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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.

            This paper will explore the two social determinants within the two selected countries to show their influence on HIV on the chosen vulnerable group, FSW. It will note major differences and similarities between the two countries to find out whether the two social determinants impact health the same way across different nations.

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. 

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