Sex workers in Rwanda say the criminalization of their activities, combined with their general isolation from society, means they are often excluded from HIV prevention, treatment and care opportunities.
Article 225 of the Penal Code states that "Any person who practices the profession of prostitution shall be liable for a term of imprisonment ranging from six months to three years or a fine ranging from 50,000 [US$81.5] to 500,000 [$815] Rwanda Francs."
Sex workers fall into the category of "most at-risk populations" in terms of HIV infection and transmission, and according to the 2010 Rwanda Behavioural and Biological Surveillance Survey the overall prevalence of HIV among female commercial sex workers was 51 percent - 17 times the national average of 3 percent.
The survey also found that condom use by sex workers was inconsistent with their paying sexual partners as well as with their chosen partners, and 36 percent of sex workers reported having had at least one sexually transmitted infection symptom in the 12 months preceding the survey.
Sex workers say the illegal nature of their profession has a direct impact on HIV prevention and treatment. For instance, when HIV-positive sex workers are jailed, they are unable to adhere to treatment. They also face stigma and discrimination by their communities and even health workers.
"I had this unrelenting cough and I was losing a lot of weight. My skin was deteriorating. The doctor - without my knowledge and consent - just conducted an HIV test," said Nelly*, a sex worker in Nyarugenge, a suburb in the capital, Kigali.
"He gave me some treatment for opportunistic infections, but didn't reveal to me that I was HIV-positive. When I went back to the health centre some time later, the reception was very cruel... No one wanted to attend to me; the nurses and all the other staff were avoiding me, just pointing fingers,” she said.
"After a long and frustrating wait I managed to see the doctor, who gave me a few tiny tablets and impolitely told me I was suffering from some incurable disease. I was confused but I came to discover, much later, I was HIV positive," she added. "I resorted to going to a far-off health centre, where they don't know about my [sex] work - at least they would treat fairly there."
But news of her HIV status had already reached her home and when she visited her family, her parents and siblings forced her to use separate cutlery, crockery and other household items.
In 2010, more than 100 civil society organizations submitted a position paper on human rights, HIV/AIDS and sex workers to the Rwandan senate, stating that the continued criminalization of the profession forced sex workers to operate covertly, and denied them access to vital healthcare.
The country's National Strategic Plan on HIV/AIDS (2009-2012) aims to reach 60 percent of sex workers with HIV prevention programmes, but criminalization makes it difficult to reach them, said Willy Mwanafunzi, the executive director of Faith Victory Association. The NGO has embarked on a three-year campaign to fight HIV/AIDS among sex workers.
"The campaign with sex workers seeks to find alternative economic activities away from [sex work]. We have so far trained over 4,000 sex worker peer educators around the country in HIV prevention, advocacy for condom use and human rights, among others, and these peer educators are also supposed to identify and recruit these sex workers into the project, but the main challenge we have had is identifying the sex workers," he told IRIN/PlusNews.
|Sex work is illegal here, so they [sex workers] tend to shy away and hide from the peer educators... They think they are working with the law enforcers|
"Sex work is illegal here, so they tend to shy away and hide from the peer educators because they do not trust their motives. They think they [peer educators] are working with the law enforcers, and this has kept them [sex workers] away. However, we have taken it upon ourselves to sensitize the authorities and our target beneficiaries that our activities are for the good of this most at-risk population," Mwanafunzi said.
Officials at the Ministry of Health told IRIN/PlusNews that sex workers were free to access the country's widely available HIV services.
"We have carried out sensitization programmes across the board… directed towards behavioural change and HIV/AIDS education to all audiences through the media and other fora,” said Dr Sabin Nsanzimana, head of the HIV/AIDS division of the Institute of HIV/AIDS Disease Prevention and Control at the Ministry of Health's Bio-Medical Centre.
“We also have in place other HIV/AIDS services, like voluntary counselling and testing, condom distribution and availability, ARV access to all...We do not offer these services in isolation of the high-risk groups.," he pointed out.
A paper authored by, among others, Rwanda's current health minister, Agnes Binagwaho, noted that "protecting the health of Rwanda's sex workers (and with them, the broader population) does not demand intensified repression.”
On the contrary, the paper on developing rights-based strategies to improve health among female sex workers in Rwanda urged “a comprehensive agenda of medical and social support to improve these women's access to health care, reduce their social isolation, and expand their economic options."
However, the paper also noted that some Rwandan lawmakers continue to advocate a hard-line approach to tackling sex work.