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Social Determinants of Health- HIV/AIDS


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            Despite some countries legalizing
prostitution, many Female Sexual Workers (FSW) have continued to record higher
risks of poor health. FSWs are found in almost all nations whether prostitution is legal or not. However, they face
many challenges ranging from social stigmatization, violence, economic and
access to health. Such factors increase their risks of contracting sexually
transmitted infections (STIs) such as HIV/AIDs are significantly higher than
that of the general public. This research seeks to identify some of the social
determinants of health affecting the infection and treatment of HIV/AIDs among
FSWs in Germany and Mozambique. These countries have been selected because prostitution is legal and regulated by the government.

The two countries are different in several ways including economic development,
access to healthcare, living environment, as well as discrimination and stigma.

            One of the social determinants of
health affecting this group is the discrimination and social injustice associated
with the profession. Discrimination of
prostitution has been around, and many
FSWs are embarrassed to associate with
the job, choosing to live a double life. As a result, majority face challenges
within their work but remain silent to avoid the discrimination that comes with
the job. The second social determinant explored is health care system. Access
to health care increases the general health of a group. With enough resources,
such as treatment and prevention measures as well as awareness, health risks
can be alleviated. This is one of the most significant determinants of
health between developed and developing nations, where lack of access to
medical care increases risks for some groups. 

Impact of Social
Determinants of HIV among FSWs

Discrimination, Stigma and Social Justice in Mozambique

            Despite prostitution in Mozambique
being legal, many FSWs continue to face stigmatization and discrimination.  As a result, many of these workers do not
seek treatment openly or even undergo regular testing (, 2015). Médecins Sans Frontières (MSF) International,
an organization in Mozambique that offers HIV testing and treatment cites
experiencing a difficult time trying to reach out to FSW. Many were afraid to
join their team on issues related to
discrimination and stigmatization they faced. To create a link between the
medical group and the sex workers, MSF sought to use sex workers as peer
doctors. This way, it was able to reach many sex workers who were afraid of
coming out to seek medical attention (, 2015).

            The discrimination and stigma faced
by FSWs in Mozambique significantly contribute
to the high prevalence of HIV considering MSF (Doctors without Borders)
indicated it stood at 50% of sex workers tested as of 2015 (,
2015). Langa et al., (2014) cite that sex workers in Mozambique often lack
health provisions afforded to the general population because of discrimination.

As a result, they face challenges accessing healthcare that suits their needs
(Langa et al., 2014). Also, fear of lack of confidentiality and stigma were identified as barriers to HIV treatment
among FSWs. The situation not only denies the workers access to health care but
also other rights such as dignity, protection against violence and other social
injustices. In an HIV seminar, the Deputy
Minister of Women’s Affairs called for the need to protect the rights of FSW
(, 2007).

Discrimination, stigma and social justice in Germany

            In Germany, just like Mozambique,
commercial sex or prostitution is allowed and regulated by the government.

However, prior to 2002 reforms, it was
classified as immoral, justifying the exclusion
of FSWs from public benefits such as health insurance, labor rights despite
paying taxes (Koster, 2018). In this
regard, sex workers in Germany continued to face discrimination and found it
difficult to access health in comparison to the general public, which limited their
access to HIV testing and treatment. The 2002 reforms made it possible for the
workers to gain access to legal rights accorded to other taxpayers including access to health insurance
and employment benefits. However, the changes did not create a national mandate
concerning zoning of prostitution. As a result, it was left to states to impose
their own zoning rules, which allowed some conservative regions to continue the
old rules. This meant that FSW in some areas still faces discrimination and social injustice (Koster, 2018).

            Despite regulations protecting the
rights of FSW, many of them have refrained from registering with the
authorities because of the discrimination and stigma associated with the
profession (Taubitz, 2004). However, unlike Mozambique HIV is low among FSWs in
Germany. Although discrimination and stigma of prostitution still limit  the workers’ access to health insurance and
other benefits, it is clear that many sex workers in Germany undergo regular
testing for STIs. In a study done to find out the rate of positive STI tests
for sex workers in Germany indicate that HIV prevalence was at 0.2% compared to
50% in Mozambique (Bremer et al., 2016;, 2015).

