ملاوي | عاملات في الجنس في قلب الاستجابة لفيروس نقص المناعة البشري

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قصة مصورة8 مايو/أيار 2019

تدير منظّمة أطباء بلا حدود برنامجًا في أربع مقاطعات في إقليم ملاوي الجنوبي لمساعدة آلاف النساء اللواتي يكسبن قوت ‏يومهن من العمل في مجال الجنس على كسر الحواجز التي تفصلهن عن الخدمات الصحية. وتتضمن الطرق التي تعتمدها ‏المنظّمة للقيام بذلك تدريب عاملات الجنس وتوظيفهن كعاملات صحة في مجتمعاتهن المحلية.‏

تم تغيير الأسماء الواردة في هذا المقال.‏

Bernadette (not her real name) a sex worker who works at a bar hotspot in Dedza, and lives in a rented room on the bar premises, along with other sex workers. Bernadette received MSF’s adapted services for sex workers as part of comprehensive care and health promotion activities conducted by an MSF team at the bar.

TESTIMONY: Bernadette (not her real name) sex worker, Dedza town hotspot
“I was born into a family of 11. We lost both parents when I was 7 years old and I was raised by my sister. I dropped out of school because I was pregnant. I was living with my grandparents, who couldn’t provide much for me. I would be at school the whole day without eating anything. So I started having sex in exchange for things, and this is how I got pregnant. At that time, I didn’t know anything about condoms or any other family planning methods. I’d heard of HIV but never thought about contracting it myself.
Today I have six children, four of them stay with my grandparents in Blantyre, the other two (twins) are staying with my sister and I send money for them.
My last partner (the father of the twins) would make a lot of money and then disappear for weeks, leaving nothing at home to support us. When he returned, I would ask him where he had been and he would beat me up like an animal, with no feeling. Sometimes my whole head would be so swollen that I couldn’t see and my whole body would ache. After the babies were born, II left him and went to my home village. I was doing casual work in restaurants, guest houses and selling charcoal.
After a while my husband and I reconciled and started living together again. But then he was arrested and jailed for stealing a cow had to bail him out using all the capital from my small charcoal selling business (45,000 MK, $62). TheVmoment he got out of prison, he went off with another woman and I was destitute. My business and marriage had fallen apart. I had to accept this and move on. I tried everything to make money but wasn’t successful. Even my relatives wouldn’t help, they would say it was my fault.
I was really fearful for my children. So I turned to sex work last October 2018 to make up the money. I looked at all the options, I wasn’t educated enough to get any job, and casual work was very tough with low pay and poor treatment. Sex work was the best option to support myself.
I’m working here at this bar (where she shares a room with another girl at the back in exchange for providing sexual services for paying clients/customers at the bar). We work at all hours, it’s mostly in the evenings but whenever there’s a client we’ll provide services. Over December I could have up to 7 or 8 clients a day.
I heard of MSF’s services in November 2018 when their staff came to the bar to share information and screening about STIs and HIV. They gave us condoms and told us about the one-stop-shop at the hospital where we could go for check-ups. This was the very first time I was given information on issues like HIV testing, sexual health, before this I didn’t know anything. I saw it as an amazing opportunity that could help me to be healthy, no matter my circumstances. I felt liberated, happy, because I was hearing things I never knew about. When we would go to the hospital clinic (one-stop clinic) we are really helped to get quick and relevant treatment, without challenges. Before, it could take the whole day to get services.
With these services, I feel more empowered than before and I’m able to negotiate protection with clients. I know how to put a condom on properly and we now have lubricant which prevents accidents.”

Bernadette, a sex worker who works at a bar hotspot in Dedza and lives in a rented room on the premises, along with other sex workers.

فقدت برناديت والديها عندما كانت تبلغ من العمر سبع سنوات وتولى جداها مهمة تربيتها، لكنهم كانوا يرسلونها إلى المدرسة من ‏دون طعام.‏

تقول برناديت التي انتقلت من قريتها للعيش في ديدزا في نهاية عام 2018، "بدأت أمارس الجنس بمقابل لأنّ جداي لم يكن ‏بمقدورهما إعالتي. وحملت نتيجة ذلك ما أدى إلى تركي للمدرسة. عندما بدأت العمل في الجنس، لم تكن لدي أدنى فكرة عن توفّر ‏الواقيات الذكرية أو أي وسيلة أخرى لتنظيم الأسرة. كنت أسمع بفيروس نقص المناعة البشريّ لكن لم أتصوّر أنّني سأصاب به ‏يومًا".

برناديت سمعت عن خدمات أطباء بلا حدود حين أتى موظفوهم إلى الحانة لتقديم المعلومات والكشف عن العدوى المنقولة جنسيًا ‏وفيروس نقص المناعة البشري. وزعوا علينا يومها الواقيات الذكرية وأخبرونا عن العيادات الشاملة حيث يمكن الحصول على ‏خدمات طبية عديدة.‏

