Living alone with her three-year-old son in Muleba, a town in Kagera, along Tanzania’s Lake Victoria shoreline, Happiness is doing her best to work hard and earn a livelihood. But in an area with few employment opportunities, especially for women, Happiness has had to make difficult choices that put her at risk.
“I was born in Muleba and lived with my parents until they separated when I was 12 years old, after which I lived with my grandmother who took care of me until I was 15, when she passed away. After that, I dropped out of school, and I had no support. I started to live alone and tried to earn money through small activities like selling dagaa [a small fish], but it was not enough. Then I met a friend who introduced me to sex work.”
Happiness’s friend told her how she could earn between 10,000–45,000 Tshs (5–20 USD) per night, with multiple partners per day. Most of her customers are men 35 years and older from wealthy areas surrounding Muleba town, as well as some local fishermen. Sex work is common in the areas around Lake Victoria, where poverty is high and people migrate frequently for work along the region’s intersecting trade routes.
“All this time I was so worried about HIV, as I was seeing many men in a week and some were refusing to use condoms. Many of my clients still don’t like condoms, and I get more money if I offer sex without a condom.”
Happiness is not alone in her worry; many people who earn money through sex work face the same struggle. But now she is finding new hope—in the form of a pill called PrEP, which stands for pre-exposure prophylaxis. PrEP can stop HIV from taking hold and spreading through the body and, if taken regularly, it can be highly effective in preventing HIV.
PrEP has come into Happiness’s life by way of a community-outreach program in Tanzania known as FIKIA, a collaboration between the Ministry of Health and Social Welfare and ICAP at Columbia University, a global health organization. Together, they are working to build a program dedicated to meeting at-risk individuals wherever they are and empowering them to protect their health.
Begun in 2016, the FIKIA project includes outreach activities at night in order to reach female sex workers, their partners, and other key populations, and this is how Happiness met Violet, an ICAP-supported community outreach volunteer. “Violet encouraged me to be tested for HIV,” Happiness recalled. “After receiving health education, I was worried because of my sexual history, but Violet informed me of the availability of medicines for HIV (antiretroviral medications, or ARVs) if I tested HIV positive, or PrEP (pre-exposure prophylaxis—an effective method for preventing transmission of the virus) and condoms if I was HIV negative; which is something that I didn’t expect. Violet added that, regardless of the result, she would support me as long as I need.”
The FIKIA project, which is supported by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) with funding from the U.S. Centers for Disease Control and Prevention (CDC), helps bring critical HIV prevention, care and treatment services to people at risk—including adolescent girls and young women—in three regions of the country, including in Kagera. The innovative project makes use of peer educators and outreach specialists both in the clinics and out in the community to bridge the gap between people in need of HIV services and distant regional health centers. ICAP works closely with the Ministry of Health and Social Welfare and other local partners to ensure that clients who are diagnosed HIV-positive get antiretroviral therapy and stay on treatment.
Beginning in September 2017, Tanzania’s National AIDS Control Program has been working with ICAP and other partners to develop a demonstration project for rolling out PrEP and HIV self-testing programs in Dar es Salaam, Kagera, and Mwanza. The project aims to reach individuals at increased risk for HIV infection, including female sex workers, and others including couples in which one partner has HIV and the other does not. In the first week, 114 people initiated oral PrEP across the three participating regions, and over the course of four months from June to September 2018, a total of 3,229 individuals—including Happiness—enrolled.
Sabasaba, a health care worker trained in PrEP delivery, recalls the first time she met Happiness: “When Happiness first heard about PrEP from a FIKIA-trained community outreach volunteer, it sounded like a joke to her; too good to be true. Happiness had wondered, ‘My first thought was, if there is no cure for HIV, how could there then be a pill that prevents HIV?’”
Happiness envisions a future where she has saved enough money to open her own food business to provide for herself and her son. Although she knows that PrEP protects her only from HIV and not other sexually transmitted infections or pregnancy, Happiness is now less stressed about her HIV risk and more hopeful that her dream can become a reality.
“Starting PrEP was my choice, which gives me peace of mind and helps me to live a happy life. I have used this medicine for three months now and I encourage my friends to use it as well, and I connect them with Violet for services. Violet has now become my good friend and I can call her any time if I need advice or help. I thank ICAP, Violet, and Sabasaba for helping my life through their good services and supplying PrEP.”
View the article in Tanzania’s Citizen (English) and Mwananchi (Kiswahili) papers:
(click images to open PDFs)