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Sex workers hold up the first issue of Amaqhawe magazine

Amaqhawe HIV prevention programme, South Africa

South Mpumalanga province has the country’s highest antenatal HIV prevalence. Although the epidemic is largely driven by sex work in taverns, our research revealed that no interventions were targeting this group. Working with sex workers, we developed and helped implement the Amaqhawe project which aims to reduce HIV infection in the district.

We have been overwhelmingly impressed by HDA's creativity and dedication in addressing the HIV prevention needs of sex workers in South Africa. The uniqueness of the Amaqhawe programme lies in the project staff’s recognition that effective HIV prevention messaging requires innovative approaches to community engagement and involvement. Developed in consultation with sex workers, the Amaqhawe programme is one that they have embraced as their own.

Marina Rifkin, Centers for Disease Control and Prevention

Key facts

  • The US Centers for Disease Control and Prevention commissioned us to design and implement a five-year programme to reduce HIV infections among sex workers in taverns in Gert Sibande district of South Africa’s Mpumalanga province.
  • The programme we designed is not only evidence-based, but tailored for its target audience – sex workers.
  • Amaqhawe is the only comprehensive Social Behaviour Change and Communication (SBCC) programme that encompasses biomedical interventions such as antiretroviral therapy within a large package of SBCC HIV prevention interventions.
  • Amaqhawe is the first programme for sex workers who operate in taverns and in peri-urban areas.
  • The programme has created a distinct brand that sex workers feel comfortable identifying with.
  • High-end health promotional material for sex workers, such as the ‘Cosmopolitan’-style Amaqhawe magazine, has never been used in South Africa before.
  • Other sex worker projects want to use the Amaqhawe brand. We have developed a brand identity manual to make this easier.
  • Our innovative work has been showcased at the fifth African Conference on Sexuality Health and Rights and the First South African Sex Work Symposium in South Africa.
  • The programme is now focusing on strategies to engage the police to help sex workers feel safer.

Challenges

HIV infection is especially high in Mpumalanga province and, with an antenatal HIV prevalence of 46% in 2012, the Gert Sibande district is the worst affected in the province. Mpumalanga’s many mines and major trucking routes connecting to neighbouring countries Swaziland and Mozambique bring in a large number of transitory male workers. Gert Sibande district has numerous taverns where trucks stop and local women, who have few employment opportunities, engage in sex work.

Despite a clear need for HIV prevention programmes among sex workers in the district, our research found that no programmes were targeting this high risk population.

There is also a recognised difficulty in accessing sex workers for such a programme because of the stigma surrounding sex work within communities and fear of arrest. Sex workers have limited legal rights and experience violence and discrimination from police.

Solution

The input and participation of sex workers is crucial to the success of Amaqhawe. Following a series of consultative workshops, sex workers named and branded the programme ‘Amaqhawe’ – an isiZulu word meaning ‘those who overcome’. Designed by and for sex workers, it has created a powerful brand focusing on sex workers as agents for change rather than transmitters of disease. Amaqhawe delivers risk reduction workshops, peer education training and wellness days for as well the first magazine for sex workers. It also engages directly with clients of sex workers.

Risk reduction workshops offer sex workers advice on health and nutrition and encourages them to share strategies on protecting themselves from the threat of crime, rape and gender based violence. Condoms and lubricants are distributed at the workshops and sex workers can be referred for services including HIV counselling and testing, anti-retroviral treatment (ART) adherence, cervical cancer screening, STI and TB screening, legal and financial advice, and support for those living with the virus. They also inform development of the programme and collect data. Workshop participants are trained to pass on risk reduction knowledge and strategies to other sex workers.

Peer education ensures that the programme is sex worker-led. Peer educators are selected from the risk reduction workshops and trained to support their peers in minimising the risks associated with sex work. Monthly support groups create an open and safe space within which to share challenges, concerns and successes. They also offer psychosocial support and provide referrals to health care services. Peer education builds a sense of unity and ownership of the programme among sex workers.

Amaqhawe runs monthly wellness days with health care service providers, in an effort to increase sex workers’ access to health care. Services provided at events include HIV counselling and testing, TB and STI screening, sexual and reproductive health care and general health care.

The programme published the first magazine for sex workers. Designed in close consultation with sex workers, the glossy quarterly publication combines beauty and fashion with health, safety and key messages around HIV risk reduction. Each article is pre-tested with a small group of sex workers, which has led to a high degree of buy-in. Our audience reception analysis revealed that the magazine resonated with sex workers and they were acting on advice provided in the articles.

Amaqhawe also directly engages with the clients of sex workers in taverns. This element of the programme creates an enabling environment for sex workers to practice less risky sexual behaviour within the tavern space. The intervention provides HIV and alcohol risk-reduction messages within the tavern, framed in an informative yet attractive and non-threatening way.

Value and benefits

  • Through fresh thinking and innovative ideas, we’re working to reduce the spread of HIV in South Africa. Reducing transmission of the virus is critical in this country, which has the highest number of HIV-infected residents in the world.
  • The Amaqhawe launch was attended by over 100 local sex workers – demonstrating a high degree of buy-in from the outset.
  • The programme has extensive reach – among the sex workers surveyed, 82% attend support groups and 79% have read the Amaqhawe project magazine.
  • Sex workers have a greater understanding of HIV and general health and wellbeing – 71% who attended training indicated they had a greater understanding of the risks and impact of HIV on their behaviour and health.
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