Bernadette (not her real name) a sex worker who works at a bar hotspot in Dedza, and lives in a rented room on the bar premises, along with other sex workers. Bernadette received MSF’s adapted services for sex workers as part of comprehensive care and health promotion activities conducted by an MSF team at the bar. TESTIMONY: Bernadette (not her real name) sex worker, Dedza town hotspot “I was born into a family of 11. We lost both parents when I was 7 years old and I was raised by my sister. I dropped out of school because I was pregnant. I was living with my grandparents, who couldn’t provide much for me. I would be at school the whole day without eating anything. So I started having sex in exchange for things, and this is how I got pregnant. At that time, I didn’t know anything about condoms or any other family planning methods. I’d heard of HIV but never thought about contracting it myself. Today I have six children, four of them stay with my grandparents in Blantyre, the other two (twins) are staying with my sister and I send money for them. My last partner (the father of the twins) would make a lot of money and then disappear for weeks, leaving nothing at home to support us. When he returned, I would ask him where he had been and he would beat me up like an animal, with no feeling. Sometimes my whole head would be so swollen that I couldn’t see and my whole body would ache. After the babies were born, II left him and went to my home village. I was doing casual work in restaurants, guest houses and selling charcoal. After a while my husband and I reconciled and started living together again. But then he was arrested and jailed for stealing a cow had to bail him out using all the capital from my small charcoal selling business (45,000 MK, $62). TheVmoment he got out of prison, he went off with another woman and I was destitute. My business and marriage had fallen apart. I had to accept this and move on. I tried everything to make money but wasn’t successful. Even my relatives wouldn’t help, they would say it was my fault. I was really fearful for my children. So I turned to sex work last October 2018 to make up the money. I looked at all the options, I wasn’t educated enough to get any job, and casual work was very tough with low pay and poor treatment. Sex work was the best option to support myself. I’m working here at this bar (where she shares a room with another girl at the back in exchange for providing sexual services for paying clients/customers at the bar). We work at all hours, it’s mostly in the evenings but whenever there’s a client we’ll provide services. Over December I could have up to 7 or 8 clients a day. I heard of MSF’s services in November 2018 when their staff came to the bar to share information and screening about STIs and HIV. They gave us condoms and told us about the one-stop-shop at the hospital where we could go for check-ups. This was the very first time I was given information on issues like HIV testing, sexual health, before this I didn’t know anything. I saw it as an amazing opportunity that could help me to be healthy, no matter my circumstances. I felt liberated, happy, because I was hearing things I never knew about. When we would go to the hospital clinic (one-stop clinic) we are really helped to get quick and relevant treatment, without challenges. Before, it could take the whole day to get services. With these services, I feel more empowered than before and I’m able to negotiate protection with clients. I know how to put a condom on properly and we now have lubricant which prevents accidents.”

في أحد الأيام، كانت إيميلي، العاملة في مجال الصحة المجتمعية مع المنظّمة، تُلقي جلسة تثقيف صحي في الحانة التي تعمل ‏وتعيش فيها برناديت التي تقول في هذا الصدد، "كانت هذه المرة الأولى التي أتلقى فيها معلومات مفصّلة حول مواضيع كفحص ‏الكشف عن فيروس نقص المناعة البشريّة والصحة الجنسية. اعتبرت أنّ هذه فرصة قيمة ستسمح لي بالحفاظ على صحة جيدة ‏مهما كانت الظروف". ‏

استمعت يومها إيميلي لكل ما كان لدى برناديت من هواجس وأجابت على كل أسئلتها، حيث أنّ إيميلي كانت أيضًا عاملة في ‏الجنس وتعلم جيدًا طبيعة الظروف التي تمر بها برناديت كل يوم.

A bar in the centre of Dedza town, near the border of Mozambique.

In Malawi, where poverty and unemployment remain high, many women turn to sex work – offering sexual services in exchange for payment of some sort - to support themselves and their families. Sex workers find themselves in high demand throughout night spots and drinking venues in cities of trade and along the busy trade and transport hubs, where truck drivers pass through.
In Mwanza, Zalewa and Dedza, three towns in western Malawi known as transport hubs, the presence of truck drivers, seasonal and industrial workers attracts a lot of sex workers who openly offer their services in hotspots and drinking venues, and often live in accommodation next to bars in exchange for providing services. In Nsanje, a more rural district in the south and one of the country’s poorest where men travel for seasonal jobs in sugar plantations, many women operate more secretly through informal networks and who often live with husbands and families.
Since 2014, MSF has been developing ways to reach sex workers and MSM (men who have sex with men) along main transport routes or busy centres of trade between Mozambique and Malawi through its ‘key populations’ projects. In Malawi, the project focuses only on female sex workers, and is located over four sites (across Mwanza, Dedza, Nsanje districts and Zalewa in Neno district ) and targeted towards female sex workers who each exist somewhere along the fluid continuum between ‘transactional’ and ‘commercial’ sex work.
By the end of 2018, of the 5171 sex workers ever enrolled in the Malawi program, 1797 female sex workers were actively attending sessions and clinic visits at the four sites combined.
Of the 5171 sex workers enrolled, out of 5021 tested, 2527 sex workers were HIV positive (50%) of which 1811 (72%) were enrolled onto the national ART program, while 863 (48%) were ‘active’ (seen within the last nine months) and 494/579 of the total were virally suppressed (85%).

A bar in the centre of Dedza town, near the border with Mozambique.In Mwanza, Zalewa and Dedza, three towns in western Malawi known as transport hubs, the presence of truck drivers and seasonal and industrial workers attracts a lot of sex workers who openly offer their services in hotspots and drinking venues. In Nsanje, a more rural district in the south and one of the country’s poorest, where men travel for seasonal jobs in sugar plantations, many women operate more secretly through informal networks and often live with husbands and families.

في الواقع، تلجأ العديد من النساء في ملاوي بسبب معدلات الفقر والبطالة المرتفعة إلى العمل في مجال الجنس بحيث يقدّمن ‏خدمات جنسية مقابل أي نوع من التعويض المادي لإعالة أنفسهن وعائلاتهن.‏

تعتبر ملاوي إحدى البلدان التي تعاني من أعلى معدلات انتشار فيروس نقص المناعة البشري. وعلى الرغم من أنّ جهودًا حثيثة ‏قد بُذلت في البلاد للتصدي للوباء، فما زالت العاملات في الجنس معرّضات بشكل كبير للإصابة بهذا المرضعاملات الجنس أكثر عرضة للإصابة بفيروس نقص المناعة البشرية بنسبة 5.4 مرات مقارنةً بالإناث بين عموم السكان. ‏ويستند هذا التقدير إلى إجمالي الانتشار بين النساء من الفئة العمرية بين 15 و49 عامًا بين عموم السكان في ملاوي (البيانات ‏الوطنية للصحة والسلامة المهنية، 2015-2016)، مقارنةً ببيانات مشروع منظّمة أطبّاء بلا حدود (2018) حول العاملات في ‏الجنس من الأعمار كافة.‏.

