The barrier HIV-stigma presents to the HIV treatment cascade is increasingly documented; however less is known about female and male sex worker engagement in and the influence of sex-work stigma on the HIV care continuum. While stigma occurs in all spheres of life, stigma within health services may be particularly detrimental to health seeking behaviors. Therefore, we present levels of sex-work stigma from healthcare workers (HCW) among male and female sex workers in Kenya, and explore the relationship between sex-work stigma and HIV counseling and testing. We also examine the relationship between sex-work stigma and utilization of non-HIV health services. A snowball sample of 497 female sex workers (FSW) and 232 male sex workers (MSW) across four sites was recruited through a modified respondent-driven sampling process. About 50% of both male and female sex workers reported anticipating verbal stigma from HCW while 72% of FSW and 54% of MSW reported experiencing at least one of seven measured forms of stigma from HCW. In general, stigma led to higher odds of reporting delay or avoidance of counseling and testing, as well as non-HIV specific services. Statistical significance of relationships varied across type of health service, type of stigma and gender. For example, anticipated stigma was not a significant predictor of delay or avoidance of health services for MSW; however, FSW who anticipated HCW stigma had significantly higher odds of avoiding (OR = 2.11) non-HIV services, compared to FSW who did not. This paper adds to the growing evidence of stigma as a roadblock in the HIV treatment cascade, as well as its undermining of the human right to health. While more attention is being paid to addressing HIV-stigma, it is equally important to address the key population stigma that often intersects with HIV-stigma.
Religion plays an important role in framing the public discourse on sexuality, especially in countries where religion fully permeates social life. We explored the perspectives of Kenyan religious leaders on sexual and gender diversity in their country’s specific context. Two hundred and twelve Catholic, Islam and Protestant leaders from urban centers and rural townships completed a self-administered questionnaire, specifically developed for this study. The leaders’ perspectives were predominantly negative. Limited acceptance was conditional on sexual minorities not engaging in same-sex practices or seeing such practices as sinful. A substantial minority (37%) endorsed the use of violence for maintaining social values, especially regarding homosexuality and gender nonconformity. The majority of religious leaders agreed on the difference between civil law and religious doctrine. Human rights principles enshrined in the Kenya Constitution were seen as also applicable to sexual and gender minorities. Decriminalization of same-sex sexuality was seen as against one’s religion. Perspectives were less negative if leaders were familiar with lesbian, gay, bisexual, and transgender (LGBT) persons. Interventions that promote intergroup contact could be effective in changing religious leaders’ mindsets and advancing human rights and health for sexual and gender minorities.
Sex work stigma can negatively impact health care utilization by sex workers, including utilization of services for HIV prevention and treatment. It is important to measure and address sex work stigma to improve access and retention in HIV and other health services, yet a gap remains in the literature on sex work stigma. This may in part be due to lack of validated sex work stigma measurement instruments. We developed a set of 26 items on experienced stigma, identified from extant research, encompassing various components and sources of sex work stigma (stigma from family, community, health care workers, and police). We then tested items in a population of 729 male and female sex workers in Kenya, recruited from health facilities in 4 sites-Nairobi, Busia, Homabay, and Kitui. Confirmatory factor analysis was used to test and establish a conceptually and statistically valid scale for measuring experienced sex work stigma. The confirmatory factor analysis supported a 4-factor experienced Stigma Scale ( 2 p Ͻ .001; root mean square error of approximation ϭ 0.06; comparative fit index ϭ 0.93; and standardized root-mean-square residual ϭ 0.05). The final 19-item scale included 4 subscales: health care worker stigma (7 items), community-level stigma (3 items), family-level stigma (4 items), and police/law enforcement-related stigma (5 items); the Sex Work Experienced Stigma Scale demonstrated good convergent, discriminant, and known-group validity as well as excellent internal consistency (Cronbach's alpha ϭ .93). Given the demonstrated This article was published Online First November 11, 2019.
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