Research Article: Barriers and Facilitators to HIV Testing Among Zambian Female Sex Workers in Three Transit Hubs

Date Published: July 01, 2017

Publisher: Mary Ann Liebert, Inc.

Author(s): Michael M. Chanda, Amaya G. Perez-Brumer, Katrina F. Ortblad, Magdalene Mwale, Steven Chongo, Nyambe Kamungoma, Catherine Kanchele, Andrew Fullem, Leah Barresi, Till Bärnighausen, Catherine E. Oldenburg.


Zambia has a generalized HIV epidemic, and HIV is concentrated along transit routes. Female sex workers (FSWs) are disproportionately affected by the epidemic. HIV testing is the crucial first step for engagement in HIV care and HIV prevention activities. However, to date little work has been done with FSWs in Zambia, and little is known about barriers and facilitators to HIV testing in this population. FSW peer educators were recruited through existing sex worker organizations for participation in a trial related to HIV testing among FSWs. We conducted five focus groups with FSW peer educators (N = 40) in three transit towns in Zambia (Livingstone, Chirundu, and Kapiri Mposhi) to elicit community norms related to HIV testing. Emerging themes demonstrated barriers and facilitators to HIV testing occurring at multiple levels, including individual, social network, and structural. Stigma and discrimination, including healthcare provider stigma, were a particularly salient barrier. Improving knowledge, social support, and acknowledgment of FSWs and women’s role in society emerged as facilitators to testing. Interventions to improve HIV testing among FSWs in Zambia will need to address barriers and facilitators at multiple levels to be maximally effective.

Partial Text

Female sex workers (FSWs) are disproportionately affected by the HIV epidemic globally.1 In Sub-Saharan Africa, FSWs have 12.4 times the odds of HIV infection compared with general population women of reproductive age.1 Testing for HIV is a critical first step in the HIV care cascade for addressing the HIV epidemic, by allowing for timely linkage to care to initiate treatment and reduce viral load, and prevent onward transmission to sexual partners. However, major gaps in the HIV care cascade remain for FSWs.2 Recent population-based evidence from Zimbabwe demonstrated that only 64% of FSWs were aware of their HIV positive status.2 Similarly, knowledge of status has been reported to be low in other regions of Sub-Saharan Africa among FSWs.3,4 Interventions to improve HIV testing coverage for FSWs are warranted, the development of such interventions must include an understanding of existing barriers and facilitators to HIV testing from the perspective of this vulnerable community.

In August 2016, semistructured focus groups (N = 5, total participants = 40) were conducted with peer educators who either currently identified as FSWs or had previously participated in sex work. Written informed consent was collected from each participant. Participants received 50 kwacha (∼US$5) as compensation for their time participating in this study. The Institutional Review Boards at the Harvard T.H. Chan School of Public Health in Boston, United States and ERES Converge in Lusaka, Zambia, approved the study.

Across five focus groups in three distinct Zambian transit hubs, discussions supported emerging themes related to barriers and facilitators to HIV testing at three inter-related levels: individual (intrapersonal), community/close social network (meso-level), and structural.

Narratives from community-based peer educators who were active or previously engaged in female sex work highlighted multilevel barriers and facilitators to HIV testing among FSWs in Zambia. Across focus groups, the intersecting levels (i.e., individual, community, and structural) underscored stigma and discrimination as a pervasive barrier to HIV testing. Previous work has shown the importance of stigma as a barrier to HIV testing and linkage to care among FSWs in diverse settings.9,23–25 Stigma-mitigating interventions may, therefore, be helpful for improving access to HIV testing in this population, and a multipronged approach may be required to address stigma-related barriers at multiple levels. Such interventions will need to be developed and implemented in a way that responds to the specific needs of the population. A previous study of a skills-building and collectivization intervention, addressing individual and structural levels of sex work-related stigma for FSWs, in India demonstrated mixed effects, with some groups reporting empowerment and some reporting reluctance to self-identify as sex workers.26 However, the majority of stigma-related interventions focus only on individual-level stigma and only a single dimension of stigma for key populations (e.g., HIV-related stigma or sex work-related stigma).27 For FSWs in Zambia, dissemination of knowledge to (individual-level) and among/between FSWs (community-level) regarding the importance of testing may help to dispel fears. Structural interventions focusing on clinic and hospital settings to promote safe and confidential spaces may also improve HIV testing for FSWs. In addition to safer spaces, interventions aimed at decreasing healthcare provider stigma toward FSWs from clinicians will be important to optimize HIV testing in this highly stigmatized population.




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