organization.

As the measures taken to contain COVID-19 continue to bite, the Bole sub-city drop-in centre will remain a critical service for female sex workers and their families.

“During the COVID-19 lockdown, many sex workers found it difficult to work and the drop-in centre has been their only source of food,” said Sister Desta Franso, an antiretroviral provider and counsellor at the clinic.

Up to 20 female sex workers use the centre every day and around 140 women are receiving HIV medication. Treatment retention at around 94% is extremely high.

“I am so happy to be able to come here to get free medication and condoms,” says Mekdes Matiyos, a regular user of the clinic. “I can also just come to take a shower and rest whenever I need to, and I don’t have to pay.”

Warm smiles greet Lily as she approaches her first stop of the day—one of the 11 brothels scattered across the country that Lily, the President of the Bangladesh Sex Worker Network, visits quarterly to check in with the women and see what assistance they need. Though her visits have been limited in recent months due to movement restrictions to curb the spread of COVID-19, Lily knows well enough that those smiles are a brave front for the troubling times that her peers have experienced.

“I see the sex workers as my sisters—I feel their happiness and pain and I try my best to solve any issue they face,” Lily said. During the COVID-19 pandemic, Lily and the 29 community-based organizations serving sex workers in the country have struggled to respond to the increased calls for support. In March, government countrywide movement restrictions meant that sex workers could no longer have clients, leaving most of them without a source of income and unable to provide for themselves or their families.

“Sex workers’ children faced challenges during the COVID situation because their mothers couldn’t arrange to provide them with food. When we [the Bangladesh Sex Worker Network] learned about this issue, we reached out to many organizations and the private sector for assistance,” explained Lily. Responding to the call to action, the network mobilized funds to support 2100 sex workers across the country. Community-led support in Bangladesh has also garnered global recognition. Most recently, a former sex worker, Rina Akter, was recognized by the BBC for her efforts, and those of her team of helpers, to serve 400 meals a week to sex workers in need.

“While a few sex workers had savings, most could not provide for themselves,” said Rahat Ara Nur, Technical Officer for the United Nations Population Fund in Bangladesh. “Through the United Nations Population Fund, we provided sex workers with COVID-19 prevention commodities, such as masks and handwashing materials, and we also developed public service announcements which were aired on community radio to ensure we raised awareness about COVID-19 precautionary measures among the community."

With the closure of entertainment venues, a classification that includes brothels, some sex workers have resorted to street-based sex work, which increases the risk of violence, condom-less sex and no pay or low pay.

Sex workers are also experiencing increasing vulnerability to gender-based violence. Without a source of income, conflicts about finances arise, and sex worker networks report that their members have experienced abuse at the hands of their spouses, partners and brothel owners.

Some sex workers report that they have become homeless because the brothels have been closed, or in some cases the residents were evicted because rent could not be paid. Many sex workers cite stigma and discrimination as a barrier for other forms of employment. Health outreach services that once provided brothels with sexual and reproductive health services, including HIV testing and prevention, have been suspended due to travel restrictions.

Bangladesh, October 2019. Credit: UNFPA Bangladesh/Naymuzzaman Prince

These developments are not unique to Bangladesh, however. Throughout the Asia–Pacific region, national and regional networks of sex workers are reporting that the COVID-19 outbreak has exacerbated the inequalities faced by sex workers, and many are either not eligible or excluded from social protection services.

“There is no government support specifically targeting sex workers. There is support for the general public, particularly those that are low income, but sex workers are not eligible for these social protections because they work in the informal economy,” said Hnin Hnin Yu, the Chairperson of Sex Workers in Myanmar (SWiM), a nongovernmental advocacy group for sex workers’ rights.

Additionally, many sex workers are migrants (international or internal) and lack the necessary papers or registration with local authorities to access the government’s support. Eligibility criteria for social support, such as documentation of income, proof of residence, national identification, contribution to existing social protection schemes and filing taxes, are all reasons given for excluding sex workers from government support. An online consultation of female sex workers from across the country, organized by UNAIDS and SWiM, revealed that apart from limited funds from humanitarian actors, none of the sex workers had received social support.

