Access to Healthcare in a time of COVID-19: Sex Workers in Crisis in Nairobi, Kenya

ABSTRACT

This paper uses empirical data collected from 117 female sex workers living in informal settlements in Nairobi and 15 healthcare providers to highlight specific effects of COVID-19 and related restrictions on healthcare access for the sex workers. We highlight the existing gender and health inequalities that have now been reinforced by the initial outbreak of the COVID-19 pandemic. Specifically, we focus on the most concerning healthcare needs for the sex workers including HIV prevention, care and treatment and sexual and reproductive healthcare. Our study findings reveal that the various restrictions imposed by the government to help curb the spread of COVID-19 to a large extent made it difficult for the sex workers to access their healthcare needs. The paper discusses the challenges of healthcare service delivery reflecting on some innovative and pioneering responses from health care providers to address the emergency situation.

KEYWORDS:

• Sex workers
• prostitution
• health care
• HIV
• reproductive health

Introduction

In times of crisis, the most vulnerable members of the society suffer disproportionately (Weiner, 2020). Sex workers represent one of the most vulnerable social groups, who for some years have been one of the World Heath Organisations key populations for the HIV global epidemic (WHO, 2014), as they experience increased impact and significant barriers to healthcare access. Key populations including sex workers are recognised by WHO and The Global Fund to Fight AIDS, Tuberculosis and Malaria (hereafter Global Fund) as experiencing widespread stigma, discrimination, state and non-state violence and harassment and criminalisation of behaviours or practices which all shape decreased access to services (Global Fund, 2020). Reports are emerging pointing to the deepening challenge of healthcare access among sex workers and other vulnerable populations such as men who have sex with men, transgender people, women and girls, impoverished settlement dwellers among others, due to the impacts of COVID-19. For example, in the UK context, Howard (2020) highlights reports from sex worker rights organisations indicating sex workers were missing crucial sexual and reproductive health services products during the lockdown (also see Sanders, 2020). Kimani et al. (2020) highlights some of the effects of COVID-19 on the health and socioeconomic status of sex workers in Nairobi, based on observations of healthcare providers and programme implementers of sexual health programmes for sex workers in Nairobi, to which this paper adds empirical evidence.

The background of the Covid-19 crisis is that HIV and sexual and reproductive healthcare are critical for female sex workers (UN AIDS, 2012; WHO, 2020). Evidence shows that the prevalence of HIV is disproportionately high among key populations such as sex workers and men who have sex with men. HIV prevalence among female sex workers is higher in Kenya than amongst the general population, 29.3% for female sex workers in 2011 (NACC and NASCOP, 2012) compared to 5.6% prevalence among the general population in 2012 (NASCOP, 2014). In 2018, key populations including sex workers, gay and men who have sex with men, people who inject drugs, transgender women and their sexual partners accounted for majority (54%) of the new HIV infections compared to 46% among the general population globally (UNAIDS, 2019). These trends are largely attributed to lack of access to HIV prevention services mainly due to criminalisation of sex work and same sex relationships as well as stigmatisation and discrimination of key populations in the social spheres and in the health sectors (UNAIDS, 2018). Owing to the high HIV rates in Kenya (AVERT, 2019), some sex workers use pre-exposure prophylaxis (PrEP) to reduce risks of infection. Also, with a significant cohort of sex workers living with HIV, many are reliant on Antiretroviral (ARV) combination medications to sustain good health: hence disruption in access to such medications has serious consequences for the sex workers. Using mathematical models, Jewell et al. (2020) estimate that a disruption in supply of ARVs lasting six months for people living with HIV could lead to over 500, 000 (471,000–673,000) HIV-related deaths among adults in Sub-Saharan Africa (p. 8)

Female sex workers have frequent sexual contact with multiple partners potentially putting them at risk of not only contracting HIV and other sexually transmitted infections, but also other negative sexual health outcomes such as unwanted pregnancies, induced abortion, sexual violence and risk of cervical cancer. Female sex workers in low and middle-income countries often lack access to sexual and reproductive health services (SRH) such as contraceptive, cervical cancer screening and sexual- and gender-based violence services (Lafort et al., 2017). In Kenya, studies show that some of the major barriers to access of SRH services by sex workers include stigma and discrimination as well as the fact that most public health interventions targeting female sex workers pay attention most to HIV/STIs prevention and management while neglecting the broader SRH needs of the female sex workers (Sutherland et al., 2011). In the face of COVID-19, there have been reports of major disruption in the production and supply chains for sexual and reproductive health (SRH) commodities including contraceptives (Kumar, 2020). Reports by the International Planned Parenthood Federation (IPPF) suggest that COVID-19 impacts including closure of their 5633 static and mobile clinics and community-based care outlets in 64 countries has disrupted access to sexual and reproductive healthcare for millions of women and girls (IPPF, 2020). Kimani et al., (2020) observe that COVID-19 was deepening existing stigmatisation of sex workers as new forms of stigma were emerging whereby sex workers were being viewed as potential spreaders of the coronavirus in their communities. They further observe that this heightened stigma at a time of COVID-19 may further hinder sex workers’ access to healthcare services.

