1. Underage and Underserved
Reaching young women who sell sex in Zimbabwe
Joanna Busza

2. Basic Overview on YWSS
20-40% adult SW report starting sex work <18 years
< 18 = officially “sexually exploited”
Increased risk of HIV & STIs
Poor negotiation skills
Less consistent condom use
Higher gender-based violence
Increased biological susceptibility
Able to attract more clients
Maintain longer working hours
Programmes reluctant to include

3. Key Issues CONSENT: Old enough to have sex so old enough to sell it?
CHOICE: Expanding opportunities for young women in constrained circumstances
COLLABORATION: Working in partnership with YWSS requires that we acknowledge their agency

5. Development & Use of an Activity Pack to Engage 15-19 year old YWSS
Case study from Zimbabwe

6. ‘Sisters with a Voice’
Clinical services (ART/ PrEP)
Health education
Over 20,000 SW clients
Community mobilisation
Peer education
Just <1% attendees were adolescents
RDS survey suggests ≈20% sex workers are under 20.
Established in 2009; now 36 sites nationally Developed in close consultation with SWs and other stakeholders

7. Age n % (min and max) * 18-24 233/655 36% (14-59%) 25-29 372/665
HIV prevalence among SWs at baseline at 14 trial sites Overall HIV prevalence 57.5% (95% CI )
Age n
% (min and max) *
18-24
233/655
36% (14-59%)
25-29
372/665
57% (38-76%)
30-39
649/948
67% (43-91%)
>40
345/440
79% (57-97%)
Total
2722
100
* percentages are RDS weighted and means of site values

8. Cascade of care for HIV+ SW by age

9. Challenges that YWSS face
Condom use and price negotiation
Dealing with rough older clients
Harassment and bullying from older sex workers
Abuse and assault by the police
Fear of being seen at the SW clinic
School interruption

10. (Age 18, HIV+, pregnant, started at 16)
Pros and Cons
“I have realised that a life of doing sex work has made me able to make a living without anyone troubling anyone. ... I have not had problems since I started sex work. My life started to improve for the better.” (Age 18, has 1 child, started at 15)
“I wish I had gone to school and finished ... I would be having a good job right now.”
(Age 18, HIV+, pregnant, started at 16)

11. Methods: Reaching Young Women
Development of Activity Pack
Monthly meetings
Training adolescent peer educators
Engagement of Social Welfare authorities
Referrals to other services

12. Activity Pack 21 participatory activities in 6 modules
Draw on existing materials for SW and adolescents
Focus on building social support & critical thinking skills
Learning to plan ahead
Covers relationships, health, safety & decision-making

13. Pilot Evaluation 143 participants across 3 sites
On average 15 attended each meeting
More intensive facilitation skills required
Activities on “the body,” sexuality, and planning for the future most popular
Among all new clients, those aged doubled from 14% in 2013 to 28% in 2015.

14. Participant Views
They treat us well despite our age. At other facilities they start asking questions like ‘why are you doing this?’ and ‘why you have an STI?’ or ‘why do you want condoms at such a tender age?’
[Older] sex workers that we meet here at the clinic later disclose us in the community, telling everyone “…this child is a sex worker”
I used to be rowdy and not care about the future, I had no hope for the future because I thought as a sex worker that's it until I had that session

15. Challenges Reaching women who do not self-identify as YWSS
Sustaining momentum
Engaging with Social Services without threatening trust with YWSS
Identifying referrals to address broader & complex needs

16. Next Steps
New sessions (alcohol use, managing money, pregnancy & parenthood)
Social media to strengthen YWSS networks & access to resources
Vocational training & microcredit partnerships
Breaking down barriers across age groups; adapting meeting locations & formats
Making Activity Pack publically available

17. Many Thanks!