August 6, 2013
Malawi 2013 © Risa Turetsky/MSF
Isabella*, a shy young woman, arrived near the end of a community outreach day organized specifically for commercial sex workers in Nsanje, Malawi.
She and two of her friends were tested for HIV; her test result was positive. During counseling and encouragement to start antiretroviral (ARV) treatment, Isabella admitted to the counselor that she already knew she was positive. She had missed two appointments at the hospital's HIV clinic and, after that, had been too embarrassed to go back. Instead, she had been taking pills from friends—sometimes without their knowledge—in order to continue her medication. Scared, she came to our clinic looking for help.
The community outreach clinic is part of MSF’s new model of care for sex workers in Nsanje, the southernmost district in Malawi. According to official estimates, the prevalence of HIV among this group in Nsanje is an alarming 82 percent, even higher than the reported national prevalence of 71 percent. With no local response targeting sex workers and a continuously low supply of condoms in the district, sex workers are drivers of new HIV infections in Malawi and in the district.
“Not only is there no special response to the needs of this highly vulnerable group, but also the women feel stigmatized and disrespected when they go to the clinics, especially for treatment of sexually transmitted infections, or STIs,” says Risa Turetsky, outreach nurse for MSF in Nsanje. “They feel stigmatized by the other patients and sometimes even the clinic staff treat them badly. This discourages most women from coming in for services, which is unacceptable and quite tragic considering the health needs of this group.”
Malawi 2013 © Risa Turetsky/MSF
MSF is implementing a targeted approach to increase access to and acceptability of care and to promote the consistent use of condoms and of antiretroviral medication (ARVs) for patients living with HIV. Monthly clinics at the local health center host outreach activities specifically for sex workers that are run by nurses and counsellors from the Ministry of Health (MoH) trained to be welcoming to sex workers. The clinics provide condoms and they put all sex workers living with HIV on medication immediately, regardless of the stage of their disease, in order to decrease their infectiousness and thus prevent new infections.
An exceedingly positive response
By the end of June 2013, the first sex worker-friendly staff were ready, and two outreach clinics were implemented. The response was exceedingly positive, with a 150 percent increase in sex workers’ visits between the first and second clinic, and comments to the staff about how comfortable they made them feel. The first outreach clinic focused on STI treatment and revealed a striking 66 percent rate of syphilis among those who presented.
One of the most important contributions by MSF is simply providing a supply of condoms to sex workers. The district struggles to maintain their supply of condoms, which makes them unavailable even for these women.
The clinic is being run jointly between MSF and the Nsanje Ministry of Health, and MSF is focused on capacity-building for the staff, since the plan is for the MoH to run the clinic independently in the future.
When Isabella did not return for care after her first visit, the newly trained, sex worker-friendly counselor tracked her down. The counselor comes from the same village, and she was able to find Isabella easily. “Our model of care encourages sex workers to feel comfortable with staff who are there for them,” Turetsky says.
These staff members will run the hospital-based clinic one afternoon per month, starting in August, specifically for the sex workers in order to avoid issues of stigma and poor treatment. As staff develop the clinics in Nsanje ‘boma,’ or town center, the plan is for MSF to expand these dedicated services throughout the district to keep sex workers like Lena healthy by helping them to stay consistently on ARVs and decrease the transmission of HIV overall.
MSF has immediate plans to scale up the project to four other commercial regions of the district where there are large numbers of sex workers. Beyond that, MSF aims to extend this approach to the Southern African region, where sex workers are encountering the same kinds of challenges.
“In order to have an impact on the epidemic and seriously try to reduce the spread of the virus, we need to start paying more attention to key groups, such as sex workers,” says Rodd Gerstenhaber, country coordinator for MSF in Malawi. “There are many women like Isabella out there and we cannot afford to have them fall through the cracks of a disadvantaged health system.”
*=name has been changed to protect patient's identity
© 2013 Doctors Without Borders/Médecins Sans Frontières (MSF)