Making It Happen in South Sudan

March 5th, 2015

 By: The International HIV/AIDS Alliance

Mary*, 19, is from Yambio in South Sudan’s Western Equatoria state and is living with HIV.  Orphaned at a young age and brought up by her aunt, she’s smart and determined to see her education through to university level if she can.  Few girls her age even reach secondary education – they often drop out early due to early marriage, adolescent pregnancy or their parents not recognizing the value of girls staying in school.
Mary also sells sex.  Finding the money for her school fees was proving difficult and she began selling sex in order to continue her schooling.  Sex work in South Sudan is criminalised and sex workers often find themselves discriminated against by healthcare providers and law enforcement agents who are known to harass them when they find condoms in their bags.
Mary is lucky in that she has been supported by the YMCA and the Alliance for Community Health Initiative (ACHI) to become a peer educator, meaning that she has become better informed about her sexual and reproductive health and rights in the process.  She now uses that knowledge to help other sex workers to protect themselves and live healthily.
In all major towns in South Sudan, sex workers in different guises – including bar maids, waitresses, tea sellers, market stall workers - form part of the social fabric and structure of the urban population.  The proliferation of bars and lodging facilities became a new phenomenon in many towns, springing up in the wake of the signing of the Comprehensive Peace Agreement (CPA) in 2005.  The establishments are mostly unregulated, employing young women and girls who are paid low wages and then supplement their income with sex work.
The nature of sex work can put young women and girls at high risk of exposure to HIV and sexually transmitted infections because of multiple partners, difficulties in negotiating condom usage, the risk of violence and a poor health service that responds weakly to their specific requirements.  Often the human rights of sex workers are jeopardised as at best they are invisible to law or at worst vulnerable to criminal prosecution, harassment or violence during processes of law enforcement.  Dedicated condom supply programmes reaching sex workers in South Sudan are rare, and HIV counselling and testing facilities are sometimes unavailable altogether.
While the CPA has held and South Sudan became independent in 2011, peace was short-lived with the country plunging into an internal crisis in December 2013.  In conflict settings, factors like the breakdown of social safeguards and lack of schooling opportunities increase the pressure to become involved in sex work and make it difficult to leave it.  During conflict, people often lose their livelihoods and have no other sources of income, and can leave young girls and women to engage in transactional sex in exchange for basic needs.  In environments where there are no HIV programmes specifically addressing sex workers’ needs,  the impact is twofold – it both impinges on the rights of sex workers to realise their right to health, and it also undermines national HIV prevention efforts.
Generally, the world’s newest country is witnessing high rates of new HIV infections with pockets of concentration among sex workers and their clients, the military and long distance truck drivers among others.  Prevalence among the military is estimated at 5% compared with the national prevalence of 2.6%.  Communities around transport corridors and cross-border points also tend to have high HIV prevalence, for example along the border with the Democratic Republic of Congo and Uganda.
Since the CPA, many foreign sex workers have migrated to South Sudan from neighbouring countries.  They tend to be more visible and feel able to speak out more than local sex workers who are largely younger, hidden because they often work from home and with a lack of strong leaders.  Being harder to find means that it’s also harder to engage with them, which is why the peer to peer approach deployed by Mary is so important.
So what are some of the other solutions?  As well as training young sex workers as peer educators, ACHI has also worked with law enforcement agents, including the police, to raise awareness of most at risk populations and HIV vulnerability.  In order to be able to provide accessible and good quality integrated HIV and sexual and reproductive health and rights services that are free from stigma and discrimination, engaging with communities and leaders in programme design and implementation is crucial, as is reaching out to the sex workers’ regular clients such as the army.
Many of the new HIV infections diagnosed in South Sudan occur in soldiers, who make up more than one third of the clients of sex workers across the country.  Because of the soldiers’ mobility, the sex workers who reside around army barracks also tend to move whenever they move.  Together the International HIV/AIDS Alliance, ACHI and the Sudan People’s Liberation Army (SPLA) are implementing a project funded by the US Department of Defence which is working with sex workers and their clients in order to increase the effectiveness of HIV prevention efforts.   The programme focuses on building linkages with garrisons, surrounding communities and sex worker networks around the barracks, and integrating HIV services within existing military healthcare facilities.  Sex workers learn how to negotiate using a condom with  clients as well as how to access services such as treatment and screening for sexually transmitted infections.
As we mark International Women’s Day this week, it’s young women like Mary who, despite ongoing conflict and insecurity in South Sudan, are making things happen by representing the voices of her community  and putting forward the case for inclusion.  Only if we gain a proper understanding of the sex work environment and of conditions for sex workers will be able to properly and efficiently plan for HIV prevention, care, treatment and support for this too often overlooked group. 
The International HIV/AIDS Alliance works with ACHI to strengthen the infrastructure and systems needed to deliver health and HIV services in South Sudan.
*Not her real name