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Protecting the health of sex workers

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When it was first set up in 1991, Manchester Action on Street Health's (MASH) task was simply to provide condoms and needle exchange. Fifteen years on and the service provides hepatitis B vaccinations and safer injecting advice and reaches street-based workers using a mobile van with seating, a needle exchange area and a room for nurse-led clinics. The service also incorporates visits to saunas for sex workers based there.

These nurse-led clinics were set up by Kate Dunkley, senior nurse practitioner, who joined the service in 2003. 'We see asymptomatic women on the van, the idea being that we're working with a hard to reach group that are quite high risk and aren't accessing mainstream services.'

A nurse team provides full genito-urinary screening, throat swabs, and blood tests for syphilis, HIV, hepatitis C and hepatitis B. Hepatitis A and B vaccinations are provided, along with safe injecting advice. Pregnancy testing is offered, followed by referral through to mainstream services if a woman is pregnant and wants to continue it through.

Frontline treatment is given for anything straightforward and uncomplicated, such as thrush, chlamydia or bacterial vaginosis. Anything requiring further investigations or ongoing treatment, including hepatitis C, HIV and syphilis, is referred on to mainstream services.

The van goes out three times a week into Manchester's city centre and sees between ten and 20 women each night for the whole service. The clinic, which runs just two of those nights from 8pm to 10:30pm, sees around five or six women per night.

Women visiting the clinic normally come for general health concerns and difficulties, rather than for full screening. Because many of them are injecting drug users, they may have abscesses or need minor first aid. 'We try not to get into doing wound dressings. We think those women would be better served somewhere with access to systemic antibiotics and adequate dressings,' admits Kate.

Surprisingly, safety for the outreach workers has not been much of an issue and incidents are rare. 'Because MASH has been around for such long time, it is well known by the women and their partners or other men,' explains Kate.

When she was setting up the service, she admits was concerned that it might be difficult for MASH - which is a charity - to access mainstream services. 'From my own experience of working in the NHS, people are afraid that it might not always be easy to work with drug users, and there's quite a fear around having a positive diagnosis and not being able to contact people. But the reality is that the service has been a dream to set up. Manchester Centre for Sexual Health has been fantastically supportive.'

Symptomatic women are fast-tracked through to GU services, and the clinic has never failed to get positive test results back to the patients. Part of the success in tracing people is down to the car outreach service which visits the two other areas of Manchester where women work, an industrial area, and a residential area.

Another aspect to MASH's service is outreach work in saunas. Kate and two other sessional nurse practitioners visit saunas and offer advice on sexual health, condom use, screening, smears and contraception. They give hepatitis A and B vaccinations, and in some of the saunas they provide sexual health screening. For 20 to 30 per cent of the women, this is the first time they have accessed sexual health screening.

Screening provides the opportunity to speak to the women privately and unearths other issues for which they want psychological support, such as a previous termination, being forced into the sex industry, being sexually abused as a child, or domestic violence. 'We're able to offer a bigger service than what we appear to be offering,' says Kate.

This 'bigger service' was very apparent for a young woman who had been a victim of trafficking - a crime Kate admits has noticeably increased over the last 18 months. 'She had been sold in the playground in her native country and brought over to the UK. She was worked in Birmingham before coming to Manchester. She told me she had recently bumped into the guy who'd brought her over to the UK. She was shaken and scared. I worked with her and the police to organise her to go to a safe house.'

Future plans for the service include offering contraceptive services, providing ongoing and emergency contraception. The nurses are trained family planning nurses but currently only provide condoms and advice. Women who need more help are referred on.

But because a lot of the work is opportunistic, it makes more sense to have an in-house service. 'It is particularly important to prevent unintended pregnancies where people's lives are already quite chaotic,' Kate points out, saying that the nurses have found that although women are very good about using condoms within their work, their use is less consistent outside of work.

Kate admits that having the service within the voluntary sector gives her the freedom to develop it responsively, rather than expecting patients to come to her. 'It's quite tight on staff constraints because you tend to be out and about a lot, but when you?re working with people who have got greater needs, it?s actually more worthwhile going out than expecting people to turn up.'

It also creates unique situations, since each woman has her own story to tell. 'You can't lump everyone together and say these people are all street based sex workers. There are numerous reasons why people get into it. That?s been a bit of an eye opener for me.'

She adds that the job can be emotionally draining, particularly when people open up about things outside her sphere of expertise. 'It's quite upsetting when you come across women working on the streets who have been violently assaulted and they accept that as something that happens in that environment.'

But she adds: 'The women we see are fantastic. You get a good rapport with people, and you see people week in, week out, so that's really nice.'

How to reach high-risk, hard to reach client groups

Work non-judgementally.Some people have very complicated lives and if you're not aware of the different issues they face, it's difficult to offer a full service.

Go out to people. Outreach work is costly and time-consuming but great chunks of the community are missed by not going to where people are.

Listen.Listening to what people say will help you learn about the issues they face and what they are involved in.

Talk openly. Don't be afraid to talk openly about what people do. You need to give health advice that?s appropriate to their area of work, which requires being able to talk about different sexual practices, for example.

What local female sex workers think of MASH's nurse-led clinics

  • Nobody knows that I do this and I couldn't take the risk of being recognised if I went to a clinic.
  • I have been to a clinic but was too scared to say what I did and didn't get the right tests.
  • I used to work the beat and me and my boyfriend used to inject so it's good I can get tested for Hep C as well as everything else. My boyfriend was tested at the drug service but it's better for me to be tested here.
  • 'I didn't know you could get infections by doing oral without until you told us. Lots of other girls don't know either so it's great you come in and tell us and we can get tested.'

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