Various commentaries and reports have highlighted the plight of women and girls during the COVID-19 pandemic. UNFPA (2020) released a Technical Note assessing the potential impacts of COVID-19 pandemic, with efforts to meet the unmet need for family planning, ending gender-based violence, female genital mutilation (FGM) and child marriage. UNFPA predicts that COVID-19 will have adverse outcomes for women and girls as the pandemic will potentially negate the gains made in achieving the goals since FGM, gender-based violence and child marriage cases could rise by 2, 31 and 13 million consecutively between 2020 and 2030. UNFPA also reports that the pandemic is already disrupting the supply of family planning commodities and could potentially lead to inaccessibility of modern contraceptives to between 13 and 51 million women depending on level of healthcare services disruption. Rafaeli et al., (2020) conducted a review to identify the secondary impacts of COVID-19 on women and girls in Sub-Saharan Africa (SSA) on issues including education, access to healthcare and reproductive health services, poverty, social protection among others. They found that women and girls in SSA were likely to suffer adverse secondary impacts due to the COVID-19 pandemic such as, increased poverty rates, food insecurity, unplanned pregnancies and school dropouts as well as reduced access to healthcare and water and sanitation. These reports provide important information on COVID-19 impacts on women and girls. However, apart from the commentaries and media reports highlighting the challenges of female sex workers during the COVID-19 pandemic (for example Howard, 2020; Kimani et al., 2020; Sanders, 2020), empirical studies highlighting the plight of sex workers and in particular access to health in the SSA context are barely available. Swan and ICRSE (2020) is one of the few studies focusing on sex workers but in the Eurasian context.

This paper uses empirical data collected from female sex workers living in informal settlements in Nairobi to highlight specific effects of COVID-19 and related restrictions on healthcare access for these sex workers. We highlight the existing gender and health inequalities that have now been reinforced by the COVID-19 pandemic. Specifically, we focus on the most concerning healthcare needs for the sex workers including HIV prevention, care and treatment and sexual and reproductive healthcare.

The study: Methods

This research project took place from April to the end of May 2020, in the city of Nairobi, Kenya, with ethical approval from the University of Leicester, UK, funded by the Global Challenges Research Fund. The research team was mostly based within the partner organisation, Bar Hostess Empowerment and Support Program (BHESP), with colleagues overseeing the project from the UK. Weekly online meetings were held between the field team and the UK researchers, where data collection and analysis were discussed as a collective. The field team have been involved in previous research projects with the University of Leicester in recent years and are committed to the principles of participatory action research. While in this case, because of restrictions there were insurmountable challenges to involve sex workers in all elements of the project design, delivery, analysis and outputs, the project was heavily practitioner informed. Practitioners from BHESP were involved in the setting of the research questions at the pre-funding stage and were involved in the real-time design and delivery of the project. Peer educators, who are sex workers, who work for BHESP were involved in contacting the respondents and scheduling meetings including liaising with the practitioners to address concerns during data collection.

BHESP used their database of service users to promote and recruit female sex workers into the study. The study also recruited healthcare workers who were purposively sampled from BHESP clinics. BHESP operates drop-in centre (DICs) in Kariobangi, Roysambu and Jogoo Road and serves sex workers living in informal settlements in these areas. The clinics offer integrated services for the sex workers including HIV prevention, testing, care and treatment services as well as family planning including modern contraceptives and cervical cancer screening services. The DICs are staffed with HTS counsellors, nurses, Clinical Officers, social and outreach workers, peer educators and nutritionists.

