South Africa’s illegal sex workers and the transgender community are warning stigma and discrimination will prevent them from being part of a bold new government initiative to stop the spread of HIV, the virus that causes AIDS.
Next month the South African government will begin offering HIV testing and treatment to all South Africans, including sex workers, who are being offered a drug that helps reduce the risk of being infected by up to 90 per cent.
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In South Africa, about 70 per cent of sex workers have HIV, among the highest rates in the world.
Transgender sex worker Sivavalo says she and others in the industry will not go to a government hospital for help because they suffer discrimination.
"It is difficult to go to a public hospital when you are transgender and you're looking for HIV medication, because they ask you all sorts of questions about who you are and what's your real name, in front of other people," Sivavalo explained to SBS.
Sivavalo says she is still identified as Robert in the public system and says doctor’s attitudes are scaring people away.
"[They] don't treat me like your other patients, which makes it difficult for some of us to even go to get the medication, because we are scared of how we will be treated in hospitals."
Protecting the vulnerable
Young sex workers just starting in the industry are considered the most exposed to discrimination, exploitation and HIV infection.
The government is offering them a new drug called Prep, or Pre-Exposure Prophylaxis, a once-a-day pill that greatly lowers the risk of infection.
Other countries are watching the bold initiative closely but there are warnings it could fail.
Counsellor Silindele Xulu says even the government's pledge to make Prep freely available is no guarantee that people will get protection.
“They won’t come and ask for prep. It’s very difficult,” Xulu told SBS at the Ukuba Nesibindi drop-in centre in Durban that caters for sex workers.
She says young sex workers are not used to negotiating with clients or asking for medical help.
"They come across and say, 'My client says to me that he's clean and he doesn't need to use protection' and 'you are too young and too sweet to be infected, so I don't think I will infect you either, and, because I have so much money, would it be possible to have fun with you without a condom?' So it's risky as well."
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Six million people in South Africa live with HIV, and about half are receiving no treatment.
Sex workers and the transgender community are considered among the hardest to reach, due to the stigma and discrimination they experience.
Fighting on the front lines
Lifeline director Pravisha Dhanapalan is on the front lines fighting HIV and says success with other public-health programs shows they only work if you take ongoing treatment into the community.
"We have been able to link up with the Department of Health and other clinical offices, where they come in onsite, whether it's in a brothel or on the street, and provide the CT test or Pap smear, all onsite. That’s what works," Dhanapalan explained.
International AIDS Society president Chris Beyrer says the risk is, if the uptake of Prep is low, people who need it most will not be able to access it.
"If people are afraid and they think that they're going to be arrested or abused by the police, then they're unwilling to get tested and unwilling to get on treatment,” Beyrer told SBS.
“Prep requires HIV testing. It requires regular HIV testing. So, if you have barriers to accessing that service, it won't work."
Sivavalo says the government needs to learn from the progressive attitude of NGOs.
“There is still a long way to go because all this is only happening because of the NGOs.
"The prep that is coming out by the government, they are only doing it on September 1.
“The NGOs are already rolling it out to the sex workers, which means they are a step ahead of the government. What else are they lacking on?”
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