Forty-eight participants were interviewed across the four cities. The median age was 28 years (interquartile range [IQR], 22–29), and the median duration of sex work was 36 months (IQR 24-54) (Table 1). Fifty two percent had obtained secondary education (≥7 years of education) and 31% had primary or no formal education. Half (52%) had never married. FSW solicited clients through bars or clubs (36%), on the street (31%), lodges (18%), and brothels (9%). For two-thirds (63%), sex work was the only source of income. All 48 participants reported testing for syphilis and HIV in the prior three months. Across the four cities, participants reported engaging in risky sexual practices and described their testing practices as habitual.
Barriers and facilitators of regular syphilis and HIV testing
Participants described several individual and health system factors as barriers and facilitators of regular syphilis and HIV testing (Figure 1). Key personal barriers included low perceived severity, misconceptions for syphilis or internalized stigma for both syphilis and HIV. Service delivery barriers included provider practices, stock-outs of syphilis testing kits, high cost of syphilis testing, stigma and discrimination, unfavorable clinic operating hours and uncaring attitudes of HIV providers. Dual testing was mainly facilitated by presence of specific-FSW or non-governmental organization (NGO) clinics that offered integrated STI/HIV testing services. At individual level, testing was mainly facilitated by fears and concerns (i.e., increased HIV risk acquisition, inability to bear children, having syphilis would make one unable to satisfy clients or inability to attract clients, suddenly becoming sick, loss of work and inability to provide for significant others, and psychological anxiety (for HIV) at individual level. A coding tree of the barriers and facilitators of regular of syphilis and HIV testing among FSW is presented in Table 2.
Low perceived severity, misconceptions, and internalized stigma
Unlike HIV, syphilis was perceived a less serious health threat by most FSW. They reported that most FSW believed in testing for syphilis after developing the disease. To them this was a barrier to routine testing.
“Syphilis is not such a big issue like HIV. One can live with syphilis…it is not easy to go and test when you have no signs. I test because when I go at our clinic in Mulago am told to test for syphilis” (30 year old FSW, Kampala).
Descriptions of internalized stigma as a barrier to both syphilis and HIV testing were amplified by fears of being seen at clinics or peers spreading rumours about one’s perceived status. Rumour mongering was associated with loss of customers and income. These fears were more common among younger participants (≤24 years).
“I sometimes fear finding people I know at the clinic….I do not want them to know that I am doing this job. Also you are given a medical form if you test for syphilis… your friends may get to know that you have syphilis and other diseases and tell other people which affects your business” (20 year old FSW, Mbale).
Provider practices
Syndromic STI management (i.e., treatment without testing), disrespectful and judgemental provider attitudes were reported to limit uptake of routine syphilis testing. Across the study sites, participants reported being prescribed antibiotics for STIs without testing even after requesting to be tested. It was observed that unlike HIV, healthcare workers (HCW) rarely emphasised syphilis testing in public health facilities unless one was pregnant.
HCWs never emphasize syphilis testing like they do for HIV….I test for syphilis when I visit the MARPI clinic in Mengo because in other hospitals you are simply asked the signs and symptoms and thereafter they write for you medicines” (a 34 year old FSW, Kampala).
Among younger participants (≤24 years), it was reported that unlike HIV, requesting a syphilis test was not easy. Such requests were associated with critical questioning from the providers. Participants reported being asked questions like, ‘Who said you have syphilis’? ‘What did you do’? ‘What signs show you have syphilis’? or ‘Are you a doctor in the consultation room’? These questions were perceived as embarrassing, disrespectful, and judgemental.
“I felt very small and embarrassed by the health care provider when I requested to be tested for syphilis. It is not easy to ask for a syphilis test. Two months ago I requested to be tested for syphilis at the hospital but the doctor looked at me and asked me who told me I had syphilis, what I had done, and which signs….I felt very small, ashamed and insecure” (22 year old FSW, Mbarara).
In contrast, uncaring attitudes of HCW were reported to limit uptake of regular HIV testing. Most participants reported that HCW were unfriendly or uncaring especially at public facilities. HCW were perceived to be non-responsive and unfriendly to FSW, which led to long waiting times.
