In Tonga, the Government has deemed sexual and reproductive health services as essential services during the COVID-19 pandemic. On this World AIDS Day, we are reminded that eliminating stigma and discrimination, and following a human rights-based and gender-responsive approach are key to successfully responding to both COVID-19 and HIV.

While sex work is often seen as a contentious issue, with many conflicting viewpoints in societies around the world, one thing is clear – sex workers have a fundamental right to accessing sexual and reproductive health care.

“We work with female sex workers throughout Tonga – in all corners of the country, even on the most remote islands,” says Katherine Mafi, Programme Manager at the Tonga Family Health Association (TFHA). “We’re the only NGO working on sexual and reproductive health in the country.”

“Personally, I’ve always been very passionate about this work,” she adds. “It’s quite fulfilling, going home at the end of the day knowing that you’re helping people, possibly even saving a life.”

TFHA has been working on sexual and reproductive health and rights for more than four decades in Tonga, offering a range of services, such as family planning, maternal and child health support, fertility and counselling assistance, as well as HIV and sexually transmitted infections (STIs) prevention and voluntary confidential counselling and testing (VCCT).

Since 2017, their work to empower female sex workers and ensure they have access to comprehensive, high quality sexual and reproductive health services has been supported by the United Nations Development Programme (UNDP) through the Global Fund-supported Multi-Country Western Pacific Integrated HIV/TB Programme.

During the COVID-19 pandemic, sexual and reproductive health has been deemed an essential service by the government, with all efforts made to avoid discontinuation of services.

“The global health crisis we’re experiencing with the COVID-19 pandemic threatens to exacerbate social and economic inequalities, and increase vulnerabilities of certain marginalized groups – including sex workers – to HIV,” says Gayane Tovmasyan, Programme Manager at UNDP Pacific Office in Fiji. “Ensuring that these sexual and reproductive health services have been able to continue unhindered has been vitally important.”

While prevalence of HIV in Tonga is low, the rates of STIs are high with a reported 22 cases per 100,000 people and increasing. Female sex workers are one of the groups who have an elevated risk.

As in many other countries in the world, in Tonga sex work is criminalized, and sex workers face structural and interpersonal violence that negatively affect their health and well-being. This includes police violence, exclusion from health services, stigmatization and marginalization. Together, this contributes to an increased likelihood of acquiring HIV and STIs than the general population.

One of the areas in which UNDP has provided support, is the procurement of much needed diagnostic equipment – specifically, SD Duo rapid testing kits – which allow for quick and accurate community-based testing of at-risk populations for HIV and syphilis. The testing is being done through TFHA’s network of service points, including three permanent clinics and 15 community-based distributors.

“What we were lacking was resources to be able to conduct community-based testing,” said Katherine, adding “the SD Duo tests are a game-changer.”

Implementing the SD Duo point-of-care test kits has enhanced the sexual and reproductive health services on offer from TFHA and also contributed to extending their geographical reach. Testing for HIV and STIs can now be done in even the most far flung communities among Tonga’s 169 islands.

In 2018-2019, 583 female sex workers were tested for HIV and provided with prevention education. Surveys conducted over this time period found a significant increase of the female sex workers reporting condom use during their last sex from 12 percent to 65 percent.

The use of digital technology is also further enabling reach of targeted groups. In partnership with the two main telecommunications companies in Tonga –Digicel and Tonga Communications

Corporation – TFHA is putting out text messages containing sexual and reproductive health promotion information four times a week to 5,000 UCALL mobile numbers around the country.

Client intake forms at TFHA’s three static clinics (on the main island of Tongatapu and the outer islands of Ha’apai and Vava’u) have shown that many people are learning about the services offered by TFHA through the text messages.

“Our static clinics have been fully accredited to provide VCCT services, including sexual and reproductive health and rights services,” explains Katherine. “Sex workers prefer to access our services since TFHA provides a one-stop approach.”

Their work empowering sex workers and strengthening their health and well-being is bringing real-world impact.

“This is our fourth year of implementation, and it is interesting to note that now our sex worker clients are comfortable enough to bring their steady partner into the clinic with them,” says Katherine, emphasizing the significance of this progress. “They bring them along and get tested as well. Contact tracing is very hard, it’s been a challenge for service providers, so this is a really positive development.”

“One of our sex worker clients recently successfully completed her schooling, which is a success story of integration. We not only provided her with condoms, we also gave her a long-lasting contraceptive method, so that she can avoid unintended pregnancy, while also protecting herself from HIV and other STIs. That’s quite a big impact. She was able to get her education.”