Implementing Comprehensive HIV/STI Programmes with Sex Workers Implementing Comprehensive HIV/STI Programmes with | Page 147

5 Clinical and Support Services 5.7 Addressing the sexual and reproductive health needs of sex workers 5.7.1 Introduction Sex workers of all genders have SRH needs and the same reproductive health rights. SRH needs are often overlooked; it is important to expand clinical services beyond STIs and HIV to address them. Making SRH services available on-site or by referral allows for sex workers’ broader needs to be attended to and increases their confidence and participation in the programme. The following SRH services should be considered: • family planning and contraceptive counselling • safe pregnancy • abortion and post-abortion care • reproductive tract cancer screening (e.g. cervical, ano-rectal and prostatic cancers) • counselling on hormone use and referral to other gender enhancement practices for transgender sex workers. Box 5.9 Case example: Government provision of SRH services to sex workers Diagonal Interventions to Fast Forward Enhanced Reproductive Health (DIFFER), an initiative in India, Kenya, Mozambique and South Africa funded by the European Commission, is exploring a “diagonal” strategy, incorporating health-systems strengthening (a horizontal approach) with more targeted outreach to sex workers (a vertical approach) to define STI and broader SRH services. Models for delivery of services to meet the needs of sex workers and women include: • government SRH services with special hours or spaces for sex worker services • government SRH services with outreach and mobile or satellite sex worker services • better coordination and two-way referral between services for sex workers run by community-based organizations or NGOs and government SRH services. Box 5.10 Hormonal therapy for transgender sex workers There is currently no consensus on the safest and most effective dosing regimens for hormonal therapy for gender transition. Several centres have developed guidance on the use of hormones. Transgender people use hormonal therapy for its feminizing (estrogen) or masculinizing (testosterone) effects. This is usually done through advice from their friends or from information on the Internet. High doses are usually administered, and these have potentially serious side-effects. High doses of estrogen may result in an increased risk of thromboembolism and other outcomes such as liver dysfunction, breast cancer, coronary artery disease, cerebrovascular disease and headaches. A qualified practitioner should be consulted when considering hormonal therapy, and people on hormonal therapy need access to medical monitoring. 125