Collaborative project

1. Stigma Research and Prevention 2.0Stepping Up the Pace for Evidence-Based Stigma- Reduction Interventions for HIV Prevention, Treatment, and Care Improving access to HIV prevention and treatment for stigmatised populations: experiences with FSW from Zimbabwe. Frances M Cowan

2. Collaborative project Zimbabwe Ministry of Health and Child Care and Centre for Sexual Health and HIV AIDS Research, Zimbabwe, in collaboration with UNFPA, PSI Zimbabwe, the National AIDS Council, University College London, the London School of Hygiene and Tropical Medicine, and RTI International.

3. Background • In Zimbabwe - criminalization of all forms of sex work, e.g. ‘loitering for the purposes of prostitution’ • Situational analysis commissioned by National AIDS Council et al in 2007 • SWs poorly served by existing health services • Establishment of national SW Program, including empowerment component

4. ‘Sisters with a Voice’ Established in 2009 with 5 sites, expanded in 2013 to 36 sites nationally Embedded within NAC’s National Behaviour Change Programme

5. ‘Sisters’ services • Developed in close consultation with SWs and other stakeholders • Clinical services supported by network of 130 peer educators • Half peer educators trained as paralegals • Community mobilisation activities • > 17,800 women seen to date

6. Access to Health Care sub-optimal “I was afraid that I would be arrested. …..” “ It’s just the thought of being seen as a sex worker that gives me the shivers …” “We are not treated well in hospitals. Sometimes if you are suffering from an STI, they will embarrass and humiliate you so that other people will know.” RDS survey in 3 sites in 2011 (n=870) • 50% of HIV+ve knew their status • 25-37% of HIV+ve SWs were on ART • 12-22% of HIV–ve SWs had HTC within 6 months • 34-67% had been stopped by police in past month • PLoS ONE 2013 8(10): e77080

7. Stigma reduces access to ART She opened my file and I saw her face just changed instantly and she looked at me like I was disgusting her. Her first words to me were ‘so you are a prostitute and you actually have the guts to come here to waste our time and drugs on you’. By the time she started taking my history I was already demoralized and I wanted to cry BMC Public Health 2013 Mtetwa

8. Cluster RCT to test whether onsite access to ART and PrEP within ‘Sisters’ programme coupled with enhanced community mobilisation will: • Increase proportion of sex workers with an undetectable viral load • Affect on HIV rates among the general population in Zimbabwe

9. Conduct baseline survey using RDS in 14 outreach sites Recruit ≈ 200 SWs per site (total n=2,800 ) Random allocation of 7 matched sites to intervention arms Process Evaluation Program data collection • SAPPH-IRe Ix Sites • Usual care plus: • HIV negatives • Repeat HTC, Offer of PrEP • HIV positives • PoC CD4; On site ART • Intensified community mobilisation with SMS adherence support • Adherence Sisters program Usual Care Sites Health education, HTC Referral to government HIV care services as needed, Syndromic STI Contraception, Condoms Cervical Ca screening, Legal advice After 18 months conduct endline survey using RDS in all 14 sites. Recruit ≈ 200 SWs per site (total n=2,800 )

10. Stigma assessed in baseline survey • Extent of social cohesion amongst SWs • Stigma as a result of work as SW • Enacted and internalised • Health care access • Including for HTC, HIV care, ART etc • Harassment from police • Fear of disclosure

11. Baseline RDS survey • 14 sites • 200 women /site • 2722 recruited • 80.9% separated / widowed • 33.2% - no religion • Weighted HIV prevalence 56% (95% CI 50-63%) • Ever GBV 53% (min-max 32- 80%) • Stopped by police last year 48% (min max 16-92%) • Fear SW disclosure by HCW 25% (min max 16-36%)

12. * Unweighted

13. Addressing stigma through intensified community mobilisation • Building trust and support • Strengthening individual agency • Individual skills building • Adherence Sisters programme • AS pairs, training and support • CBT, problem solving • SMS reminders • Building collective efficacy • Group problem solving • Empowering linkage and retention in care

14. In summary • Findings from the SAPPH-IRe baseline survey confirm high levels of perceived and enacted stigma • Women perceive stigma relates to their work • SAPPH-IRe intervention aims to build a ‘sisterhood’ to help women support each other, build emotional resilience to improve their access to HIV related prevention and care

15. Acknowledgements And Others Valentina Cambiano UCL Samson Chidiya – UNFPA Tarisai Chinyaka – CeSHHAR Calum Davey – LSHTM Jeffrey Dirawo – CeSHHAR Vimbai Mdege NAC Sibongile Mtetwa - CeSHHAR Sithembile Msembiri - CeSHHAR Phillis Mushati - CeSHHAR BasileTambashe - Country Representative UNFPA Co Investigators • Joanna Busza - LSHTM • Dr Milton Chemhuru Provincial Medical Director Midlands • Dagmar Hanisch -UNFPA • James Hargreaves LSHTM • Dr Nyasha MasukaPMD MatebelelandNorth • Sue Mavedzenge RTI International • Dr Owen Mugurungi – Director HIV AIDS and TB Unit, MoHCC • Andrew Phillips UCL • Professor Simba Rusakaniko UZ-CHS