This indicates that
discrimination and stigma among the two countries do not affect HIV prevalence the same way. One of the main reasons
is the difference in regulations between
the two countries where Germany has a
better regulatory system in terms of health provision to FSWs in
comparison to Mozambique.

 Health Care
System in Mozambique

            Mozambique has one of the most impoverished health care systems in the
world. According to World Health Organization (WHO), only 36% of the population
can access a hospital within 30 minutes while only 50% have access to proper basic healthcare with 30% not being able to
access health facilities for various reasons (WHO, 2018). HIV is among the most significant contributors to the burden of
disease in the country. Based on this,
FSWs in the country lack access to proper healthcare
especially after considering that they make up some of the poorest and
marginalized groups. As a result, many of these sex workers  do not
have adequate access to clinical facilities.

            Also, prostitution in the country
can depend on the economic condition of the time, unlike Germany where sex
workers will mostly practice their business in one area. In Mozambique, it is
typical for sex workers to be on the constant
move in search of clients along the towns
booming economically (, 2015). As a result, many can be away from
health facilities providing them with the necessary treatment and screening for
HIV. To curb the situation, MSF set mobile clinics between the most traveled routes by FSWs and truckers to
increase access to treatment in a project dabbed the Corridor Project
(, 2015). This does increase access to treatment but not to all. This
movement also increases the risks of HIV infection in cases where the sex
workers lack access to condoms and proper knowledge on how to use them. A case
in point is an MSF peer educator in Tete, Mozambique who got into prostitution
at a young age and had no knowledge of using a condom and got infected
(, 2015). Despite having a poor
health system, FSWs in Mozambique also lack
adequate awareness on prevention and treatment.

Health Care System in Germany

            Germany, being a developed country
has one of the best healthcare and
welfare system in comparison to many countries including other developed
nations. Germany, in comparison to Mozambique, has a stable health care system
where is it statutory to have health insurance for all people working and
living in the country (PubMed Health, 2015). There is also private insurance
where individuals earning high incomes can pay to receive coverage. Healthcare
within Germany is financed by premiums
paid by clients and their employers as well as from tax surpluses. There is a
principle of solidarity where the healthy
help the ill as all people under the statutory health insurance receive equal rights to treatment regardless of income
or amount contributed to insurance (PubMed Health, 2015).

            With such a system, many people even
those earning lower wages have decent access to healthcare. FSWs in Germany do not have the same rights considering they
have to register as prostitutes with authorities to get health insurance.

However, with the Schoenberger Model,
infected individuals can receive treatment privately a home, which reduces the
stigma associated with visiting a hospital (Wtopstaff, 2012). Also, allowing
nurses to dispense treatment without the supervision of doctors has increased coverage. In addition, Germany started creating awareness
concerning HIV and AIDS quite early, which helped reduce the stigma associated
with the disease. As a result, HIV prevalence even among vulnerable groups
including sex workers is low.


            Evidently, Discrimination, stigma and
social justice and health care systems are significant social determinants of
health in both Germany and Mozambique for FSWs. However, these social determinants
do not have the same influence in the two countries. It is clear that Germany,
being a developed nation has better regulations when it comes to prostitution.

Although the regulations are not always followed and sex workers
continue to face discrimination, the situation is far better than the one found
in Mozambique. One of the main reasons causing the difference in how much influence
the two social determinants have in each of the countries is the economic
situation or stability. On the one hand, Germany has more resources dedicated
to the welfare of its citizens including FSWs while Mozambique struggles to
provide basic health to its people. This increases the disparity in the prevalence
of HIV/AIDS among FSWs between the two countries.

Also, the fact that Mozambique sex workers move a lot between the
cities in such of lucrative areas for their business increases their chance for
infection as they risk lacking adequate access to preventive measures such
condoms and also treatment for those infected.

Germany, on the other hand, has stable economy especially in the cities,
eliminating the need for moving between different places. However, being a
developed country, Germany has good
infrastructure, and sex workers can
access healthcare from most of the regions.