وفي ظل عدم تمكن العاملات في الجنس من الوصول إلى المعلومات والخدمات الصحية بالقدر الذي يتمتع به باقي أفراد ‏المجتمع المحلي، فهنّ معرّضات أكثر بخمس مرّات من الآخرين للإصابة بفيروس نقص المناعة البشري، ويواجهن بشكل كبير ‏خطر الحمل غير المرغوب فيه وخطر الإصابة بمختلف أنواع العدوى المنقولة جنسياً. ‏

MSF counsellor educator Joan Chapema provides HIV testing services to a sex worker in her home in Dedza, as part of MSF’s outreach activities where an MSF community team comprising of a community health worker and counsellor provide discrete and confidential home visits.

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Door to door HIV testing service (HTS)
In Mwanza, Dedza, Nsanje districts and Zalewa in Neno district, MSF conducts discrete door-to-door HIV testing services (HTS) at sex workers’ roomsas part of the sex worker project’s focus on HIV detection and prevention.
To start, MSF community health workers – themselves sex workers who have been recruited from their local communities and trained - visit hotspots to identify new and known sex workers, raise awareness around HIV and offer of HIV testing. For those sex workers who are willing and agree to be tested, an appointment is made and the community health worker and MSF counselor educator visit the sex worker at home.
During the visit the counselor gives information, conducts the test, and gives counseling according to the result. If found HIV positive, the counselor provides a referral and the community health worker links the sex worker to the nearest ‘one-stop’ clinic for treatment and further support. If the test is negative, counseling is given on prevention and a follow up appointment is made in three months to test again.
Sex workers living with HIV face huge difficulties of trust when keeping their status confidential. Building trust and discretion, including around confidentiality, is the community health worker’s biggest strength. — المرشدة ومسؤولة التثقيف الصحي في أطبّاء بلا حدود جوان تُقدّم خدمات الكشف عن فيروس نقص المناعة البشرية ‏إلى عاملة في الجنس في منزلها في ديدزا. كجزء من أنشطة التوعية الميدانية الخاصة بأطبّاء بلا حدود، يُجري فريق ‏مجتمعي يتضمن عاملة صحية ومرشدة اجتماعية زيارات منزلية سرية وخاصة.‏

Sex workers receive condoms and lubricant during a health promotion session conducted discretely at a hotspot in Nsanje. During sessions, health workers distribute supplies of lubricant and male and female condoms, which become precious commodities for sex workers in protecting themselves from HIV and other STIs.

Comprehensive care in the community and health education

In all four project sites (IMwanza, Dedza, Nsanje districts and Zalewa in Neno district ), MSF community health workers (who are themselves sex workers) visit communities and hotspots with a backpack of health promotion tools, which they use to conduct health education sessions. Topics include safer sex, HIV and STI prevention, sexual and gender based violence, hygiene, family planning & contraception and TB and cervical cancer. They also provide sex workers with condoms, lubricant, initial doses of PEP (post-exposure prophylaxis), pregnancy testing and sexual violence screening, and emergency contraception methods. A lay counsellor supports HIV testing services, counselling, TB and STI screenings and referrals. From the community the community health workers help to identify and navigate sex workers in need of medical care to MSF-run ‘one-stop’ clinics which are located in public health facilities run by the Ministry of Health. — تتلقى عاملات في الجنس الواقيات الذكرية خلال جلسات التوعية الصحية الخاصة في نقطة ساخنة في نسانجي. ‏وتوزّع العاملات الصحيات السوائل المزلقة والواقيات الذكرية والنسائية التي تتحوّل إلى سلع ثمينة لعاملات الجنس ‏لحماية أنفسهن من فيروس نقص المناعة البشرية وغيره من العدوى المنقولة جنسيًا.‏

في هذا الإطار، تشير عاملات الجنس إلى أنّهن يتعرضن إلى الوصم بالعار وإلى أعمال العنف في كثير من الأحيان خلال ‏حياتهن اليومية، وذلك من قبل الشرطة والزبائن وأصحاب الحانات وحتى الشريك. فيما يرى البعض أنّ هذه المخاطر تشكل ‏جزءًا من طبيعة المهنة، إلا أنّ تمكين العاملات في الجنس من خلال تزويدهن بالمعرفة وطرق الوقاية يعتبر أمرًا أساسيًا يسمح ‏لهن بحماية صحتهن.‏

تقول إحدى العاملات في مجال الصحة المجتمعية لدى المنظمة في ديدزا، أليس، "كانت تخجل العاملات في الجنس في ‏الماضي من زيارة المراكز الصحية خوفًا من التمييز والوصم بالعار، خصوصاً في حال تشخيص إصابتهن بفيروس نقص ‏المناعة البشري. وإذا احتاجت أي مرأة إلى تلقي الوقاية ما بعد التعرض للفيروس (علاج يقي من الإصابة بفيروس نقص المناعة ‏البشري في حال أخذه خلال 72 ساعة من التعرّض)، لم تكن تذهب إلى المستشفى لأنّها تعلم أنّها لن تحصل على المساعدة ‏هناك". ‏

وتضيف أليس، "تحتاج العاملات في الجنس إلى الحصول على الرعاية الصحية بشكل يومي لأسباب كثيرة كفي حال تمزّق ‏الواقي الذكري أو الإصابة بعدوى منقولة جنسيًا أو في حال الحاجة إلى فحص الكشف عن سرطان عنق الرحم".‏

MSF nurse mentor Chrissie Nasiyo (middle) along with another MSF staff member engage with a group of sex workers during an outreach clinic in Nsanje.

