/ 4 June 2020

Sex workers abandoned as Covid-19 crackdowns undo Africa’s HIV efforts

Uganda Health Virus
Outreach: Esther (centre), a staff member of the nongovernmental organisation Lady Mermaid’s Bureau, which advocates for the human rights of female and bisexual sex workers, distributes items to those who have been hard hit by the lockdown in Uganda. (Sumy Sadurni/AFP)

In the days before the Covid-19 crisis, Ugandan sex worker Lillian Namiiro worked on the Tanzanian border, educating colleagues and connecting people to the national HIV response. 

She would remind government workers to send antiretroviral drugs to nearby health centres and checked on whether sex workers needed drug refills. She gathered them for health talks encouraging them to test for HIV and get pre-exposure drugs (PrEP) or antiretroviral treatment. 

But with the Covid-19 crisis “all that ended. The sex workers who want drugs can’t get it. Everything ended,” Namiiro says. When she called the government health workers, asking for drugs, she was told to wait until Covid-19 ended.

Uganda’s ban on public gatherings ruled out the health talks for sex workers. When transport was prohibited, except for cargo trucks, Namiiro knew that the health outreach teams could no longer reach her community. While some of these measures are now easing, bans on public transport and gatherings remain. 

Countries across Africa rolled out similar Covid-19 measures, causing major disruptions to health systems, with people being unable or afraid to go to the hospital for regular care such as antenatal services, childbirth and immunisations. 

From 24 interviews in five countries by the independent global media organisation Open Democracy, it is apparent that the most disrupted HIV-related services were those intended to prevent new infections, especially among populations considered most at risk of HIV, including sex workers. 

Health workers and sex workers in Uganda, Kenya, South Africa, Nigeria and Mozambique said they came up with creative ways to ensure registered HIV patients continue receiving drugs such as home deliveries using bikes and multi-month refills. 

But HIV testing, PrEP, drop-in centres for vulnerable groups and medical male circumcision, were scaled back and sometimes closed — all of which are vital in detecting and preventing new infections. 

‘People are going to die’

“We expect many more new cases of HIV to be reported in the coming months and weeks,” says Thomas Abol, executive director of Keeping Alive Society’s Hope (Kash), a Kenyan organisation that serves sex workers and men who have sex with men. UNAIDS and the World Health Organisation (WHO) have sounded similar alarms. 

Under the Nairobi government’s Covid-19 restrictions, Kash closed its drop-in centre in Kisumu for people who may not feel safe going to a regular clinic, including sex workers and lesbian, gay, bisexual, transgender, intersex and queer people. It offers HIV testing, counselling, doctor consultations, PrEP and monthly antiretroviral drug refills.

In South Africa, Megan Lessing, the spokesperson for the nongovernmental organisation Sex Workers Education and Advocacy Taskforce, said their outreach work — talking to sex workers where they live and work — and their walk-in HIV clinic stopped for the first five weeks of lockdown.

Lessing described how government officials removed sex workers living on the street in Cape Town, including many trans sex workers, and put them into a shelter far from support services. After a public outcry, this camp was closed, but many sex workers are too afraid to return to their usual working areas, making it difficult for health check-ins. 

Before the pandemic, the five countries were, in total, registering nearly 620 000 new HIV infections a year, according to WHO data from 2018. “People are going to die. Aids is going to multiply,” Namiiro warns.

In 10 other African countries, similar HIV service reductions were reported in March to an International Planned Parenthood Federation survey of its network of sexual and reproductive health clinics.

Unintended consequences 

Sex workers say that although the risk of coronavirus infection has scared off many of their clients, they can’t stop working and observe the health advice on physical distancing to prevent the spread of the coronavirus. In the five countries, sex workers said they have not benefited from the official cushions meant to tide people over while the Covid-19 restrictions are in place.

Sex work is illegal in South Africa, so sex workers are unable to claim unemployment benefits. “I have applied for the on-off relief of R350 that the government announced for unemployed people, but so far I’ve got nothing,” said a sex worker in Cape Town.

In Uganda, health authorities identified cross-border truck drivers as the “importers” of the coronavirus and warned sex workers off them. Truckers are a major client group for sex workers at border points and along the transit routes in the region. 

Kyomya Macklean, who runs Alliance of Women Advocating for Change, an organisation of 10 000 sex workers in Uganda says: “We were asked to disclose the number of individuals in every district and their names and contact information.” 

The Ugandan authorities weren’t clear on why they needed this information. Knowing that these same authorities had previously conducted raids on sex workers to enforce the “no contact with truckers” directive, the organisation did not reveal the identities of their members. The food aid was denied. 

Even at the local level, she says, sex workers were passed over during government food aid distribution, because many live and work in motels, but a presidential directive closed hotels and other public spaces. 

The same happened in Kenya. “Government relies on their structure, the chief and sub-chief. The chiefs decide who is vulnerable. So it’s looking very difficult for support from government to end up with sex workers”, says Abol from Kash.

“Girls actually live in these brothels, other than just working there,” said Penina Mwangi, the director of the NGO Bar Hostess Empowerment and Support Programme in Kenya. “So when they were closed, they were closed with the girls in there. We invested 35 years in dealing with HIV, but now we’ve been locked out.”

Across the continent, Covid-19 responses are increasingly seen as steeped in stigma, discrimination, rights abuses and unintended consequences. “It’s like they deployed an entire barracks at the border for us,” Namiiro says of Uganda targeting sex workers. 

“The police find us, they beat us,” says Louisa Pedro, about her experience as a sex worker in Mozambique during the Covid-19 crisis. 

These measures are also attracting resistance from the very groups considered super-spreaders of coronavirus. Truck drivers at the Kenya-Uganda border staged a strike against the measures targeting them and some have reportedly disappeared to avoid compulsory institutional quarantine. 

Activists and health workers who have been responding to the continent’s longstanding and bigger HIV epidemic for decades are surprised that their countries adopted such counter-productive top-down contagion controls, instead of tapping into home-grown knowledge on community-based management of epidemics. 

HIV experience ignored

“We have invested the past 35 years in dealing with the HIV pandemic. We have experience and expertise on how to manage a response through a gender and human rights lens,” says Lillian Mworeko, the East African regional director for the International Community of Women Living with HIV. “But we have been locked out and cannot contribute meaningfully,” she says of the national Covid-19 responses in the region. 

Truckers and sex workers are also among the most-at-risk for HIV, but are treated very differently compared with how they are treated in the Covid-19 response. Namiiro, for example, is part of a country-wide network of peer counsellors — volunteers who are picked from these populations to work with officials, which is instrumental in getting people to voluntarily seek testing and treatment. These practices seem to have been dropped because of lockdowns, bans, compulsory testing and other top-down approaches for Covid-19.

Confirmed coronavirus cases on the continent are less than 150 000 (as of June 4). Some argue that the continent’s measures against coronavirus are working. Modelling data from the WHO suggests that, without controls, 44-million people could get Covid-19 and 190 000 might die in Africa in the first year of the pandemic. 

On the other hand, the continent is already home to more than 25.8-million people who live with HIV and sees about 950 000 deaths and more than 2.2-million new infections each year, according to WHO data from 2018. So far, what is controlling the newer pandemic appears to be worsening the older one. 

To balance HIV and other health priorities with controlling the coronavirus pandemic, the continent may have to use the proverbial old broom that “knows all the corners”: designing and implementing even this epidemic response in consultation with its people. — Additional reporting by Arya Karijo, Estacio Valoi and Stephanie Ohumu

This article was first published by openDemocracy’s Tracking the Backlash project