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

基于性别的暴力是一个优先的公共卫生问题，也是对妇女权利的侵犯。它对一般妇女的健康和福祉造成严重后果，特别是从事高风险职业的妇女，如女性性工作者，她们可能面临来自伴侣和客户的风险。在这些群体中，暴力行为与心理健康状况不佳有关，包括焦虑和抑郁、高风险性行为、艾滋病毒和性传播感染率高，并可能导致妇女放弃艾滋病毒支助和预防服务，而在这些环境中，50%以上的女性性工作者艾滋病毒呈阳性。我们知道，通过利益攸关方和社区动员、促进权利和改变社会规范，结合幸存者识别、护理、通过性传播感染/艾滋病毒方案提供支助和减少伤害，可能是减少暴力发生和支助幸存者的最有效办法，但目前的方案主要侧重于应对-在性健康和生殖健康（SRH）服务中纳入基于基础的方法。我们目前在马拉维南部针对女性性工作者开展的工作，采用以社区为基础的方法，与目标服务提供者合作，减少艾滋病毒和其他性传播感染的传播，在这项工作中，我们探讨了暴力与性健康和心理健康风险之间的关系，以及开展性工作的更广泛环境的影响。我们发现，性工作者报告的暴力比例很高（超过50%），除了性健康和生殖健康服务提供者在暴力事件发生后提供的基本咨询和转介外，对那些遭受暴力的人几乎没有什么支持，只有41%的事件向警方报告。为了开始改变这种情况，本研究将整理在撒哈拉以南非洲其他地方有效的证据，并将其与我们在这方面已经知道的联系起来。我们将与女性性工作者以及地方组织和当局（包括卫生和性健康和生殖健康服务提供者）、马拉维法律协会和警方密切合作，共同制定一系列不同的、相互关联的方法，以反映妇女在这一环境中的生活现实。我们将共同努力，重点确定哪些措施可能最有效地改善支助遭受暴力侵害的妇女的对策，同时也将共同努力，为妇女创造保护自己免遭暴力侵害的途径，并加强支助妇女的更广泛的机构。这将是制定多部门干预措施的第一阶段，有可能减少和预防暴力，改善马拉维南部卖淫妇女的身体、社会和精神福祉。

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.