Outreach ‘One-stop clinic’

Nsanje district is a largely rural area where access to health facilities is limited by long distances. MSF and health ministry staff therefore work together to provide regular ‘one-stop’ clinics conducted as outreach sessions on specific days at different sites, either in a rented room in the community, close to where sex workers live and work, or in health ministry facilities (hospitals, centers).
The ‘one-stop’ clinics allow for discrete care and take full advantage of the single visit to offer a comprehensive package of health services during one consultation, including HIV testing and initiation, counselling, ART refills, TB screening and referral, STI testing and treatment, family planning, care for victims of sexual violence, and referral for viral load and cervical cancer screening.
During the ‘one-stop’ clinics in Nsanje, health education talks are given by the MSF community health worker, who uses interactive flip charts designed by sex workers or other teaching methods to promote knowledge of safer sex, HIV and STI prevention, sexual and gender based violence, hygiene, family planning & contraception and cervical cancer.

TESTIMONY Chrissie Nasiyo, MSF nurse mentor, Nsanje

“I’ve been working in this project for two years. I love working with the girls because they have stories to tell. Maybe you can judge them from the outside but if you hear their story, you might feel whatever they are doing is not wrong, they are doing that for a purpose.
For someone to say ‘I’m a sex worker’ can be difficult because of the culture, the stigma, the discrimination that goes with it. That’s why someone who goes to a clinic can’t say ‘I’m a sex worker’, because she’s afraid of being discriminated against. Of course, sex workers can feel differently about disclosing, some don’t care at all.
People usually mean ‘commercial’ sex workers when they talk about sex work, because it’s a job for her. She wakes up, gets dressed and goes to a hotspot to find a customer. But most ‘transactional’ sex workers don’t accept that what they are doing is sex work, because they don’t go to hotspots or places where ‘commercial’ sex workers work. She might be working class, going to her normal job, and having multiple partners in exchange for goods, but she won’t accept she’s a sex worker.
Commercial sex workers approach it like a business, ‘I need to protect myself’, but transactional sex workers are less likely to know about and test for HIV and STIs. They are more at risk than commercial sex workers, because they don’t know what they are doing is sex work, they don’t know about prevention, they feel it’s just normal. Defining it for these women can help them get healthcare.
In MSF’s projects we offer the same services for ‘commercial’ and ‘transactional' sex workers, we just reach them in different ways. When we go for an outreach clinic, first the community health worker gives a health talk in the waiting area to the sex workers, depending on what she’s prepared, as there are a range of talks. Then the participants are offered more condoms and prevention methods, HIV and STI testing, family planning, refills of ART if they are HIV positive. The majority are HIV positive.
One of the ways that MSF uses to identify sex workers in the community is through the community health workers. Despite them being MSF employees, they are also sex workers, and it’s easy for them to identify other sex workers. They’re the ones that mobilise the women to attend the ‘one-stop’ clinics.
For younger women engaging in sex work, these young girls mostly don’t know how to protect themselves from getting HIV, STIs, or unintended pregnancies. Many of their issues are related to lack of health information, which results in a lot of HIV infection around this age.’
If someone has chosen to do sex work, you can’t change her mind. But if you provide services, how they can protect themselves, then you can help them protect themselves.” — الممرضة المرشدة في أطبّاء بلا حدود كريسي ناسيو (في الوسط) إلى جانب موظفات أخريات في المنظّمة يتفاعلن ‏مع مجموعة من عاملات الجنس خلال جلسة توعية في نسانجي في ملاوي. يناير/كانون الثاني 2019.

في هذا السياق، تعمل منظّمة أطباء بلا حدود إلى جانب وزارة الصحة لتقديم خدمات تلبي الاحتياجات الخاصة بالعاملات في ‏الجنس علمًا منها بوجود مواطن القصور التي يجب معالجتها. وللتواصل مع العاملات في الجنس في ديدزا وموانزا وزاليوا ‏ونسانجي، درّبت المنظّمة عاملات كإيميلي وأليس لكي يصبحن عاملات في الصحة المجتمعية، حيث أنهن قد مررن بأنفسهن ‏بتجربة العمل في مجال الجنس وبما تجلبه من تحديات ومخاطر. ‏

وتسمح لهن هذه التجارب المشابهة بإقامة روابط خفية مع عاملات في الجنس أخريات وفهم أوضاعهن الصحية وتوجيههن نحو ‏الخدمات الطبية التي يحتجنها. بالإضافة إلى ذلك، خضع فريق العمل الصحي في العيادة إلى التدريب اللازم للتوعية حول كيفية ‏تقديم الخدمات بشكل يناسب هؤلاء النساء.‏

تقول إيميلي، "نحن نتعامل مع العاملات في الجنس بلطف واحترام مما يساعد على تقبّلهن لنا ويشجعهن على طلب المساعدة ‏الطبية".‏

مارغريت يتضمّن عملي طرق أبواب محلات بيع المشروبات الروحية وأماكن العمل في الجنس كي ألتقي بالعاملات وأقدّم لهن معلومات ‏حول الكشف عن فيروس نقص المناعة البشرية وحول كيفية العناية بصحتهن.‏

Margret (not her real name) MSF community health worker, sex worker project, Mwanza.

MSF Community health workers
Reaching hidden, vulnerable and stigmatised sex workers with packages of sexual and reproductive care means designing and delivering services to answer to the needs and lives of sex workers themselves. Central to this model are the community health workers, who as sex workers themselves have experienced the challenges and dangers faced by others, and are able to reach other sex workers through networks of trust and discretion.
Sex workers living with HIV face huge difficulties of trust when keeping their status confidential. Building trust and discretion, including around confidentiality, is the community health worker’s biggest strength.
Each of the four project sites is lead by two or more community health workers, who play a vital role of reaching and educating sex workers, providing materials such as condoms and lubricant, and navigating them towards healthcare in the ‘one-stop’ clinics.

