Co-design of a multi-sectoral intervention to address gender-based violence amongst Female Sex Workers in Malawi

Gender-based violence (GBV) is a priority public health issue and violation of women's rights. It has severe consequences on the health and wellbeing of women in general and particularly women in high-risk occupations such as female sex workers, who may be at risk from both partners and clients. Amongst these groups violence is linked to poor mental health including anxiety and depression, high-risk sexual behaviours, high levels of HIV and sexually transmitted infections (STIs) and can lead to women dropping out of HIV supportive and preventive services, in settings where over 50% of female sex workers are HIV positive. We know that interventions that address GBV prevention, response and accountability through stakeholder and community mobilization, rights promotion and changing social norms combined with survivor identification, care, support and harm reduction through STI/HIV programmes are likely to be the most effective in reducing both occurrence of violence and in supporting survivors but current programmes focus mainly on response-based approaches integrated within Sexual and Reproductive Health (SRH) services. Our current work in Southern Malawi with female sex workers uses community-based approaches to reduce transmission of HIV and other STI infections in collaboration with targeted service providers and within this work we have explored the relationship between violence and sexual and mental health risks and the influences of the broader environments within which sex work is conducted. We found high rates of violence reported by sex workers (over 50%) and that there was little support for those who experienced violence beyond basic counselling and referrals provided by SRH service providers following incidents of violence and only 41% of incidents were reported to police. To begin to change this situation, this study will collate evidence from what has worked effectively elsewhere in sub-Saharan Africa (SSA) and link this to what we already know in this context. We will work closely with female sex workers and local organisations and authorities including health and SRH service providers, the Malawi Law Society and the police to co-develop a range of different, linked approaches that reflect the reality of women's lives in this setting. Together we will focus on identifying those that are likely to be most effective in improving responses supporting women who have experienced violence but also to work together to create ways for women to protect themselves from violence and to strengthen the wider institutions to support them. This will form the first stage in developing a multi-sectoral intervention with the potential to reduce and prevent violence and improve the physical, social and mental well-being of women who sell sex in Southern Malawi.

We will develop a theoretically-driven, multi-sectoral intervention to promote effective violence prevention and response amongst high-risk female sex workers (FSW) in Malawi. Gender-based violence (GBV) is associated with poor mental health, high-risk sexual behaviour, high incidence of HIV and sexually transmitted infections (STIs) and poor HIV outcomes. GBV prevention amongst FSW is a priority rights-based need but programmes focus largely on response-based approaches integrated within Sexual and Reproductive Health services. Whilst these have shown effectiveness in developing capacity of outreach workers based in drop-in centres for HIV/STI prevention to provide support and referral, there is little evidence that this approach has reduced incidence of violence amongst FSW. In response to national (and global) policy priorities and working closely with those most affected, we will evaluate coverage, accessibility and quality of current violence response initiatives and use best practice, co-design approaches with participatory, systems thinking tools to develop a multi-sectoral intervention. The outcome of this project will be a pilot intervention with three objectives: to strengthen service response though survivor identification, care, support, and harm reduction integrated within STI/HIV prevention strategies, to strengthen prevention through community mobilisation, rights promotion and social norms change and to increase justice through local accountability. Working with key stakeholders including FSW, service providers, police, policy-makers and the Malawi Law Society, this intervention will benefit FSW communities directly through improved supportive response to GBV and indirectly through changing social norms, structures and practices. The overarching aim of the intervention will be to improve the physical, social and mental well-being of FSW through multi-sectoral approaches to violence prevention and response in urban Malawi.