How sex workers take charge of their health

Doctors Without Borders are working with community-based organisations to improve sex workers’ access to health care, including through trained peers who provide advice, support and linkage.

Dedza town and Zalewa trading centre in Neno lie along M1, Malawi’s main trade route used by trucks on their way to and from Tanzania as well Mozambique. Many people, mainly women, make a living through sex work.

Some have turned to sex work due to a lack of support, resources, professional training or family hardship and traumatic life events.

Others have lost parents or have been left destitute by their husbands while yet others have survived sexual abuse, including incest and exclusion from their communities.

Isolation and financial hardship make sex workers and their children extremely vulnerable in terms of health and safety. 

Big dilemma

Hamida*, 29, used to run a vegetable and charcoal business in Mangochi along the southern shoreline of Lake Malawi.

When her husband left her for another woman four years ago, she could no longer provide for her family.

“I started [sex work] in 2020 to support my three children and four brothers and sisters,” she says. “Every month I send them money, but it’s never enough. I often go to bed on an empty stomach.”

on her part, Agnes*, 42, has been a sex worker since 2008 when her husband died, leaving her four children and two grandchildren.

She founded one of two community-based sex workers’ organisations supported by Doctors Without Borders, alternatively known as Médecins Sans Frontières (MSF) in French.

She narrates: “I generally have two or three clients a day and I earn around K6 000.

 “The worst thing about this job is having sex with men and then not paying. This happens very often. Some customers beat us up and steal from us.”

Most of the sex workers MSF teams support have difficulty accessing health care due to their precarious situation and widespread stigma.

The stigma comes from “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,” says Charlie Masiku, MSF project coordinator for CBOs.

During six years of providing direct support, MSF teams have helped sex workers in Dedza and Zalewa form community organisations, develop skills and feel empowered to access to health care.

Trained sex workers work as peers to carry out health promotion initiatives on topics, including safe sex practices and contraception. They also provide support in the fight against sexual violence and help prevent sexually transmitted infections (STIs).

Peer support

At the heart of their approach are shared experiences. For example, peers provide information on pre-exposure prophylaxis (Prep), a treatment to prevent HIV transmission.

They also train their peers on screening for HIV and human papillomavirus, which causes cervical cancer.

For the latter, the peers travel door to door to visit other sex workers and collect samples for lab testing. 

Every other week, an MSF team consisting of a nurse, a health promoter and a psychologist visit certain 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 centers, but they can’t afford to go to a hospital two hours from home. So, we meet young women with very advanced health problems,” says Masiku.

Progress has been made, but challenges persist for sex workers

In recent years, the economic situation and work environment has steadily deteriorated for sex workers. Inflation is rising and the local currency has been devalued.

Sex workers are facing increasing abuse by customers and with transaction prices falling, many have to take more customers each day. 

“Capacity-building in the field of health is crucial and a step in the right direction,” explains Masiku. “However, these women also need to receive economic and social support from other organisations for them and their children to get out of this situation.”

Agnes, 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 do so, what am I going to do to earn money?”

Since the beginning of the year, MSF teams have established links with local organisations that could pay children’s school fees or help women develop professional skills for other sources of income.

The skills include 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, over 1,800 women have benefited from sexual and reproductive health services, mental health support, health promotion, and treatment.—Msf

*Names changed to protect privacy