TESTIMONY: Margret (not her real name), MSF community health worker, Mwanza
“I am a Community Health Worker based in Mwanza. My job includes going door to door and visiting bottle stores and brothels where I meet sex workers and provide them with information related to HIV testing and how they can take care of their health. For now, most of the girls are healthy, and they know their HIV status.
I went into sex work 20 years ago after losing both of my parents. My relatives who took care of me were also poor. I left school early, so I didn’t have a certificate of education which made finding decent employment difficult, so I started sex work.
At first my relatives were so uncomfortable, I was a source of embarrassment. They suggested I change my name and move away from Blantyre. So I left and came here to Mwanza.
We used to be arrested at night whenever the police felt like it. People used to look at us as animals, but things have changed. With MSF coming (to Mwanza) and us learning about our rights, things got better.
Things have improved between sex workers, police officers and health workers. Nowadays when we are arrested it means we have done something against the law, otherwise things are smooth. Now when there is an incident of sexual violence, and it is reported, the police respond swiftly so that the victim gets the right support as quickly as possible. At the same time the perpetrator is summoned by the police.
My employment as a community health worker has also improved my relationship with my relatives. People know that we are like any other person who can contribute. And that HIV affects everyone.”

Margret (not her real name), an MSF community health worker who plays a vital role in reaching out to and educating sex workers, providing materials such as condoms and lubricant, and navigating them towards healthcare in the ‘one-stop’ clinics.

توجّه العاملات في الصحة المجتمعية أيضًا العاملات في الجنس إلى عيادات "الزيارة الشاملة" التي تديرها المنظّمة في مرافق ‏وزارة الصحة أو في غرف تستأجرها المنظمة في المجتمعات المحلية قرب أماكن إقامتهنّ وعملهنّ.‏

تعتبر عيادة "الزيارة الشاملة" مركزًا يمكن للعاملة في الجنس قصده بسهولة وسرية تامة في الأوقات التي تناسبها. خلال جلسة ‏واحدة، يمكن للطبيب أنّ يقدّم للمريضة عددًا من الخدمات تتضمن فحص الكشف عن فيروس نقص المناعة البشريّ بالإضافة ‏إلى العلاج والاستشارة، والكشف عن السل بالإضافة إلى الإحالة إلى الجهة المناسبة لتلقي الرعاية، وخدمات الرعاية الجنسية ‏والإنجابية بما فيها الكشف عن حالات العدوى المنقولة جنسيًا ومعالجتها والحصول على وسائل منع الحمل والكشف عن ‏سرطان عنق الرحم وتقديم العلاج للعنف الجنسي إما في العيادة أو من خلال الإحالة.‏

A sex worker walks out of the waiting area of the MSF-run ‘one-stop’ clinic at Mwanza district hospital.

تقول برناديت في هذا الصدد، "بفضل هذه الخدمات، أشعر بأنّني أكثر قوة وأستطيع أن أتفاوض مع الزبائن لاستعمال أساليب ‏الوقاية".‏

تقول الكثير من العاملات في الصحة المجتمعية اللواتي يعملن في المنظّمة أنّهن لجأن للعمل في مجال الجنس بعد إنجابهن ‏لأطفالهن في سن مبكرة وتخلي عائلتهن عنهن أو فقدان أزواجهن وذلك للقدرة على إعالة أطفالهن. وتواجه تلك العاملات النبذ من ‏قبل عائلاتهن ومجتمعاتهن المحلية كما يتعرضن للإساءة والعدائية لقاء خيارهنّ في العمل.‏

A sex worker celebrates a negative HIV results after a discrete visit by MSF’s counsellor and community health worker where she was offered HIV testing services (HTS) in the privacy of her home.

Door to door HIV testing service (HTS)
In Mwanza, Dedza, Nsanje districts and Zalewa in Neno district, MSF conducts discrete door-to-door HIV testing services (HTS) at sex workers’ roomsas part of the sex worker project’s focus on HIV detection and prevention.
To start, MSF community health workers – themselves sex workers who have been recruited from their local communities and trained - visit hotspots to identify new and known sex workers, raise awareness around HIV and offer of HIV testing. For those sex workers who are willing and agree to be tested, an appointment is made and the community health worker and MSF counselor educator visit the sex worker at home.
During the visit the counselor gives information, conducts the test, and gives counseling according to the result. If found HIV positive, the counselor provides a referral and the community health worker links the sex worker to the nearest ‘one-stop’ clinic for treatment and further support. If the test is negative, counseling is given on prevention and a follow up appointment is made in three months to test again.
Sex workers living with HIV face huge difficulties of trust when keeping their status confidential. Building trust and discretion, including around confidentiality, is the community health worker’s biggest strength. — تحتفل عاملة في الجنس بالنتيجة السلبية لاختبار فيروس نقص المناعة البشري بعد زيارة خاصة أجرتها مستشارة ‏وعاملة في مجال التوعية المجتمعية لدى أطبّاء بلا حدود لتقديم خدمات فحص فيروس نقص المناعة البشري ‏بخصوصية في منزلها.‏

استطاع البرنامج الذي تقدمه المنظمة أن يقلل من الوصم بالعار الذي يلحق بالعاملات في الجنس في مناطقهن كما أنّه أثّر ‏بشكل إيجابي على قدرة وصول العاملات إلى الخدمات الصحية الجنسية والكشف عن فيروس نقص المناعة البشري.‏

تقول مارغريت، "في حين كان بعض الناس ينظرون إلينا في السابق وكأنّنا حيوانات، تغيرت الأمور منذ ذلك. تحسنت اليوم ‏نظرة الآخرين للعاملات في الجنس وأصبح الناس يفهمون أنّ فيروس نقص المناعة البشري قد يصيب أي أحد. وإذا أردنا معالجة ‏هذا المرض بشكل تام للأبد، علينا أولًا أن نعترف بأنّنا جميعًا بشر رغم اختلافاتنا".‏

Ketisha (not her real name) 16 years, an adolescent who engages in transactional sex stands in the door way of a bar hotspot in the centre of Mwanza town, where sex workers rent rooms to entertain clients.

