By Andrea Mooney, Communications and Knowledge Management Advisor, PSI
Female sex workers (FSWs) are at heightened risk of both HIV infection and unintended pregnancy. Although programs targeting FSWs emphasize HIV prevention and condom promotion, they typically overlook the broader reproductive health needs of these women. This week at the International Conference on Family Planning (ICFP), a presentation on the MULU/MARPs HIV Prevention Project by PSI/Ethiopia highlighted the importance of effective integration of family planning and HIV services. The word “MULU” when translated from Amharic, means complete, while MARPS is the acronym used for “most at-risk populations.”
In its initial phase, the MULU/MARPs project focused on reducing the number of new HIV infections among key populations in Ethiopia, including female sex workers. The project operated through a combination prevention lens that included behavioral interventions (e.g., interpersonal communication activities and community wide events), biomedical interventions with integrated clinical services and referrals, and structural components to comprehensively address the needs of female sex workers. Services at MULU facilities ranged from peer education and HIV counseling and testing, screening and treatment of sexually transmitted infections (STI), routine screening for gender-based violence, to condom provision and dual-protection promotion.
In Ethiopia, although the national HIV prevalence is 1.1%, it is a much higher 24% among FSWs – a long underserved group. FSWs also face higher incidences of unintended pregnancy – the national rate is 25% — and abortions, as well as low contraceptive use. This suggests a significantly greater unmet family planning need among this particular group. Moreover, while women living with HIV have the same reproductive needs as their uninfected counterparts, as a result of stigma, they are more likely to seek health services through targeted HIV interventions aimed at key high-risk populations.
As a result of this obvious and growing need for effective contraception, family planning services were introduced into the MULU project in 2013, with funds from the USAID Support for International Family Planning Organizations (SIFPO) project. Using GPS mapping data, PSI Ethiopia identified 23 priority towns with service gaps in voluntary family planning due to the absence of relevant programs by NGOs and government partners.
To increase the uptake of voluntary family planning among FSWs, project facilities began offering routine family planning counseling and referral services to clients. At the community level, “drop-in centers” were created to provide the women a safe space where they could shower, do laundry, and rest, as well as have access to different contraception methods such as condoms, oral contraceptives, injectable, implants and emergency contraception. In the capital city, Addis Ababa, the project also made use of portable tent sites to better reach FSWs with integrated service offerings.
Within 12 months of implementation, FSWs represented 75% of the 3,334 clients who had accessed family planning services at MULU facilities. Participants were more likely to choose long-acting reversible contraceptives (LARCs) after family planning consultations. The results also showed that service integration reduced costs, enhanced access to services, and minimized potential missed opportunities for female sex workers.
The MULU/MARPs approach maximized both resources and opportunities for female sex workers to gain increased access and informed choice about family planning. Ultimately, integration proved to be an important and promising platform for improving both reproductive health and HIV outcomes among key populations.
Photo Credit (banner): Caitlin Quade