“When Global Fund to Fight AIDS, Tuberculosis and Malaria assistance for COVID-19 was allocated, funds for people living with HIV included the most vulnerable sex workers to receive food provisions,” said Mr Myo, Community Support Adviser for UNAIDS in Myanmar. “However, we recognized that this was an ad hoc solution that reached a small portion of the vulnerable population and there is a need for more sustainable support, such as social protection, for sex workers.”

It has become clear that focused support for sex workers must be prioritized. Recognizing that more needs to be known about the gaps in social protection for sex workers, UNAIDS in collaboration with the United Nations Population Fund and the World Food Programme are exploring the possibility of conducting a needs assessment and vulnerability mapping initiative of female sex workers during the COVID-19 pandemic. Data from the community-led mapping initiative will be used to inform programming for livelihood support, food security, improved access to antiretroviral therapy, sexual and reproductive health services and gender-based violence prevention and response services.

Commenting on the prospects of the United Nations agencies joining forces to coordinate a vulnerability mapping exercise with sex worker networks, Ms Nur expressed excitement about how this advocacy tool will not only help to identify the challenges that sex workers face during the COVID-19 outbreak, but it would also catalyse further work to mobilize resources for programmes and address injustices that pre-date the COVID-19 pandemic.

Hnin Hnin Yu cites discrimination and harassment from police as a long-standing challenge facing sex workers’ rights. During the COVID-19 outbreak, communities have reported increased police surveillance, harassment, including physical violence, and demands to pay fees to conduct sex work. In response, SWiM provides community-led, peer-to-peer legal aid for sex workers who have been arrested, educating them about their rights.

For those working closely with community-led organizations it has been inspiring to see that although sex worker networks and the sex workers they represent have seen challenges all around them, they have done their best to support their peers. There is hope that the data gathered in a vulnerability mapping exercise would not only generate the evidence needed to advocate for expanding the reach of social protection and humanitarian response services to be inclusive of sex workers, but could also inform the scale-up of community-led programming. 

GENEVA, 10 December 2020—UNAIDS announces the launch of its Solidarity Fund, which will support social entrepreneurs and micro-business owned by key populations facing special hardship during the COVID-19 pandemic.

“Key populations are among those disproportionally impacted by COVID-19,” said Winnie Byanyima, UNAIDS Executive Director. “COVID-19 has highlighted and exacerbated the profound and widening economic and social inequalities. We must act to support and protect the people who are most impacted by the pandemic.”

Experience from the COVID-19 and HIV pandemics, and from other diseases, such as Ebola, has shown that key populations are more likely to be impacted by food insecurity, face barriers to health care and access to medicines, and suffer losses of livelihood, unemployment, homelessness and domestic violence.

Launched today, Human Rights Day, the new Solidarity Fund will support social entrepreneurs and small-scale businesses owned by people living with HIV, women or members of key populations, including sex workers, transgender people, people who use drugs and gay men and other men who have sex with men, the people who so often have their human rights violated.

“The fund will help bridge the gap between aspirations and opportunities of people from my community. It places trust and gives us a chance to show our innovation and entrepreneurship with no limitations,” said Maite Schneider, the cofounder and Chief Executive Officer of TransEmpregos.

To be piloted initially in five countries—Brazil, Ghana, India, Madagascar and Uganda—with a US$ 250 000 budget from UNAIDS, the initiative will scale up to additional countries over the coming months, with a goal of raising an additional US$ 3 million to US$ 5 million in 2021–2022.

UNAIDS will closely work with community networks, national innovation ecosystems, the private sector and other partners to create tailored support, especially capacity development on social entrepreneurship and mentoring to enhance the sustainability of social ventures and impact for the wider community, with special attention given to young key populations.

Among the partners is the venture development and investment platform Social Alpha, which will provide mentoring and entrepreneur support to the chosen beneficiaries. “We look forward to partner with communities and UNAIDS on the Solidarity Fund and leverage our experience in working with social entrepreneurs for solving complex social, economic and environmental challenges,” said Manoj Kumar, the Chief Executive Officer and founder of Social Alpha.

UNAIDS

The Joint United Nations Programme on HIV/AIDS (UNAIDS) leads and inspires the world to achieve its shared vision of zero new HIV infections, zero discrimination and zero AIDS-related deaths. UNAIDS unites the efforts of 11 UN organizations—UNHCR, UNICEF, WFP, UNDP, UNFPA, UNODC, UN Women, ILO, UNESCO, WHO and the World Bank—and works closely with global and national partners towards ending the AIDS epidemic by 2030 as part of the Sustainable Development Goals. Learn more at unaids.org and connect with us on Facebook, Twitter, Instagram and YouTube.