Sexually exploited adolescents and young women
In Malawi, the participation of females under 18 years in some form of sex work is considered as sexual exploitation and a contravention of human rights’ law. Yet despite the legal situation, many adolescents and young women in Malawi engage in some form of sex work in exchange for money or goods. These young girls are a particularly vulnerable group who face high risks of contracting HIV or STIs as well as becoming pregnant due even greater challenges than adult sex workers in getting information and appropriate healthcare.
10.6% (549) of those enrolled in MSF’s sex worker project in Malawi are under the age of 18, with around 50% enrolled being between 18-24 years of age. MSF data shows that the risk of HIV infection among young sex workers increases exponentially around the ages of 18 to 24 years. While HIV prevalence among girls aged 18-24 years (MSF data, 2018). While providing sexual and reproductive healthcare for adolescents is a highly sensitive issue, this data underscores the critical importance and potential for providing HIV prevention at an early age, while working closely with social support services.
MSF has been piloting an adapted model for teen activities ias part of the sex worker project in Malawi. Sexually exploited adolescents and young women engaged in sex work are identified by community health workers or recruited by their peers. Weekly sessions are run for groups of adolescents by trained counsellors and community health workers to provide health talks and opportunities for in-depth discussion. A comprehensive package of HIV, TB and sexual and reproductive healthcare is also provided including HIV testing services, counselling, ART initiation and follow up, pregnancy tests, and STI screening and treatment, Family planning, screening for sexual violence, TB and cervical cancer screening. The sessions run by MSF staff are interwoven with other leisure and vocational activities and offer an opportunity to link adolescents to care as well as social services with the support of an MSF social worker.

TESTIMONY Ketisha*, adolescent engaged in transactional sex, 16 years, Mwanza

“When I was at school I had a relationship which resulted in me getting pregnant.
Unfortunately, the man that impregnated me refused to accept responsibility. However after I had delivered the man came back and asked me to forgive him. We started living together. At first all was fine, but the man started showing signs of wanting to move out of the marriage, which eventually happened.
When I started living alone things became tough. I tried to find a way that should help me earn a decent living. The more I tried the tougher it became. I never imagined that one day I would find myself in a bar. I started visiting bars as a way of supporting myself. This is how I ended here in Mwanza doing sex work.
For me to be a sex worker doesn’t mean I never tried alternative ways to support myself financially. I really tried. I tried to sell mandasi (fritters) but things didn’t work out. After that I tried selling green maize but in the end, it was all struggles. I tried to go for casual work but the employer would either pay me late or less than agreed.
To be honest, being a teenager plying my trade as sex worker is not easy, especially with my age. I get asked why at my age I am at the bottle store instead of being at school. They kind of take advantage of my age to say all sorts of things. My parents don’t know that I am a sex worker.
I remember one evening a man told me that he wanted a short time with me. We agreed the fee and then I took the man to my room. But then he changed the terms of our business and told me that he wanted to have sex with me without a condom. When I tried to protest he said if I refused he would kill me. That evening I had sex with the man without using the condom. It shattered my heart and still pains me. Of course that morning I went to the one stop centre run by MSF where I was helped, including with PEP treatment.
When I look around, a lot of teen sex workers are facing a lot of challenges. They are being forced to sleep with older men without the use of any protection. They are being forced to sleep with older men without getting paid. They are sleeping with older men at a fee less than they agreed. If they protest, they are physically assaulted.
MSF is helping me and other teen sex workers in various ways. For example, when we are sleeping with an older person there is some gel that we use. We are also advised to use condoms all the time to avoid HIV and other STIs. If it happens that we had a client and the condom burst during the act, they advise us to visit them at the hospital as soon as possible.
To me MSF is my fountain of happiness. When the Community Health Workers visit us, all they do is to provide advice without looking down upon us. They are the most humble people you ever meet.” — كيتيشا، 16: "عندما كنت في المدرسة، حملتُ بعد علاقة جنسية ورفض الرجل تحمّل مسؤولية الأمر. عندما انتقلت ‏للعيش بمفردي، أضحى كل شيء صعبًا. حاولت إيجاد طريقة لأحظى بحياة كريمة، وكلما حاولت، ازدادت الأمور ‏صعوبة. بدأت أقصد الحانات كطريقة لأجني رزقي. وهكذا انتهى بي المطاف هنا في موانزا أعمل في مجال الجنس."‏

Maria (not her real name) a sex worker who lives in Dedza, who was a victim of violence from one of her clients. Maria received comprehensive HIV prevention and sexual and reproductive services from MSF’s sex worker project in Dedza. — ماريا (وهو ليس اسمها الحقيقي) عاملة في الجنس تعيش في ديدزا، وقد وقعت ضحية للعنف من قبل أحد زبائنها. تلقت ماريا خدمات الرعاية الوقائية الشاملة ضد فيروس نقص المناعة البشرية وخدمات الصحة الجنسية والإنجابية لدى مشروع رعاية عاملي الجنس الذي تديره أطباء بلا حدود في ديدزا. ملاوي، يناير/كانون الثاني 2019.

Jennifer (not her real name) 26 years, in her rented room in a more upmarket rest house in Mwanza, where she provides sexual services for clients. Jennifer receives comprehensive services from MSF’s sex worker project which provides HIV and sexual and reproductive healthcare for sex workers in four sites in Malawi.

