Bibliography

Policies in Malawi explicitly mention the need for focus on services for commercial sex workers (CSWs) because of their susceptibility to HIV infection and the potential risk they have of spreading the virus. This study aimed to explore and address barriers to coverage and uptake of HIV prevention and treatment services among CSWs in Area 25 Lilongwe district, Malawi, using Participatory Reflection and Action (PRA) methods. The work was implemented within a programme of the Regional Network for Equity in Health in east and southern Africa (EQUINET co-ordinated by Training and Research Support Centre (TARSC) in co-operation with Ifakara Health Institute Tanzania, REACH Trust Malawi and the Global Network of People Living with HIV and AIDS (GNPP+). An initial baseline survey in 20 health workers and 45 CSWs showed high knowledge but poor rating of access and uptake of HIV prevention, testing and treatment services, due to both barriers in the community and in the services themselves. A PRA process drew out further detail and experiences of the barriers faced, with priorities identified as: • Lack of early treatment seeking practices amongst CSWs • Ill treatment of CSWs at health facilities by Health practitioners • Lack of adherence to treatment by most of CSWs. The PRA process itself raised issues of gender violence and abuse that CSWs face (including through attitudes and practices in health care services) that dehumanise them, and perpetuate their own harmful behaviours. The group of CSWs and health workers as a whole identified interventions that were immediate and feasible to address the three barriers they prioritized. An intensive intervention, involving door to door counseljng, engagement at places of work, formation of joint committees between CSWs and health workers and sensitization of health workers was implemented, steered and reviewed by the team with the CSWs and health workers themselves. Health workers and CSWs reported in a follow up survey improvements across all areas in the assessed baseline, except for quality of health services. Health workers reported improvements in the same areas noted by the CSWs, although their rating of improvements were generally a little more modest than the CSWs. We suggest that a public health PHC oriented approach to services for CSWs recognize, listen to, involve and build capacity in CSWs and ex-CSWs, and the civil society organisations that work with them, as a primary group for reaching and mobilizing uptake of services in CSWs.