Making HIV services more friendly for sex workers

Judgement, criminalisation and stigma are probably the biggest issues that prevent sex workers from accessing the health services they need.

Charles says: “Punitive laws are linked to discrimination, stigma and violence and our members are not able to access healthcare services because of these draconian laws.”

Grace says: “There is the self-stigma from sex workers themselves, stigma from the service providers and also stigma from society. When we look at stigma from society, sex work is perceived as an abomination in an African context. So if you are a sex worker and also HIV positive, they look at it like you went for it. It really brings a double stigma.”

Sex workers know that their safety and wellbeing could be put at serious risk if they cannot trust a healthcare worker.

Charles says: “We need health workers to stop revealing our clients’ personal details to others. We have sex workers who are HIV positive, others are LGBTQ. And so having their personal information revealed, this is really a big mess to the community. We know there are some members who don't access services in some hospitals because of that kind of thing.”

Grace says: “Sometimes you can go to seek services and maybe you meet your community member or your relatives, who are going to spread all the information about you. We have a lot of service providers who are not trained on key population services. So there is a lot of stigma that comes with this, they announce your positivity [HIV status], they mishandle you during the services and they don't address you the appropriate way that you're supposed to be addressed, so this also makes sex workers not to be able to access services.”

Grace says: “When sex workers test HIV positive and at the same time they are pregnant, or if they have been living positively and they become pregnant, the health facilities where they usually go often don’t provide services for preventing transmission of HIV to the baby. So it forces the centre to transfer them to facilities that can provide care both for the pregnant woman and her child. But these facilities are usually not sex-worker friendly, so this also makes sex workers stop accessing services.”

Even if people are well-meaning, ignorance can cause discrimination. Arrange for sensitisation training to help you and other healthcare workers understand the health needs and feelings of sex workers.

Charles says: “Healthcare workers should be sensitised on sex workers’ health, we realised that they don’t understand how to adequately service this population.”

Grace also makes the point that facilities often have new staff starting, so it is important that training is run regularly.

Grace says: “Service providers should embrace continuous medical education. Also, involve the sex workers themselves in implementation of the programme. Getting their ideas on how they want to be treated, how they want to be handled – this would really help.”

Global evidence, as reported in the BMJ, demonstrates that when countries criminalise sex work it has a negative impact on their response to the AIDS pandemic.

Charles says: “We know that decriminalisation has an effect of reducing violence and we know that when violence is reduced, HIV infections reduce as well.”

Decriminalisation is the process of changing the law to remove criminal sanctions against an act – such as sex work – so it is no longer considered a crime. This doesn’t mean the act becomes legal but people can no longer be prosecuted for the act. Ultimately the best outcome for sex workers and their dignity will be to legalise their work. This would maximise their ability to exercise key rights, including to justice and health care. But decriminalisation is an important step towards making sex work safer and increasing access to HIV prevention and treatment services.

Look for ways to petition your leaders and law makers on this issue. Get your voice heard.

Consider opening specialised clinics for sex workers that have more flexible opening hours and allow sex workers to easily access services at different clinics.

Grace says: “Sex workers work at night and they sleep during daytime, but this is when they're supposed to go and get their refills, or go and do testing. Also, many sex workers move around a lot for their work, and their usual clinic may be too far away. But they’re not allowed to visit a different clinic without a transfer, which isn’t easy to get.

“And another issue is that many facilities are only geared on HIV services. So if the facilities can embrace other treatments, like opportunistic infections, if they can get those treatments in the facility this would help.”

Nurture a culture where healthcare professionals and peer educators take pride in providing non-discriminatory and ethical healthcare provision.

Grace says: “We have service providers that have their opinion, their values, their opinionated religion and culture and they bring it to the health facilities. So this makes it difficult for sex workers to access services because they feel judged. Also some service providers are not confidential. So they address you the way they feel like and they meet you on the street and they say ‘you didn't come for your refills’. And this is a service provider who should be keeping your information private.”