Socio-demographic characteristics
A total of 227 FSWs participated in 23 sessions of PGDs. Twenty-one of the FSWs who participated in PGD sessions were also interviewed through IDIs. The median age of the study participants was 24 years. Of the 227 participants, 18 (8%) had never been to school, and 117 (51.5%) had completed primary school education. One hundred forty-six participants (64.4%) reported to have been involved in sex work for more than one year. Sixty-three per cent of FSWs (143) solicited their clients from recreational facilities (e.g. hotels, bar, disco halls). Table 2 describes participants characteristics.
Table 2: Participants socio-demographic characteristics(n=227)
Variable
|
Median [Range] or N (%)
|
Age
|
24 [18-42]
|
Marital status
|
Single
|
106 (46.7)
|
Living with a permanent partner (cohabiting/married)
|
89 (39.2)
|
Divorced
|
24 (10.6)
|
Widow
|
8 (3.5)
|
Children (living)
|
None
|
43 (18.9)
|
1 child
|
106 (46.7)
|
≥2 children
|
78 (34.4)
|
Education
|
|
Never attend formal education
|
18 (8)
|
Completed some primary school
|
117 (51.5)
|
Secondary school
|
80 (35.2)
|
Post-secondary education
|
12 (5.3)
|
Duration in sex work
|
Less than 1 year
|
43 (18.9)
|
1-3 years
|
109 (48)
|
> 3 years
|
37 (16.4)
|
Cannot remember
|
38 (16.7)
|
Site where FSW solicited clients
|
Streets / roadsides
|
48 (21.1)
|
Recreational facilities
|
143 (63.1)
|
Homes or brothels (private venue)
|
28 (12.3)
|
Social media (e.g. websites)
|
8 (3.5)
|
Awareness and attitude about HIV testing
Knowledge about the availability of HIV testing, and testing practices was generally high, where 93.0% of participants reported having tested for HIV in the past two years. Of those who tested, 13.6% reported to be HIV positive. Among those who tested HIV negative, 80% were willing to test again. Over half (56.3%) of those who indicated that they would test again thought that HIV testing services were supposed to be offered only in the health facility setting.
When participants were asked if they ever heard about HIV self-testing, only 25% reported to know it, among whom none had ever heard of HIVST done using oral fluid. However, when informed about the possibility of having HIVST using oral fluid, majority of IDI participants were in favour of the test because the process would be non-invasive.
Participants' positive viewpoints about HIVST
Improved confidentiality, convenience and empowerment
In all PGDs, the participants reached the consensus that introduction of HIVST would be positively received. FSWs thought the availability of HIVST would minimize dependency on health workers, and inconveniences they encounter when seeking services from the health facilities. The perception that HIVST would restore self-autonomy is captured by a remark made by one of FSW from a PGD session:
If test kits for HIVST become available at our homes, it’s very easy for us to test when we need it…. They’ll test immediately instead of delaying or postponing. Testing HIV at health facility requires people to make some prior preparation to reach the facility [PGD_ Iringa]
Participants in all 23 PGD sessions reached a consensus that, availability of HIVST can guarantee complete confidentiality during HIV testing. The view that availability of HIVST would improve confidentiality was also echoed by 17 FSWs (out of the 21 who participated in IDI) during IDIs.
Don't you know that if you are tested by someone else s/he will know your status and start telling other people that you are already infected?[...] If they bring kits to us [we shall test ourselves] and, nobody else will know [the results] [IDI_30years_Shinyanga]
Participants believed that the introduction of HIVST would also help to mitigate stigma and discrimination ascribed to sex work and to the people living with HIV. Three FSWs who participated in IDI expressed mistrust if the HIV test is conducted at health facilities, health workers might disclose their HIV status to other people. FSWs anticipated that the availability of HIVST would help to minimize breach of confidentiality.
