by Jules Montague
Sex workers in Mozambique are providing health support to those at the margins of society. They face political and financial challenges, but against the odds they are helping thousands. Jules Montague reports.
It’s late when we reach Inhamízua on the outskirts of the city.
Stalls sell crackling chicken feet and sizzling plantain. Scores of men and women are gathered by a makeshift bar topped with corrugated steel. Spirits are high. The sound of laughter rises above the rumble of trucks trundling by.
Light from the gas station across the road illuminates the scene. Some of the women sit on white plastic chairs, nursing infants. It’s a nativity scene of sorts, set under coconut trees and soundtracked by Marrabenta-style dance music surging from a battered loudspeaker.
Luisa* and I walk behind the bar, through dried mud and over shards of glass and used condoms. We’re at the huts now. It’s 80 meticais for five minutes – about a pound. A bottle of beer in this town, to put things in context, costs 55.
In Beira, like everywhere else, sex sells – and there’s a good chance that HIV will be part of the transaction. Truckers drive here along the trade corridor that stretches from Zimbabwe’s eastern border. The end of their journey is a Mozambican port city where life expectancy is less than 50 and HIV rates are among the highest in the world. When they leave, that legacy often follows them.
One in ten adults in Mozambique is HIV positive, making the country’s HIV prevalence the eighth highest globally. But while the government has made progress on controlling the epidemic in recent years, reaching the marginalised along the Beira corridor has remained difficult.
How do you reach a population that is perpetually mobile? A population fearful of police intimidation, or of being found out by friends and family? In their eyes, they have little to gain from meeting you and everything to lose. To reach them, you need an innovative approach.
On we go, Luisa and I and the others, to place after place late into the night. Hotspots they call them, each one the same – makeshift bars with white plastic chairs, pumping music, overturned trucks, stacks of old tyres, broken beer bottles, and every time those huts out back.
© Billy Clark
Luisa is a peer educator – part of a team that dispenses medical advice to the local community – but will return to these streets as a sex worker when money is low.
And her story is the story of this project.
For here in Beira, I’ve discovered a group helping people to help themselves – even as Mozambique threatens to fall back into the political chaos of its past. Amid the discord, this project is countering the seeming inevitability of contracting HIV along the transport corridor by enabling sex workers to become peer educators for a couple of nights each week, sometimes more. Joined by counsellors and outreach workers, they provide safe-sex guidance, offer advice on family planning, and deliver on-the-spot HIV testing. They distribute condoms and lubricants. And, crucially, they connect some 3,800 sex workers and 4,500 long-distance truck drivers to health clinics they might otherwise never visit.
This is the Corridor Project, established by Médecins Sans Frontières (MSF) in January 2014. And despite its perilous situation, it’s reaching the unreachable.
The story of Mozambique’s HIV epidemic is embedded in its history of bloodshed.
After a decade of armed struggle, Mozambique gained independence from Portugal in June 1975. Hundreds of thousands of Portuguese fled, including many who worked in healthcare. By Independence Day, just 80 doctors remained in the whole of the country.
The Mozambique Liberation Front (FRELIMO) came to power, but inherited a fractured country with a fragile infrastructure and few skilled workers. Within two years a brutal civil war had broken out, with FRELIMO violently confronted by the Resistência Nacional Moçambicana (RENAMO), an armed and much-feared rebel movement. Over the next 15 years, up to a million died and 10 per cent of the country’s population became war refugees.
Yet as HIV ravaged neighbouring countries, Mozambique was shielded by limited population movement into the country.
A peace agreement was eventually reached in 1992, and with international help the government began to focus on improving the country’s main transport corridors to restore economic growth. Ripe for development was the Beira corridor, spanning the 300 km from the Indian Ocean to Zimbabwe’s eastern border. Previously marred by dilapidated infrastructure, staff shortages and bandit attacks, transport links from Beira’s rehabilitated port soon stretched to surrounding countries.
Mozambique was open for business.
But development came at a cost. When populations become more mobile, so do sexually transmitted infections like HIV. Long-distance drivers, for example, are more likely to engage in transactional sex, with a string of partners. They frequently make overnight stops, arriving with money to spend in the midst of poorer communities.
Within 15 years of its first, solitary case, one million people in Mozambique were living with HIV
And so after the civil war, truck drivers often carried HIV from stop to stop along the Beira corridor until they reached their families at home. Sex workers followed the money. And HIV followed them all.
