Background
Although female sex workers (FSWs) are highly exposed to sexual and reproductive health (SRH) risks, such as HIV and other sexually transmitted infections (STI) [
1‐
3], unwanted pregnancies [
4‐
6] and sexual violence [
7,
8], general health services are often not adapted to the specific context and needs of FSWs. When attending SRH services, such as for STI/HIV testing and care, family planning, cervical cancer screening and sexual and gender-based violence, FSWs often do not disclose as such by fear of stigmatisation and discrimination, providers do not actively assess their risk, and sometimes national guidelines provide insufficient guidance on how to offer care adapted to their high-risk profile [
9]. In the wake of the HIV epidemic, and because of the key role FSWs have in it, several initiatives have been taken in the past decades to improve HIV/SRH services for FSWs, either in the form of parallel services adapted to the FSWs’ needs [
10‐
13] or through interventions to make general HIV/SRH services more FSW-friendly [
10].
The DIFFER project (Diagonal Interventions to Fast-Forward Expanded Reproductive Health) is an operational research project that aims at improving access to FSW-adapted HIV/SRH care by linking services targeted at FSWs with the general health services [
14]. It is designed as a set of case studies, with the ‘case’ being a well-defined geographical area where sex work is common. One of these is the Tete-Moatize area in Mozambique. The adjacent cities of Tete and Moatize are intersected by a major transport route connecting Malawi to Zimbabwe and the port of Beira. There is a rapidly growing mining industry, attracting travellers, migrant labour and sex workers. Certain practices associated with sex work, such as publicly soliciting clients, are illegal in Mozambique, and FSWs are therefore a marginalised population.
The towns have a number of health care facilities, including 1 provincial hospital, 8 public health centres and 4 private clinics. In Moatize, a stand-alone drop-in clinic for most at risk populations offers basic HIV and SRH services during the evening and is therefore called the Night Clinic. It is operated by a non-governmental organisation, through an agreement with the district health department that supplies the drugs and medical supplies and the health staff who provides the services after hours against over-time compensation [
13].
The DIFFER project applies a methodological framework for health systems research, starting with a detailed situation and policy analysis that informs the development of site and context-specific packages of interventions to strengthen SRH service delivery. These packages are then implemented and on completion of the intervention the feasibility, acceptability, effectiveness, cost-effectiveness and sustainability are evaluated. The baseline analysis applied a convergent parallel mixed methods design, combining multiple qualitative and quantitative research methods [
15,
16]. We assessed both the offer and the demand side. The use of HIV/SRH services by FSWs and barriers to use were assessed through a cross-sectional survey and focus group discussions with FSWs, and its results are presented elsewhere. What HIV/SRH services are available, and to what extent they are adapted to the needs of FSWs, was assessed through a policy and situational analysis. The research questions to be addressed by this analysis were (1) what national policies exist in regards to HIV/SRH service provision, and to what extent these policies address the particular needs of FSWs; (2) what HIV/SRH services are locally provided and to what extent are they adapted to the needs of FSWs; and (3) what is according to policy makers and health providers the best model to improve access to HIV/SRH services for FSWs. The current article presents the findings of the baseline policy and situational analysis of the availability of HIV/SRH services in Tete-Moatize.
Methods
Study components and populations
The baseline analysis consisted of (1) a policy analysis and (2) health facility-level assessments.
The policy analysis comprised of a review of all national policy and strategy documents and guidelines on HIV/SRH programmes and interventions with key populations, and of interviewing key informant (KI) policy and decision makers using a semi-structured guide. KI were eligible if they had an important role in defining HIV/SRH/FSW strategies at either local (district or province) or national level, and included both government officials and representatives from agencies supporting the government. Topics addressed included current policies, strategies and guidelines on HIV/SRH and key populations, availability of HIV/SRH services in the public sector, access to and use of the public services by FSWs, and appreciation of different models to enhance access to services for FSWs.
All health facilities in Tete/Moatize with sex work hotspots in their catchment area were assessed. These were 5 public health centres, 1 private clinic and the Night Clinic. The public health centres fell into three different types: a type 1 small public health centre offering only basic primary health care (n = 1); type 2 larger centres that also offer secondary health care (n = 3); and a type 3 centre with both in-patient and outpatient care (n = 1). In addition, we assessed the gynaecology department of the public referral hospital. First, a standardised facility audit tool was completed that comprised of an interview of the facility manager, an inventory checklist filled out during the facility visit, and an observation check list filled out by an observer on another day of the audit. The tool assessed the scope, volume and capacity of existing SRH service delivery. Next, all providers of HIV/SRH care services (family planning, HIV testing services (HTS), HIV care, STI care and cervical cancer screening) at the 5 public health centres and the hospital were interviewed, using a structured questionnaire. Interview topics included practices of SRH care and attitudes towards and case management of FSWs. Lastly, to document practices conducted during HIV/SRH consultations, as reported by female users, a representative sample of women (18 years and older) attending HIV/SRH services at the 5 public health centres were interviewed after exiting the services. The target sample size was 100 to allow the measurement of practices with sufficient precision (p = .50, d = .15). The number of participants recruited per facility and per service was proportional to the number of women attended at the facility and service in the previous year. Participants were interviewed face-to-face using a structured CAPI (QDS™) questionnaire that addressed socio-demographic characteristics, the type of services received and appreciation of the services.
All study participants provided written informed consent and the study protocols were approved by the National Committee of Bioethics for Health in Mozambique and the Commission for Medical Ethics of the University Hospital Ghent.
Data analysis
KI interviews were audio-recorded, transcribed and manually analysed for key concepts. Answers were deductively and selectively coded, using a theoretical framework, by topic addressed, type of HIV/SRH service and type of policy maker [
17]. The information collected during the facility audits was transcribed in a spreadsheet and manually analysed. The provider and user data were analysed using Intercooled Stata version 11.0 (College Station, Texas, United States).
