“When they know that you are a sex worker, you will be the last person to be treated”: Perceptions and experiences of female sex workers in accessing HIV services in Uganda

Abstract

BackgroundHIV prevalence among female sex workers (FSWs) in high burden countries in sub-Saharan Africa varies between 24 and 72%, however their access to HIV services remains limited. This study explored FSWs’ perspectives of the barriers and opportunities to HIV service access in Uganda.MethodsThe cross-sectional qualitative study was conducted between October and December 2013. Twenty-four focus group discussions were conducted with 190 FSWs in 12 districts. Data were analysed using manifest content analysis, using Atlas.ti software, based on the socio-ecological model.ResultsFSWs indicated that HIV services were available and these included condoms, HIV testing and treatment, and management of sexually transmitted infections. However, access to HIV services was affected by several individual, societal, structural, and policy related barriers. Individual level factors included limited awareness of some prevention services, fears, and misconceptions while societal stigma was prominent. Structural and policy level barriers included inconvenient hours of operation of the clinics, inflexible facility based distribution of condoms, interuptions in the supply of condoms and other commodities, and limited package of services with virtually no access to lubricants, HIV pre- and post-exposure prophylaxis, and support following client perpetrated violence. Policies such as partner testing and involvement at antenatal care, and using only one facility for antiretroviral drug refills hindered HIV service uptake and retention in care. FSWs had major concerns with the quality of services especially discrimination and rude remarks from providers, denial or delay of services, and potential for breach of confidentiality. However, some FSWs reported positive experiences including interface with friendly providers and participated in formal and informal FSW groups, which supported them to access health services.ConclusionDespite availability of services, FSWs faced major challenges in access to services. Comprehensive multilevel interventions targeting individual, societal, structural and policy level barriers are required to increase access to HIVservices among FSWs in Uganda. Policy and institutional adjustments should emphasize quality friendly services and expanding the package of services to meet the needs of FSWs.

HIV Testing and Counseling Among Female Sex Workers: A Systematic Literature Review

“…Seventeen articles examined HIV knowledge, including knowledge of available HIV testing sites in the area [19, 29, 31, 33–36, 38–41, 45, 47–51]. FSWs who had heard prevention messages in HIV communication campaigns were more likely to test [33, 47, 51].…”

“…About half of the articles reviewed assessed how FSWs’ social interactions influenced their decision to test for HIV [18–20, 24, 26, 29, 34, 38, 40, 41, 43, 45, 47–51]. Positive attitudes and support from peers, family and partners facilitated HIV testing [19, 20, 24, 26, 29, 34, 40, 41, 45, 48–51].…”

“…Positive attitudes and support from peers, family and partners facilitated HIV testing [19, 20, 24, 26, 29, 34, 40, 41, 45, 48–51]. In China, women were more likely to test if accompanied by peers [19, 20].…”

“…In Russia, family support was an important condition for accessing healthcare, including HIV testing, as women could rely on their family financially and emotionally [24]. Participation in self-support groups in India [18] and Uganda [51] and receiving condoms from HIV prevention programs in China [38] facilitated testing. Positive views of FSWs’ employers towards HIV testing [41, 45] or requiring the test [43, 50] increased the uptake.…”

“…Fears of being identified as HIV+ [24, 26, 31, 34, 36, 41, 47–51] or as a sex worker [20, 26, 31, 34, 41, 46–52] were reported as barriers to testing in a number of studies. FSWs could refuse HIV testing [29, 36, 41, 48, 50, 52] or fail to collect test results [48] if afraid of receiving an HIV+ diagnosis.…”