By Alick Ponje
It is a cold Saturday night with fine drizzles pattering on the popular Devil Street in Lilongwe. The sides of the street, which are often typically lined up with brochette stalls, are literally empty.
A light-skinned woman, covering herself with a thick black pullover, high red boots and a fitting denim pair of trousers, saunters into a bar and perches on a tall stool planted in a slightly darker corner of the spacious room.
Her eyes sluggishly move to a television screen behind the counter and land on a news ticker about World Aids Day and the biggest announcement on the day.
“I think HIV self-testing is the way to go for Malawi,” the lady, who identifies herself as Nomsa, says offhandedly. Then she falls silent as if drifting into deep meditation.
A stealthy, closer look at her face, beaded with cold sweat, reveals traces of a troubled soul. She has just arrived from the village where she attended her cousin’s funeral.
Accounts from the grapevine indicate he died from Aids-related ailments after failing to get treatment in time.
Without warning, Nomsa declares that having participated in a number of HIV-awareness meetings, she is more empowered to sweet-talk her fellow female sex workers (FSWs) into going for testing.
“HIV testing is sometimes taken for granted. Yet, it has far-reaching consequences. Knowing your status gives you a sense of freedom,” she explains, to no one in particular.
There are only a few people in the bar—mostly men.
The bartender raises the volume of his music system as if to drown Nomsa’s words. She does not give up.
“I made the decision to get tested two years ago.Last year, I gave birth to an HIV-negative baby because I was put on treatment immediately after I tested positive,” she says daringly.
In her trade, such disclosures have the likelihood of scaring potential clients away, but Nomsa feels she has an obligation to let others know that fighting HIV and Aids is a collective affair.
During trainings organised by various organisations such as the National Aids Commission and the Family Planning Association of Malawi, sex workers, who are among those at high risk of contracting the virus,are constantly alerted on how they can protect themselves and their clients.
The messages have stuck in Nomsa’s mind and she willingly passes them on to her fellow sex workers and their clients.
As the drizzle outside lets up, a man and a woman, firmly holding each other, stagger into the bar and proceed to the rooms section.
“Remember to protect yourselves,” Nomsa shouts to the two. It is unclear if they have heard her.
Living in ignorance
Turning her eyes to the TV screen again, she watches Minister of Health, Atupele Muluzi, declare that Malawi has approximately 1.1million people living with HIV.
“By the end of September this year, we have managed to get 796,100 people on treatment and out of those on treatment, 708,688 people are now virally suppressed,” Muluzi says in a statement delivered in Parliament.
The progress enchants him. But he also appreciates that such numbers also highlight that 100,000 people are yet to know their HIV status.
They are mostly those who shun the conventional testing and counselling systems and, therefore, require innovative strategies.
They include Provider Initiated Testing and Counselling, Index Case Testing that targets sexual partners and children of HIV positive index clients and self-testing.
The principal goal is to help people know their HIV status.
“We are also expanding test services into strategic [locations]such as workplaces, hotspots with high risk behaviours and places of entertainment,” Muluzi says.
His sentiments on self-testing attract the attention of more sex workers and their potential clients who keenly watch as the minister demonstrates the process in front of his fellow lawmakers.
It is a simple process: one just collects their own specimen of saliva from the mouth which is then added to the test kit before they can know their results in a few minutes.
Muluzi stresses that Malawi is only distributing self-test kits that have been accredited by the World Health Organisation.
“If they test positive, the person should then seek a further test at one of the many test facilities to confirm the result,” he explains.
For a negative result, however, there is no need for further action unless one has had a recent HIV exposure or faces an ongoing high risk of HIV infection.
“In these cases, repeat testing should be considered after three months from potential exposure,” he says.
The expiry of his time on TV in this instance prods one man in the bar into acknowledging that the newest strategy of HIV testing in Malawi could attract more men who often shun the conventional systems.
“Now there is no reason not to get tested. This strategy is like we do with malaria. It is amazing how the world is striving to deal with HIV and Aids,” he says.
Then the rest of the merrymakers take to the dance floor to drown their sorrows. Nomsa hopes that her message and that from Muluzi have sunk into some hearts as one after another, pairs disappear into the darkened parts of the street in suggestive postures.
Sex workers in the HIV equation
Whatever they would be doing and how they would be doing it has a significant bearing on the fight against HIV and Aids.
In their poster abstract presented at the HIV Research for Prevention Conference in Madrid, Spain, last October, researchers Wezzie Loraet al pointed out that FSWs engagement in HIV research is desirable to achieve the 90-90-90 goal.
This is particularly so in Malawi where HIV prevalence among them is estimated at 25 percent compared to women of the general population which is at 12.9 percent.
“However, FSWs are seldom heard and their HIV prevention needs are constantly marginalised in HIV prevention interventions,” the researchers state.
Their study, conducted in Blantyre to understand the lived experience of FSWs in the context of HIV self-testing, found that the nature of their work influenced their HIV and Aids experience including recognising the benefits of HIV testing and treatment.
“FSWs presented sex work as a risky but necessary business for their survival and family upkeep,” the abstract reads in part.
Nomsa believes that her business being risky should be the more reason to get tested. It is her desire that others should embrace that thought.
Beyond sex workers
In another abstract presented at the Spain conference, scientists Jillian Pintye, from University of Washington, and eight others advanced that HIV self-testing may provide a unique opportunity to increase knowledge of partner HIV status.
They further posited that pregnant and postpartum women in HIV high-burden settings frequently do not know their partners’ status and that this has been strongly associated with HIV acquisition.
The researchers concluded that among pregnant and postpartum women in Kenya, having a partner of unknown HIV status was common and associated with high acceptance of HIV self-tests for male partners.
While a similar study may not have been conducted in Malawi,trends seem to be comparable. Men typically shun HIV testing but preliminary assessments on self-testing show they rush for it more than women.
In the course of her trade, Nomsa has seen several working girls falling pregnant.
Her biggest worry has been that most of them do not care about testing so that they can be immediately put on medication and save their unborn babies.
“Sex workers do not like visiting prenatal clinics. With the self-testing initiative, they will be able to test for HIV in their privacy and make appropriate decisions,” she says, watching her mates enter and leave nearby rooms with their clients, the chilly weather failing to rain out their resolve.
Her involvements in HIV awareness crusades have turned her into an activist of some sort.
She is adamant about sticking around Devil Street to continue preaching to those that have not yet grasped her message.
“Researchers are doing their part. It is time for those of us at high risk to help combat the epidemic,” Nomsa declares boldly.
She then shifts to the bar’s entrance to peep into the dimly-lit stretch which is now crawling with merrymakers who have defied the cold snap to pour into Malawi’s shortest and, probably, busiest street.
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