Reaching the most marginalised in the time of COVID-19

© Corporación Kimirina
In Ecuador vulnerable populations including transgender women and sex workers are struggling to take care of their health needs as well as to make ends meet

In Ecuador, one of the countries hardest-hit by the crisis, one community organisation has adapted at speed to ensure marginalised groups have the support they need.

Every country has its own COVID-19 story to tell but one of the most distressing so far has been that of Ecuador, where bodies have been left lying on the street for days. The coastal province of Guayas has been called South America’s ground zero for COVID-19, with Guayaquil – Ecuador’s most populated city – thought to have more cases to date than some Latin American countries have in total.

With an economic catastrophe looming, poverty on the rise and a crippled health service, vulnerable populations including transgender women and sex workers are struggling to take care of their health needs as well as to make ends meet.

A humanitarian crisis

Amira Herdoiza is executive director of Kimirina, a community organisation at the forefront of the HIV response in Ecuador and a Frontline AIDS partner. She believes that the challenges facing marginalised groups at the moment are threefold.

First, ensuring that HIV prevention and care services continue to reach them. Second, the risk of their overall health being badly affected because of comorbidities going untreated and the impact of poor nutrition due to a lack of finances. And third, fresh attacks on their human rights.

“The social violence, the stigma, the discrimination is worse,” she says. “This is a huge humanitarian crisis.  A lot of them don’t have a place to live, they don’t have enough to eat.”

She continues: “The impact for the HIV response with key populations who are traditionally excluded from a society that wants to discard people could be very strong so we have to be firm in our programmes, in our response, in our convictions about human rights.”

Kimirina has been working closely with other organisations around the country to get emergency assistance to those most in need, but in Guayaquil Amira and her team have had to make some hard choices because of the enormity of the situation. Based on their extreme vulnerability, older transgender women and sex workers have been prioritised with telehealth services and other vital support, including being trained up with entrepreneurial skills to be able to make a living.

Drawing on collective intelligence

Being able to provide life-saving health services and information by phone or online is proving critical for many of our partners during the pandemic. When lockdown was first announced in Ecuador, Kimirina started using a telemedicine system to keep community HIV services open and to continue supplying antiretrovirals (ARVs) and pre-exposure prophylaxis (PrEP).

Because the organisation had a good stock of drugs in place, it has been able to give out a longer lasting supply than usual to help see clients through the first few weeks of lockdown. Kimirina is now in conversation with the Ministry of Health and the relevant municipal authorities about going one step further and delivering medication using mobile units. However, Amira is concerned that in a few weeks from now they might be facing quite a different scenario: “Now we have enough medicines for PReP and PEP, but we are very worried because we know that there won’t be enough in the near future.”

This situation hasn’t been helped by the initial chaos when lockdown was announced and the subsequent lack of coordination and clear guidance from the Ministry of Health. Some doctors in the public sector were even prescribing ARVs to people without HIV, in the mistaken belief they would treat coronavirus.

Amira is clear that, with the government not disclosing the full extent of the pandemic, it was on the ground knowledge that enabled Kimirina to respond effectively in the early stages. “Our colleagues from the local communities were really clear about what was happening and what we could do,” she says, “so we built a collective intelligence and we’ve continued that. It’s impossible to work in an epidemic without the communities and the HIV response has proved that, for COVID-19 it’s the same thing.”


Despite the many hurdles to overcome in order to continue delivering services, looking after colleagues – many of whom are from vulnerable groups – is a priority for Amira and her team. A mental health programme has been introduced and includes tips for living in isolation, coaching, yoga and a weekly virtual get together with everyone.

Looking ahead, Amira hopes that lessons from the HIV response around diagnostics can be applied to the current pandemic, with resources being invested to train up community leaders to carry out high quality testing for COVID-19. She believes that community organisations in particular have much to offer in this area, which is fundamental to the response.

“These possibilities are opportunities,” she says. “It’s very terrible to say that but when you have a problem where people are dying, where the situation is terrible, you have to react immediately, to be very proactive, to be very creative, to look for innovation.”

She also believes that civil society needs to call on bodies like the Pan American Health Organisation (PAHO) for greater transparency. “I think countries like Ecuador are hiding a lot. If we don’t tell the truth as a society, we are not dealing with this epidemic and every six months, every nine months we will have problems again”. In the meantime, Kimirina remains steadfast in its mission to champion the rights and needs of the most marginalised.

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