A qualitative approach was deemed most suitable to capture the lived experiences of the sex workers during the COVID-19 pandemic despite the many challenges that the virus and the government restrictions afforded. Interviews with sex workers and healthcare providers were conducted via mobile phone either as a phone or WhatsApp call since in-person interviews were not possible due to restrictions on movement in Nairobi and concerns over catching the virus. Interviews with sex workers were mainly conducted in local languages, Swahili and Sheng’; the languages commonly used by the sex workers. The study and issues of confidentiality and consent was explained via text message, and arrangements were made to ask sex workers about their immediate experiences of coping under COVID-19 and lockdown. Respondents were paid Ksh. 300 (approximately $3 at the time of the study) in mobile airtime or data for engaging with the process. The fact that the data was being collected as the events of the COVID-19 crisis were unfolding made it easier for the respondents to express their lived experiences as they occurred. There were however some problems with doing virtual interviews: phones were sometimes shared, were not charged, had no data, or there were issues with discussing sex work-related activities when living in communal settings.

A semi-structured interview guide was used to collect the data. The range of questions that were asked related to income, housing, health, service provision, food security, working conditions, doing sex work, police, gender-based violence. A total of 117 female sex workers and 15 healthcare providers were interviewed. The number of respondents was determined by data saturation, when no new data was forthcoming from the respondents. This may seem like a large sample for a qualitative study however there are several reasons for this. Firstly, we were keen to ensure that we had sex workers represented across the three main regions where the DICs operate. We secured the following respondents: Kariobangi 47; Jogoo Road 50; Kasarani 20. Secondly, the interviews were short – often around 15–20 minutes maximum. Therefore, we were keen to gather as much data as possible in the short window of time we had allocated to the data collection phase. Thirdly, we are aware that getting involved in research with communities who live together can often mean that many people are keen to express their experiences and thoughts. We think the uptake was high because sex workers were unoccupied because of lockdown and entirely out of their ordinary routine, as well as looking to contact with BHESP for emergency service provision.

The study participants

This study focused on female sex workers who are BHESP service users. Table 1 presents the age of the sex workers by area of residence. Majority of the sex workers were young: more than half (87) were 33 years and below. The youngest was 16 years and the oldest 46 years. Almost all the sex workers had children or dependents and were mostly the sole breadwinners for their families. Sex work was the main source of livelihood for the sex workers with a majority of them entirely dependent on it. The sex workers reside in Nairobi East's informal settlement areas that are within and neighbouring Kariobangi, Kasarani and Jogoo road. These include Korogocho, Huruma, Dandora, Kayole, Kiamaiko, Mathare, Saika, Mwolem among others. In this study, we did not explore other demographic characteristics of the sex workers such as level of education, marital status but these details have previously been documented in a baseline survey of BHESP service users conducted in 2018 (Hassan, Sanders, & Mwangi, 2018).

Table 1. Age of respondents by area of residence.

AGE RANGE	KARIOBANGI	JOGOO ROAD	KASARANI	TOTAL
16–24	10	19	9	38
25–33	24	26	9	59
34–42	11	5	2	18
43+	2	0	0	2
TOTAL	47	50	20	117

During the interviews, the field team would conduct the interviews and take notes as the interviews progressed. The notes were further typed out and shared with the entire research team with discussion on gaps and areas of further interrogation. A spreadsheet was used to record the verbatim data from participants under the anticipated questions that formed the question guide. In this regard we were clear what the general themes were before the data collection but of course we were not aware of the actual content. The spreadsheet of data was then shared with the broader research team and we decided on the appropriate themes to report back on. This paper only reports on those relating to health, whilst other papers in progress report on economic impacts of Covid on sex workers and also of the informal settlement clearance that took place in Nairobi at the time.

Access to Healthcare for Sex Workers amidst COVID-19 Restrictions

Since March 13, 2020 when the first case of COVID-19 was reported in Kenya, the government of Kenya like many others across the world took various proactive measures for the containment of the disease. These include the cessation of movement, dusk to dawn curfew, stay-at-home requirements and a ban on all forms of gatherings – religious, political and social. The government enforced containment measures by deploying police to ensure adherence to the night curfew, social distancing and wearing of face masks. While these measures have been deemed the most effective in containing the spread of the COVID-19 disease, they have had some adverse impacts on the social, economic and well-being of the citizens. Our study findings reveal that the various restrictions imposed by the government to help curb the spread of COVID-19 to a large extent made it difficult for the sex workers to access their healthcare needs. In this section, we present the primary COVID-19-related barriers to access to healthcare that emerged from our findings including movement restrictions, social distancing measures and the broader economic effects of COVID-19.