“I went to take an HIV test at government facility but the care was not good…doctors were too busy to attend to us that I spend the whole day in the hospital….now I test whenever I go to Kampala at a clinic in Mengo” (30 year old FSW, Mbarara).
Unavailability of supplies and high cost
Older participants (≥30 years) cited being discouraged to seek syphilis screening due to frequent stock outs of testing kits and medicines. They observed that unlike HIV, testing kits for syphilis and antibiotics were seldom available at public health facilities.
“Unless you are pregnant, it is not easy to be tested for syphilis in public facilities because testing kits and medicines are not available” (32 year old FSW, Kampala).
STI testing was reported to be more expensive than HIV testing at private clinics. The low cost of HIV testing was attributed to the availability of several testing clinics.
“At least for HIV you can find many cheap testing places; testing for syphilis is very expensive in private clinics” (28 year old FSW in Mbale).
Discrimination and stigma
Experiences of discrimination were reported as to be a barrier to HIV testing by all participants. However, this mainly occurred at public health facilities unlike sex worker friendly clinics.
“I used to test for HIV from the main hospital but once HCW realize you are a sex worker no one wants to attend to you or you will be the last to be seen. However, there are many testing canters in Arua….I now test from Reproductive Health Uganda” (a 28 year old FSW, Arua).
Unfavourable operating clinic hours
Some participants reported unfavourable clinic working hours as a barrier to HIV testing. This was mainly in Kampala, the capital city.
“Like a week ago I went to a city council clinic not far from here. I reached there like at 3:00 pm to take an HIV test… but I was told to come the following day because the clinic had closed…I was very demoralized” (29 year old FSW, Kampala).
Fears and concerns
Regular testing for syphilis and HIV was mainly driven by fears and concerns about the impact of syphilis and HIV on one’s own health, work, family responsibilities and future aspirations. Older participants (≥30 years) reported fear of suddenly becoming sick, being unable to work and providing for one’s children as a motivation for their regular testing behaviour. They expressed high risk perception for acquisition of HIV and other STIs, and believed one needed to remain physically attractive and strong to survive in sex work. They reported testing for both HIV and syphilis as they believed poor physical health was associated with failure to attract or satisfy customers. Regular testing meant accessing ART and STI treatment if one was found positive. Testing was also required before getting a post-exposure prophylaxis (PEP) prescription.
“I fear if I suddenly become sick and stop working…I am in this job for my children. No one will take care of them if I allow myself to become sick. In this job you have to test for HIV and other diseases such that if found positive you immediately start medicine otherwise you will not be able to satisfy customers and continue working…. so for me, I test for HIV, syphilis, and hepatitis B at RHU [Reproductive Health Uganda] every 6 months” (32 year old FSW, Arua).
“I sometimes try to insist on condom use but clients offer more money for unprotected sex….and sometimes I have nothing to eat or feed my child…so I test for HIV almost every month to feel relieved” (20 year old FSW, Mbale).
Similarly, dual syphilis and HIV testing was reported among participants with childbearing and marriage intentions. Syphilis was believed to cause infertility. The fear of being unable to bear children in the future promoted syphilis testing.
“In this job one can easily acquire infections that can affect their private parts (vagina) and even the uterus….for me, at some point, I want to quit this job, get married and have children in future so I normally go to test for syphilis and HIV every two months” (23 year old FSW, Mbarara).
Social influences
Some participants reported testing for syphilis and HIV due to the influence of a distant partner or boyfriend who lived in a different part of the country. The partners were usually not aware of their participation in sex work. Their testing behaviour was motivated by request of the partner for fear of being infected.
“My boyfriend is not aware I do this job….we usually meet once every four months and normally he insists we must first test for HIV and syphilis” (23 year old FSW, Kampala).
Sometimes the demand for unprotected sex by male clients influenced frequent HIV testing behaviour. This occurred among younger participants with strong positive body image perceptions or marriage intentions.