Meanwhile, refugees returned from neighbouring countries – another factor believed to have contributed to a rise in HIV rates. Mozambique’s first case was reported in 1986. By the end of 1992, there had been 662 confirmed cases. By 1998 that number had risen to 10,863.
These spiralling rates partly represented improved diagnostics, but the figures went far beyond this. Within 15 years of that first, solitary case, one million people in Mozambique were living with HIV.
Yet solid political and economic reforms had led Mozambique to become one of the fastest-growing economies in Africa, with GDP growth of 7 per cent per annum. The government prioritised HIV prevention and treatment, and international donors stepped forward. The number of people on HIV treatment grew 37-fold between 2004 and 2013.
By mid-2016, about 900,000 people living with HIV were receiving antiretroviral treatment, three times as many as in 2012. Expanded treatment coverage for pregnant women living with HIV resulted in a 73 per cent decline in new infections among children in just three years. New HIV infections among adults dropped by 40 per cent from 2004 to 2014.
Mozambique had become a shining example of how to battle an HIV epidemic. Yet there was a missing piece in the puzzle.
Its HIV success story did not extend to the Beira corridor – it didn’t even come close.
Our group receives a warm welcome at our next stop – Pinta Boca’s Premium Bar. Many of the peer educators are familiar faces here.
Luisa carries a notebook and collects the telephone numbers of sex workers who want to be called during the week with advice on how and where to get antiretroviral drugs. Quanto custa? They’re free, Luisa replies. To one woman standing by a pool table, its legs embedded deep in the mud and cues nowhere to be seen, Luisa says yes, she can get refills at the clinic if she has run out. And TB treatment, too? Sure, Luisa says. She’ll call her tomorrow with advice.
The pages of Luisa’s notebook are filling up fast.
A man drinking a bottle of Impala beer approaches one of the women sitting on a white plastic chair by the roadside. She passes her baby gently to a fellow worker and walks towards the huts with the truck driver. A rapidinha, they call it – a quickie.
The Corridor Project is not about one organisation. It’s really about 300
Jaime – a counsellor from MSF – has joined us tonight. He knows this crowd well, too. As he bounces one of the infants on his knee, a camionista, a long-distance truck driver, steps forward. “Can I have the test?” he asks. Jaime walks him towards the van and the man gets an HIV test there and then. A preliminary result follows 15 minutes later. If his test is later confirmed as positive, he will join the 1.5 million others in Mozambique living with HIV at the last count.
We end up back in the van – now 144 red condoms lighter, each 53 millimetres wide and made of natural latex rubber. Luisa and others like her are just the right people to be here: better suited than well-meaning outsiders who, without relatable experiences, might never be able to connect with those at risk in such a profoundly personal way.
Luisa, 29 years old and a mother of five, tells me that her ex left her soon after she was gang-raped. The attack gave her HIV. For her, it was too late. But not for these women, she believes.
By the end of this week, her notebook will be full.
© Billy Clark
It’s fair to say there was an endless amount of bargaining to get the MSF Corridor Project off the ground – and no better woman to contend with this than its Brazilian coordinator, Daniela Cerqueira Batista.
A psychologist by background, Daniela is effortlessly glamorous in a Goan beach sort of way. There are kisses on either cheek and arms flung around those she meets. Her messages have more emojis than mine have characters. Her energy is resolutely undiminished by this oppressive heat, despite managing a team of 90 here in Beira.
When she saw how expensive books were at a local sale here, she set about trying to establish a library. When she couldn’t find a Pride flag, she picked up a multicoloured umbrella back in Brazil. And so on Rua Dom Francisco Gorjão, the umbrella now forms an improvised Pride symbol stuck above the front door of MSF’s Beira headquarters.
Meeting after meeting it took to set up the Corridor Project – with local NGOs, transport sector representatives, law enforcement agencies, Ministry of Health officials, truckers’ unions, border community representatives and customs personnel. Add to that input from donors and funding institutions, including the US President’s Emergency Plan for AIDS Relief (PEPFAR), the Global Fund and many others.
The Corridor Project is not about one organisation. It’s really about 300. In a country of 43 languages.
