1. 1 Integrated HIV/SRH clinical services for female sex workers in Madagascar - a case study

2. 2 Alliance in Madagascar Alliance has been present in Madagascar since 2001 Alliance works with Key populations : - Sex workers - Men who have sex with Men - People living with HIV/AIDS - Out of school youth

3. 3 Key actions Community based mobilization and prevention, including anti-stigma Capacity building of the Civil Society organisations (including sex workers associations) Partnership with local authorities, the private and public sectors Advocacy to improve the environment

4. 4 PARTICIPATORY ASSESSMENTS with sexworkers Participatory assessments with sex workers to better understand their reality and needs Some problems were identified, such as : – stigma and discrimination against sex workers (community, local authorities, health workers…) – abuses and violence of different kinds – Sex workers are not willing to go to the health centres

5. 5 What are the reasons that prevent sex workers to go to the health centres? Sex workers couldn’t afford the costs of health care and treatment The quality of the services provided by the health centre is not satisfying i.e. cool reception by the health workers, comings and goings for one service, … Female sex workers are embarrassed by male doctors

6. 6 Sex workers are routinely directed to STI and HIV/AIDS services (even if they go for malaria treatment!) They are forced to have a monthly medical visit and, they must possess the “White Card” which is considered as a professional card instead of a tool of follow-up of the health (and a source of police harassment) What are the main reasons that prevent sex workers to go to the health centres?

7. 7 What did the Alliance do to help in solving these problems? Integrating HIV/AIDS prevention in Sexual and Reproductive Health context Building partnership with sex workers associations - – direct actions towards sex workers to improve their general health competency and to reduce barriers encounter in accessing effective health services, – creation of toolkit towards sex workers by sex worker associations –actions that aim to improve the environment in which they are living

8. 8 Direct actions - Supporting the development of sexual and reproductive health projects by sexworkers’ associations - Technical assistance to sex workers associations when they implement these projects - These projects were financed by Alliance and FPP

9. 9 Main activities in these projects Participatory discussions on sexual and reproductive health and related themes such as health care, hygiene, rights, negotiation with clients to use condoms… Peer approach to mobilize sex workers to take care of their general health including sexual and reproductive health - not only to refer them to the health center for STI diagnosis Advocacies to mobilize local stakeholders such as the police, health services, … to act against stigma.

10. 10 Creating a toolkit together with sex workers To have better impact on spreading the messages, a workshop was held with the sex workers to assist them to develop their own tools of communication. These include calendar, posters, films… – One example of the tools created is the "Carnet de Sante" which replace the “white card” : this allows them to take in hand their sexual and reproductive health but also their general health

11. 11 Actions to improve the environment Improving the participation of sex workers in influencing policies Supporting the networking of associations of sexworkers in Madagascar (FIMIZORE) Association to protect all’s rights. This network plays an active role in the advocacy for better consideration of sex workers’ human dignity and rights, especially concerning the access to health care

12. 12 The results seem to be encouraging Sexworkers associations are now considered as “Key sectors” : are members of different “Local AIDS Committee” In terms of quantified results : 5,000 sex workers were reached by the projects implemented The project implemented by the association “TSY KIVY” in Fort Dauphin was considered as among the “Best Practices” listed by the ONUSIDA and the SE/CNLS (National Committee against AIDS).

13. 13 The results seem to be encouraging In some regions of the island : – sex workers can make free consultations, as everyone, for general health as well as sexual health. – sex workers use “Sanitary pads“ when they go to health centres Sexworkers are more aware of their health as reflected by their increasing visits to the health centres

14. 14 Lessons learned The participatory approach is very important because it helps to better understand the reality and problems of the sex workers At the local level, sex workers benefit from projects which respond to the problems identified during the participatory appraisal process Participatory discussions build “Capital social”

15. 15 Lessons learned Having “fixed” surgery hours or days instead of being an encouragement for attending the clinics is a barrier in the access to health care : source of discrimination Sex workers are more willing to take care of their health when they are not forced to do so and when they understand the benefits that they can get from it. Better impacts can be obtained when the communication toolkit for a key population is developed and created by members of this key population - messages are more appropriate

16. 16 Lessons learned Integrating HIV/AIDS with Sexual and reproductive health is more appropriate because problems related to SRH such as STI, undesired pregnancy, family planning services… are much closer to their reality than HIV/AIDS. When they take care of their SRH, they also protect themselves against HIV/AIDS.