Socio-demographic characteristics
A total of 227 FSWs participated in 21 sessions of PGDs. Twenty three 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 engaged 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 the participants’ characteristics.
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 being 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 re-test thought that HIV testing services were supposed to be offered only in the health facility setting.
When participants were asked if they have ever heard about HIV self-testing, only 25% reported to know it, among whom none reported to have ever heard of HIVST done using oral fluid.
Participants’ positive viewpoints about HIVST
Improved confidentiality, convenience and empowerment
In all PGD sessions, the participants reached the consensus that the 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 belief that HIVST would restore self-autonomy is captured by a remark made by one of the FSW from a PGD session:
If kits for HIV testing become available at our homes, it’s very easy for us to test when we need it […]. We shall test promptly without any delay. Testing HIV at health facility requires people to make some prior preparations to reach the facility [PGD_ Iringa]
In all PGD sessions, the participants reached the consensus that, availability of HIVST can guarantee complete privacy during HIV testing. The view that availability of HIVST would improve privacy was also echoed by 17 FSWs (out of the 23 who participated in IDI).
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 [results] [IDI_30years_Shinyanga]
The participants believed that the introduction of HIVST would also help to mitigate stigma and discrimination ascribed to sex work and the people living with HIV.
People are not trustful. You cannot even trust your siblings. [Your sibling] can inadvertently tell other people that you know our sister is sick. [if HIV status becomes known to other people] that will be the end of your business[…] Remember there is a possibility of being stigmatised. [IDI_44years_Mbeya]
Three FSWs who participated in IDI reported that, they were reluctant to seek HIV test at health facilities because they feared that health workers may disclose their HIV status to other people. According to them the availability of HIVST would help to minimize breach of confidentiality. FSWs who had already visited health facilities for HTS reported that HIV testing involved prolonged biomedical protocol before they receive their test results. These participants believed that availability of HIVST will help to save the time they would lose to seek HTS.
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 pay a range of Tanzania shillings 2000 - 3000 [equivalent to USD 1 - 1.5] 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. We could therefore spend three thousand for HIV testing and use the remaining money 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). Alternatively, participants preferred the test kits to be available in informal sites including community spots, guesthouses, public washrooms and pubs, or through community based organisations (CBOs) 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, FSWs 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 a reactive test, appeared not to be aware of the “assisted” option of HIVST.
Other participants thought self-testing would allow FSWs to dliberately expose their clients to HIV infection. The view that self-tes ting 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 the assisted option of HIVST expressed a 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 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 a 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 FSWs. 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 Kiswahili 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.