Abstract
Introduction. While four in ten female sex workers (FSWs) in sub-Saharan Africa are infected with HIV, only a small proportion is enrolled in HIV care. We explored facilitators and barriers to linkage to HIV care among FSWs receiving HIV testing services at a community-based organization in periurban Uganda. Methods. The cross-sectional qualitative study was conducted among 28 HIV positive FSWs from May to July 2014. Key informant interviews were conducted with five project staff and eleven peer educators. Data were collected on facilitators for and barriers to linkage to HIV care and manually analyzed following a thematic framework approach. Results. Facilitators for linkage to HIV care included the perceived good quality of health services with same-day results and immediate initiation of treatment, community peer support systems, individual's need to remain healthy, and having alternative sources of income. Linkage barriers included perceived stigma, fear to be seen at outreach HIV clinics, fear and myths about antiretroviral therapy, lack of time to attend clinic, and financial constraints. Conclusion. Linkage to HIV care among FSWs is influenced by good quality friendly services and peer support. HIV service delivery programs for FSWs should focus on enhancing these and dealing with barriers stemming from stigma and misinformation.
Highlights
While four in ten female sex workers (FSWs) in sub-Saharan Africa are infected with HIV, only a small proportion is enrolled in HIV care
Key informant interview (KII) participants were selected from peer educators who were trained by Reach Out Mbuya HIV/AIDS Initiative (ROM) and were involved in following up FSWs to encourage them to access HIV care
Key emerging issues (i) Good attitude and friendliness exhibited by counsellors (ii) Counsellors provided detailed information and encouragement to start treatment (iii) Good follow-up support using phone calls and home visits (iv) Same-day results and immediate initiation on treatment (v) Linkage and retention support: encouragement and reminders from peers trained by ROM (vi) Short distance to the clinic (i) Encouragement from group members (ii) Restored hope (iii) Money for food and capital to start business (i) Continue work (ii) Avoid signs of opportunistic infections (iii) To live longer and take care of their children (i) Sick friends improving (ii) Sick colleagues dying of HIV
Summary
Female sex workers (FSWs) are at high risk of HIV infection and transmission. A systematic review conducted in over 25 countries with medium and high HIV prevalence indicated that 36.9% of sex workers in sub-Saharan Africa were HIV positive with some countries having HIV prevalence as high as 70.7% [1]. Several studies have highlighted barriers to linkage to care among female sex workers including discrimination by hospital staff [3, 7], delays at the health facility [8, 9], lack of money for transport and food, fear of drugs, stigma [3], use of drugs and alcohol [9], fear to be seen by clients [8], lack of knowledge about the treatment center [10, 11], and delays in accessing treatment among those who felt they were still healthy [9] While these barriers have been reported, there is still limited information on linkage to HIV care among sex workers in sub-Saharan Africa, on effective linkage models to inform scale up of HIV interventions among sex workers [12]. We conducted a study to identify the facilitators and barriers to linkage to HIV care among the FSWs who tested positive in order to design appropriate HIV interventions for this key population group
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