There are significant gaps in HIV testing among key populations at higher risk of HIV infection, resulting in suboptimal levels of knowledge of their HIV status. HIV testing is a critical gateway to HIV prevention and treatment services. Without knowledge of HIV status, people cannot access life-prolonging HIV treatment services.

Analysis of data from special surveys shows that, on average, about two thirds of sex workers and gay men and other men who have sex with men globally either had taken an HIV test and received the results within the past 12 months or had previously tested positive for HIV—meaning that about one third did not know their HIV status. This testing gap was even larger for people who inject drugs. These surveys are often conducted where key population-friendly services are available and may overstate overall testing coverage.

The Ashodaya pre-exposure prophylaxis (PrEP) demonstration project for female sex workers in south India has shown how PrEP and HIV prevention programmes can be strengthened and their implementation accelerated beyond pilot projects.

While PrEP has been shown to be highly efficacious, with nearly 100% protection if it is taken as directed, delivering a successful PrEP programme is challenging. HIV prevention efforts among sex workers have traditionally focused on condom use, and while a range of successful programmes have contributed towards the decline in new HIV infections in the Asia–Pacific region, sex workers still experience a disproportionate burden of infection. In 2019, 9% of the estimated 300 000 new HIV infections in the Asia–Pacific region were among sex workers and globally the relative risk of HIV infection is 30 times higher among sex workers than among the general population.

PrEP is a relatively recent addition to the range of HV prevention options available. It involves someone who is HIV-negative taking antiretroviral medicines prior to possible exposure to HIV. Although recommended by the World Health Organization (WHO) for all people at substantial risk of HIV since 2015, PrEP is inaccessible to the majority of key populations, including sex workers, and their partners in the Asia and the Pacific region. There is limited evidence on PrEP use among women, and particularly among female sex workers, in Asia and the Pacific.

The Ashodaya PrEP demonstration project was one of two community-led and community-owned initiatives to provide PrEP to female sex workers supported by the Bill & Melinda Gates Foundation (the other was led by the Durbar Mahila Samanwaya Committee Kolkata). Sex workers in India had been concerned by the fact that, although condom use was high, some sex workers still acquired HIV.

“Our project shows that community-led PrEP delivery can be effectively integrated into the existing HIV prevention and care services for sex workers and result in high retention and adherence. Policymakers need to consult with us, listen to us and trust us as we know what works for us and how to make it work. We have an obligation to make PrEP available as an additional prevention tool in a safe and sustainable way and we are advocating for that,” said Bhagya Lakshmi, Secretary of Ashodaya Samithi.

The PrEP demonstration project, which began in April 2016 and ended in January 2018, reported good results. High levels of continuation on PrEP were reported, with 99% of the 647 participants completing the 16 months of follow-up. For women, it is critical to take PrEP daily to maintain protection. Although adherence was only 70% at month three, this increased to 90% at month six and was 98% in the final month of the project. Self-reported adherence was verified in the blood of a subset of participants at months three and six.

The project not only helped to dispel some common fears about PrEP but showed benefits in bridging the prevention gap. Rather than undermining condom use, it remained stable. Condom use was high for occasional clients, at approximately 98%, but lower for repeat clients (87–96%) and regular partners (63%). There were also no increases in symptomatic sexually transmitted infections and no cases of HIV acquisition during the follow-up period.

Several factors contributed to the success of the Ashodaya PrEP project, including:

• Fully integrating PrEP into an existing range of health services, outreach and community mobilization. This approach recognized that PrEP is not just a medicine or a standalone service but is part of a prevention and health package, including sexual and reproductive health services.
• Communities leading the way: planning, implementation and monitoring. 
• Preparing the community and ensuring ongoing engagement. An intensive process of community preparedness and ongoing engagement allowed sex workers to make informed decisions about participation.
• Addressing excluded groups early. Recognizing that many community members would miss out, the community was proactively informed that not all members would be eligible for PrEP under the demonstration project, given the limited places and scope.
• Prioritizing continued engagement over perfect adherence. Drawing on Ashodaya’s existing network of peer outreach workers allowed for individualized adherence support strategies to best meet the needs of PrEP users, both in terms of scaling up support when dips in adherence were observed and through referrals to Ashodaya’s comprehensive package of health and social services beyond PrEP.