In Mwanza and Dedza districts, and Zalewa in Neno district, MSF uses the ‘one-stop’ clinic approach combined with outreach services targeted towards sex workers who offer their services openly and often work and live together in rented accommodation near transport hubs or at hotspots and bars.
Community health workers – themselves sex workers who have been recruited from their local communities and trained - conduct weekly health promotion sessions at different sites where they provide condoms and lubricant, and facilitate door-to-door HIV testing services (HTS) with a trained counsellor.
The MSF community health workers identify new sex workers or those in need of medical care and navigate them towards MSF’s ‘one-stop’ clinics in nearby Ministry of Health centres in the three sites. Here, MSF clinicians offer a comprehensive package of HIV care plus sexual and reproductive healthcare, all offered in a single visit. MSF has reached approximately 3851 sex workers across these three sites.

TESTIMONY Jennifer (not her real name) sex worker, Mwanza, 26 years.

“I started sex work on 1 October 2008. I am a single mother with two kids. My husband was a professional thief, and when I tried to talk him out of earning a living by theft the result was divorce. He said it was impossible for him to stop stealing because he started out that way. In the end the only way I thought would help me support my two kids was to go into sex work.
When my relatives heard what I was doing, I was chased away and told that I should never go back home. But blood is thinker than water, and later on they welcomed me. My two kids now stay with my mother.
As a sex worker there are a number of challenges. Some clients will not want to pay after sleeping with you. Some beat you up arguing that sex is supposed to be free, others steal the money you have made.
My most painful moment was being tricked by a client. I asked for payment upfront but he said he would pay me after sex. Afterwards, he refused to pay. To make things worse he didn’t use a condom. He just left. By this time, I’d heard about PEP from MSF so I ran to the hospital to get treatment.
Another client paid in advance and came to my room. He asked me to go and buy chips, so I did but when I came back I found that he had stolen my money and clothes.
An MSF health worker and community worker came to urge us to use condoms all the time. I know about sexual and reproductive health and HIV testing from them.
In my work it’s common for men to try and convince me to sleep with them without using any protection. One time I slept with a man that resulted in me contracting STIs.
Now I know about HIV testing, and how to protect myself in case the condom bursts during sexual activity or if I had unprotected sex.” — ‏جنيفر، 26: " أنا أم عزباء لولدين. أواجه الكثير من التحديات بصفتي عاملة في الجنس. يرفض بعض الزبائن الدفع ‏بعد ممارسة الجنس، بينما نتعرض في بعض الأحيان للضرب بحجة أن الجنس يجب أن يكون مجانيًا، ويسرق ‏آخرون المال الذي جنيناه. أكثر لحظة مؤلمة لي هي عندما خدعني أحد الزبائن. ولتزداد الأمور سوءًا، لم يستخدم ‏الواقي الذكري. أسرعتُ إلى عيادة أطباء بلا حدود لأتلقى العلاج الواقي من انتقال فيروس نقص المناعة".‏

Mary (not her real name) a sex worker at one of her friend’s rented rooms, next to the bar where she lives and works in Dedza town centre. Mary received comprehensive care including for syphilis from MSF’s sex worker project in Dedza, which provides adapted packages of HIV and sexual and reproductive healthcare to sex workers.

In Malawi, where poverty and unemployment remain high, many women turn to sex work – offering sexual services in exchange for payment of some sort - to support themselves and their families. Sex workers find themselves in high demand throughout night spots and drinking venues in cities of trade and along the busy trade and transport hubs.

Comprehensive care in the community and health education

In all four project sites (IMwanza, Dedza, Nsanje districts and Zalewa in Neno district ), MSF community health workers (who are themselves sex workers) visit communities and hotspots with a backpack of health promotion tools, which they use to conduct health education sessions. Topics include safer sex, HIV and STI prevention, sexual and gender based violence, hygiene, family planning & contraception and TB and cervical cancer. They also provide sex workers with condoms, lubricant, initial doses of PEP (post-exposure prophylaxis), pregnancy testing and sexual violence screening, and emergency contraception methods. A lay counsellor supports HIV testing services, counselling, TB and STI screenings and referrals. From the community the community health workers help to identify and navigate sex workers in need of medical care to MSF-run ‘one-stop’ clinics which are located in public health facilities run by the Ministry of Health.

TESTIMONY Mary (not her real name) sex worker, Dedza, 24 years
“I have been coming to this place since 2017 and have been here for a total of nine months. We are about ten girls in total. We share depending on how many sex workers need accommodation at the compound. I share a room with my roommate who is also my best friend.
I met MSF when I had syphilis. An MSF Community Health Worker came and advised me to go to the hospital for medical attention. Since then I haven’t had issues. With the one-stop centre, we no longer experience insults from health workers. Every time we have an issue we go straight and get all the necessary help.
I started sex work in 2015. When I was in Form 3, I got married but my father wasn’t happy with our marriage and after a while, we separated. The man left me with one child. Because I had left school for marriage, my father said he would never pay school fees for any girl child again. He also refused to pay school fees for my sister.
So I went into sex work as a way of paying the school fees for my sister. She has managed to finish her secondary school. But I can’t help her with fees for tertiary education. She wanted to do journalism, but I can’t help her. I just can’t. I am also paying school fees for my brother.
Our business varies – sometimes we make money, sometimes not. For now things are working. These two months of January and February normally are the difficult months. If you make MK4000.00 ($5) then you have made a lot of money. But some nights we might not have even one customer. Charges vary as well, like this time its MK1000.00 ($1.3) or MK800.00 ($1.1) per time. In extreme cases, the charge goes as low as MK500.00 ($0.69).
Our job is full of risks. Some people verbally insult us, calling us whores. Then there are clients who after sleeping with you refuse to pay. Other clients deliberately make sure that the condom bursts for their own reasons. Others take off the condom during sex. This tends to happen a lot if you are new in the trade. Now that I am experienced, it can’t and doesn’t happen.
Though I am still healthy, I want to leave sex work. I joined two village saving loans groups where we contribute money and get the money back with interest after 6 months. If all goes well I want June or July to be my last months in sex work. I want to go back home and start a charcoal business to support myself.” — ‏ماري، 24: "قابلتُ منظّمة أطبّاء بلا حدود عندما كنت مصابة بمرض الزهري. أتت عاملة في مجال الصحة ‏المجتمعية من المنظّمة ونصحتني بالذهاب إلى المستشفى لتلقي الرعاية الطبيّة. ولم أصب منذ ذاك الحين بأي مشكلة. ‏من خلال عيادة "الزيارة الشاملة"، لم نعد بحاجة إلى تلقي الإهانات من العاملين الصحيين. في كل مرة نواجه فيها ‏مشكلة، نتوجّه مباشرةً إلى المركز ونحصل على كل المساعدة اللازمة."‏

