Addressing sex workers’ lack of access to health services in the SADC region

Whether viewed as victims of structural social inequality or persons making autonomous decisions to sell their labour, or both, sex workers – and sex work in general –  have long been subjected to polarised opinions. Many of these are mired in points along the moral spectrum, with feminists also holding differing views on the subject. However, one unambiguous area is sex workers’ fundamental right to accessing sexual and reproductive health (SRH) services. 

According to the Global Network of Sex Worker Projects (NSWP), sex workers generally face stigma and discrimination and are routinely perceived as vectors of disease, thereby impeding their access to SRH services and ultimately, their ability to safeguard their health. Similarly, a 2017 study on the SRH outcomes among female sex workers (FSWs) in Johannesburg and Pretoria found that in addition to the aforementioned barriers, physical and emotional abuse, along with high levels of mobility and illegal immigration status, all contribute to if and how often sex workers are able to access SRH services. 

“Being on the margins of most societies and engaging in – more often than not – illegal activities, key populations were, for many years, excluded from the national health discourse.”

Key populations and the HIV burden

Alongside a rights-based approach to sex work, there is also social development rationale for ensuring SRH and rights (SRHR) in the SADC region, the epicentre of the HIV burden. Sex workers are considered a key population; populations that strongly influence the dynamics of HIV transmission by being at an increased HIV risk. Key populations include men who have sex with men (MSM), people in prisons, people who use drugs, sex workers and transgender people.

Being on the margins of most societies and engaging in – more often than not – illegal activities, key populations were, for many years, excluded from the national health discourse. Due to lack of quality data on the size of key populations, it was also common for governments to deny the scale of the challenge of meeting their needs. But this has changed in recent years. According to the 2018 Global AIDS Update released by UNAIDS, available data indicates that approximately 47% of new global HIV infections in 2017 were among key populations and their sexual partners.

Looking at data between 2014 and 2017, the report positions Lesotho as leading the high HIV burden among female sex workers with an approximate prevalence of 70%. eSwatini and Malawi are both at approximately 60%, with South Africa and Zimbabwe just below 60%. The report also states that criminalising same-sex relations, sex work and drug use inadvertently permits discrimination, harassment and the violation of the rights of key populations. This also isolates key populations and discourages them from accessing services.

The impact of criminality of sex work and regional policy responses

In 2019, NSWP launched its Global Mapping of Sex Worker Laws, highlighting the fact that for most SADC countries for which information is available, there is criminalisation of some aspect of sex work such selling, soliciting or organising. For example, the 2017 Namibia Gender Analysis, compiled by the Legal Assistance Centre, revealed that although sex work for reward is not specifically outlawed in Namibia, a number of related activities – such as running a brothel, the procurement of sex workers, the soliciting by sex workers and loitering – are. The study also highlighted that a major concern for sex workers is lack of access to healthcare.

Similarly, the illegality of sex work in South Africa is rooted in the Sexual Offences Act 23 of 1957 and The Criminal Law (Sexual Offences and Related Matters) Amendment Act 32 (2007). According to the South African-based Asijiki Coalition for the Decriminalisation of Sex Work, criminalisation has resulted in, among other things, driving sex workers underground and away from services.

SADC response

It is against this backdrop that the SADC Regional Strategy for HIV Prevention, Treatment and Care and Sexual and Reproductive Health and Rights Among Key Populations (the KP Strategy) was developed and validated in 2017. “The KP Strategy is very important because SADC Member States have paved the way forward on how they would like to address the issues regarding key populations, including sex workers,” notes Dr Alphonse Mulumba, Senior Program Officer in the Social and Human Development Unit at the SADC Secretariat.  “Although member states may move at different paces, they all look towards making sure all SADC citizens receive HIV and health services and no one is left behind.”

The KP Strategy was developed with the participation of all relevant constituencies, including civil society organisations (CSOs) and organisations of key populations. It provides regional guidance to member states on creating a favourable policy and legislative environment for key populations, and ensuring access to comprehensive and available SRHR services, including legal and psychosocial support. All SADC member states are expected to domesticate the KP Strategy and ensure it is aligned to national frameworks. The KP Strategy also presents an important accountability framework since governments are required to report regularly on progress against its 13 indicators, which include the number of member states with institutionalised mechanisms to address stigma against key populations and the number of member states with functional technical working groups representing key populations in national AIDS response coordination mechanisms.

South Africa’s Strategic Plan for HIV, TB and STIs 2017-2022 addresses issues of key populations substantially and in this way, is aligned with the Regional KP Strategy. The Strategic Plan also makes reference to the National Sex Worker HIV Plan 2016-2019. These comprehensive frameworks call for law reform, building the capacity of healthcare workers to respond to needs of sex workers, addressing stigma and discrimination and building the capacities of key populations to advocate for equality in access to health.

Developing concrete strategies to reach sex workers

Leveraging the potential within the national policy environment, the Sex Worker Education and Advocacy Taskforce (SWEAT), piloted a low-cost model for sex work programming in the Chris Hani District of the Eastern Cape in South Africa in 2017. The model contains a strong peer education and training package and calls for close collaboration between peer educators and staff at health facilities. The study concluded that if scaled up in 20 towns, an additional 10 000 sex workers could be reached with services each year. Critically, the project enjoys the strong support of both the District Health Department and the Eastern Cape Department of Health. 

The social, religious and cultural diversity of the SADC region is perhaps too rich and diverse to expect a broad social acceptance of sex work, and key populations in general, anytime soon. However, it is encouraging that the health and overall wellbeing of key populations is not determined by this, but rather is guided by an emerging, progressive policy environment.

(Main image: Ugandan activists with tape over their mouths take part in a protest against the amount and handling of police investigations into murders and kidnappings of women in Kampala on June 5, 2018. – Sumy Sadurni/AFP/Getty Images)

The opinions expressed in this article are those of the author(s) and do not necessarily reflect the views of SAIIA or CIGI.

23 April 2019