“We cannot stop new HIV infections in Asia and the Pacific if we stick to business as usual,” said Eamonn Murphy, Director, UNAIDS Regional Support Team for Asia and the Pacific. “PrEP answers an unmet need and expands the prevention options for people at substantial risk of HIV. We need to scale up PrEP as an additional effective HIV prevention intervention. The principles of the Ashodaya PrEP demonstration project is a model not only for India but for the entire region. The lessons learned from the project are critical to informing the way forward in the prevention agenda.”

From conceptualization to planning, implementation and monitoring, the Ashodaya PrEP project was a community-led process. In 2018, the pilot project ended and analysis of the results was completed with support from UNAIDS India and WHO. Since then, Ashodaya has trained a cadre of community members as advocates for PrEP in partnership with the All India Network of Sex Workers and with support from AVAC. Ashodaya, with support from UNAIDS, WHO, the Durbar Mahila Samanwaya Committee and the All India Network of Sex Workers, is also continuing to advocate for PrEP with the Indian National AIDS Control Organization (NACO). Ashodaya is also exploring opportunities for community social franchising and marketing of PrEP to further support access. NACO has developed a draft national PrEP policy and guidelines. The community is eagerly waiting for the resumption of PrEP services.

In 2019, the proportion of new adult HIV infections globally among key populations and their sexual partners was 62%. This shift to an HIV epidemic increasingly among key populations is a result of the strong progress in HIV prevention in settings with high HIV prevalence in eastern and southern Africa, combined with a mixture of progress and setbacks in lower-prevalence regions.

Key populations—which include sex workers, people who inject drugs, prisoners, transgender people, and gay men and other men who have sex with men—constitute small proportions of the general population, but they are at elevated risk of acquiring HIV infection, in part due to discrimination and social exclusion.

“After COVID-19 kicked in, it has been too difficult to get customers,” says Teddy Francis John, a sex worker from Zanzibar. Since the outbreak of COVID-19, she has faced increased difficulties to earn an income to provide for herself and her two children.

“Everything has become tough and I had to start a small business of selling alcohol—local brew,” she says. The business also helps her meet new clients, as they come to her for drinks and are less vigilant about social distancing guidelines.

Ms John used to live and work in Zanzibar town, but to better earn an income and avoid paying rent, she decided to move to a more rural area. Here, she says, she can more easily find new customers for her local brew.

Rehema Peter is facing a similar situation, just on the other side of the ocean on Tanzania Mainland. She lives in the crowded suburb of Temeke in Dar es Salaam and works as a sex worker and volunteers as a peer counsellor for people living with HIV and for people who use drugs.

Her clients were regulars who used to come to her house, or she would visit those she could trust in their homes. But when COVID-19 broke out, they stopped coming.

“Coronavirus made life very hard. Payment at work used to be little and when COVID-19 came it reinforced the situation. On the side of my partners [clients], they stopped visiting and calling me. The very few who used to visit me often, I called them, but they said they have no money because of COVID-19, as some stopped going to their jobs,” says Ms Peter.

At her job as a peer counsellor she was offered fewer shifts, meaning a lower income. Because she is a former drug user, she has received some support through the Tanzania Network for People who Use Drugs (TaNPUD), which has been supported by UNAIDS to distribute food and hygiene items to people who currently use drugs and people in recovery.

“I just try to be calm and find other means [of income]. I’m searching for additional organizations that can help or support me anyhow. I also try to prepare soap and oil from the knowledge that TaNPUD gave me and I sell it,” says Ms Peter.

Continued services

Both Ms Peter and Ms John are living with HIV and are on HIV treatment. Due to the advocacy and assistance of UNAIDS and other partners of the Tanzanian government, disruptions to HIV services have been minimal in the country. This is felt by both women.

“During this time, it has become difficult to get services in government health facilities; unless you go to a private hospital where you must have cash. However, there is no problem at all in getting HIV-related services, including my treatment,” says Ms John.

Ms Peter say she can now get three months multi-month dispensing of antiretroviral treatment—even up to six months—since the healthcare staff do not want congestion in the clinics. This has helped both women in adhering to their treatment.