Movement restrictions

The cessation of movement in and out of Nairobi was introduced abruptly leaving no consideration for those who had temporarily travelled out of Nairobi to go back to their homes. Some sex workers in our study had been stranded outside of Nairobi without knowledge of alternative services which could meet their healthcare needs. One sex worker described her predicament locked out of Nairobi and unable to access health services:

I am a mobile sex worker (call girl), I had travelled out of town with a client. After the movement ban in and out of Nairobi, the client left to pick up something in Nakuru town leaving me in the hotel room. But he never came back for like two days. I was unable to sustain the bills so I had to be chased out of the hotel. Now I am unable to access the health services that I need, I am still new here in Nakuru and I don't know anyone here it's really a challenge to access any medical service. (Sex worker,18 years, Jogoo Road)

The cessation of movement not only affected those locked out of Nairobi but also those within the city. In May 2020, the government announced cessation of movement in and out of Eastleigh area; one of the areas in Nairobi identified as a hotspot for the spread of COVID-19. The partial lockdown of the area initially imposed for 15 days and later extended to 30 days was marked by heavy police presence and roadblocks at major entry points.¹ Cases of police aggression (including tear gas and water cannons) were reported as police responded to uprisings by Eastleigh residents opposed to the lockdown as well as the closure of businesses including markets and shopping malls.²

The sex workers residing there also felt stranded as there is no BHESP clinic or a sex worker-friendly facility within the Eastleigh area. One sex worker expressed her concern because she had been forced to go without PrEP while another could not get a refill of her ARVs:

I live in Eastleigh, and take my PrEP supplies from Jogoo Road clinic, with the lockdown, I have been forced to stop taking PrEP. (Sex worker,26 years, Jogoo Rd)

I have missed my appointments to the clinic at BHESP. I was supposed to go collect my ARVs but now with the lockdown, how will I go to collect them? I cannot visit the public health facility because of stigma and discrimination. (Sex worker, 21 years, Jogoo Road)

COVID-19 has caused fear and anxiety among many people. Government restrictions on movement are said to have heightened the fear and anxiety surrounding COVID-19 leading people to not use health services for other health matters. As one of the staff at BHESP observes, sex workers were staying at home and neglecting HIV prevention and treatment services out of fear of catching the virus:

Among our clients we notice that the fear of COVID-19 is higher than that of HIV so some opt to stay indoors rather than come for services. This has been fuelled by the government's restrictions of curfew and cessation of movements. (Administration officer, BHESP)

The dusk to dawn curfew was also cited as one of the key barriers to healthcare access for sex workers. An outreach worker at BHESP explains that the curfew was denying young adolescents and sex workers adequate time to interact and share at their Safe Space:

We have a Safe Space for the young adolescents where they talk with their peers. They used to share a lot, talk freely, advise and support each other. They are able to open up to each other and go home having relived a bit of their burden. Currently they are not getting adequate time at the Safe Space. Some of them used to stay at the Safe Space from morning to evening but currently it is not possible because we are now taking them in groups and each group comes at a specific time. We have to limit the time because of the curfew. (Outreach Worker, BHESP)

Further, the night curfew has forced the sex workers to change their operations and work during the day. An outreach worker observes that the sex workers were forfeiting visits to the clinics because they had limited time during the day to work and go to seek healthcare services before the curfew hours:

Most sex workers are now working during the day so sometimes they do not have enough time to come for the services before the curfew time. (Outreach worker, BHESP)

Curfew restrictions and cessation of movement coupled with police brutality on those found breaking the rules further intensified the challenges of accessing healthcare for sex workers as observed by a health worker:

Recently some clients from Biafra tried to sneak out to come to the drop-in Centre (DIC) for services but the police found them and turned them back. The police are really mistreating them. (Clinical Officer, BHESP)

Social distancing measures

To observe social distancing measures, healthcare facilities are reportedly limiting the number of clients they are serving at any one time. Sex workers explained that this had increased the waiting time at healthcare facilities, causing inconvenience and deterring access:

Most of the services are available but they are taking a lot of time to be offered. Most of the health care centres we go to are taking only five patients at a go and that is affecting our ability to get the services we need. (Sex worker, 24 years, Kariobangi)

A nurse at BHESP observed that due to the increased waiting time, some of the clients grow impatient and leave before they get the services while others feel they are being avoided or rejected:

