The sex workers who are stopping HIV
Tags: HIV

The story of Mozambique’s HIV epidemic is embedded in its history of bloodshed.

After a decade of armed struggle, Mozambique gained independence from Portugal in June 1975. Hundreds of thousands of Portuguese fled, including many who worked in healthcare. By Independence Day, just 80 doctors remained in the whole of the country.

The Mozambique Liberation Front (FRELIMO) came to power, but inherited a fractured country with a fragile infrastructure and few skilled workers. Within two years a brutal civil war had broken out, with FRELIMO violently confronted by the Resistência Nacional Moçambicana (RENAMO), an armed and much-feared rebel movement. Over the next 15 years, up to a million died and 10 per cent of the country’s population became war refugees.

Yet as HIV ravaged neighbouring countries, Mozambique was shielded by limited population movement into the country.

A peace agreement was eventually reached in 1992, and with international help the government began to focus on improving the country’s main transport corridors to restore economic growth. Ripe for development was the Beira corridor, spanning the 300 km from the Indian Ocean to Zimbabwe’s eastern border. Previously marred by dilapidated infrastructure, staff shortages and bandit attacks, transport links from Beira’s rehabilitated port soon stretched to surrounding countries.

Mozambique was open for business.

But development came at a cost. When populations become more mobile, so do sexually transmitted infections like HIV. Long-distance drivers, for example, are more likely to engage in transactional sex, with a string of partners. They frequently make overnight stops, arriving with money to spend in the midst of poorer communities.

Within 15 years of its first, solitary case, one million people in Mozambique were living with HIV

And so after the civil war, truck drivers often carried HIV from stop to stop along the Beira corridor until they reached their families at home. Sex workers followed the money. And HIV followed them all.

Meanwhile, refugees returned from neighbouring countries — another factor believed to have contributed to a rise in HIV rates. Mozambique’s first case was reported in 1986. By the end of 1992, there had been 662 confirmed cases. By 1998 that number had risen to 10,863.

These spiralling rates partly represented improved diagnostics, but the figures went far beyond this. Within 15 years of that first, solitary case, one million people in Mozambique were living with HIV.

Yet solid political and economic reforms had led Mozambique to become one of the fastest-growing economies in Africa, with GDP growth of 7 per cent per annum. The government prioritised HIV prevention and treatment, and international donors stepped forward. The number of people on HIV treatment grew 37-fold between 2004 and 2013.

By mid-2016, about 900,000 people living with HIV were receiving antiretroviral treatment, three times as many as in 2012. Expanded treatment coverage for pregnant women living with HIV resulted in a 73 per cent decline in new infections among children in just three years. New HIV infections among adults dropped by 40 per cent from 2004 to 2014.

Mozambique had become a shining example of how to battle an HIV epidemic. Yet there was a missing piece in the puzzle.

Its HIV success story did not extend to the Beira corridor — it didn’t even come close.

Our group receives a warm welcome at our next stop — Pinta Boca’s Premium Bar. Many of the peer educators are familiar faces here.

Luisa carries a notebook and collects the telephone numbers of sex workers who want to be called during the week with advice on how and where to get antiretroviral drugs. Quanto custa? They’re free, Luisa replies. To one woman standing by a pool table, its legs embedded deep in the mud and cues nowhere to be seen, Luisa says yes, she can get refills at the clinic if she has run out. And TB treatment, too? Sure, Luisa says. She’ll call her tomorrow with advice.

The pages of Luisa’s notebook are filling up fast.

A man drinking a bottle of Impala beer approaches one of the women sitting on a white plastic chair by the roadside. She passes her baby gently to a fellow worker and walks towards the huts with the truck driver. A rapidinha, they call it — a quickie.

The Corridor Project is not about one organisation. It’s really about 300

Jaime — a counsellor from MSF — has joined us tonight. He knows this crowd well, too. As he bounces one of the infants on his knee, a camionista, a long-distance truck driver, steps forward. “Can I have the test?” he asks. Jaime walks him towards the van and the man gets an HIV test there and then. A preliminary result follows 15 minutes later. If his test is later confirmed as positive, he will join the 1.5 million others in Mozambique living with HIV at the last count.

We end up back in the van — now 144 red condoms lighter, each 53 millimetres wide and made of natural latex rubber. Luisa and others like her are just the right people to be here: better suited than well-meaning outsiders who, without relatable experiences, might never be able to connect with those at risk in such a profoundly personal way.