But these alliances ultimately proved fruitful, explains Daniela, establishing firm links with port companies who hold staff education sessions, community theatre groups who put on productions with safe-sex themes, and organisations who run workshops on domestic abuse. And the project would be incomplete without its linkage to care – the health centres at Ponta Gêa and Munhava.
Some lessons you just won’t find in textbooks. In the early days, those working as part of the project wore MSF T-shirts but were shunned – sex workers and truck drivers associated the charity solely with HIV care and didn’t approach the peer educators in case others thought they were HIV positive. Staff at the health centres soon learned to dispense antiretroviral drugs in boxes that had fake labels – that way, patients could go home with a box that looked like it was just full of painkillers.
They want to change their own lives and help their sisters on the streets
Mobile clinics have now been established along the corridor, with adapted opening times; sex workers and truck drivers work unconventional hours. MSF counsellors and peer educators make door-to-door visits and stop by 200 hotspots along the corridor. And their staff support care at government health centres so that stigma and discrimination do not drive these marginalised populations away. The Corridor Project now stretches across Mozambique and has been extended to Malawi and Zimbabwe.
More recently, MSF has introduced health passports for all patients diagnosed with HIV who are on treatment. Containing test results and medication regimens, they allow for continuity of care along the corridor. MSF are working to have these multilingual passports recognised in Zimbabwe and Malawi – if they are successful, patients could receive uninterrupted HIV treatment across borders.
And then there are the peer educators. At those makeshift bars, it’s Luisa and the others who engender a sense of genuine trust, connection, camaraderie and solidarity. They’ve been there; sometimes they still are. And back at Rua Dom Francisco Gorjão, they’re involved in all aspects of the project – design, implementation, decision making and oversight, at the community level and nationally. Luisa has a chance, if she wants it, to progress through the organisation; several peer educators have become counsellors. Others have been supported to set up their own businesses.
© Billy Clark
Luisa receives remuneration for her peer educator role. I ask Sebastiana Cumbe, supervisor of psychological support, how this factors into sex workers signing up to this project. “Yes, there is a salary,” she tells me. “But it’s not just that. They want to change their own lives and help their sisters on the streets.”
Not many projects provide that linkage to care, a bridge between community and clinic. A 2016 study assessed healthcare programmes for sub-Saharan African truck drivers in 30 countries. Of 22 programmes, only three covered testing and care for conditions other than HIV, such as TB and malaria. Few tested for other STIs. Just above half have been evaluated to date. And where data has been gathered, it primarily focuses on the number of sites established, staff trained, resources used or clients reached. It’s one thing to give out condoms, but another thing for people to use them. Few projects have reported on impact indicators such as changes in infection rates.
In 2016, 71 per cent of the HIV-negative sex workers in the Corridor Project were retested at least once, with 94 per cent still HIV negative when retested. It’s these sorts of metrics that should help scale up and sustain the programme.
If, that is, the project can weather the political challenges faced by Mozambique, both now and in the future.
“You’re sick,” Luisa’s partner had said to her. He had just found out that she had been raped. Then, he left her.
She had already been a sex worker for some time when it happened. Her first child had been born when Luisa was 14; her second, four years later. So she became the family breadwinner when her partner couldn’t get a job.
She remembers her first day on the streets. Overcome by shame when she saw a neighbour, she ran home before a single transaction. But two days later, with no food for her children, she returned.
She always ensured her clients wore condoms, even though they would pay more if they didn’t have to. The ones who refused, she refused them too. She remained HIV negative.
I would have been more ashamed if I had to beg my friends for money. This was a conscious decision
“Half the money now,” the client had said that night. “Half the money after we have sex.” He wanted her to travel away from the huts. In the car, he phoned his friends.
“He took out a gun and told me, ‘Get out,’ and I did. He told me to take my clothes off and I did. His friends arrived. They had sex with me, five people. But they didn’t use a condom. Afterwards, he left me there. I had no strength left, and then I took my clothes, I hitched a ride and went to the hospital.”
Luisa’s internal and external injuries were so severe that she was unable to work for another six months.
She was tested again, not too long after. She was HIV positive.
Worldwide, sex workers are 12 times as likely as the general population to be HIV positive. Across 16 sub-Saharan African countries surveyed in 2012, the prevalence of HIV among sex workers was 37 per cent.
