As USAID Pulls Out of Zimbabwe, Only Sex Workers Can Afford Lifesaving HIV Medication
- Winile Ximba
- 1 day ago
- 8 min read
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Whenever 34-year-old sex worker Sibongile needs to refill her prophylactic HIV medication, she strolls to the back of a lumber and iron building in Epworth’s notorious PaBooster neighborhood, waiting for a daring nurse who will deliver her two packets of pills stored in a small plastic jar.
The nurse drops the white pills into her handbag, a $10 note changes hands, and the nurse vanishes.
Epworth is one of the largest slums in Harare, the capital of Zimbabwe, and PaBooster one of its busiest locations for sex workers and revellers. According to sex workers, it is frequently visited by daring locals and Asian migrants who seek willing partners for no-limit unprotected sex, a significant issue in HIV high-burden nations like Zimbabwe.
However, since pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) pills that are part of the World Health Organization (WHO) Model List of Essential Medicines were introduced in Zimbabwe in 2015, Sibongile and other sex workers no longer fear the consequences of sex with no condoms.
Sibongile, whose last name is withheld by The Xylom for safety and privacy reasons, says that nurses see the black market as an opportunity to earn extra cash on the side, because public hospital workers do not supply pills to sex workers.
“Nurses scold us, saying we are emptying their medicine cupboards, putting pressure on bloodworks resources, and indulging in irresponsible sexual behavior,” she says. “I take pills each time after intercourse with a client who shuns condoms. Our suppliers are greedy nurses and related staff at Parirenyatwa Hospital (the largest referral and teaching hospital in Zimbabwe), who sell us the drugs for $5 a packet.”
Legally purchasing PreP and PEP pills from private pharmacies can be expensive for sex workers, who are required to submit to expensive medical tests on top of purchasing the pills.
Several local and Asian migrants who indulge in unprotected sex also benefit from the black market, saying they can purchase PreP and PEP pills supplied by illegal pharmacies for an upfront cost of $30 without any of the required bloodwork, says Munros Njekete, a well-off dealer who owns small-scale gold mines in Penhalonga, eastern Zimbabwe.
“PEP, PreP pills for a dollar? Easy deal in Zimbabwe,” he says. For just $30, pharmacy cashiers supply him with a three-month supply of medicine that he passes off to his Chinese and Indian gold-dealing clients who seek protection against HIV during their hedonistic escapades in Harare’s nightlife.
“It’s unworkable, the black market is only our option,” says Hilda, a sex worker in Avenues, Harare’s most famous red-light district, whose last name is withheld by The Xylom for safety and privacy reasons.
Sex work has dramatically grown in Zimbabwe in the last ten years — there are 40,491 female sex workers in Zimbabwe, representing 1.23% of the female population aged 15-49 years. Poverty and a collapsed national currency, a world-record national inflation rate, as well as fewer job opportunities for women than for men, have left several women with few options other than hawking themselves on the streets, Sibongile says. “It’s what pays our kids’ fees, puts bread on the table, pays for hospital bills.”
Despite its apparent poverty, Zimbabwe has a vast array of minerals and other resources, including lithium, gold, cobalt, and other rare earth metals, which have attracted thousands from Asian nations such as China, India, and Pakistan, who come to Zimbabwe legally and illegally to benefit from mining. About 25,000 Chinese nationals are reportedly living and working in Zimbabwe. Sex workers in Avenues say that many of these men are “flush with money,” with “tens of thousands of US [dollars]” from mining, smuggling, or simply reselling precious metals. Many of them don’t bring along their partners and families, becoming part of the sex workers’ rich clientele who like to indulge in “sex with protection,” Hilda says.
“They are daring. One Chinese gold miner offered me $150 for unprotected sex; I refused,” she says. “He upped his figure to $250. I agreed and used the $30 to buy under-the-table PEP pills within 24 hours of the act.”
Prophylactic pills for HIV are offered for free in Zimbabwe’s public hospitals to everyone, prioritizing rape victims, serodiscordant partners, and pregnant women, says Aspect Maunganidze, chief secretary of the Zimbabwe Ministry of Health. However, the Ministry of Health has ruled that any recipients of the medication must first get tested for HIV to determine if they are already infected, as PreP and PEP pills are useless in such cases. Recipients must also undergo assessments before and after taking the medication to determine the liver and kidney reaction of recipients. All dispensing physicians must follow these strict requirements.
Sex workers say these requirements make it difficult for them to access the drug. But here’s where the apparent poverty of Zimbabwe plays a role. Parirenyatwa Hospital nurse Valerie, whose last name is withheld by The Xylom for safety and privacy reasons, says that nurses and physicians who make backdoor drug deals are driven by the circumstances. “Tell the government to pay us living wages first,” she says, given that nurses make about $200 a month, less than the average wages in the country.
To make ends meet, Valerie says they divert stocks of PEP and PreP pills from their clinic dispensaries and sell them to thousands of sex workers without first testing them for HIV. “I double my salary monthly via this backdoor gig. Otherwise, I would have migrated to the UK and abandoned my job as a nurse in Zimbabwe,” she says.
Emigrating to the UK to search for a better life has become popular among Zimbabwean nurses. In 2020, more than 2,600 nurses from Zimbabwe emigrated to the UK. In 2023, more than 4,500 emigrated, a trend that has left hospitals hanging by a lifeline.
