Sex workers, meaning people who exchange sex for money or goods, are a severely stigmatised population (1) and extremely vulnerable to adverse sexual health outcomes, such as sexually transmitted infections (STIs), including HIV, unwanted pregnancies, cervical cancer, or sexual violence (2-4). Sex workers usually operate away from their place of origin, are not familiar with the local general health services, and access is further hampered by bad reception by service providers and other service users, and opening times not suited to the sex workers lifestyle (5,6). For this reason, several non-governmental initiatives provide parallel services specifically targeting sex workers, either at stand-alone clinics or through outreach (7).
In the context of an implementation research project, aiming at better aligning targeted services with the general health services, we conducted cross-sectional surveys among a representative sample of approximately 400 female sex workers (FSWs) in four cities: Mysore in India; Mombasa in Kenya; Tete in Mozambique; and Durban in South Africa. We explored, through structured face-to-face interviews, where sex workers procure commodities and services for sexual and reproductive health (SRH). We compared service utilization across the four cities and assessed if it was significantly different.
Although across cities, FSWs most commonly sought care for the majority of HIV/SRH services at public health facilities, most especially in Durban (ranging from 65% for condoms to 97% for HIV care), the places where FSWs last obtained SRH services differed substantially between cities. Targeted services had only a high coverage in Mysore, and only for STI care (89%) and HIV testing (79%). In Durban, the only targeted services that had a reasonable coverage were mobile HIV testing (39%) and condom distribution (26%) by a non-governmental organization. Private-for-profit clinics were important providers in Mombasa (ranging from 17% for STI care and HIV testing to 43% for HIV care), but in none of the other cities.
When asked what the most important reason for the choice of care provider was, convenience appeared more important than aspects of quality of care. In Durban and Mombasa it was proximity, in Tete ‘where they always go’, and in Mysore the cost of care. Where available, clinics specifically targeting FSWs were more often chosen because of shorter waiting times, quality of care, more privacy and friendlier personnel. These findings appear to indicate that they are perceived to have a higher quality of care than other providers.
Our conclusion is that interventions to improve the use of services by sex workers have to be tailored to the particular context of each setting. In the African cities, the public health services are by far the main provider and it has to be ensured that they are FSW-friendly. The findings in Mysore show that targeted services can reach high coverage, and these services need to be strengthened and expanded in the African cities. Linkages and referral systems between targeted and general health services need to be established, clearly defining the role of each.