We are wary of the dangers of contracting COVID-19 so we now allow only 5 clients at a time in the clinic. This has its downside because some when told to wait they get impatient and leave without the service. Some may feel like we do not want to attend to them and they go away complaining. (Nurse, BHESP)

Sex workers further highlighted that the restrictions on social gatherings had denied them the chance to meet in their psychosocial support groups:

We used to have organised outreaches as BHESP peers and we are not able to continue now. This means we can't earn from these but also we have more people who are not getting the peer support they need. We no longer have psychosocial support groups which help us to check on each other. (Sex worker,23 years, Kasarani)

COVID-19 has further worsened pre-existing discrimination and stigma for sex workers in public health contexts as they are now being perceived as the carriers of the Coronavirus. Social distancing measures were being used to further the discrimination and stigma for sex workers. This was highlighted by some of the sex worker who participated and expressed their disappointment with the public health facilities citing that some healthcare providers were taking the social distancing measures too far and were not examining the patients properly:

It is a challenge to get services in other hospitals at this time other than BHESP. Some doctors are keeping distance, they are not assessing patients properly because of Corona fears. They just recommend some medication which sometimes may not help you. (Sex worker,29 years, Kariobangi)

Sexual and reproductive health access

For the sex workers we interviewed, sexual and reproductive health is at the centre of their healthcare needs with them having multiple commercial sexual partners. Also with the majority being of child-bearing age to have access to contraception and other reproductive health services is crucial. Therefore, in this section we pay more attention to the impacts of COVID-19 on reproductive healthcare access for sex workers.

As alluded to in the previous section, COVID-19 has dominated the global public health agenda in 2020. Governments through their ministries of health have channelled many of the resources to combating COVID-19 thereby overlooking some other healthcare needs (FHI360, 2020). Kumar (2020) observes that production of contraceptives had been disrupted by the closure of large pharmaceutical companies that supply low and middle-income countries. Multiple respondents in our study indicated that they had been missing some of the reproductive health commodities including family planning options and pregnancy test kits. This has raised fears among the sex workers that they may suffer unwanted pregnancies, yet the current conditions are not conducive:

One of the main commodities we lack is family planning. During this time if we are not careful we will deliver a lot of ‘corona babies’. There is a problem with Norplant and the family planning injectables are also not available for continuing women. This is not good for us. (Sex Worker, 40 years, Kasarani)

There is a shortage of pregnancy tests and family planning follow up services (Sex Worker, 26 years, Kasarani)

One of the health workers confirmed that there was indeed some shortage of certain family planning options in the country:

These days we are sometimes experiencing shortage of family planning options. We get them from the County Government but it seems there is a shortage because sometimes we place the order and they deliver less than we had ordered. (HTS Counsellor, BHESP)

Our research found that the disruption of supply for reproductive health commodities due to the focus on COVID-19 had led to a neglect of routine reproductive healthcare services especially in the public health centres.

For now, when you visit the public health facility, we cannot be given contraception, priority has been given to responding and attending to emergency cases. (Sex workers, 20 years, Jogoo Road)

We also found that this was not only an issue for family planning but also other related services such as post-natal care as illustrated by one of the sex workers who was nursing an infant at the time of the interview:

I can get my healthcare needs from BHESP but it is a challenge getting services for my four months old baby. I am not getting good services at the County Government hospitals, for example they are not checking weight and for conditions such as a cold they tell you to just breastfeed the baby. (Sex worker, 23 years, Kariobangi)

The economic challenges facing the sex workers were also undermining their access to reproductive healthcare. Several respondents cited lack of money for transport as a major reason for missing their family planning appointments as illustrated:

With the lockdown, sex workers are missing on their routine family planning methods. I was supposed to go for my third month injection, but now I cannot afford to go because I am not able to afford transport. (Sex Worker, 34 years, Makadara)

I was due for my three months family planning injection last month, but I was not able to go get it at BHESP DICE, because transport has been hiked and I cannot afford it. (Sex Worker, 18 years, Jogoo Road)

I have missed my family planning injection because cannot afford transport to go to the clinic. (Sex Worker, 25 years Makadara)

Inaccessibility to the BHESP clinics where they get the family planning services free of charge meant that the sex workers go without the contraception because they could not afford to buy it themselves. One of the sex workers expressed her distress as she had already become pregnant. She said she could not afford contraceptive nor transport to collect contraceptives from the BHESP clinic: ‘Just in three months of lockdown I am already pregnant. I was not able to afford contraception and transport to the DICE (Sex worker, 18 years, Makadara). Although there are some public health centres close to most of the informal settlements where most sex workers live, the experience of one young sex worker we interviewed further highlights the discrimination sex workers in Nairobi face when seeking services in mainstream public facilities. This shows that public health facilities in most cases were no alternative for those who could not access BHESP clinics:

