HIV self‐testing and oral pre‐exposure prophylaxis are empowering for sex workers and their intimate partners: a qualitative study in Uganda

Abstract

Introduction: HIV self-testing (HIVST) and oral pre-exposure prophylaxis (PrEP) are complementary, evidence-based, selfcontrolled HIV prevention tools that may be particularly appealing to sex workers. Understanding how HIVST and PrEP are perceived and used by sex workers and their intimate partners could inform prevention delivery for this population. We conducted qualitative interviews to examine ways in which HIVST and PrEP use influence prevention choices among sex workers in Uganda. Methods: Within a randomized trial of HIVST and PrEP among 110 HIV-negative cisgender women, cisgender men and transgender women sex workers (NCT03426670), we conducted 40 qualitative interviews with 30 sex workers and 10 intimate partners (June 2018 to January 2020). Sex worker interviews explored (a) experiences of using HIVST kits; (b) how HIVST was performed with sexual partners; (c) impact of HIVST on PrEP pill taking; and (d) sexual risk behaviours after HIVST. Partner interviews covered (i) introduction of HIVST; (ii) experiences of using HIVST; (iii) HIV status disclosure; and (iv) HIVST's effect on sexual behaviours. Data were analysed using an inductive content analytic approach centering on descriptive category development. Together, these categories detail the meaning of HIVST and PrEP for these qualitative participants. Results: Using HIVST and PrEP was empowering for this group of sex workers and their partners. Three types of empowerment were observed: (a) economic; (b) relational; and (c) sexual health. (i) Using HIVST and PrEP made sex without condoms safer. Sex workers could charge more for condomless sex, which was empowering economically. (ii) Self-testing restored trust in partners' fidelity upon being reunited after a separation. This trust, in combination with condomless sex made possible by PrEP use, restored intimacy, empowering partnered relationships. (iii) HIVST and PrEP enabled sex workers to take control of their HIV prevention efforts and avoid the stigma of public clinic visits. In this way they were empowered to protect their sexual health. Conclusions: In this sample, sex workers' use of HIVST and PrEP benefitted not only prevention efforts, but also economic and relational empowerment. Understanding these larger benefits and communicating them to stakeholders could strengthen uptake and use of combination prevention interventions in this marginalized population.

Effect of HIV Self-Testing on PrEP Adherence Among Gender-Diverse Sex Workers in Uganda: A Randomized Trial

“…However, some caution regarding the utility of HIVST for sexual decision-making is warranted; oral fluid self-test kits may be misinterpreted and have low sensitivity in acute HIV infection and in persons taking PrEP or antiretroviral therapy, which may result in false-negative results and a false sense of safety. 17,51,52 We found no evidence of behavioral risk compensation among sex workers in agreement with previous reports. 53,54 In contrast with previous studies, we observed a lower likelihood of sex acts unprotected by condoms among MSM and TGSWs but not FSWs.…”

“…Sex workers use point-of-sex testing (ie, using HIVST kits to screen paying partners) as a risk reduction strategy in settings where partners pay more for condomless sex acts. 17,[45][46][47] Studies of FSWs, MSM, and TGSWs suggest that point-of-sex testing empowers and informs sexual decision-making such as avoiding sex act or insisting on condom use with paying partners who tested HIVpositive. 11,[48][49][50] This ancillary benefit could motivate HIVST use among sex workers.…”

“…In addition, we qualitatively explored how HIVST and PrEP influenced prevention uptake among sex workers and their partners. 17 Study data were reviewed by an independent data monitoring committee. Intervention design was informed by protection motivation theory.…”

Willingness to use and distribute HIV self-test kits to clients and partners: A qualitative analysis of female sex workers’ collective opinion and attitude in Côte d’Ivoire, Mali, and Senegal

“… 23 In a PrEP program in Uganda, female sex workers reported using HIVST to test clients to earn more money by accepting condomless sex. 29 This “benefit” was also perceived by female sex workers in this study. Without pre-exposure prophylaxis (PrEP), there could be a risk of HIV exposure if HIVST is performed with a partner or client who was recently exposed to the virus.…”

“You are not a man”: a multi‐method study of trans stigma and risk of HIV and sexually transmitted infections among trans men in Uganda

“…The study was conducted at the Makerere University Infectious Diseases Institute research clinic in Kasangati, Uganda. Since 2018, five HIV prevention research studies among trans women and trans men have been implemented at the research facility, which is easily accessible by public transportation [ 24 ]. The research team utilizes a trans‐inclusive approach incorporating community engagement, provider sensitivity training, peer support, inclusion of trans people in research design and implementation, and as co‐investigators and members of the community advisory group, plus quarterly consultative meetings for trans people, peers and research staff.…”