You are Wasting our Drugs: Health Service Barriers to HIV Treatment for Sex Workers in Zimbabwe

This 15-page journal article shares findings from Zimbabwe on health service barriers to HIV treatment for sex workers. According to the article, although disproportionately affected by HIV, sex workers (SWs) remain neglected by efforts to expand access to antiretroviral treatment (ART). Improving treatment access for SWs is critical for their own health, programme equity, and public health benefit. Programmes working to reduce SW attrition from HIV care need to proactively address the quality and environment of public services. Sensitising health workers through specialised training, refining referral systems from sex-worker friendly clinics into the national system, and providing opportunities for SW to collectively organise for improved treatment and rights might help alleviate the barriers to treatment initiation and attention currently faced by SW.

Three focus group discussions (FGD) were conducted in Harare with HIV-positive SWs referred from the 'Sisters With a Voice' (SWV) programme to a public HIV clinic for ART eligibility screening and enrolment. Focus groups explored SWs’ experiences and perceptions of seeking care, with a focus on how managing HIV interacted with challenges specific to being a sex worker. FGD transcripts were analysed by identifying emerging and recurring themes that were specifically related to interactions with health services and how these affected decision-making around HIV treatment uptake and retention in care.

For the most part, sex workers experience many of the same barriers as the general population as reported throughout literature on treatment programmes in resource poor settings. Key barriers identified in a wide range of settings include direct and opportunity costs of attending services; distance to facilities and poor or expensive transport; lack of support from family or others, particularly if HIV status has not been disclosed; dissatisfaction with the quality or delivery of services; competing health or religious belief; and anxiety induced by pervasive HIV-related social stigma.

The key findings of this report are as follows:

• Supply side barriers: Participants emphasised service-related determinants of attrition, regardless of their level of interaction with the hospital to which they had been referred. Women with direct experience of the clinic described how hospital nurses openly expressed their hostility to sex workers, and conducted examinations and counselling with a negative attitude. Most women who had gone to the referral hospital felt they would not access services there again. In all 3 FGDs, women described how hospital staff would go to the waiting area and make public announcements that all the sex workers present should go queue at the back or stand in a separate line. Participants discussed feeling embarrassed, shy, and unworthy of the service because of the stigma associated with their work. Internalised shame and anxiety about being known to be a sex worker reduced women’s confidence to attend treatment services. Sex workers reported they would spend up to 8 hours at the hospital, wasting the whole day instead of doing something productive to earn money. Some work as vegetable vendors during the day so attending the hospital resulted in loss of income.
• Demand side barriers: Participants in the study mentioned a range of other factors that limited their retention in care. Financial and logistical barriers impeded health service use. For instance, although the Sisters with a Voice programme paid the initial consultation fee and for CD4 count test, other charges are associated with treatment, e.g. women had to bear other costs such a US$10 fee for consulting a doctor for management of opportunistic infections. Respondents also worried that ART patients require more nutritious diets than a "normal" person, necessitating changes in their routine feeding habits. They felt that ARV drugs "were too strong" to take along with their regular diet of "sadza" (ground corn) and "muriwo" (green vegetables). Travelling time was also perceived as a barrier to treatment. Some sex workers reported having to travel the day before their appointment so as to arrive as soon as the clinic opened. This was seen as tiring, boring and wasting productive time when they could be earning.

The articles states that despite renewed interest in extending HIV treatment to sex worker communities, this study confirms that a wide range of health systems and structural barriers can contribute to high attrition rates, even when targeted and "sex worker friendly" services exist. Under 15% of HIV-positive sex workers who were referred from the SWV clinics for free specialised care attended more than one scheduled appointment, and over half did not take up referral at all. Discrimination from health care workers has been found to impede health-seeking behaviour of sex workers in a wide range of contexts, and dissatisfaction with waiting times or quality of care has been shown to cause sex workers to attend private or informal services even when free treatment is available.

According to the article, following the study, the programme has initiated several measures to reduce the barriers, stigma, and discrimination confronted by sex workers in all clinic sites. Efforts to make registration and attendance affordable and less daunting appear to have inadvertently contributed to some SW's perception that they can be identified and thus will receive further discrimination. Addressing this may require intensified efforts to change attitudes among public providers and make referral forms and the overall referral process more discreet. Another option, however, is to decentralise HIV care and provide specialised "sex worker friendly" clinics to operate.

Focused interventions may not be adequate to ensure sex workers remain engaged across the care continuum and achieve adherence levels required for treatment success. Great attention needs to be paid to links within the health system, and how sex worker friendly services can work to reduce discrimination faced by sex workers outside their own clinics and programmes. Referral mechanisms need to be monitored, and both supply and demand side barriers addressed through existing programmes.