I went to a public health facility near me, but I was told I am too young to be using family planning and that I should abstain. Now I am worried of getting pregnant again. (Sex Worker, 18 years, Jogoo Road)

We further found that economic challenges were deepening the sex workers reproductive health challenges by making them prone to sexual exploitation. A clinical officer at BHESP observed that some young sex workers were being tricked by their clients to discontinue contraception so that they can marry them:

We have noticed that young sex workers are opting to remove the Norplant and when we ask them what other option they want to use they say they just want to stay without contraceptives. We suspect that maybe they have clients who want take advantage of them by making empty promises of marrying them if they bear them a child. We try to talk them out of it because we know their background- some are still living with their parents and they will only fall into deeper problems. (Clinical officer, BHESP)

We found that the situation was particularly difficult for sex workers who were pregnant or had given birth during the COVID-19 crisis. The nursing mothers were lacking care and resources to cater for their needs as well as those of their infants. For some of the nursing mothers, the need to focus on nursing their babies and regaining their strength was keeping them from resuming their sex work hence deepening their financial challenges. In addition, they were wary of the possibility of contracting the Coronavirus while working and exposing their infants to it. Hence, some were depending on their family members and neighbours for their upkeep. For others who had no one to turn to for their daily needs, they had to resume working. This is reflected in some of their statements:

I got a baby recently, in April so I do not even have the ability to go out and seek clients. Life is now hard. Am just staying at home, I am no longer working. I only go out when I need to take my baby to the clinic and I am back. I do not want to expose myself to Corona so I avoid going out a lot. I am depending on my mother. My neighbours have also been good to me since they know I have an infant, they give me priority when government donations are brought. But they are brought once in a while, they are not so regular … . I have to find a way of getting back to work but I have to wait till my baby turns at least 3 months. (Sex worker, 30 years, Kariobangi)

I am suffering because I am not getting enough income to cater for my needs. I have a 4 months baby and I cannot afford essentials like diapers … . Clients are paying very poorly- ksh 50 (0.5 usd) and the highest I get is ksh 500 (5 usd). I accept it because I have many financial problems. (Sex worker, 23 years, Kariobangi)

Reproductive health challenges for the sex workers during the COVID-19 pandemic are further compounded by the housing problems in the informal settlements where the sex workers mainly reside. Apart from the challenge of raising house rent at the time of COVID-19, some of the sex workers were grappling with homelessness. In most cases, dwellers of informal settlements lack security of tenure and were at risk of forced evictions. Early in May 2020, the government of Kenya demolished an informal settlement in Kariobangi North leaving an estimated 8000 residents homeless (OHCHR, 2020). Some sex workers were caught up in the evictions including one who was pregnant at the time. She expressed her distress and uncertainty of giving birth while facing homeless and loss of income:

My situation is bad. I used to stay in Kariobangi but our houses were demolished. I have since moved in with a friend but I do not feel comfortable. I feel I am a bother to her because I have a child and I am currently pregnant and almost giving birth. I am suffering so much, in my condition I cannot get clients. I feel COVID-19 came with loads of misfortunes for me. (Sex worker, 26 years, Kariobangi)

She further expressed desperation as she had tried to seek laundry jobs but could not sustain them due to pregnancy complications:

I was trying to do laundry jobs but I stopped. I would get backpains and sometimes bleed, I had to stop. In the past whenever my sex-work was down, I would do laundry jobs but now my situation does not allow … I need money to rent a place of my own, I will give birth soon and I will only add a burden to my friend. (Sex worker, 26 years, Kariobangi)

Another critical reproductive health service for the sex workers is cervical cancer screening. One of the sex workers indicated that cervical cancer screening was unaffordable and although it was a free service at BHESP, she reiterated the high transport costs following the pandemic as a major barrier to accessing this service. The issues for women are far reaching in relation to accessing a range of health care services, which could lead to life threatening scenarios.

Discussion: Implications for sex workers’ health

From our findings, it is evident that the COVID-19 pandemic has not only adversely affected the livelihoods of sex workers but also their access to healthcare. This undoubtedly has implications for their well-being. In this discussion we would like to draw attention to three key findings and their implications: firstly, the implications for reduced access to sexual and reproductive health commodities; secondly, the implications for HIV prevention; and finally, the third implication of the lack of access to key health care services related to the rise in stigma faced by women involved in sex work.

