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19-year-old Joseph Ikatlholeng attends the Botswana Family Welfare Association (BOFWA) clinic in Gaborone every three months to receive antiretroviral treatment for HIV. He’s currently at university, studying for a degree in transport and logistics. “I hope to start my own transport business, maybe in the future an airline,” he says, laughing at the grandeur of his dreams.   Joseph first came to BOFWA when he and his boyfriend decided to start practicing safe sex in March 2017. “I had put myself in risky situations so thought I should get tested for HIV,” he says.   After learning he was HIV positive, Joseph tried out a few clinics to receive his treatment, but found BOFWA to be the most confidential and friendly. Sitting in the clinic behind the doctor’s desk, he says, “I never have any problems coming here. I feel comfortable here. At [the government clinic] there is no privacy; most of my friends are there. Sometimes if you go there you find them suspecting something, and everyone will be knowing your status. That’s why I prefer BOFWA.”     Feeling safe is important to Joseph, who regularly faces discrimination as a man who has sex with other men. “Last week I was walking along, and these guys came past in the car shouting “gay, gay, gay.” I experience that treatment a lot.”    Now, he and some LGBTI friends in Botswana are trying to work with their community to change the status quo about LGBTI people in the country. “We’re trying to tell the elders that we are here, we’re trying to change perceptions that LGBTI people are not just on drugs and having sex,” he says.  

“I’m a sex worker and peer outreach worker for the Nkaikela Youth Group. We reach the other sex workers because we are the ones that know them. We go to their houses, we go to the hotspots like clubs and the street; we reach them and encourage them to come here [to the Youth Group],” says Jackie Selelo, 34, sitting in one of the temporary office buildings at the Nkaikela Youth Group in Gaborone.   With the support of BOFWA nurses, the Nkaikela Youth Group provides a range of sexual health care to sex workers: “They need health services for STIs, smear tests, HIV tests, and to be enrolling onto antiretroviral treatment for HIV,” Jackie explains.   Female sex workers are in a particularly high-risk group for contracting HIV – the prevalence rate is 61.9% among the community – so having access to testing and treatment is vital. However, Jackie says many women don’t feel safe going to the government clinic. “They don’t accept us. It’s like we’re doing this because we want to, and just bringing disease. We’re not comfortable there and so sex workers are not [being tested and treated] in large numbers. Before BOFWA we were dying in large numbers because we were afraid of those clinics.”     The difference between being treated by the staff at BOFWA is huge, according to Jackie. “We get a good service with BOFWA, they’re helping us to come for tests and they’re treating us good. With BOFWA if you come for HIV testing and were positive they would initiate you on to treatment the same day. Any problem you could discuss with them without fear, like they are your brothers and sisters.”   She’s concerned that if funding continues to be cut, BOFWA nurses will stop coming to the Youth Group completely. “If they stop it will be difficult for us. We will die, we will be infected,” she says.  

