June Woodford is a child and family therapist from Dunedin New Zealand. She shares her recent experiences and insights from her work with Médecins Sans Frontières (Doctors Without Borders) in the HIV programme in Malawi. Here, HIV rates are among the 10 highest in the world, with more than one in 10 people estimated to be infected.
As a child and family therapist from Aotearoa, New Zealand it is not unusual for me to find myself sitting with a group of monosyllabic, nonchalant looking teenagers. Although the behaviour of young people remains universally constant, it is the context that is completely different today. I am ‘downtown’ in the market area in Nsanje, southern Malawi with Médecins Sans Frontières working as a counsellor on an innovative HIV project. On this hot, humid day I am meeting with a group of sex workers in an uninhabited building with bare walls and floor, it is furnished only with a few plastic garden chairs and a lot of dust.
The prevalence of HIV/AIDS in Malawi is currently 10.3 per cent. But in Nsanje, a rural area, it is estimated to be as high as 16-20 per cent compared to 5.4 per cent in Australia. The combined factors of poor education, unknown HIV status and unsafe sexual practice have contributed to the current rates. Given the high prevalence of HIV and the correlating low rates of safe sexual practice, Médecins Sans Frontières is targeting high risk groups such as mixed-status couples – where one partner is infected by HIV and the other is not – adolescents and sex workers.
This targeted approach, in which Community Outreach Clinics are linked to monthly clinics at the health centre specific for sex workers, are run by nurses and counsellors who are trained to be sex worker-friendly. The clinics provide condoms and “Treatment as Prevention,” meaning they treat all HIV positive sex workers regardless of the stage of their disease to decrease their infectiousness and thus prevent new infections.
It is in the course of this work that I am meeting with the adolescent sex workers. Though focused on the primary goal of treatment as prevention, I can’t help but view this meeting through my ‘therapist eyes’. One of the group members calls herself ‘Emily’ and states she is 19. She looks much younger and is dressed in a tiered but tattered halter neck dress which ironically fades from white to ‘shades of grey’ as the fabric descends across her thighs. ‘Emily’ is unlikely to be her family name but European names have become popular as a result of the influx of media (including pornography) burgeoning across Malawi. Emily’s skimpy dress reveals multiple, tell-tale scars that point to of a history of neglect or abuse or perhaps both.
The average family in Malawi has six children. Developmental psychologists state that even the most motivated parents will struggle to meet the needs of all children in a family that exceeds five children. This, coupled with economic pressures in a resource poor country where the cost of living has recently increased by 25 per cent, finds some parents estranging themselves from older children who are forced to make their own way in the world. Girls are at a particular disadvantage as very few of them (16 per cent) complete primary school.
Common to all young people, is the fact that disconnection from education and family increases vulnerability for a range of adversities. Adolescent girls like Emily often find themselves needing not only money to meet their basic needs, but also search for emotional attachment in the absence of the family context. The combination of relational, developmental and economic vulnerability makes sex work one of few employment options available to women and so it comes as no surprise that, according to UNICEF, girls and women in the 15–24 age group account for 58 per cent of new HIV infections in the country.
Since the origins of the HIV/AIDS epidemic men have favoured younger sex workers who they perceive to be less likely to be infected with HIV. Young women are actually at increased risk of contracting HIV due to functional and hormonal immaturities. Despite the bias toward younger women, currently business is competitive with fewer men in the district due to a paucity of seasonal work and more women turning to sex work to procure an income. The current rate for sex with a condom is the equivalent of $ 4.50 NZD but women can charge double this amount for sex without a condom. It would be simple to attribute the financial drivers alone as the cause of increased risk for sex workers but this is a more complex situation.
Médecins Sans Frontières and other nongovernmental organisations offer family planning services to sex workers but many decline these services, explaining that they hope to conceive. Motherhood in Malawi is a significant status symbol. In addition, motherhood may fulfil the attachment needs and provide a love object in the form of a baby for young women estranged from their family. However, the reality is that a conception will demand unprotected sex, and the increased economic demands of an infant are likely to compound the already dire socio-economic situation. In order to compete in a saturated market or conceive, young women like Emily may be willing to engage in sex without a condom. This may remediate some of their immediate deprivation, such as the need for family, food and shelter but conversely, in the long term this risk can rob them of their health and eventually their lives.
As I watch Emily walk away from our meeting, her second- hand satin dress shimmering shades of grey in the afternoon sun I wonder if I returned to Malawi in 10 years’ time, would I see her here, or will she have sold her life for less than 10 dollars?
To find out more about Médecins Sans Frontières visit www.msf.org.au