Zimbabwe’s National Sex Work Programme Frances M Cowan 1

Overview Rationale for establishing programme Demonstration project Scale up Geographic scale up Service provision Research to support programming

Rationale ZNASP I 2006-2010 No action framework for these vulnerable populations had as yet been developed Situational analysis commissioned by NAC, IOM, UNAIDS and UNFPA 2007 Recommended that SWs needed dedicated services given led to the SW Program

‘Sisters with a Voice’ 2009 Set up two model programmes - one urban (static) and one highway (outreach) Harare, and Nyamapanda corridor

Implementation Process Community Sensitization FGDs with SWs Key informants NGOs Stakeholders Meetings Rural and urban Sites Establishment Peer Educator Recruitment and training

Two models Static sites Outreach sites Drop-in centre which aims to: Open daily Drop-in facility Clinical care/condoms Health education Outreach through peer educators Links to VFU and ZLHR Hotspots along highways – clinic based One day / 2 weeks Staffed by nurse and outreach worker Programme supported by Peer Educators between visits

Geographic scale up 2010 expanded to 16 sites nationally (3 static and 13 ‘outreach’ sites Harare, Mutare and Bulawayo

Services Provided HIV testing and counseling and assisted referral for HIV +ve women Syndromic management of STIs Free male and female condoms Contraception Health education HIV prevention education Legal advice

Peer educators > 170 trained nationally Initial 5 days training, 3 day refresher annually Community supervision through programme outreach workers Supervision meetings with nurses and outreach workers every month Monthly stipend (same as for BC facilitators)

Research to support scale up RDS survey in 3 sites in 2011 (n=870) 50-70% of SWs HIV + 50% of HIV +ve knew their status 25-37% of HIV +ve SWs were on ART 12-22% of HIV –ve SWs had HTC within 6 months 66% of women reported consistent condom use with clients Sex workers being well networked Violence common “I was afraid that I would be arrested. …..” “ It’s just the thought of being seen as a sex worker that gives me the shivers …” Cowan et al PLoS ONE 2013, Mtetwa et al BMC Public Health 2013; Mtetwa 2015 BMC public Health

2013 – Geographic expansion - 36 sites

2013 – Service expansion Clinical services LARC - IUD and implants [Cervical cancer screening] Community empowerment /mobilization Training of SW paralegals Awareness raising district medical staff and media

Community mobilisation Training of outreach workers Participatory community mobilisation meetings initiated at 3 sites Initially led by outreach workers Women identified their needs and priorities Number of women attending meetings increased over time Number of women accessing clinical services increased

Community mobilization Sisters with a Voice Peer Education Manual developed Staff and peer educators have been trained to deliver session

Cluster randomised trial of enhanced ART prevention and treatment – including PrEP Goal: to reduce the % of SWs living in communities with viral load > 1,000 copies/ml

2014 – expand services for YWSS Goal to improve the acceptability, increase uptake and support for young women who sell sex. Although 20% of sex workers in surveys report that their SW but was <20 years only 4% of programme attendees were aged <20. YWSS are particularly vulnerable to HIV and poor SRH

Young Sisters program – 3 sites Sisters programme as delivered Close collaboration with MoLSW Additional cadre of peer educators aged 15-19 Training tailored to their needs and priorities Training as lay child protection officers (for some) Training as paralegals (for some) Paired with older peer educators as mentors Development and piloting of age-specific community empowerment materials Expanding geographic scope (2016)

Determining Impact in 3 sites 2011->2015 HIV prevalence remains high HIV positive SWs better engaged with treatment services Knowledge of status has improved Reported condom use has increased

Proper inclusion of sex workers and other key populations is essential to reach 90: 90: 90 The principles of good public health demand that we strive to reach all affected populations with core HIV services even when facing difficult cultural contexts, severe stigma and discrimination, or challenging security environments. Won’t get to 90:90:90 without it Change photo Ambassador Birx May 2014

Acknowledgements Phillis Mushati Getrude Ncube Andrew Phillips Basile Tambashe Ramona Wong-Gruenwald Hellen Zitenga Joanna Busza Valentina Cambiano Milton Chemhuru Samson Chidiya Tarisai Chiyaka Calum Davey Jeffrey Dirawo Liz Fearon Emily Gwavava Stephano Gudekeya Dagmar Hanisch James Hargreaves Karin Hatzold Travor Mabugu Nyasha Masuka Sue Mavedzenge Vimbai Mdege Tendai Mhaka Sibongile Mtetwa Boniface Mudenge Owen Mugurungi Sithembile Musemburi Acknowledge sisters and logo