Sex work, migration and HIV: South Africa’s health system can – and should – take a lead

Last week saw the launch of the South African Health Review (SAHR) 2016 edition at the Health Systems Trust Conference in Johannesburg. The conference convened around 300 healthcare workers, policy- and decision-makers, civil society groupings and academics in a bid to strengthen South Africa’s efforts towards the global public health agenda.

However, according to a chapter in the annual Review, “South Africa will not reach the United Nations Joint Programme on HIV and AIDS (UNAIDS) 90-90-90 targets unless adequate attention and political will are invested in sensitive, appropriate and evidence-based responses to sex worker health”.

The authors of the chapter – Dr Andrew Scheibe of the Desmond Tutu HIV Centre, Dr Marlise Richter of Sonke Gender Justice, and Prof Jo Vearey of the African Centre for Migration & Society (at the University of the Witwatersrand) – argue that current legal frameworks criminalising sex work and restricting immigration not only have negative health and economic consequences for sex workers but for the South African public as a whole.

Entitled Sex work and South Africa’s health system: addressing the needs of the underserved, this is the first time that the Review has focused on sex workers in the public health system. The authors make use of the World Health Organization (WHO) health system ‘building blocks’ in their analyses, and stress the need for effective leadership and adequate training in South Africa’s public health system in meeting sex workers’ health rights.

“Strong leadership, appropriate financing, competent health workers, high quality information and appropriate medical products and services are the foundation of an effective health system. From the sex work perspective, South Africa has made strides to enhance some of these building blocks but a lot still needs to be done to ensure sex workers have equitable access to high quality, evidence-based services that affirm their rights”, says Scheme.

Sex work and the law
The Sexual Offences Act of 1957 – a remnant of the apartheid-regime’s Immorality Act, amended in 2007 to include sex workers’ clients – criminalises all aspects of sex work in South Africa. This means that the sex worker, their client and anyone who lives off the earnings of a sex worker are considered criminals.

In 2000 the South African Law Reform Commission (SALRC) was mandated to research and provide evidence-based recommendations on legal reform options for governing sex work (under the Sexual Offences Act ‘Adult Prostitution’ Law Reform Project 107). However, it was only in 2013 that the Commission finally released its research report to the Department of Justice and Constitutional Development (DoJ & CD) for deliberation. These have still not been made available to the public.

Research has consistently documented the far-reaching effects of criminalisation on sex worker vulnerability to HIV and other illnesses. Various international bodies recommend the decriminalisation of sex work to ensure public health, including the United Nations Development Programme (UNDP), the Global Commission on HIV and the Law, the Joint United Nations Programme on HIV and AIDS (UNAIDS) and the World Health Organization’s (WHO).

Sex work, health and migration
According to a 2013 size estimate study, there are approximately 153 000 sex workers in South Africa. This indicates that selling sex is a viable livelihood option for many residing in the country. In 2013, the first multisite integrated HIV biological behavioural surveillance (IBBS) found that HIV prevalence among female sex workers was 71.8% in Johannesburg; 39.7% in Cape Town, and 53.5% in Durban.

Even though the authors of the chapter acknowledge the significant progress having been made in expanding health services to sex workers – such as the launch of the ‘South African National Sex Worker HIV Plan 2016-2019’ in March this year – they argue that stigmatisation, discrimination and violence meted out against sex workers undermine these efforts.

Kholi Buthelezi the National Coordinator of Sisonke – South Africa’s movement of sex workers – explains the challenges sex workers face in accessing treatment, “What happens when sex workers are arrested on Fridays over weekends is that police deny us access to our antiretroviral therapy (ART) and Pre-Exposure Prophylaxis (PrEp) treatments. Do government clinics, hospitals and the South African Police Service know about the roll-out of PrEp and the importance of adherence?”.

Documented cases have also proven that negligence and abuse of power by government officials are major deterrents to sex workers seeking legal, social and health services. Discrimination by health care providers, police brutality and confiscation of ‘condoms as evidence’ discourage sex workers from practicing safe sex and adhering to ART and other chronic treatment. The ‘Sex Worker Plan’ strongly condemns such practices.

