1. Zimbabwe’s National Sex Work Programme
Frances M Cowan 1

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

3. Rationale
ZNASP I
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

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

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

6. 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

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

8. 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

9. 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)

10. Research to support scale up
RDS survey in 3 sites in (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

11. 2013 – Geographic expansion - 36 sites

12. 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

13. 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

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

15. 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

16. 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

17. 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)

18. 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

19. 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

20. 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