“When I was sick,” Luisa tells me, “my children ended up not going to school because I couldn’t afford paying for the school truck, because I didn’t have money left. MSF always came to take me to the hospital, to do everything. I didn’t have anything left to eat because I couldn’t go on the streets. They gave me a letter and I went to collect food, even when I said I had HIV. And I started to take some medicine. Slowly, I recovered.”
Luisa has five children now, aged between two and fourteen.
She became an MSF peer educator two years ago. As she walks through that dried mud and over those shards of glass, I see something in her. Energy. Empathy. A need to be there for others the way others were there for her.
She works less frequently on the streets than she did before. But she does not regret her choices. “I would have been more ashamed if I had to beg my friends for money. This was a conscious decision. When my heart tells me to do something, I do it.”
© Billy Clark
Back at Rua Dom Francisco Gorjão, I meet 22-year-old Antonio*. He explains how the Corridor Project reaches out to other at-risk populations, not just those connected to sex work. Similar strategies are used for each group, despite their differences.
Antonio knew as a child in Maputo that he was different from his friends. Or at least he was made to feel different. As he played with dolls and cookery sets, his stepmother told him to play with cars, to make friends with boys instead of girls. In his teens he was sent to live in Beira with his cousins. “Here I felt comfortable,” he says. “I was able to paint my nails, freely wear make-up and dresses.” He was sometimes bullied at school. But Beira became his home.
His journey with his own family has been more difficult. He visited his sister’s house recently with a gay female friend. Afterwards, his sister said if she were to discover her daughters were gay, she would murder them with her own hands.
Antonio works as a peer educator for men who have sex with men (MSM). Globally, gay men and other MSM are 19 times more likely to be living with HIV than the general population. A recent Beira study found a third of MSM over the age of 25 are living with HIV.
Another recent study suggested a third of MSM in Beira had never been tested for HIV. Fourteen per cent of those said that this was because they simply did not know where to go.
These interventions are a necessary first step. The larger question is what can we do to remove stigma and other barriers
With such high HIV rates in Beira’s MSM, the cornerstone of MSF’s work here is to scale up preventative strategies. This is where PrEP comes in – pre-exposure prophylaxis. By taking a certain combination of drugs in one daily tablet, people can reduce their risk of contracting HIV by more than 90 per cent. (It does not protect against other STIs, and missing doses decreases its effectiveness.)
José Carlos Beirão manages the PrEP Operational Research Project, established within the Corridor Project in 2016, and the only one of its kind in Mozambique. So far 214 participants, MSM as well as female sex workers, have been recruited, with a target of 250. Beirão hopes that by the end of the project, he’ll be able to understand the demand for PrEP and the feasibility and acceptability of implementing a wide-scale PrEP programme.
I ask Ken Ho, an HIV specialist and prominent PrEP researcher at the University of Pittsburgh, whether he thinks the corridor approach might be applicable to settings far outside Beira.
“We know that young black MSM are disproportionally impacted by HIV,” he explains. “These are the same people who may have limited access to healthcare because of lack of insurance, distrust of medical institutions, or fear of stigmatisation.” And so he sees the corridor approach as being relevant in the USA, at least initially in establishing a link with difficult-to-reach populations.
But he sounds a note of caution: “The risk is that these targeted interventions function more like Band-Aids and allow – perhaps even encourage – the underlying problems to persist. So I think they are a necessary first step. The larger question is what can we do to remove stigma and other barriers that are responsible for the disparities in the first place.”
Antonio’s confidence has grown since his schooldays, he tells me.
For him, it’s about visibility. When he arrived in Beira, nobody looked like him. Now he sees others who do. Boys growing up today, he believes, will have a chance to think differently because of this: I see it, I can be it.
I am outside Beira’s airport, right where José Manuel was shot dead in April 2016. He was a RENAMO member of the National Council for Defence and Security. Formerly the civil war rebels, RENAMO are now the opposition party. Human Rights Watch noted reports that it had taken the police ten hours to arrive on the scene.
Armed conflict resumed in Mozambique in 2015, after two decades of peace. The results of the 2014 general election, won by FRELIMO, were bitterly contested by RENAMO. There were summary executions of villagers, abductions and sexual violence, political assassinations, raids on health clinics, attacks on civilian buses, and even reports of mass graves.