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"I suspect I contracted HIV from my sex work. There were times I had to engage in risky sex, depending on the money on the table." Gabatswane used to go to the BOFWA clinic in Selebi Phikwe for treatment. “I enjoyed the confidentiality that they had there, compared to the government [clinic] where everyone knows everything. It was comfortable talking to the BOFWA providers.” Due to the Global Gag Rule’s funding cuts, the BOFWA clinic has been forced to close. Share on Twitter Share on Facebook Share via WhatsApp Share via Email Goabaone, sex worker & peer outreach worker "I've been a female sex worker for 5 years and a peer outreach worker for the last two. I was looking at the problems that us sex workers encounter, and thought that this peer outreach system might be able to help,” says Goabaone, explaining how she came to work with MCDA. Since the Global Gag Rule funding cuts the scheme has ended, and she now has to refer them to the government clinic. BOFWA was different: “At BOFWA we felt free, there is no stigma. They didn’t ask [how you got the infection], they just treated you every time,” Goabaone says. Share on Twitter Share on Facebook Share via WhatsApp Share via Email Jackie, sex worker & peer outreach worker “I’m a sex worker and peer outreach worker for the Nkaikela Youth Group. We reach the other sex workers because we are the ones that know them. We go to their houses, we go to the hotspots like clubs and the street; we reach them and encourage them to come here [to the Youth Group],” says Jackie, 34. “We get a good service with BOFWA, they’re helping us to come for tests and they’re treating us good. With BOFWA if you come for HIV testing and were positive they would initiate you on to treatment the same day. Any problem you could discuss with them without fear, like they are your brothers and sisters.” Read Jackie's full story here Share on Twitter Share on Facebook Share via WhatsApp Share via Email Joseph, university student Joseph, 19, first came to BOFWA in 2017 when he and his boyfriend decided to start practicing safe sex. “I had put myself in risky situations so thought I should get tested for HIV,” he says. After learning he was HIV positive, Joseph tried out a few clinics to receive his treatment but found BOFWA to be the most confidential and friendly. Sitting in the clinic behind the doctor’s desk, he says, “I never have any problems coming here. I feel comfortable here. At [the government clinic] there is no privacy; most of my friends are there. Sometimes if you go there you find them suspecting something, and everyone will be knowing your status. That’s why I prefer BOFWA.” Read Joseph's full story here Share on Twitter Share on Facebook Share via WhatsApp Share via Email Keanantswe, BOFWA client A few months after beginning her HIV treatment the BOFWA clinic was forced to close due to the Global Gag Rule funding cuts. “In April I received a call from my nurse telling me the clinic is being closed. She gave me tablets for two months up to June 2018. She told me I will get transferred to a government clinic," Keanantswe says. Although getting treatment is now much harder for her, she has to continue going every month or risks getting sick and even dying. “We have lost so much without BOFWA, not only me, but many women. I wish it would open again,” she says. Share on Twitter Share on Facebook Share via WhatsApp Share via Email

Amina is a peer educator trained by Family Planning Association of Malawi’s (FPAM) Linkages project. “I am a HIV positive sex worker and a peer educator,” she says. “I have 51 other sex workers in my care, I inform them on testing and treatment, also about STI treatment and condom use. I teach about the disadvantages of sharing ART (anti-retroviral therapy) and encourage them to go for tuberculosis testing if they are coughing.” Another educator called Cecilia adds: “I reached out to 60 female sex workers. We are all friends and they trust me. I refer them to services and we address abuse by the police. They rape us and steal our money but through the project, we can follow up since the project has access to the managers of the police.” Basic sexual health information Her colleague Florence says: “It also helped that the rogue and vagabond law was repealed.” The law was a permanent curfew, giving the police the power to round up, fine or jail anybody who was on the streets after eight o’clock at night. Lucy, also a peer educator, says part of the work is giving basic information. “I teach my friends on HIV and GBV (gender-based violence),” she explains. “And I teach how to use condoms and lubricants and how to persuade clients to use condoms. I also talk about family planning. Many female sex workers do not know they need it.” “The project helped me with condoms and I shared that with others,” says another client of the programme, Angela. “Through the project, I got tested for HIV and treated for STIs. I also encourage pregnant sex workers to go for pre-natal care so that they do not infect their babies. It is the first time that an organisation like FPAM worked with us. We got respected within the community because we are knowledgeable.” In the year the Linkages project ran, 627 female sex workers were supported in getting tested for HIV, the initiation of anti-retroviral treatment and therapy adherence. 2,700 women were referred to services and many more received information. The HIV prevalence rate among female sex workers went down from 77% to 62%. Global Gag Rule effects FPAM’s Linkages project was phased out in 2016 due to the Global Gag Rule. The effects are keenly felt amongst those who benefitted from the project: Amina says: “Many stopped taking medication. Healthcare facilities are not for us. I sing in a church choir, which is important to me. If they find out what I do, they will throw me out.” “My family thinks I work at a filling station at night,” says Lucy. Cecilia adds: “This project has to come back, please bring it back. If not, we will all die early.”