We found that there was a shortage of family planning options and even where available, some of the sex workers could not access them. As a result, some sex workers were already struggling to accept the harsh reality of carrying unwanted pregnancies. This situation is further likely to trigger unsafe abortions among the sex workers. Similarly, SWAN and ICRSE (2020) reporting on a survey of seventeen sex worker organisations from thirteen countries in Europe and Central Asia found that COVID-19 disruptions had led to limited access to HIV/STIs and sexual and reproductive health services for sex workers in most of the countries. In collaboration with Avenir Health, John Hopkins University (United States) and Victoria University (Australia), the United Nations Population Fund estimates that about 47 million women in 115 low and middle income countries could lack modern contraceptives if COVID-19 restrictions, specifically lockdowns, continued for 6-months with high healthcare service disruptions (UNFPA, 2020). The report also suggests that the unmet need for modern contraceptives would result in about seven million unplanned pregnancies in these countries. We also found that sex workers who were pregnant or nursing infants at the time of the research not only lacked basic needs including food but were also lacking care. Cone (2020) observes that reduced access to SRH services in times of crisis increases risks such as maternal and infant deaths. For instance, during the 2013–2016 Ebola crisis in Sierra Leone, due to disruption in maternal health services and reduced healthcare-seeking out of fear of the outbreak led to about 3,600 deaths resulting from maternal and neonatal deaths and still births. Taking the findings from sex workers in Nairobi, there are real concerns that both the lack of physical access to clinics and a steady and consistent supply of contraceptive drugs will have an adverse effect. With the dire financial stresses facing this group of women, risky sexual practices in their commercial and personal lives may well have increased as they try to earn what little money they can.

Our second core finding suggests that HIV infections could rise among the sex workers and their clients due to increased risk behaviours and lack of adherence to antiretroviral therapy (ART) for those living with HIV. These include engaging in unprotected sex especially for higher pay yet some were finding it difficult to adhere to the proper use of pre-exposure prophylaxis (PrEPs) and post-exposure prophylaxis (PEPs). Further, some sex workers who were on HIV treatment were facing barriers to adherence. Such risk behaviours are likely to increase new cases of HIV infections and other STIs as well as the risk of HIV-related mortalities. In addition, with the reduction and intermittence of outreach services which help in monitoring HIV infections and carrying out HIV prevention work amongst sex workers, it is possible that the infections rates may increase unnoticed. We also found that there was a shift in attention by government from management of existing diseases and medical conditions to the new threats of coronavirus. The shift in government attention was affecting the supply of medical supplies and nutritional packs for the HIV positive sex workers. This is likely to expose sex workers to malnutrition especially during the COVID-19 crisis where most of them were unable to provide food for themselves and their families as their incomes were reduced drastically or in some cases ceased entirely. This redirection of funding to COVID-19 prevention and treatment, has been identified as problematic particularly for key populations and guidance has been produced to enable continued access to HIV prevention services and treatment, sexual health and family planning services during the COVID-19 crisis (FHI360, 2020).

UNAIDS in a press statement issued on 11th May 2020 warned that the gains made in combating HIV could be lost due to disruption of health services and HIV prevention and treatment supplies during the COVID-19 crisis. Citing the modelling conducted by Jewell et al., (2020) indicating that if there were a six-month disruption in HIV supplies and treatment, estimates of excess AIDS-related deaths in sub-Saharan Africa for a year ranged from 471,000–673,000, UNAIDS notes that this would mean reversing the progress made towards reaching the 2020 global target of fewer than 500 000 AIDS-related deaths worldwide. UNAIDS called for governments to take action to ensure the gains made in combating HIV are not watered down by the response to COVID-19. The ministry of health in Kenya has an opportunity to work closely with informal healthcare providers and sex worker organisations not only to help in ensuring the gains made in combating HIV are not negated but also in winning the battle against COVID-19. Corburn et al., (2020) notes the informal healthcare providers are the most effective channel to reach residents of informal settlements as they are the first point of entry for the residents into the healthcare systems. Sex worker organisations such as BHESP could be involved in providing COVID-19 testing among sex workers. Such organisations could also be instrumental in facilitating contact tracing among vulnerable and marginalised populations such as the sex workers.