Generic, low-cost HIV medicines, including antiretrovirals, are managed by the National Pharmaceutical Company, a Zimbabwean warehouse agency that distributes these medications upon their arrival from Asia to hundreds of public hospitals across the country for free. They are sometimes supplied to private pharmacies for a markup fee.
“The leakages are not happening at [the National Pharmaceutical Company] but at the end point, at public hospitals, where dodgy syndicates are selling [antiretroviral] stocks into the black market,” says Ajira Maloti, a former nurse who lost his job in 2021 after challenging the corruption at Parirenyatwa Hospital.
Corruption in Zimbabwe’s rundown public hospitals is so rife, Maloti says, that nurses ask patients for cash to give preferential treatment to some patients, desperate trainees pays thousands of dollars to secure spots at medical school, and patients pay pharmacy cashiers “sweetener fees” to obtain stocks of painkiller drugs and vaccines that are supposed to be free.
“There are key sub-groups that can’t easily access anti-HIV medications without being criminalized, and these are undocumented migrants, sex workers, etc,” Maloti says. “It’s immoral, but these side-hustles are lucrative for impoverished healthcare staff.”
But experts say this thriving black market could also have bigger consequences for Zimbabwe’s public health network.
Maloti says he knows rape victims who required emergency PEP treatment, but were unable to find it in public hospitals because nurses had diverted some of the stock to the lucrative black market. They were forced to spend money at private pharmacies instead.
“I even paid for a PEP supply for a desperate friend of mine who was raped and horrified to hear there was no PEP at her local clinic,” he says.
According to Maunganidze, the clinical impact of black market PreP and PEP drugs is the potential mismanagement that results from wilfully having sex without condoms, or as he calls it, “a thrill laced with danger.” He says that PreP and PEP pills can be hard on the liver and kidneys, and taking the pills without medical testing can be “a fool’s errand.”
Zimbabwe also has one of the highest rates of antiretroviral treatment resistance, with more than 5% of infected patients showing signs of resistance to all drug regimens. This means that those taking medication without monitoring could not only endanger other patients but also waste resources, especially if they are already infected.
These crimes can be difficult to police, especially when PreP and PEP medications are being diverted to street markets by nurses at public hospitals. Technological solutions like implementing electronic barcodes in state pharmaceutical warehouses can work only so far, he says. Once the medicines are distributed to thousands of public clinics, “the paper trail of who dispenses which medicine can be easily subverted,” he says.
Maunganidze tells The Xylom that the police are on alert and will not hesitate to arrest anyone caught selling PreP and PEP medicines smuggled from hospitals and subject them to severe punishment.
Sibongile says that after each treatment of PEP, she vomits, loses her appetite and sleeps for prolonged hours, and feels dizzy for days. This prevents her from going back on the streets and causes her to miss a few days’ earnings. Yet, she and other sex workers view the black market medicines as “lifesavers.”
“I don’t think I have HIV. I don’t have the symptoms for years despite condomless sex, thanks to these PreP and PEP stuff,” she says.
She says the nurse at her local clinic who supplies her with the medication keeps an eye on her condition and assures her that side effects are normal and expected.
Sibongile has benefited greatly from the black market medication for other treatments as well. “I got syphilis once and got penicillin antibiotics from the streets too,” she says.
Indian and Thai companies such as Cipla, Arbro Pharmaceuticals, and Mankind Pharma have cornered the market of HIV medication in Africa, supplying low-cost, life-saving, and generic HIV prophylactics and antiretroviral pills.
India, colloquially known as “Africa’s pharmacy,” for the unmatched ability of its pharmaceutical companies to provide low-cost generic pills and medication for everything from diabetes and hypertension to HIV. According to the Pharmaceutical Export Promotion Council of Africa, India reported more than $4 billion worth of total pharmaceutical exports to Africa during 2021. Indian officials hail Africa as a “huge potential” market for India’s production.
A single pill combination of the drugs tenofovir, lamivudine, and dolutegravir, collectively known as TLD, is the common means of HIV prophylaxis in Africa, generally supplied by Indian drug manufacturers.
However, most sub-Saharan African nations — with the exception of a handful such as South Africa and Botswana — are too poor to buy such medication. These difficulties encourage more black markets to pop up in countries to provide medication to those who need it.
Zimbabwe is not alone in this predicament. Countries like South Africa have also been gripped by black markets of Asian-manufactured medicines, where genuine and fake medicines are being sold on the streets without a doctor’s supervision.
In South Africa, migrants are resorting to buying antiretrovirals, antibiotics, and other drugs smuggled from Malawi and Zimbabwe — these medicines are being sold openly in Johannesburg's streets. In Zimbabwe, a street market has emerged for fake anti-rabies medicines that bear the fabricated logos of Human Biologicals Institute, a division of the renowned drug company Indian Immunologicals Limited.
The United States President’s Emergency Plan for AIDS Relief, a U.S. government initiative established to address the global HIV/AIDS epidemic, is the main pro-bono financier for HIV prophylactics and antiretrovirals, with the United States Agency for International Development, better known as USAID, acting as the technical distributor on the ground.
As the Trump administration shutters USAID operations globally, it risks the health of countries like Zimbabwe, which says the Zimbabwean health minister, could run out of HIV prophylactics and antiretrovirals in about six months’ time.
The existence of the black market doesn’t make it any easier. Maunganidze said if PreP and PEP medication continues to be diverted towards street markets, the Trump administration could cite it as one of the reasons to further cut necessary medical aid to African countries.
