HIV self-testing services for female sex workers, Malawi and Zimbabwe
WHO Bulletin - "In sub-Saharan Africa, the proportion of HIV infection in the general female population that is attributable to sex work is estimated to be between 13.6 and 22.1%. In spite of the overall reduction in new HIV infections in the general population, the prevalence and incidence of HIV among female sex workers remain extremely high. At the same time as being disproportionately affected by HIV infection, female sex workers are highly marginalised and least likely to take up voluntary counselling and testing (VCT) services, as they have to contend with multiple barriers to accessing services. (Summary by Kate Molesworth, Swiss TPH)
A recently published study by Napierala et al “HIV self-testing services for female sex workers, Malawi and Zimbabwe” in the Bulletin of the World Health Organisation, presents an assessment of the acceptability and accuracy of HIV self-testing among female sex workers. The two countries were selected as they present different contexts and approaches to HIV reduction among female sex workers. Zimbabwe has one of the few nationally scaled programmes for sex workers in Africa, which was established in 2009, but in Malawi, by contrast, there was relatively little programmatic focus on this key population until 2015, when dedicated services were introduced.
In order to refine systems for national scale-up through existing services, the study in Zimbabwe, made an assessment of the acceptability and accuracy of HIV self-testing among female sex workers. It assessed their preferences for HIV self-testing versus standard provider-delivered testing as well distribution preferences and support strategies. The study in Zimbabwe concluded that female sex workers were able to accurately self-test and found the method to be highly acceptable. Clinical follow-up was very high, with 99% of wo men who self-tested positive attending HIV services within he following 2–4 weeks. Furthermore, all the women interviewed reported that they would recommend self-testing to family and friends, and a further 81% reported that they would recommend self-testing to clients.
In Malawi, the study explored the context and needs of female sex workers for HIV self-testing and shaped a peer distribution model that was implemented to assess the uptake of self-testing kits and post-test support services. This identified three categories of female sex worker: bar-based, street-based and home-based. Street-based female sex workers were hard to reach for services, although, along with home-based workers, they were more independent and tended to have stronger support networks than bar-based workers. All female sex workers were highly mobile, following periodic transaction sex markets, although bar-based female sex workers were less so. As initial research indicated a preference for peer distributors of self-testing kits, implement ation re search tested this method. This revealed that users preferred self-testing under a peer distributor’s supervision, and in the case of illiterate women, that the test was carried out by the peer distributor. The study also revealed instances of harm associated with self-testing and disclosure, notably physical violence, mostly perpetrated by an established partner, in the context of pre-existing relationship violence. Some peer distributors reported experiencing social stigma, questioning of their credentials and low-level violence perpetrated by female sex workers and other community members.
Self-testing for HIV has been shown by Napierala et al to be acceptable and feasible for female sex workers in the two countries as they need, and often desire, frequent re-testing. It provides a step towards addressing inequities in access to HIV services and increasing the uptake of testing and timely access to treatment among female sex workers. In this way, self-testi ng has t he potential to reduce morbidity and mortality amon sex workers and transmission of the virus to clients and their partners, by enabling early awareness of infection, initiation of antiretroviral therapy and suppression of viral load.