Before the COVID-19 crisis, Ugandan sex worker Lillian Namiiro worked on the Tanzanian border, where she also educated her fellow sex workers and connected her community to the national HIV response.
She reminded government workers to send antiretroviral drugs (ARVs) to nearby health centres. She checked whether sex workers needed drug refills, and gathered them for health talks about HIV tests, pre-exposure drugs (PrEP) or ARVs.
But with the COVID-19 crisis, “All that ended. The sex workers who want drugs can’t get them,” Namiiro says. When she called the government health workers to ask for drugs, she was told to wait until COVID-19 was over.
Uganda’s ban on public gatherings ruled out health talks for sex workers. When transport was prohibited, except for cargo trucks, Namiiro knew that the health outreach teams could no longer get to her community. While some of these restrictions are now easing, bans on public transport and gatherings remain.
Countries across Africa have rolled out similar measures, causing major health system disruptions. People are afraid or unable to visit hospitals for regular care such as antenatal services, childbirth and immunisations.
openDemocracy has learnt from 24 interviews across five countries that the most disrupted HIV-related services are those meant to prevent new infections, especially among populations considered most at risk of HIV – including sex workers.
Health workers and sex workers in Uganda, Kenya, South Africa, Nigeria and Mozambique said they have found creative ways to ensure registered HIV patients continue receiving drugs, such as home deliveries by bike and multi-month refills.
But HIV testing, PrEP, drop-in centres for vulnerable groups, and medical male circumcision have been scaled back and sometimes stopped completely – though all are vital in detecting and preventing new infections.
"People are going to die! AIDS is going to multiply!"
“We expect many more new cases of HIV to be reported in the coming months and weeks,” says Thomas Abol, executive director of Keeping Alive Society’s Hope (KASH), a Kenyan group that serves sex workers and men who have sex with men. UNAIDS and the World Health Organization (WHO) have sounded similar alarms.
Under the Nairobi government’s COVID-19 restrictions, KASH closed its drop-in centre – a safe space in Kisumu for people who may not feel safe going to a regular clinic, such as sex workers and LGBTIQ people. It offers HIV testing, counselling, doctor consultations, PrEP and monthly antiretroviral drug refills. `
In South Africa, Megan Lessing, spokesperson for the NGO Sex Workers Education and Advocacy Taskforce (SWEAT), says that their outreach work – going into communities to talk to sex workers where they live and work – and their walk-in HIV clinic stopped for the first five weeks of lockdown.
Lessing describes how government officials removed sex workers who were living on the street in Cape Town, including many trans sex workers, and put them into a shelter far from support services. After a public outcry, the shelter was closed, but many sex workers are too scared to go back to their usual working areas.
Even before the pandemic, the five countries were registering nearly 620,000 new HIV infections in total per year, according to WHO data from 2018. “People are going to die! Aids is going to multiply!” Namiiro warns.
In ten other African countries, similar reductions in HIV services were reported to an International Planned Parenthood Federation (IPPF) survey of its network of sexual and reproductive health clinics, in March.
Abandoned, without food or financial assistance
Sex workers say that while the risk of COVID-19 infection has scared off many of their clients, they still can’t stop working, to observe the health advice on social distancing. In all five countries, sex workers said they have not benefited from the official cushions meant to tide people over the coronavirus restrictions.
For example, sex work is illegal in South Africa, so sex workers are unable to claim unemployment benefits. “I have applied for the one-off relief of R350 ($24) that the government announced for unemployed people, but so far I’ve got nothing,” said a sex worker in Cape Town.
In Uganda, health authorities identified cross-border truck drivers as ‘importers’ of coronavirus and warned sex workers off them. Truckers are a major client group for sex workers at border points and along the transit routes in the region.
Macklean Kyomya, who runs Alliance of Women Advocating for Change (AWAC), a member organisation of 10,000 sex workers in Uganda, says that the government refused a request for food aid from the sex workers.
“We were asked to disclose the number of individuals in every district and their names and contact information,” she says, although the Ugandan authorities weren’t clear on why they needed this information. Knowing that these same authorities had previously conducted raids on sex workers to enforce the “no contact with truckers” directive, Kyome did not reveal these identities. The food aid was denied.
Even at community level, Kyome says, sex workers were passed over during government food aid distribution, because many live and work in motels, even in ‘normal’ times, and per a presidential directive, motels were supposed to be closed.
“Girls actually live in these brothels, other than just working there,” said Peninah Mwangi, director of Bar Hostess Empowerment and Support Programme (BHESP), in Kenya. “So when they were closed, they were closed with the girls in there.”
“It’s like they deployed an entire barracks at the border for us,” Namiiro says of Uganda’s targeting of sex workers. “The police find us, they beat us,” says Louisa Pedro, about her experience as a sex worker in Mozambique during the crisis.
Some measures have been counter-productive, attracting resistance from the very groups considered to be coronavirus super-spreaders. Truck drivers at the Kenya/Uganda border staged a strike against the measures targeting them, and some have reportedly disappeared into communities to avoid institutional quarantine.
"We invested 35 years in dealing with HIV. But now we’ve been locked out"
Activists and health workers who have been responding to the continent’s long-standing and bigger HIV and Aids epidemic for decades are surprised that their countries adopted such top-down controls, instead of tapping into home-grown knowledge on community-based management of epidemics.
“We have invested the last 35 years in dealing with the HIV pandemic. We have experience and expertise on how to manage a response through a gender and human rights lens,” says Lillian Mworeko, a regional director for the International Community of Women Living with HIV (ICWEA) in East Africa.
“But, we have been locked out and cannot contribute meaningfully,” she says of the national COVID-19 responses in East Africa.
The tactics used to reach the most-at-risk groups for HIV – including truckers and sex workers – are established and successful. Namiiro, for example, is part of a country-wide network of peer counsellors – volunteers picked from these populations to work with officials and encourage people to seek testing and treatment.
But for COVID-19, these practices seem to have been dropped in favour of lockdowns, bans, compulsory testing and other top-down approaches.
Confirmed coronavirus cases in Africa stand at under 165,000 (as of 4 June 2020), according to official counts. Some argue that the continent’s response measures are working. WHO modelling data suggests that, without controls, 44 million people could get infected and 190,000 might die in Africa in the first year of the pandemic.
On the other hand, the continent is already home to more than 25.8 million people living with HIV and Aids, and sees about 950,000 deaths and more than 2.2 million new infections each year, according to WHO data from 2018. At this point, what is controlling the newer pandemic appears to be worsening the older one.
Additional reporting by Arya Karijo, Estacio Valoi and Stephanie Ohumu