This theory-based qualitative study aimed to assess the acceptability and feasibility of HIVST for FSWs in Cotonou, Benin, in order to inform the development of a tailored program for Beninese key populations. Eight major domains of the TDF were used to explore the potential determinants of HIVST use: knowledge, reinforcement, social influences, beliefs about capabilities, intentions, behavioural regulation, beliefs about consequences and emotions.
The results indicate that there is a high level of HIVST acceptability within the FSWs population in Cotonou and its surroundings. All the study participants showed interest in using HIVST if made available in Benin. This finding is compatible with the results of several studies conducted in different contexts which show high acceptability of HIVST in key populations1,13,15,22,23,24,25,26,27,28,29,30,31,32,33,34. HIVST seemed to be particularly attracting for the participants because it promotes autonomy and privacy. When saliva-based, it also is a painless test that is easily accessible. Concerning the different HIVST distribution modalities, the majority of our participants said that they preferred to receive them from NGOs dedicated to FSWs or health care facilities that they already visit on a regular basis. FSWs have also shown great interest in the HIVST secondary distribution. Participants made it clear that the devices have to remain free of charge to maintain their attractiveness to FSWs.
Only two participants (6.9%) had already heard about HIVST before the study. The fact that participants had few or no knowledge about HIVST offered the opportunity to collect answers free from external influences. FSWs low level of knowledge was expected since HIVST is a relatively new screening method that is not yet available in the country. Our participants’ low awareness of HIVST is also consistent with results from other studies conducted in low and middle income countries1,28. Since HIVST is not well known among FSWs and the Beninese general population, it is necessary to raise awareness about it through information campaigns. HIVST national implementation will only be feasible in Benin if mass education programs are first put in place to inform the population about its use and its limitations.
All 29 FSWs interviewed thought HIV self-tests were easy to use without assistance. All participants were confident in their ability to use the device properly and to follow the instructions. However, unlike other research, our study methodology did not allow any direct assessment of FSWs’ capacity to use HIVST since there was no observer or evaluator. Still, it is well known that strict instructions adherence is essential to obtain reliable results from HIVST. In fact, many studies have shown that mistakes are frequently made when performing HIVST, especially among populations with low levels of education28,35,36,37,38,39,40,41,42,43. The interviewer asked participants by which steps they had used the device. While most women were able to describe the key steps, some inconsistencies in their responses were noted, which suggest that errors in execution and interpretation could have been observed if the study methodology had provided this type of direct evaluation. We believe that appropriate, clear and concise user instructions are essential to minimize errors and maximize HIVST performance. In this regard, the majority of participants mentioned that the in-person demonstrations, the manufacturer's illustrated instructions and the advices given by community animators, PEs and health professionals had helped to build their confidence in their ability to use the device properly.
This study highlighted the fact that FSWs experience stigmatization and social exclusion in Benin. In this context, HIVST implementation must be done carefully, to avoid targeting only FSWs. Broadening HIVST access to all high-risk individuals might be a way to mitigate the stigma surrounding HIVST.
HIVST implementation often raises concerns about risk compensation. In our study, although the majority of FSWs said that they did not intend to change their sexual behaviors because of HIVST, some of them tended to stop using condoms with their boyfriends when they obtained non-reactive self-test results. In our opinion, seroselection could be acceptable in a regular couple; however, in an open couple as for FSWs, this strategy requires a high screening frequency from both stable partners. Thereby, HIVST implementation will have to be part of a global prevention program which includes counselling, STI screening and promotion of consistent condom use. Health care professionals and community animators will have to frequently remind HIVST users that this method does not screen for other STIs and that condom use is still important.
Our study also shows that some clients may use HIVST as a negociation tool to obtain unprotected transactional sex with FSWs. In our opinion, if a client offers a higher price for unprotected sex, the FSW mitigates her risks by first requiring that the client uses the HIV self-test and demonstrates his HIV-negative status. In this situation, if the client agrees to perform the test and obtains a non-reactive result, the FSW has a minimal risk of acquiring HIV by having unprotected sex with this client, especially when HIV incidence is low in the general population. In this context, HIVST serosorting may be a protective practice for FSW, although less effective than consistent condom use. In other words, HIVST seroselection is still safer than unprotected sex with a partner of undetermined HIV status. However, this approach is opposed to WHO official recommendations, which advises to avoid using HIVST for serosorting purposes or to justify high-risk sexual behavior11.
Three participants in this study used HIVST to retest, after being tested positive through standard HIV testing in a formal health facility in the past. These FSWs had initially denied their diagnosis and refused ART. HIVST enabled them to acknowledge their results, accept their diagnosis and initiate appropriate treatment. This finding is consistent with other research which show that retesting for HIV is frequent among people living with HIV27,44,45. This result suggests that HIVST could enable people who had previously disengaged to re-engage in care.
In our study, FSWs were encouraged to share HIV self-tests within their social network. This distribution strategy had already been shown successfull in studies conducted in different countries13,46,47,48,49. In our study, HIVST secondary distribution was well received among FSWs’ boyfriends and regular clients. In addition, the majority of secondary users asked for FSWs’ help or direct assistance to perform the test. Only three participants reported their boyfriends’ refusal to use the self-tests.
The principal strength of this study is the use of the TDF to categorize and understand factors associated with HIVST acceptability within the FSWs population of Cotonou and its surroundings. Even if it is difficult to explain how the different domains influence each other, the TDF is appropriate to explore a wide range of barriers and enablers to HIVST use. Unlike other studies that used only quantitative methods to explore HIVST acceptability, this study led to a better understanding of participants’ perceptions by using qualitative methods. These qualitative results will help understand the findings from the quantitative part of the study that is in progress.
Another strength of our study is the fact that we capitalized on structures already established in Benin to facilitate our pilot project. We relied on the participation of two user-friendly health centers already dedicated to FSWs and four local NGOs to promote and distribute HIV self-tests. These organizations were in place long before our project, and were already well-known by FSWs. In our opinion, using structures already in place allows us to draw better conclusions about this program feasibility.
The study has a few limitations. Since all the 14 domains of the TDF were not explored, some elements related to HIVST acceptance could have been omitted. However, the TDF was developed in the aim of choosing the most relevant domains according to the situation. Secondly, as for all qualitative studies using interview techniques, our study was subject to social desirability bias; participants may have overestimated their regular condom use or failed to disclose their HIV-positive status. Finally, since the majority of participants (75.9%) has accessed HIVST through community-based distribution, we were not able to gain a good understanding of the experience of FSWs who had been offered HIV self-tests in health facilities (13.8%) or as part of the secondary distribution (10.3%).