A nightclub at Balaka Town is bulging with sex workers and their clients in search of pleasure and money. Within the compound, faint lights from florescent tubes are casting small beams onto an entrance into an adjoining room.
An organisation fighting the spread of HIV in the Eastern Region district has found such places well-situated for their cause.
Willing sex workers and their clients are getting tested in the vicinity of where they work or have fun and the nocturnal clinic has already reached out to hundreds, some of whom have been initiated on treatment after confirming their status with more formal health facilities.
Those diagnosed HIV-negative are willing to continue taking care of themselves, but there is something nagging them.
“There are several ways of preventing contracting the virus that we have at our disposal, but we understand we are still at risk,” says 23-year-old Vanessa who has been in the oldest profession for four years.
Vanessa has taken part in a dozen workshops aimed at gauging views of women in her trade on how they can prevent the spread of the virus which continues to attack tens of thousands of Malawians every year.
In her profession, abstinence is an impossibility.
She fervently fights to protect herself and her clients, too, in the process. Still, Vanessa believes other ways that are saving lives elsewhere would be handy in her trade.
“We have heard about products such as PrEP [Pre-Exposure Prophylaxis] which are apparently slicing new HIV infections in countries that are using them. During HIV workshops, the drugs have been mentioned several times and I understand that in Malawi, they are not in use yet,” she says.
In sub-Saharan Africa, countries such as South Africa, Kenya and Lesotho that are scaling up PrEP are focusing on adolescent girls and young women.
On the other hand, the United States of America, most European countries, Australia, Thailand, Brazil, Vietnam and the Philippines, according to Avert—a United Kingdom-based international HIV and Aids charity—largely focus on gay men and other men who have sex with men.
South Africa, Kenya and India are also focussing on women in Vanessa’s trade.
These are among high-risk populations which, according to Avert, can prevent infection by taking a pill every day.
“When someone is exposed to HIV through sex or injection drug use, these medicines can work to keep the virus from establishing a permanent infection.
“When taken daily, PrEP is highly effective for preventing HIV. Studies have shown that PrEP reduces the risk of getting HIV from sex by about 99 percent when taken daily. Among people who inject drugs, PrEP reduces the risk of getting HIV by at least 74 percent when taken daily,” Avert says.
Vanessa believes that a combination of PrEP and condom use can significantly protect her kind, among whom HIV prevalence is at around 65 percent, and their clients.
And every night a nocturnal clinic comes to their doorsteps to provide HIV testing and prevention services, she persistently tells her fellow sex workers not to give in to men who abhor protection.
“Even if PrEP was rolled out among us, I would still urge my fellow sex workers not to be careless. After all, organisations that want the drug introduced in Malawi tell us that it does not protect against other sexually transmitted infections,” she says.
Vanessa just hopes PrEP will be scaled up in Malawi so that populations at risk of infection are protected and protect others who are exposed to their ways.
Such a wish is shared by a biomedical HIV prevention advocate, Ulanda Mtamba, who argues that controlling the spread of HIV needs the mainstreaming of various technologies including PrEP which can also be handy to women who are often thrust onto the periphery of making decisions on sex.
“We are talking about what we need to do beyond 2020 because it is clear that other means of preventing the spread of the virus need to be complemented by these technologies.
“The risk of getting HIV from sex can be lower if populations at risk combine PrEP with condoms and other prevention methods,” Mtamba, an Aids Vaccine Advocacy Coalition former fellow, says.
The World Health Organisation (WHO) recommends that populations at substantial risk of HIV infection should be offered PrEP as an additional prevention choice, as part of comprehensive prevention.
And Mtamba further suggests that treatment on its own in Malawi is proving to be not enough despite that the country has registered gains in controlling the virus through the model.
“The fact that new infections are not substantially going down clearly shows we have to diversify the fight. Treatment as prevention is effective but it only works where someone has been tested and put on medication.
“That is where PrEP becomes handy because an HIV-negative person will be protected as long as they consistently take the drug. This is a globally accepted prevention method,” Mtamba says.
She suggests that Malawi can first start providing PrEP to groups at risk before scaling it up among the rest of the population.
But that is entirely up to the government which holds the policy direction on implementing the prevention method which was approved in December 2018.
“We really want our Ministry of Health to up the game. They should consider this prevention product with the swiftness that they have done with others such as voluntary medical male circumcision,” Mtamba challenges.
She further says products such as PrEP will further expand options for women who have “very few” prevention methods at their disposal despite that they play important roles in research aimed at controlling the spread of the virus.
“Women have to choose products that appeal to them as long as they have been approved and are effective. Only then will the fight against HIV be as comprehensive as possible,” Mtamba says.
In March 2019 HIV policy updates, the Ministry of Health announced that in efforts to maintain Malawi’s “global leadership” in the fight against HIV, the nation should keep the highest-risk members of the population HIV negative through the use of PrEP.
“PrEP is approved for use in Malawi for clients at high risk of HIV acquisition, targeting key populations, [adolescent girls and young women] and sexual partners of people with HIV. These clients should be treated without stigma through a client-centred HIV prevention approach,” the ministry said.
But to date, PrEP is not available in public health facilities where these targeted populations can access the drug.
Director of the HIV and Aids unit in the Ministry of Health, Rose Nyirenda, said last week that the ministry has developed national guidelines on PrEP and that “very soon” Malawians will be told the direction the nation is taking on the drug.
“We have been piloting PrEP in Blantyre and Lilongwe, targeting adolescents and female sex workers. We are pooling together the data from the few sites where we did the piloting before we can scale up the treatment in the country,” Nyirenda said.
Vanessa hopes that the scaling up will be done as soon as possible.
The knowledge that she has gained from HIV workshops allows her to imagine that a comprehensive prevention package is what the country needs in fighting the epidemic.
“No one should be left behind. We hear this message now and again on the radio and during meetings so why are we being left behind?” she queries before disappearing behind the veil of darkness outside her regular drinking place.