The results of the different research methods were triangulated to provide an answer to the research questions. Responses given by policy makers during the key informant interviews were cross-checked with the information from the policy documents and synthesized into a summary table presenting key findings per HIV/SRH service. The information from the facility audits was side-by-side compared to the responses given by providers and users on what and how services are provided, to reach an integrated conclusion.
Discussion
The objective of the situation analysis was to document what HIV/SRH services were available in the Tete/Moatize area, and to what extent they were adapted to the needs of high-risk women such as FSWs, to better guide a planned intervention to improve access to HIV/SRH services for FSWs.
In the study area, there were three providers of HIV/SRH services: the public sector, a number of private for-profit clinics and a clinic specifically targeting sex workers and other high-risk populations.
The public health sector was by far the most important provider of HIV/SRH services. It offered most essential HIV/SRH services, although that some important services were not (yet) or insufficiently available, such as the contraceptive implant, female condoms, cervical cancer screening, SGBV services and TOP. However, the offered services were not at all adapted to the specific needs of women with a high-risk behaviour such as FSWs. This despite the fact that a substantial proportion of the HIV/SRH clients had risk factors or reported to have engaged in sex work.
Internationally, FSWs are increasingly being recognised as a key population in the fight against HIV, and several guidelines have in past years been developed on how to implement HIV/SRH programmes with female sex workers [
18,
19]. These guidelines are however only slowly impacting national-level policy making, and most sex work programmes in Africa have limited coverage and a narrow scope of services [
10,
20]. According a 2014 UNAIDS report, only a third of countries had sex worker risk reduction programmes, varying in quality and reach [
9]. In Mozambique, it is clearly under pressure from the international community that the Ministry of Health is gradually giving more attention to key populations. It will be important to encourage this process and further develop strategies and guidelines adapted to the needs of sex workers, and other key populations.
Public health providers insufficiently assessed sexual behaviour and risks, and were not identifying FSWs who attend their services. While providers claimed that they routinely ask about sexual behaviour and give out condoms, only half of the clients reported that the provider had addressed HIV prevention and few had received condoms. Most providers did not know if FSWs attended their services, indicating that they do not pro-actively assess if a client is at high risk. There is clearly a need to improve the providers’ skills in assessing risk behaviour and provide FSW-appropriate services.
The assessed public health facilities faced significant shortages in the conditions under which the services are offered. Mozambique is a resource-limited country, ranking 180/188 in the 2015 human development index [
21], and these shortages are a nation-wide problem [
22,
23]. This is a reality that will not easily change and that has to be taken into account when deciding how to best ensure access to quality HIV/SRH care for FSWs.
Conditions were much better at the private clinic but it offered only a few services, at relatively high cost. A greater role of the private sector in the provision of SRH services is often encouraged, in particular in countries where this sector is an important health care provider [
24,
25]. In Mozambique however, the private health sector is a relatively recent phenomenon and has still limited coverage [
23]. In our context, it appears therefore not to be a valid alternative to the public sector.
The only alternative was the Night Clinic, a clinic established as part of a an HIV prevention project along transport corridors targeting FSWs and truck drivers, and jointly operated by an NGO and the government [
13]. It had better conditions in terms of infrastructure, equipment and staffing, and provided services adapted to FSWs’ needs, but had a more limited geographical range and scope of services.
There is no international consensus on what is the best approach to guarantee that FSWs have sufficient access to HIV/SRH services. Establishing parallel services specifically for key populations is generally the approach preferred by FSWs themselves and that best ensures access and appropriate care [
11‐
13,
26], but it is more costly, less sustainable (because of often having little government support and relying on project-based funding), and has a risk of stigmatisation [
10‐
12,
27,
28]. In Mozambique, there was no government policy on how to best ensure access to health services for marginalised populations such as FSWs. Government policy makers clearly favoured an integrated approach where access to the public health services is ensured by making them more FSW-friendly. Projects financed by the international community have established over the past years several FSW-specific health services in the country, mostly in the form of small stand-alone clinics, such as the Night Clinic [
13,
29]. Government policy makers accepted the existence of these services, but mostly as a temporary measure until access to the public health system is improved. The HIV/SRH care providers had no outspoken opinion on the subject, and mostly favoured an approach where FSWs are attended both at the public services and at separate clinics. Health centre managers were all in favour of piloting new interventions to make their services more FSW-friendly, but warned that this might be hampered by their lack of staff and space.
Each of the components of our study has certain limitations, such as reporting bias when conducting face-to-face interviews. However, we believe that we reduced these limitations to a minimum by using a mixed-methods design, and reaching integrated conclusions by comparing the results of complimentary methods. Together with the findings of the other part of the baseline analysis, that assesses the needs from the FSWs’ perspective, it will provide guidance for the development of an appropriate intervention package.
Abbreviations
ART, antiretroviral therapy; DIFFER, diagonal interventions to fast-forward expanded reproductive health; FP, family planning; FSW, female sex worker; HIV, human immunodeficiency virus; HTS, HIV testing services; IUD, intra-uterine device; KI, key informant; MCH, maternal and child health; NGO, non-governmental organisation; OPD, out-patient department; PEP, post exposure prophylaxis; SGBV, sexual and gender-based violence; SRH, sexual and reproductive health; STI, sexually transmitted infections; TOP, termination of pregnancy
Acknowledgements
The authors acknowledge all people who kindly gave their consent to participate in the key informant interviews, health facility assessments, health care provider interviews and client exit interviews, as well as the staff of ICRH-Mozambique and the Tete Provincial Department of Health who facilitated the study, and the DIFFER Community and Policy Advisory Board in Mozambique.