حول مشروع أطباء بلا حدود لتوفير الرعاية للعاملات في الجنس في ملاوي

تعمل منظّمة أطبّاء بلا حدود منذ العام 2014 مع وزارات الصحة الوطنية والشركاء لتعزيز الرعاية الصحية المُقدّمة إلى ‏العاملات في الجنس والرجال الذين يمارسون الجنس مع الرجال - أي الأفراد الذين يواجهون عادةً صعوبة في الحصول على ‏الرعاية الصحية – وذلك على طول خطوط النقل الرئيسيّة أو في مراكز التجارة المزدحمة بين موزمبيق ومالاوي من خلال ‏مشروعها المسمى "مشروع فئات السكان الرئيسيّة". ويستهدف المشروع في ملاوي العاملات في الجنس في مقاطعات موانزا ‏وديدزا ونسانجي وفي زاليوا في مقاطعة نينو. ‏

وتُنظّم جميع المواقع التابعة للمشروع أنشطة توعية ميدانية وتتضمّن عيادات "الزيارة الشاملة" المتواجدة في مرافق وزارة الصحة ‏أو في المجتمع المحلي، وتُلبي احتياجات العاملات في الجنس‎ ‎مثل تقديم الواقيات الذكرية والعلاج الوقائي بعد التعرض للفيروس، ‏وهو دواء يُقلّل من خطر انتقال فيروس نقص المناعة البشري. وتوظّف المنظّمة وتدرّب في جميع المواقع عاملات في الجنس ‏كعاملات في مجال الصحة المجتمعية ليصلن إلى زميلاتهن من خلال الشبكات السرية والمشاركة المجتمعية.‏

وبحلول نهاية عام 2018، تم تسجيل 5,171 عاملة في الجنس في مشروع أطبّاء بلا حدود في ملاوي والتمست 1,797 عاملة ‏الرعاية الصحية بانتظام. ونصف المريضات المسجلات مصابات بفيروس نقص المناعة البشري، وتشكّل نسبة 85 بالمئة ‏منهن حالات تم كبت الفيروس فيها، أي أن النساء قادرات على تقلي العلاج ما يُمكِّنهن من البقاء في صحة جيدة ويُقلّل من ‏احتمال نقل فيروس نقص المناعة البشري في حال مارسن الجنس من دون وقاية.‏

الخدمات الصحية المُقدّمة في إطار مشروع أطباء بلا حدود لتوفير الرعاية للعاملات في الجنس

الخدمات المجتمعية: تُنظّم العاملات في مجال الصحة المجتمعية جلسات تثقيف صحي منتظمة في المجتمع المحلي أو في ‏منازل العاملات في الجنس تتطرق إلى مواضيع تشمل ممارسات الجنس الأكثر أمانًا والوقاية من فيروس نقص المناعة البشري ‏وأمراض العدوى المنقولة جنسيًا والعنف القائم على النوع الاجتماعي والعنف الجنسي والنظافة الصحية وتنظيم الأسرة ومنع ‏الحمل والسل وسرطان عنق الرحم. كما تُقدّم إلى العاملات في الجنس الواقيات الذكرية والسوائل المزلقة ووسائل منع الحمل في ‏الحالات الطارئة والجرعات الأولية من العلاج الوقائي ما بعد التعرض للفيروس واختبار الحمل والكشف عن العنف الجنسي. ‏وتزور المستشارات المُدربات، وفقًا للمواعيد، العاملات في الجنس في المنزل لإجراء فحص فيروس نقص المناعة البشرية ‏وتوفير الاستشارات والكشف عن السل والعدوى المنقولة جنسيًا وإجراء الإحالات.‏

العيادات الشاملة أو مراكز "الزيارة الشاملة": تهدف "الزيارة الشاملة" إلى تلبية الاحتياجات الصحية لكل عاملة جنس في زيارة ‏واحدة، مستغلةً بذلك الفرصة لتلبية الاحتياجات الصحية الكافة في مرة واحدة. يُقدّم الطاقم الطبّي المُدرب مجموعة شاملة من ‏خدمات الصحة الجنسية والإنجابية وخدمات فيروس نقص المناعة البشري باستخدام نهج مُناسب للعاملات في الجنس: فتُجرى ‏فحوصات فيروس نقص المناعة البشري ويُستهل العلاج وتُوفَّر الاستشارات والأدوية المضادة للفيروسات القهقرية وخدمات ‏رعاية المصابات بالفيروس ويقاس مستوى الحِمل الفيروسي ويُكشف عن السل وتُجرى الإحالات ويُكشف عن أمراض العدوى ‏المنقولة جنسيًا ويُوفَّر العلاج وخدمات تنظيم الأسرة ورعاية ضحايا العنف الجنسي ويتم الكشف عن مستوى الحِمل الفيروسي ‏وسرطان عنق الرحم وتوفير العلاج.‏

حول أطباء بلا حدود

المشاريع والبرامج

أين نعمل

موقع أطباء بلا حدود

عاملات في الجنس يكسرنَ الحواجز التي تحرمهنّ من تلقي الرعاية الطبية وينشرنَ الوعي الصحي

79%

79%

16%

16%

5%

5%