Implementing Comprehensive HIV/STI Programmes with Sex Workers Implementing Comprehensive HIV/STI Programmes with | Seite 174

6 Programme Management and Organizational Capacity-building

Implementing a scaled programme for sex workers
6.2.5 Prioritize
Financial resources are usually insufficient to cover all sex workers in the entire country with the
same package of services; as a result, programmes must prioritize both interventions and locations.
This may be accomplished by varying the way in which technical components are delivered and by
prioritizing those areas where the largest number of sex workers and those at highest risk may be
reached. The following are considerations for prioritization:
Where to establish services
• Locations with the largest number of sex workers in a geographic area: This allows a few
implementing organizations with the attendant management costs to reach a large proportion of
sex workers. Large numbers of sex workers are usually found in urban areas or in places where
there are large numbers of men without their families (extraction industries, construction projects,
truck stops, migrant farm labour, etc.).
• Locations with sex workers at higher risk of infection: Higher risk is determined by factors
such as the number of paying partners, type of sex (anal sex is higher risk) and the agency and
experience of sex workers, e.g. brothel-based sex workers may be at higher risk than street-based
sex workers because of their decreased agency and higher number of clients; newer sex workers
may be at higher risk because they have less experience in negotiating condom use and avoiding
or mitigating violent situations.
What services to provide: At a minimum, they should include:
• Harm reduction commodities including adequate availability of condoms and lubricant, and
needles and syringes. These are essential for sex workers to protect themselves. In many settings,
supplies are completely inadequate to the need. See Chapter 4 and Chapter 5, Section 5.5.3 for
full details.
• Community empowerment activities to increase service reach and effectiveness and sex worker
agency. As Chapter 3 explains in detail, community mobilization activities are increasingly being
shown to be cost-effective and should be considered part of an essential package and not just
“nice to have”.
• Referrals to accessible and acceptable clinical services for reproductive health, STIs, hormone
replacement therapy, HIV testing, antiretroviral therapy (ART), tuberculosis (TB), hepatitis B vaccine
and management, and opioid substitution therapy (see Chapter 5 for more details). High-quality
referral services are sometimes more difficult to establish than project-owned services. Referral
services often require behaviour change on the part of the providers to ensure that they are nondiscriminatory, non-stigmatizing and confidential; and on the part of sex workers, who may have
experienced abuse or discrimination from service providers on earlier occasions. Sometimes is it
necessary to work with administrative bodies to change clinic hours to make them more accessible
to sex workers. Moreover, training of staff is often necessary to familiarize them with sex workerspecific clinical protocols. Some programmes use voucher schemes to increase access to clinical
services from private providers. In the long run, however, effective referrals to respectful, accessible
services may be more sustainable than programme-run clinical services if the level of use by the
community is high.
• Addressing key structural barriers such as violence and police interference with service delivery.
These are determined by the local context (see Chapter 2 for more details).

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