Mozambique was in danger of plunging back into the chaos of its past. Faced with violence from both sides, over 11,000 Mozambicans fled to Malawi and Zimbabwe. By the end of 2016, a truce had been agreed, and most of the refugees had returned, but many families remain internally displaced.
In 2016 economic growth halved, with a downturn in commodity prices. And then there was an astonishing and ultimately devastating admission from the government: it had guaranteed $1.5 billion in secret, unconstitutional loans. Fourteen donor countries and multilateral institutions – including the UK, the International Monetary Fund and the World Bank – promptly suspended direct support to the state budget. The foreign debt burden has risen to $9.9bn – up 20 per cent a year over the last five years.
By the beginning of 2017, cholera outbreaks had become so common that they were barely making the national news. The cost of bread and other staples was rising. The currency was falling. Nurses were not being paid. The ceasefire is still holding, but uneasily so.
Ordinary people in Mozambique are paying a high price. It is possible the Corridor Project will, too.
The average Mozambican’s daily struggle remains to lift themselves out of poverty
Health infrastructure is already in a perilous state. There are only three doctors per 100,000 people, one of the worst ratios in the world. Already more than half the population must walk an hour or more to their nearest health facility. Just over half of health facilities lack electricity and 41 per cent have no running water.
Mozambique expert Alex Vines has been head of the Africa Programme at Chatham House, an international affairs think-tank in London, since 2002. How will recent political and economic developments affect healthcare in Mozambique, I ask him, and in turn the Corridor Project?
Vines points out that the ceasefire is at least indefinite, and that better rains over recent months have provided some economic respite. “But the debt burden – because of the undisclosed loans scandal of 2016 and suspension of direct budget support by international donors – has seriously impacted the government’s finances, and this has a knock-on impact on healthcare and HIV programmes,” he explains.
Mozambique receives more than 95 per cent of its HIV programme funding through international donors. The Corridor Project depends heavily on this funding, and it could suffer profoundly. Vines is hopeful, though: “I believe the international donors will resume their direct support of the government but will require greater accountability. Trust is central to this.”
What happens next to the support of healthcare, and in turn to the Corridor Project, he believes, will partly depend on the outcome of an ongoing independent audit into those murky secret loans.
But a question remains, Vines says, about some leading donors. Donald Trump has proposed a cut in US global health funding, which will affect projects in Mozambique related to family planning. Who will fill those gaps remains unclear. Mozambique’s longstanding status as a donor darling is now far from secure.
The withdrawal of funding for the Corridor Project is something Caroline Rose, MSF’s head of mission in Mozambique, is only too aware of, even at ground level. “In the field we are receiving more and more requests from health facilities in trouble: ‘Could you fix our ambulance?’ ‘Could you transport our drugs from our clinic to the districts?’ ‘Could you pay for fuel?’” She is negotiating with international donors to the project, encouraging them to implement interim funding strategies until more long-term solutions are ironed out.
Vines envisages that the country will have a difficult few years before large-scale exporting of gas reserves starts, in the mid-2020s. Mozambique is now entering another election cycle that will doubtless be contentious, and which will likely span the next two years. “Meanwhile, the average Mozambican’s daily struggle remains to lift themselves out of poverty.”
And so women like Luisa will continue to walk towards those huts each night. They will take further risks to feed their families. As Mozambique’s uncertain future unfolds, ventures like the Corridor Project will be needed more than ever.
© Billy Clark
Luisa is healthy and optimistic for her future, for the future of her children. The corridor is where she has found, at different times, a livelihood, unspeakable trauma, a feeling of community and now a sense of purpose. In some ways it has defined her life, even as it has endangered it.
In 2014, the Corridor Project was established to reach the unreachable. Night by night, hotspot by hotspot, from one gas station to the next. It’s early days, but already it has connected with thousands of sex workers and truck drivers. Preliminary figures suggest this is giving a significant boost to HIV prevention and treatment. And the project refuses to fade even in the face of precarious funding streams and a deeply fractious political climate.
The night is over for us. In a few hours, the sun will rise. Traders will set up their stalls at Mercado do Goto to hawk fruit and vegetables. Fishermen will repair their nets by Macúti beach lighthouse, their wooden boats pulled high up onto the sand. Luisa will walk her children to school.
Daniela will fling open the doors of her office under the Pride umbrella.
The Corridor Project will live to see another day.
* Some names have been changed.
Author: Jules Montague