In addition, the fact that the majority of sex workers in the country are either internal or cross-border migrants – coupled with South Africa’s restrictive Immigration Act – further compounds sex workers’ health risks. As a result, ensuring treatment adherence amongst migrant and mobile sex workers continues to be a key concern for South Africa’s health system. Indeed a World Health Assembly resolution, passed in 2008, specifically calls for public health systems to improve their responses to migrant and mobile populations.

Vearey asserts that, “Migration and mobility are realities in the southern African region, with most people moving – both within South Africa and across border – in search of improved livelihood opportunities. Some who move find work as sex workers, and some will have worked as sex workers before they moved. Sex work remains criminalised and it is increasingly difficult for job-seekers and foreign nationals without ‘critical skills’ – including those working informally or as sex workers – to obtain a legal status in South Africa”.

What needs to be done
The chapter concludes with recommendations on addressing inequalities experienced by sex workers, in order to strengthen South Africa’s public health system. Some recommendations include:
– that the Department of Justice and Constitutional Development propel the law reform process and decriminalize sex work;
– government increases investments to enable universal health care access for all, including sex workers;
– healthcare workers and police should be trained to provide sensitive and competent services for all marginalised groups, including sex workers;
– challenging unconstitutional donor restrictions that prevent organisations that provide services to sex workers from advocating around legal reform; and
– harmonising regional responses to HIV in relation to mobility and migration

“It is essential that efforts to improve health system responses to sex work also engage with migration – including movements within South Africa and across borders. This has important implications for the management of communicable diseases, particularly HIV. With the recent – and welcomed – move to roll-out PrEP in South Africa, there is an urgent need to ensure that mobility is considered in the ways in which PrEP will be delivered, and monitored”, adds Vearey.

Leaving no one behind
When asked about the editorial decision to include a sex worker health perspective in this 19th edition of the Review, Managing Editor Ashnie Padarath explains, “We were prompted by the issue of meeting our health Sustainable Development Goal, and it’s call to ‘leave no one behind’. This is an attempt to bring the Most At-Risk and Vulnerable Populations’ (MARPs) health issues into the mainstream. So we are encouraged that sex workers’ health is now being taken seriously”.

Sisonke has also welcomed the progress made in addressing sex workers’ health needs through the inclusion of this chapter in the Review, but points out the need for follow through with the recommendations made.

“The implementers of PrEp need to look at the criminalisation of sex work first. Because sex work is criminalised in this county will sex workers not indirectly be admitting that they are practicing sex work by asking police for access to their PrEP when detained?”, Buthelezi asks. She ends off by emphasising the need for sex work to be decriminalised in order to ensure that sex workers’ rights are upheld.

About the author: Ntokozo Yingwana is a Researcher and PhD Candidate at the African Centre for Migration & Society (Wits), working on the Migration and Health Project Southern Africa (maHp). Through a series of unique research and public engagement projects, maHp aims to generate and communicate knowledge in order to improve responses to migration, health and wellbeing in the Southern African region.

About Ntokozo Yingwana

Ntokozo Yingwana joined the African Centre for Migration & Society (ACMS, at the University of the Witwatersrand) in April 2016 as the Communication and Research Uptake Officer, and a PhD Candidate. Ntokozo holds a Masters in Gender and Development from the Institute of Development Studies (IDS, at the University of Sussex in England), funded by the Chevening UK Scholarship. Prior to joining ACMS she worked for IDS as the Content Coordinator for the Open Knowledge and Digital Services Unit.

Ntokozo’s experience and skills are in journalism, online media, advocacy, open access/knowledge and research. She freelances as an Online Media Consultant, Digital-storytelling Trainer, and Researcher. However, her main passion lies in gender, sexuality and sex worker rights’ activism in Africa. In the past she has worked for the Sex Worker Education and Advocacy Taskforce (SWEAT), the African Sex Worker Alliance (ASWA), and the Global Network of Sex Work Projects (NSWP).

Under maHp Ntokozo supports the project’s communication and research uptake.