Strengthening early identification of pediatric HIV cases

Reaching out to key populations in Dar es Salaam

By Jacqueline Namfua
Koku breastfeeds her 7-month old daughter
UNICEF Tanzania/Namfua
22 April 2016

Meet Koku Silasi, a 36 year old woman from Bukoba, northern Tanzania where she worked as a farmer, barely making ends meet. She is separated from her husband and has a 13-year old boy who lives with her husband in Bukoba. She currently lives with her 7-month old daughter, Mary, in Dar es Salaam.

Tandika is a highly congested area on the outskirts of Dar es Salaam, where you find about 200 rooms for sex workers to run their business/accommodate their clients. In October 2014, Koku travelled by bus from Bukoba and found herself in one of these rooms.

“My older sister sent me bus fare to come to Dar es Salaam. And then she found me a room and she paid the full rent for six months (approx. USD 18). She told me that I will now start to work as a sex worker because that is what we all do. I had never done anything like this before and so I felt horrible but what could I do? I couldn’t go back home because I didn’t have money for bus fare,” said Koku with much sadness.

I had never done anything like this before and so I felt horrible but what could I do?

National HIV prevalence is at 5.1 per cent in Tanzania, however among key populations such as sex workers it is at an alarming 31.4 per cent. Consequently, in 2013, UNICEF Tanzania’s partner, a local faith-based organization called Pastoral Activities and Services for people with AIDS Dar es Salaam Archdiocese (PASADA) scaled up interventions to reach more vulnerable population groups, including women who sell sex.

To date, a total of 1,628 female sex workers have been provided HIV testing and counselling by PASADA staff and out of those, 105 were found to be positive. All the women who tested positive were enrolled into PASADA services, which includes: receiving prevention of mother to child HIV transmission (PMTCT) (antiretroviral treatment); management of opportunistic infections; tuberculosis diagnosis and treatment; care and support services; continued supportive counseling; and HIV and educational support to their children, as well as referrals to other partners offering livelihood opportunities, where possible.

Every evening around 7pm Koku takes her daughter to a neighbor’s house so that she can watch over her while she attends to her clients. She then collects her daughter around 11pm and pays the neighbor Tsh 1,000 (approx. USD 0.58). Koku only accepts clients in the evenings and on average she gets about 6-7 clients per day; during the day she takes care of her daughter and house chores.

“I sit on my stool outside my room and if a man likes me then they come in and we agree on the price which is Tsh 3,ooo (approx. USD 1.75) per session. I don’t do oral sex or anal sex and all my clients must wear a condom. Thankfully, I have never had violent clients, but just in case, we do have masai men here to protect us.” Koku buys her own condoms, (a box of condoms is Tsh 3,500, approx. USD 2.05), which she keeps in her room. She then points out with sadness that, “In this small room is where I bring my clients. This same room is also my home and in this same bed is where Mary and I sleep.”

According to Alison Jenkins, UNICEF Tanzania, Chief of HIV/AIDS, PASADA’s services are receiving more positive acceptance among the key populations.

“Through its innovative outreach and non-judgmental, confidential and supportive approaches to service delivery, PASADA is reaching some of the most vulnerable key populations with services that are critical to their health and well-being, as well as that of their children. PASADA has worked hard to ensure that their health care providers have become more accepting of and supportive to key populations, and their children.”

“I know PASADA because they occasionally come and visit us to test us for HIV and counsel us. The last time I got tested was when I went for antenatal care in Bukoba while I was pregnant with Mary. But I have never been tested since I started working as a sex worker. But today PASADA is here to visit us, I will get tested so that I can know my status,” said Koku.

However, despite the successes, PASADA is still facing some challenges in implementing its programmes. Key populations need health care facilities that can provide a lot of privacy as they are often stigmatized by other patients seeking care in the same facilities. Most of the key populations are reached through outreach interventions, therefore financial resources and reliable transportation are critical. Furthermore, disclosure to partners is a major challenge among all key populations.

UNICEF Tanzania plans to continue working closely with PASADA to reach all children infected and/or affected with HIV. The main aim of the project is to help reduce child and adolescent morbidity and mortality due to HIV and AIDS. PASADA with support from UNICEF visits communities to offer HIV testing and counselling children and adults and where necessary refer positive children to care and treatment.

PASADA uses a combination of approaches to intensify pediatric case finding for children and adolescents. One such approach includes children of HIV positive parents from key populations, which includes sex workers. Given the high stigma against people living with HIV in Tanzania, sex workers do not want to be seen get tested for HIV. PASADA goes from room to room to test as well as counsel the sex workers individually. Koku did get tested that day and her result was negative.

While sitting in her tiny room and holding her baby, Koku says that, “I don’t like my job at all but right now I have no other option. I am forced to do this job until I can save enough money to get out of here. No one in my family knows what I do here, except for my sister. My dream is to get back home to Bukoba to start a small business and continue farming so that I can educate Mary so that she can have a better life than me.”