Nowadays, people are not trustful. We cannot even trust our siblings [since] they will inadvertently tell [...] that you know somebody is sick […]and remember there is a possibility of being stigmatised [and] that's the end of your business [IDI_44years_Mbeya]
Participants described other health facility level challenges that would be solved when HIVST becomes available. FSWs who had already visited health facilities for HTS recalled that HIV testing involved prolonged biomedical protocol before they receive their test results.
Preferences on HIVST delivery points and willingness to pay for HIVST
Participants reported that they would be willing to contribute a modest amount of money to access HIVST. In most PGDs, participants felt that they would be willing to contribute a range of Tanzania shillings 2000 - 3000 [equivalent to USD 1.6 - 2.5] per kit. A participant further describes this:
I wish the price [of HIVST test kit] to be around two to three thousand shillings [...] because we earn about ten thousand shillings from a single client. A person may spend three thousand for HIV testing and use the remaining amount for the home chores [IDI_21years_Shinyanga]
In all PGDs, participants expressed preference toward HIVST over health facility-based testing. Participants would like to see HIVST kits to be available in nearby pharmacies (highest priority), private health facilities (medium priority) and public health facilities (lowest priority). A few participants preferred the test kits to be available in informal sites including community spots, guesthouses, public washrooms and pubs. Alternatively, some participants suggested that the test kits be dispensed through non-governmental organisations serving FSWs.
Participants negative viewpoints about HIVST
Social narratives and discourses about sex workers and HIV transmission
Adverse social norms and stigmatizing narratives toward HIV and people living with HIV were described as barriers to self-testing. Participants acknowledged their own increased risk for HIV infection due to their involvement in high-risk sexual behaviour. Consequently, FSW reported fear of self-testing, because they suspected themselves to be already infected with HIV and were not able to cope with the reactive test. Participants from the study, who were concerned about coping with reactive test, appeared not to be aware about the “assisted” option of HIVST.
Other participants thought self-testing would allow FSWs to expose their clients to HIV infection deliberately. The view that self-testing will create room for FSWs to expose clients to HIV maliciously was raised in two PGDs.
Most of the women involved in sex work are not safe […]. So, if HIVST becomes available [they will test themselves and, they will never disclose their HIV positive status to their partners [PGD_Dar es Salaam]
If testing is done secretly, there will be an increased spread of HIV, because after a person has discovered to be infected, she will deliberately transmit HIV to other people [PGD_Iringa]
Fear of social harms
Despite considerable support for HIVST, several considerations were expressed about potential adverse outcomes related to conducting an HIV test without oversight by trained professionals. Four participants who were not aware of the availability of assisted option of HIVST expressed concern that, a reactive test result may cause severe distress to FSW utilizing HIVST.
Most of the time I think of the test outcomes […] what if the test shows that I am [HIV] positive? […] What will I do? […] I like to be tested by someone else so that if it happens that I am positive and the service provider is friendly, then she will know how to make me feel like a normal person [IDI_21years_Mbeya]
When people discover that they have HIV, they always get shocked. Having HIV may cause people to commit suicide. So, it’s hundred times better if the test is done by a trained person who provides counselling so that persons who test HIV positive come to term with their condition [IDI_41years_Iringa]
Multiple participants also raised a concern about users' error, especially relating to lack of capacity to interpret the test among FSW. Some participants were sceptical about the credibility an individual would put in a result obtained by oneself. One FSW participating in IDI expressed a Kiswahili saying "mganga hajigangi” (a healer cannot heal/treat her/himself), to describe how even if FSWs were trained, they could not diagnose themselves.
There is a Swahili proverb that says, a doctor cannot diagnose or heal her/himself. (Laughter) We don’t have the courage and skills to test ourselves […] You may test and deceive yourself that you have tested negative while you are HIV positive [IDI_32years_Mbeya]
In two PGDs, participants raised the concern that HIVST might damage or strain marital relationships. Some participants wondered that availability of HIVST kits might encourage male partners to force their spouses to test and disclose her status. The main concern was the potential for physical harm or psychological distress in case of discordant HIV results within a couple.