Malawi: Sex workers take charge of their health

In Malawi, Doctors Without Borders (MSF) teams are working with community-based organisations to improve access to healthcare for sex workers. Some of them are trained and identified as "peers" to advise, support and respond as effectively as possible to the needs, particularly the medical needs, of these women.

The towns of Dedza and Zalewa lie along the main trade route through Malawi, used by trucks on their way from Tanzania to Mozambique. Many people, mainly women, end up there to try and make a living from sex work.

Difficult family situations, traumatic events in their lives and a lack of support, resources or professional training led them to turn to sex work as a way out. Some sex workers have lost their parents or been left by their husbands, leaving them alone and destitute; others have suffered sexual abuse, including incest, and have been excluded from their communities. Isolated, their economic situation makes them and the children living with them extremely vulnerable in terms of health and safety.

Hamida *, aged 29, used to run a vegetable and charcoal business in Mangochi, further north. When her husband left her for another woman four years ago, she was no longer able to provide for her family. “I started in 2020 to support my three children and four brothers and sisters. Every month, I send them money, but it's never enough. I often go to bed with an empty stomach," she says.

Agnes * is 42 years old. She has been working as a sex worker since 2008, when her husband died, leaving her four children and two grandchildren. She is the founder of one of the two community-based sex workers' organisations supported by MSF. "Every day, I generally have two or three clients and I earn around 6,000 kwacha (R65.01). The worst thing about this job is having sex with men and them not paying. This happens very often. Other times, the customers beat us up and steal from us," she explains.

Most of the sex workers that the MSF teams support have difficulty accessing care, due to their precarious situation and the stigma to which they are subjected. "These include unwanted pregnancies, unsafe abortions that can lead to serious complications or even death, a high prevalence of sexually transmitted infections, particularly HIV, and often injuries caused by clients", explains Charlie Masiku, MSF's Community Based Organisations project coordinator in Malawi. After six years of direct support to sex workers in Dedza and Zalewa, MSF teams have helped them to form community organisations, starting in 2020, and to develop the skills needed to empower them in terms of access to healthcare. Trained sex workers, identified by others as "peers", now carry out health promotion initiatives (on safe sex practices, contraception, etc.), provide support in the fight against sexual violence and are also involved in preventing sexually transmitted infections.

Sharing experience and information is at the heart of their approach. For example, they provide information on Pre-Exposure Prophylaxis (PrEP) to protect HIV-negative sex workers and deliver training in screening for HIV and the human papillomavirus, which causes cervical cancer. For this activity, they go door to door to other sex workers to collect samples and thereafter send them to the lab for testing.

Every other week, an MSF team consisting of a nurse, a health promoter and a psychologist visit some locations to provide more in-depth medical support. “Sometimes we refer women to hospitals for health problems that can't be treated by our teams or in local health centres, but they can't afford to go to a hospital two hours from home," continues the project coordinator. “So we meet young women with very advanced health problems.”

But in recent years, the economic situation and working environment of these women has steadily deteriorated: inflation is rising, and the local currency, the kwacha, has been devalued. Customers are abusing them more and more, transaction prices are falling, and they have to increase the number of customers they receive each day.

"Capacity building in the field of health is very important and a step in the right direction. However, these women also need to receive economic and social support from other organizations to enable them and their children to get out of this situation", explains Charlie Masiku.

Agnès, whose 23-year-old daughter has also become a sex worker, confirms: "I suffer a lot to find food for the girls and uniforms for school. But it's very difficult to stop because if I stop now, what am I going to do to earn money?"

Since the beginning of the year, MSF teams have been trying to establish links with local organizations that could help pay children's school fees or help women develop professional skills that would enable them to obtain other sources of income, by growing and selling fruit and vegetables, making soap or raising livestock. This is crucial to making a difference to women's health and lives in the long term.

Since 2022, more than 1,800 women have benefited from sexual and reproductive health services, mental health support, health promotion and treatment.

*The names were changed to protect the people’s privacy

In this avenue of Dedza are the bars where women engaged in sex work come every night to look for clients. Photographer: Diego Menjibar | Location: Malawi |Date:13/10/2023

Memory Saweruzika records information from a sex worker in Dedza. MSF works with peer sex workers as Memory, a group of sex workers who have organized themselves into Community Based Organizations (CBO) to defend their sexual and reproductive rights. Photographer: Diego Menjibar | Location: Malawi |Date:13/10/2023

Jacqueline Zulu, MSF's health promotion officer, holds PREP and PEP medication before giving it to sex workers. MSF provides anti-HIV drugs to sex workers to prevent sexually transmitted diseases. Photographer: Diego Menjibar | Location: Malawi |Date:13/10/2023

A sex worker from Zalewa waits to be seen by Christine Muntali, MSF's Sexual and Reproductive Health nurse supervisor, in the team's ambulance. Photographer: Diego Menjibar | Location: Malawi |Date:13/10/2023Miriam Mbwana, MSF's mental health counsellor, talking to a sex worker in need of psychological support. Photographer: Diego Menjibar | Location: Malawi |Date:13/10/2023

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