“I test for HIV whenever a client requests for sex without a condom. I am very pretty and many clients want to have sex with me “live” (without a condom) but I only agree if the man agrees and tests negative (20 year old FSW, Mbale).
Perceived fidelity of test results
Some participants expressed doubt about the accuracy of their HIV-negative test results. To confirm these results, repeat tests were sought from other clinics. Some FSW reported engaging in unprotected sex, or had HIV-positive clients, but continued to test HIV-negative. Others had doubts about whether a drop of blood drawn from a finger stick could capture their HIV status correctly. When testing was done with a regular client or boyfriend, some FSW sought repeat tests because they feared their client or boyfriend could have bribed clinic staff to change the test result.
“I do not think a drop of blood from a finger gives correct HIV results…in outreaches, HCW have tested people we know have clients on antiretroviral drugs negative….I have messed up a lot but they continue test me negative…I keep testing because I don’t believe [my test results]” (32 year old FSW, Kampala).
Habitual testing and self-efficacy
HIV testing was described as habitual by most participants. Receipt of previous HIV-negative test results gave them courage to test again. Some reported maintaining a diary of testing dates as a reminder.
“I cannot say no to any man who comes with money. I have made it a habit to test for HIV every three months….I keep a diary where I record dates” (28 year old FSW, Arua).
Prior testing for HIV resulted in empowerment and self-efficacy that was frequently described as a facilitator for engaging in regular HIV testing.
“My parents died of HIV and so my relatives thought I was HIV positive but since I tested negative I have developed the courage to always test for HIV every month” (26 year old FSW, Kampala).
We observed that some participants tested for syphilis because it was offered at an antenatal clinic.
“I have learnt to test for syphilis every three months because when I was pregnant it was a must to be tested for HIV and syphilis” (22 year old FSW, Arua).
Presence of FSW-specific clinics offering both STI and HIV testing
Participants from Kampala, Mbale and Mbarara cited existence of specific FSW-friendly clinics in Kampala as an enabler of their periodic syphilis and HIV testing behaviours. Reasons for preference of these clinics included testing for all STIs, availability of testing kits and medicines, approachable and caring-healthcare providers among others.
“Here in Mbarara I went to government facility but the care was not good…now days when I go to Kampala I visit a clinic in Mengo because I can explain my problems to doctors…get counselling and be tested for all STIs…they care about us and I find it convenient” (28 year old FSW, Mbarara).
NGO clinics that provided integrated services including STI and hepatitis B virus testing at a low cost, promoted syphilis and HIV testing.
“I usually test at RHU, an NGO clinic because even with small money I am tested for syphilis, HIV and hepatitis B” (28 year old FSW, Arua).
Availability of many testing clinics for HIV
HIV testing services were reported to be easily accessible in all cities. All participants cited existence of several testing facilities ranging from free government clinics, NGO clinics, private clinics, and occasionally community-based testing outreaches.
“For me, it is easy to test for HIV every 3 months because there are many testing centers. I used to test from the main hospital but when healthcare workers know your business (sex work) they take long to serve you….now I go the health center” (29 year old FSW, Arua).
These facilities provided choice regarding availability, acceptability, convenience, and affordability. The commonly preferred testing sites were FSW-friendly clinics, public health facilities, and NGO run clinics. Private clinics and community-based outreach campaigns were the least preferred.
I used to test from a private clinic but I worried a lot waiting for results….at the main hospital, services are free and healthcare workers prepare you before (pre-test counselling) and after testing….you get a lot of information about HIV” (28 year old FSW, Mbale).
Reasons for these preferences included provision of a range of STI testing services, availability of testing kits and antibiotics, approachable and kind HCW for specific FSW-clinics. Public health clinics offered free testing services, health education and pre-test counselling. Private clinics were preferred for being nearby or trusted to provide accurate test results. Outreach campaigns were said to be convenient.
“I do sometimes test for HIV and syphilis at the MARPI clinic at Mulago especially when I want to get PEP….but normally I test from private clinics because they are near or when healthcare workers come and test us from here” (30 year old FSW, Kampala).