Luisa, 29 years old and a mother of five, tells me that her ex left her soon after she was gang-raped. The attack gave her HIV. For her, it was too late. But not for these women, she believes.

By the end of this week, her notebook will be full.

© Billy Clark

It’s fair to say there was an endless amount of bargaining to get the MSF Corridor Project off the ground — and no better woman to contend with this than its Brazilian coordinator, Daniela Cerqueira Batista.

A psychologist by background, Daniela is effortlessly glamorous in a Goan beach sort of way. There are kisses on either cheek and arms flung around those she meets. Her messages have more emojis than mine have characters. Her energy is resolutely undiminished by this oppressive heat, despite managing a team of 90 here in Beira.

When she saw how expensive books were at a local sale here, she set about trying to establish a library. When she couldn’t find a Pride flag, she picked up a multicoloured umbrella back in Brazil. And so on Rua Dom Francisco Gorjão, the umbrella now forms an improvised Pride symbol stuck above the front door of MSF’s Beira headquarters.

Meeting after meeting it took to set up the Corridor Project — with local NGOs, transport sector representatives, law enforcement agencies, Ministry of Health officials, truckers’ unions, border community representatives and customs personnel. Add to that input from donors and funding institutions, including the US President’s Emergency Plan for AIDS Relief (PEPFAR), the Global Fund and many others.

The Corridor Project is not about one organisation. It’s really about 300. In a country of 43 languages.

But these alliances ultimately proved fruitful, explains Daniela, establishing firm links with port companies who hold staff education sessions, community theatre groups who put on productions with safe-sex themes, and organisations who run workshops on domestic abuse. And the project would be incomplete without its linkage to care — the health centres at Ponta Gêa and Munhava.

Some lessons you just won’t find in textbooks. In the early days, those working as part of the project wore MSF T-shirts but were shunned — sex workers and truck drivers associated the charity solely with HIV care and didn’t approach the peer educators in case others thought they were HIV positive. Staff at the health centres soon learned to dispense antiretroviral drugs in boxes that had fake labels — that way, patients could go home with a box that looked like it was just full of painkillers.

They want to change their own lives and help their sisters on the streets

Mobile clinics have now been established along the corridor, with adapted opening times; sex workers and truck drivers work unconventional hours. MSF counsellors and peer educators make door-to-door visits and stop by 200 hotspots along the corridor. And their staff support care at government health centres so that stigma and discrimination do not drive these marginalised populations away. The Corridor Project now stretches across Mozambique and has been extended to Malawi and Zimbabwe.

More recently, MSF has introduced health passports for all patients diagnosed with HIV who are on treatment. Containing test results and medication regimens, they allow for continuity of care along the corridor. MSF are working to have these multilingual passports recognised in Zimbabwe and Malawi — if they are successful, patients could receive uninterrupted HIV treatment across borders.

And then there are the peer educators. At those makeshift bars, it’s Luisa and the others who engender a sense of genuine trust, connection, camaraderie and solidarity. They’ve been there; sometimes they still are. And back at Rua Dom Francisco Gorjão, they’re involved in all aspects of the project — design, implementation, decision making and oversight, at the community level and nationally. Luisa has a chance, if she wants it, to progress through the organisation; several peer educators have become counsellors. Others have been supported to set up their own businesses.

Luisa receives remuneration for her peer educator role. I ask Sebastiana Cumbe, supervisor of psychological support, how this factors into sex workers signing up to this project. “Yes, there is a salary,” she tells me. “But it’s not just that. They want to change their own lives and help their sisters on the streets.”

Not many projects provide that linkage to care, a bridge between community and clinic. A 2016 study assessed healthcare programmes for sub-Saharan African truck drivers in 30 countries. Of 22 programmes, only three covered testing and care for conditions other than HIV, such as TB and malaria. Few tested for other STIs. Just above half have been evaluated to date. And where data has been gathered, it primarily focuses on the number of sites established, staff trained, resources used or clients reached. It’s one thing to give out condoms, but another thing for people to use them. Few projects have reported on impact indicators such as changes in infection rates.

In 2016, 71 per cent of the HIV-negative sex workers in the Corridor Project were retested at least once, with 94 per cent still HIV negative when retested. It’s these sorts of metrics that should help scale up and sustain the programme.

If, that is, the project can weather the political challenges faced by Mozambique, both now and in the future.