“There is death behind the money,” explains Lola Phiri – not her real name. “You can spend the whole week in the cell. Even if you haven’t done anything, the police demand sex to pay for you to be free.”
In the midday calm under the weight of the sun, outreach teams from Doctors Without Borders (MSF) meet with Lola and other sex workers by their booking rooms, keeping fresh under the shade on cool waxed floors.
Sex workers often share rooms and rest together, while fixing their hair or feeding their babies and preparing a pot of food in advance of the next shift.
Lola didn’t look well. Her co-workers said she was too weak to get up from the floor by herself after clients left. She had recently come from a neighbouring country and had run out of her antiretrovirals (ARVs). She had borrowed from friends, each knowing that sharing their precious pills put them more at risk of running out of the medication and sickness as well, but this is what they do. This is solidarity.
They knew Lola couldn’t risk going to the clinic for a refill. Showing up without a local health card could put her at the mercy of police or immigration officers that might deport her before she’d made enough money to return home with.
MSF works with sex workers in Malawi and Mozambique – where in Beira more than 10% of the young women in sex work become HIV positive every year. They are mostly aged between 20 and 35 years. Many are economically vulnerable, and have been divorced or abandoned by their partners, becoming the sole breadwinners for their families. In these MSF projects, 73% of the workers we see are HIV positive by the age of 35.
They aren’t all formal sex workers and don’t all recognise what they do to earn a living as “sex work” but, like Lola, they know the risks – including HIV infection and physical violence. And because sex work remains criminalised when these risks turn real, or when they are injured or sick, the sex workers we see are often too scared to seek out help.
When they do, often they are met with prejudice and, in the health services, this makes them reluctant to trust health workers or come back.
Here in South Africa, an estimated 155 000 people earn a living from sex work and between 40 and 70% of female sex workers may be living with HIV, shows research released in 2013 and 2015 by the South African National Aids Council and the health department. In Johannesburg, almost three-quarters of sex workers were HIV positive, but only 20% of those who knew their status were on ARVs.
I’m a nurse. When my colleagues and I counsel sex workers like Lola, we try to remind them about how to protect themselves from HIV infection, but we can’t protect them from the violent society they live in. Our lawmakers can.
Research published in 2014 in The Lancet medical journal found that decriminalising sex work could prevent between a third and almost half of all new HIV infections globally in the next 10 years among workers and clients.
And why could decriminalising sex work be such a powerful tool in the fight against HIV? Because it reduces workers’ exposure to violence and police harassment while giving people access to safe work environments, the study found. This is why the World Health Organisation and the United Nations Joint Programme on Aids support decriminalisation.
But after almost two decades of work reviewing South Africa’s stance on sex work, the law reform commission has recommended that the country continues to criminalise sex workers, in a report released for public comment in May. Its finding threatens to undermine government’s own plan to provide the country’s sex workers with better HIV prevention and care.
To do my job as a nurse, I need lawyers and government officials to do theirs. I need them to understand the vulnerability of sex workers so that the health care that I want to provide — care that is not only adequate but comprehensive — is possible. I want to know that people — who often already live particularly difficult lives — won’t be blocked from care by health workers who label them as “troublemakers” before thinking of them as human beings.
For that to happen, the law must change. But we, as health workers, have to change too — in the way we talk about sex and see sex work. It’s relatively easy to talk about malaria or even Ebola, but when we have to talk about sex, few people are comfortable.
And it can happen. In our areas of work, many of our colleagues now recognise sex work as a legitimate occupation – even if laws don’t. This means they provide short courses of antiretrovirals, as part of post-exposure prophylaxis, to HIV-negative sex workers when workers report possible ‘occupational exposure’ to HIV whether because condoms burst, or they were powerless to negotiate safe sex in the first place. In some places, peer educators — available at all hours in communities — now provide this service.
Some progressive departments of health are now in support of this. In Mozambique, we are providing the HIV prevention pill or pre-exposure prophylaxis (PrEP) to sex workers – just as South Africa has begun doing. PrEP can reduce a person’s risk of HIV infection by more than 90% depending on how well it’s taken, studies have shown.
However, PreP isn’t enough, HIV testing needs to be more accessible. Self-testing for HIV is one way to increase reach and we will soon provide this too.
For more than 40 years, MSF has spoken out about populations in need of healthcare from war zones to natural disasters, and when societies turn their back on people. We do this because we are a humanitarian organisation that responds to the most neglected, marginalised and vulnerable populations in the world – and in southern Africa, this includes sex workers. That is why MSF fieldworkers and staff in the region decided to support the call for the decriminalisation of sex work in 2016.
We don’t normally speak out on law or rights, but it’s not always bombs or floods that pose the biggest risk to our patients.
Lucy O’Connell is a nurse experienced in sexual and reproductive health and MSF’s focal point for key populations in Southern Africa. She writes in her personal capacity.