Facilitators and Barriers to Linkage to HIV Care among Female Sex Workers Receiving HIV Testing Services at a Community-Based Organization in Periurban Uganda: A Qualitative Study

Abstract

Introduction. While four in ten female sex workers (FSWs) in sub-Saharan Africa are infected with HIV, only a small proportion is enrolled in HIV care. We explored facilitators and barriers to linkage to HIV care among FSWs receiving HIV testing services at a community-based organization in periurban Uganda. Methods. The cross-sectional qualitative study was conducted among 28 HIV positive FSWs from May to July 2014. Key informant interviews were conducted with five project staff and eleven peer educators. Data were collected on facilitators for and barriers to linkage to HIV care and manually analyzed following a thematic framework approach. Results. Facilitators for linkage to HIV care included the perceived good quality of health services with same-day results and immediate initiation of treatment, community peer support systems, individual's need to remain healthy, and having alternative sources of income. Linkage barriers included perceived stigma, fear to be seen at outreach HIV clinics, fear and myths about antiretroviral therapy, lack of time to attend clinic, and financial constraints. Conclusion. Linkage to HIV care among FSWs is influenced by good quality friendly services and peer support. HIV service delivery programs for FSWs should focus on enhancing these and dealing with barriers stemming from stigma and misinformation.

Facilitators and Barriers to Linkage to HIV Care and Treatment among Female Sex Workers in a Community-based HIV Prevention Intervention in Tanzania: a qualitative study

“…Besides, providing support services through peer-escorted referral for individuals diagnosed with HIV promoted linkage to care. As observed in other settings, our analysis shows that peer-escorted referrals increased confidence and encouraged some FSWs to accept linkage to care (17). These findings underscore the need for expanded coverage of peer-based prevention interventions and comprehensive HIV services for FSWs (18–20).…”

“…We found that some Sauti Project intervention elements were critical in influencing [motivators for] linkage to care. Consistent with other studies conducted in SSA, use of peer-educators for reaching FSWs enabled a peer-to-peer sharing of knowledge about prompt care and available alternatives for HIV services, which created a demand for both project and health facility-based HIV clinical services (17). Besides, providing support services through peer-escorted referral for individuals diagnosed with HIV promoted linkage to care.…”

Community-based HIV treatment service delivery model for female sex workers in Tanzania: Evaluation findings

“…The retention rate in this study's intervention group is also similar to rates found in other countries implementing communitybased ART, particularly those supported by LINKAGES, a USAID-funded project implemented by FHI 360, where the program provided active referrals and support for FSWs to access ART (e.g., through community-based outreach, ART provision at drop-in centers, and support from peer educators and case managers) (LINKAGES 2018). The 12-month retention rate in the comparison arm (77 percent) likely reflects the numerous structural barriers faced by FSWs in accessing facility-based ART services as reported by other studies in Africa (Mountain et al 2014;Nakanwagi et al 2016;Scorgie et al 2013). While retention in the intervention arm remained steady from 6 to 12 months in this study, the retention in the comparison arm decreased considerably by 12 months.…”

“…Data on these indicators among FSWs in Tanzania are limited; however, they are likely lower than among the general population. A recent study among community-recruited FSWs in Tanzania indicated that 31 percent were previously aware of their HIV status, out of which 69 percent were on ART and, of those on ART, 70 percent were virally suppressed (Nakanwagi et al 2016).…”

“…Sex workers face greater challenges than the general population in accessing HIV care and treatment services once diagnosed with HIV. Barriers for initiating, being retained in, and adhering to ART include the inability to attend regular medical appointments, difficulty reaching distant clinics, out-of-pocket costs associated with care, lack of knowledge and misperceptions of treatment, fear of being known as an FSW and/or HIV-positive, providers' stigmatizing attitudes, and negative experiences dealing with the health care system (Mountain et al 2014;Lancaster et al 2016;Nakanwagi et al 2016;Scorgie et al 2013). FSWs in Iringa and Njombe regions also reported significant barriers in accessing general population services, including being denied HIV testing services, providers' lack of knowledge and sensitivity to meet FSWs' needs, and HIVrelated stigma and discrimination (Research to Prevention [R2P] 2013).…”