It used to take Matilda Meke-Banda six hours on her motorbike along dirt roads to reach two remote districts and deliver sexual and reproductive health (SRH) services. In this part of southern Malawi, Machinga, family planning uptake is low, and the fertility rate, at 6.6, is the highest in the country. The Family Planning Association of Malawi, known as FPAM, runs a clinic in the town of Liwonde and it’s from here that Matilda travelled out six times a month. “We have established six watch groups, they are trained to address SRH issues in the community,” she explains. Luc Simon is the chair of one of those groups.  “We teach about Family Planning,” he says. “We encourage parents and young people to go for HIV testing. We address forced early marriages, talk to parents and children to save a lot of young people.” And there are a lot of myths to dispel about family planning. Elizabeth Katunga is head of family planning in the district hospital in Machinga: “Family Planning is not very much accepted by the communities. Many women hide the use of contraceptives,” she says. “Injectables are most popular, easy to hide. We have cases here where husbands upon discovery of an implant take a knife and cut it out. It is not that people want big families per se but it is the misconceptions about contraceptives.” FPAM’s projects are based at the Youth Life clinic in Liwonde. The clinic offers integrated services: Family planning, HIV services, STI screening, cervical cancer screening and general healthcare (such as malaria). This joined-up approach has been effective says FPAM’s executive director Thoko Mbendera: “In government health facilities, you have different days, and long queues always, for family planning, for HIV, for general health, which is a challenge if the clinic is a 20 km walk away.There are privacy issues.” But now, FPAM’s services are being cut because of the Global Gag Rule (GGR), mobile clinics are grounded, and there are fears that much progress will be undone. Some of FPAM’s rural clients explain how the Watch Groups work in their community. “It starts with me as a man,” says group member George Mpemba. “We are examples on how to live with our wives. We are non-judgemental; we embark on a mutual learning process. Our meetings are not hearings, but a normal chat, there is laughing and talking. After the discussion we evaluate together and make an action plan.” Katherine, went to the group for help: “There was violence in my marriage; my husband forced himself on me even if I was tired from working in the field. When I complained there was trouble. He did not provide even the bedding. “He is a fisherman and he makes a lot of cash which he used to buy beer but nothing for us.I overheard a watch group meeting once and I realised there was a solution. They talked to him and made him realise that what he was doing was violence and against the law. It was ignorance.Things are better now, he brings money home, sex is consensual and sometimes he helps with household chores.”

It is 9.00pm in Lilongwe, the capital of Malawi , the fish market is one of the “hotspots” where the Family Planning Association of Malawi’s (FPAM) opens its trailer doors to  sex workers, a “key population” in the fight against HIV. Thoko Mbendera is the Executive Director of FPAM: “Key populations are groups whose needs you have to address if you ever want to bring down HIV prevalence in the general population. Sex workers clearly need help here: the HIV prevalence rate among them is 77% while among the general population it is 10.2%.” The clinic offers STI screening, family planning, HIV testing, tuberculosis (TBC) testing and cervical cancer screening. Outside, peer educators distribute condoms and talk to waiting clients. Thoko Mbendera says: “This group does not (have) access the public health sector, it is simple not an option for women who do not disclose what they do to anyone, so in the Linkages program we reach out to the hot spots at night.” Florence Mushani, is the coordinator of Linkages: “In the project we trained 63 peer educators. They are HIV positive; they approach their colleagues with information and advice. Our goal is the 90-90-90 target meaning 90% of sex workers know their status, 90% of HIV positive women are on anti-retroviral treatment (ART), and 90% of the women on ARTs will be virally suppressed. We also trained 21 peer navigators; they support others to adhere to therapy. We pay them a small stipend of 25 dollars a month, we expect a lot of them.” Tusekele Mwakasungula is FPAM’s Programs Manager: “The goal of the peer educators training is to build up the person,” he says. And it shows: these women are no shy victims of an unjust society, they are self-confident and outspoken, determined to improve the situation of female sex workers.” FPAM’s Linkages project was phased out in 2016 due to the Global Gag Rule.