The sex workers on the frontlines of the HIV response in Malawi

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Photo Story6 May 2019

An MSF programme in four districts in southern Malawi is helping thousands of women who earn their living from sex work to overcome barriers to health services, in part by training and employing sex workers as health workers in their communities.

Names have been changed, unless otherwise indicated.

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.

Bernadette lost both her parents when she was seven years old and was taken in by her grandparents, who would send her to school without food.

“I started having sex in exchange for things as my grandparents were not able to provide for me. This is how I got pregnant and dropped out of school,” says Bernadette, who moved from her village to Dedza at the end of 2018. “When I became a sex worker I didn’t know anything about condoms, or any other family planning methods. I had heard of HIV but never thought about contracting it myself,” she says.

Bernadette I heard of MSF’s services in November 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.

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.”

“This was the very first time I was given information on issues like HIV testing and sexual health,” says Bernadette after MSF community health worker Emily gave a health education session at the bar where she works and lives. “I saw it as an amazing opportunity that could help me to be healthy, no matter my circumstances.” Emily listened closely to what she had to say; because she too was a sex worker, she knew where Bernadette came from and what she was facing every day.

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.

In Malawi, where poverty and unemployment remain high, many women like Bernadette turn to sex work – offering sexual services in exchange for payment of some sort – to support themselves and their families.

Malawi has one of the world’s highest rates of HIV, and while the country has made huge strides in fighting the epidemic, sex workers remain extremely exposed. With much lower access to health information and healthcare than others in the community, sex workers are over five times more likely to contract HIV, and face much higher risks of unwanted pregnancies and sexually transmitted infections (STIs).Sex workers are 5.4 times more at risk of HIV infection that their female counterparts in the general population. This estimate is based on the total prevalence among women aged 15-49 years in the general population in Malawi (National MDHS data, 2015-2016), compared with MSF project data (2018) on sex workers all ages.

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

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. — Sex workers receive condoms during a health promotion session conducted discretely at a hotspot in Nsanje. 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.

Sex workers report stigmatising attitudes and often violence in their daily lives – from police, clients, bar owners and even partners. While these risks are seen by many as part of the job, empowering sex workers with knowledge and prevention methods is key to protecting their health.

“In the past, most sex workers shied away from visiting health centres for fear of discrimination and stigma, especially if they were found to be HIV positive. If women needed post-exposure prophylaxis [treatment that prevents HIV if taken within 72 hours of exposure], they just didn’t go to the hospital because they knew they wouldn’t be helped,” said Alice Matambo (real name), an MSF community health worker in Dedza. "Sex workers need healthcare in their daily lives: if a condom bursts, if they have an STI, or need to be screened for cervical cancer.”

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.” — MSF nurse mentor Chrissie Nasiyo (middle) engages with a group of sex workers during an outreach clinic in Nsanje. Malawi, January 2019.

Recognising these gaps, MSF has been working with the Ministry of Health to provide services that meet the specific needs of sex workers. To connect with sex workers in the towns of Dedza, Mwanza, Zalewa and Nsanje, MSF has trained sex workers like Emily and Alice as community health workers, as they have themselves experienced the challenges and dangers associated with sex work. This shared experience enables them to discreetly link with other sex workers, understand their health situation and explain the medical services they need. Medical staff in the project have also been given sensitivity training to provide friendly services for sex workers.

“We approach sex workers gently and with respect, which makes them accept our approach, and look for medical help,” Emily says.

Margret, Community Health Worker 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.

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.

The community health workers also guide sex workers towards ‘one-stop’ clinics run by MSF in Ministry of Health facilities or in rented rooms in communities close to where sex workers live and work.

The ‘one-stop’ clinics are easy for sex workers to access discreetly and at convenient times. In a single visit, clinicians provide services like HIV testing, treatment and counselling; TB screening and referrals for care; and sexual and reproductive healthcare, including screening and treatment for STIs, access to contraception, cervical cancer screening, and treatment for sexual violence, which is either delivered on the spot or on referral.

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

“With these services, I feel more empowered than before and I am able to negotiate protection with the clients. I know how to put a condom on properly, and we now have lubricant which prevents accidents,” says Bernadette.Lubricants play an essential part in safer sex. Adequate lubrication is essential to prevent excessive friction, which could cause the condom to tear resulting in HIV infection or pregnancy.

Many of the community health workers employed by MSF say they resorted to sex work after having children at a young age and being abandoned by their families or losing the support of their husbands to take care of their children. They are often shunned by their families and communities, facing abuse and hostility because of what they do.

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. — A sex worker celebrates a negative HIV test result after a discrete visit by an MSF counsellor and community health worker, offering HIV testing services in the privacy of her home.

The programme has seen reduced levels of stigma against sex workers in their areas, as well as having a positive impact on their access to HIV testing and sexual healthcare.

“While some people used to look at us as animals, things have changed,” says Margret. “Today, the perception that people have towards sex workers is improved. Today, people understand that HIV affects everyone. And if we are to deal with HIV once and for all, the first step is to accept and recognise that, despite being different, we are all human beings.”

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.” — Ketisha, 16: “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. When I started living alone things became tough. I tried to find a way that could help me earn a decent living. The more I tried the tougher it became. 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."

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. — Maria (not her real name), a sex worker who lives in Dedza, 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. Malawi, January 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.” — Jennifer, 26: “I started sex work on 1 October 2008. I am a single mother with two kids. 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. By this time, I’d heard about PrEP from MSF so I ran to the hospital to get treatment."

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.” — Mary, 24: "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.

About MSF’s sex worker project in Malawi

Since 2014, MSF has been working with national health ministries and partners to increase healthcare for sex workers and men who have sex with men - people who often have a difficult time accessing healthcare - along main transport routes or busy centres of trade between Mozambique and Malawi through its ‘key populations’ project. In Malawi, the project focuses on reaching female sex workers in Mwanza, Dedza, Nsanje districts and in Zalewa in Neno district. All project sites combine outreach activities with a ‘one-stop’ clinic, located at Ministry of Health facilities or in the community, that address the specific needs of the sex workers like access to condoms and post-exposure prophylaxis, a drug which reduces the risk of HIV transmission. In all sites, MSF employs sex workers as trained community health workers to reach their peers through discreet networks and community engagement.

By the end of 2018, 5,171 sex workers were enrolled in MSF’s project in Malawi and 1,797 were actively seeking regular care. About half of the enrolled patients are HIV-positive, of which 85 per cent are virally suppressed, meaning that the women are able to take their treatment well, they are more likely to stay healthy and less likely to transmit the HIV virus in the event of unprotected sex.

Health services offered by MSF’s sex worker project

Community services: Community health workers conduct regular health education sessions in the community or in sex worker’s homes, on topics including safer sex, HIV and STI prevention, sexual and gender-based violence, hygiene, family planning and contraception, and TB and cervical cancer. They also provide sex workers with condoms, lubricant, emergency contraception methods, initial doses of post-exposure prophylaxis, pregnancy testing and screening for sexual violence. On appointment, trained counsellors visit sex workers at home to provide HIV testing services, counselling, TB and STI screenings and referrals.

‘One-stop’ clinics: Trained clinicians offer a comprehensive package of HIV and sexual and reproductive care using a sex worker-friendly approach: HIV testing and initiation, counselling, refills of antiretrovirals, HIV care and viral load monitoring, TB screening and referrals, STI testing and treatment, family planning, care for victims of sexual violence, viral load and cervical cancer screening and treatment. The ‘one-stop’ clinics aim to address each sex worker’s health needs in a single visit, using the opportunity to address all of her health needs in one go.

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The sex workers on the frontlines of the HIV response

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