In this study, results suggest that anticipated and experienced stigma amongst sex workers, from healthcare workers in public health facilities, was a major barrier for sex workers who could not access BHESP clinics to seek healthcare services during the COVID-19 pandemic. We found that although some of the public health facilities were geographically more accessible for sex workers, most sex workers, who could not access BHESP clinics, opted to go without the healthcare services they needed for fear of discrimination and stigma from non-specialist practitioners. Some who had tried seeking services at the public health centres reported that they were either turned away or were unsatisfied with the services received. A study by Nyblade et al., (2017) similarly showed that sex-work stigma when accessing healthcare services was a major barrier in seeking HIV counselling and testing services as well as general healthcare services.. Stigma and discrimination can contribute to high HIV prevalence among key populations due to lowered uptake of HIV prevention and treatment services as well as engagement in riskier behaviours.

Sex workers also need protection from the COVID-19 disease. Elmore-Meegan et al., (2004) observes that sex workers are often viewed as potential channels of spreading infections such as HIV and other STIs, hence the need to manage them to protect others. They note that this results in stereotyping of sex workers ‘as reservoirs of infections’ while they are also at risk of getting the same infections and transmition.. This perception worsens their plight especially during times of crisis because there is less focus on protecting them. World Health Organisation shows that people with underlying medical conditions, particularly non-communicable diseases, are at a higher risk of Coronavirus infection and suffering severe disease in case they contract the virus. Although, the same has not yet been confirmed for those living with sexually transmitted diseases such as HIV (Platt et al., 2020), the World Health Organization warns that those who are immunocompromised are more susceptible to opportunistic infections including COVID-19.

A major limitation of this study is that the study interviewed sex workers covered by BHESP services only. Since these sex workers have their healthcare needs mainly provided through BHESP, it is possible that generalising our results may under represent the healthcare access challenges during COVID-19 because there are sex workers who are not connected to specialist sex worker provision. However, this study has provided clear evidence of heightened healthcare access challenges due to the COVID-19 crisis even for sex workers linked to sex worker organisations offering specialised healthcare services.

Conclusion

Interventions that can increase access to healthcare services for the sex workers during the critical time of COVID-19 pandemic are crucial. The study has demonstrated that the impact of COVID-19 on the livelihoods of the sex workers was a major barrier to healthcare access for the sex workers. Loss of income, lack of food and unaffordable transport services had direct impact on healthcare access for the sex workers. Hence, healthcare and economics must be tackled together. Where sex workers are excluded from government protection schemes, adequate housing outside informal settlements, and poor employment prospects in the mainstream economy, there is a real crisis amongst sex workers whilst Covid-19 dominates health care provisions. Sex workers are already at risk of health care concerns around sexual and reproductive health as well as HIV, and the current context has exacerbated this risk. This has a domino effect in relation to how infants and children are affected, as well as wider families and communities which have traditionally relied on the income of sex workers for their sustenance.

Interventions that can cushion sex workers from the harsh economic realities of COVID-19 will undoubtedly go a long way in improving healthcare access for the sex workers. BHESP has rolled out various initiatives including distributing food packs and emergency bedding to the sex workers. In addition, BHESP are developing an intervention tool to increase access to ARVs and other medications which uses innovative approaches. BHESP has experience of using online platforms and phone technology to deliver peer information, advice and advocacy for sex workers and this is being enhanced to use technology to reach out further to women who are mobile and transient. This intervention tool fuses an online digital solution, a phone app with a flexible outreach model, purchasing an old school transport mode, a motorcycle, to deliver essential medications to sex workers. One of the positive elements of the Covid crisis is that NGOs have had to respond flexibly to the needs of their service users, and to adapt existing services to a set of restrictions which were previously unimaginable. It is with the dedication of organisation across the globe such as BHESP and the peer educators who carry out vital work that sex workers will be given a life line to survive this crisis.

Acknowledgements

The team would like to thank the efforts of BHESP peers who worked alongside the project at a very difficult time, and for BHESP agreeing to partner for this work in the midst of a crisis. The University of Leicester reacted quickly to fund this research from the Global Challenges Research Fund.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by Global Challenges Research Fund (GCRF) to the University of Leicester [grant number SandersLeicester].

Notes

1 https://www.nation.co.ke/kenya/counties/nairobi/eastleigh-lockdown-residents-wake-up-to-11-roadblocks--487486

2 https://nairobinews.nation.co.ke/general/eastleigh-turned-into-a-ghost-town-by-covid-19-lockdown