Increased stigma

Both Ms Peter and Ms John have experienced an in increase in the stigma and social exclusion they also face as sex workers and as women living with HIV during the COVID-19 outbreak.

“As some people know that I am living with HIV, they tease me. They say ‘prepare yourself for death. People like you never heal. You must prepare for your final journey’” recounts Ms Peter. She has faced discrimination in the community, but her family stands by her.

Ms John also faced increased gossip and mocking of her because of her work.

“People in my surrounding communities started mocking me and others. They gossiped as to how I would earn a living as there are not going to be customers because of the COVID-19 outbreak.” Says Francis John

Despite the COVID-19 outbreak being declared over in Tanzania and despite their continued efforts to find other means of livelihood, earning an income is still hard for the two women, due to continued social distancing regulations.

“[It] has been very difficult to provide this service and this harmed us economically. I know COVID-19 has affected the whole world but it has affected sex workers more because of the nature of our services; it involves proximity,” says Ms John.

The town of Corriverton in Guyana lies far east, on the Suriname border. Miriam Edwards, the Executive Director of the Guyana Sex Work Coalition, hired a taxi early last Thursday to take her team of peer counsellors there. They planned to conduct welfare checks, offer HIV testing and distribute care packages, masks and condoms as part of a project supported by the Office of the United Nations High Commissioner for Refugees (UNHCR). It’s a nearly 200-mile trip from the capital, Georgetown. Since the COVID-19 outbreak, the regular bus hasn’t been available. Other changes to the flow of life have been devastating for sex workers in Guyana.

“Because of the curfew they are not able to work. Plus the children are home full time. They (the sex workers) can’t make any moves. Some are able to look (work) for money, but in doing so they take more risk. Workshops are not their first priority,” Ms Edwards says plainly. “Their main need is food and sanitization.”

COVID-19 has meant fewer opportunities for work and more competition. A Dominican sex worker reported being attacked by a pair of local women. Her face was swollen and stitched when Ms Edwards got to Corriverton.

One Venezuelan woman ventured out during the curfew. She alleges that police officers in the border town detained her and demanded sex. When she refused, one of them hit her with his gun.

Another Venezuelan sex worker had gone missing since the previous weekend. Her documents and clothes were left in her hotel room, but she still hasn’t turned up.

The complications around sex work in Guyana have deepened since COVID-19. At a time when many locals are out of work, migrants have been particularly affected by joblessness. More of them are exchanging sex for money to survive. 

According to a recent Response for Venezuelans (R4V) report by UNHCR and the International Organization for Migration, there have been more reports of sex workers facing eviction or being at risk due to job loss.

“This situation increased their vulnerability of becoming victims of human trafficking, exploitation and gender-based violence,” the report says.

Meanwhile, many Guyanese sex workers have found it difficult to access the social support provided for formal-sector workers by the government.

“The problem is that many in authority don’t see sex work as work,” Ms Edwards said.

But some do. According to Rhonda Moore, Programme Manager at the National AIDS Programme, during COVID-19 the HIV Food Bank has expanded its reach to HIV-negative members of key populations. This includes female, male and transgender sex workers.

Ms Edwards points to the need for even more targeted social support, including for single mothers, migrants and those working in the interior.

The Guyana Sex Work Coalition’s strategy has been to pair the distribution of nutrition support and hygiene supplies with offers of HIV testing and safety reminders on COVID-19, HIV and sexually transmitted infections. According to Ms Edwards, this is a time of high stress and uncertainty and her clients are not necessarily able to absorb mass media messages. Text reminders and phone calls have been key approaches to ensuring that individual sex workers are informed and to address their unique challenges. Sometimes they need medication or money for transport. Many of the migrants need a safe space.

UNAIDS is embarking on a project with the Caribbean Sex Work Coalition to help national networks address sex workers’ knowledge, HIV prevention and social support needs during COVID-19.  A major goal of the project is region-wide advocacy to encourage Caribbean governments to include sex workers in their planning and protection.

“Sex workers need to be included in national social protection schemes and many of them need emergency financial support,” said James Guwani, Director of the UNAIDS Caribbean Sub-Regional Office. “To win the battle against COVID-19 or HIV, we must give life to the principle of leaving no one behind.”