Introduction
According to the Joint United Nations Programme on HIV and AIDS (UNAIDS), 36.7 million people were living with HIV globally by end of the year 2016, yet 30% did not know their status [
1,
2]. Majority of the people living with HIV/AIDS come from low and middle income countries with 25.5 million living in Sub-Saharan Africa. Globally, the number of new infections has declined from 2.1 m in 2015 to 1.8 m in 2016 [
1,
2]. The number of people receiving HIV treatment has also drastically increased over the recent years, particularly in resource-limited countries. By the end of 2016, more than half (53%) of the people living with HIV/AIDS had access to treatment [
1,
2]. Although countries have made significant progress against HIV/AIDS, the efforts are not fast enough to achieve the global 90:90:90targets for HIV elimination [
3].
According to the viral load dash board-Uganda as of November 2018, 78% of all PLHIV know their status, 86% of all PLHIV have been enrolled into care, and 77% of all persons on ART are virally suppressed but this varies by region and age category. However, the current dash board does not take care of the different categories of key populations (KP) including female sex workers (FSW) but they should be far below the current global target of HIV elimination because of poor health seeking behavior due to their being highly mobile and unconducive legal environment in Uganda.
By end of 2016, 1.4 million people were living with HIV in Uganda. The adult HIV prevalence was 6.2% (those aged 15 to 64 years) [
4]. Women were more disproportionately affected with 7.6% of adult women in Uganda living with HIV/AIDS compared to the men at 4.7% [
5]. Among adults living with HIV who reported knowledge of their HIV status, 58.5% reported current use of ART: 61.9% of HIV positive women and 52.4% of HIV positive men [
5]. The Uganda AIDS Commission (UAC, 2014) estimated over 54,549 female sex workers in Uganda and the National HIV Investment Case (2015–2025) indicates an HIV prevalence of 35% while UNAIDS (2014) estimates the prevalence at 34.2%. The high HIV risk among sex workers arises from high rates of unprotected sex, alcohol, drug use, and non-use of condoms. This is coupled with the discriminatory laws to sex work and the limited capacity to bargain for the right to social protections among others [
6].
Key populations continue to lag behind the general population in achieving 90–90-90 HIV outcomes. Current estimates suggest that 47% of all continuing HIV transmissions globally are driven by KPs and their sexual partners (UNAIDS, 2018). Among the FSWs, the rate of new HIV infections was 13 times greater than in the general population (UNAIDS special analysis, 2018). Similarly, the risk of acquiring HIV for people who inject drugs (PWID) was 22 times higher than for people who do not inject drugs, and 13 times higher for transgender (TG) women than adults aged 15–49 years (UNAIDS. Miles to Go Global AIDS Update, 2018). In Uganda’s HIV epidemic context, KPs at high risk of HIV constitute the following population categories: Men who have Sex with Men (MSM), FSW, PWID, People in closed setting (Inmates and prisoners), Unifromed forces, and TG (UAC, 2015). A FSW is any adult who engages in the act of exchanging money for sexual services with a client. This involves negotiation and exchange of money for a sexual service and it is a regular income-generating practice that can take place anywhere. A FSW can work independently as individuals (on the streets) or for a company. They may also be managed by a pimp, or work as part of a brothel and bars among others.
In Uganda, FSWs are markedly underserved and marginalized by HIV prevention programmes, they face sexual violence associated with Sexual Gender Based Violence (SGBV) from clients due to failure to pay the agreed amount of money or having sex without a condom and yet it was not agreed upon during the initial negotiations. They also have concurrent multiple sexual partners, they practice risky sex with limited access to condoms and treatment of sexually transmitted infections (STI). Drug-use is also common among the FSWs which could result in impaired judgment of risky sexual behaviours. Addressing such challenges is critical to the success of HIV care programs.
In Uganda, HIV testing is conducted in health facilities, community settings, and homes. Over the recent past, emphasis has been placed on strategies such as workplaces testing, outreach to most at risk groups, and mobile or mass testing, especially during testing campaigns [
6]. HIV testing for FSWs is currently being done at the static health facilities, in the community at the drop in centers or during the outreaches and self-testing in some parts of the country is being offered for sex workers through their peers or health workers. The number of people accessing HCT has increased over time from 5.1 million in 2012 to 10.3 million in 2015 [
6].
In Uganda, sex work is illegal. Therefore, because of its criminalization and associated social stigma, FSWs do not access HIV health care services and if they do, they conceal their occupation from health care workers. It was estimated that FSWs and their clients accounted for 18% of the new HIV infections in 2015/2016 [
6]. Given the impact of the FSWs’ high HIV prevalence on the overall HIV prevention and care efforts, special interventions have been designed to address the challenge among the various categories of key populations including FSWs. Specific community-based HIV testing service delivery models such as static facilities, outreaches through moonlight services, outreaches to safe spaces, bars, clubs, lodges, brothels, and Camps (using a mobile van), and peer to peer mechanism have been designed and implemented. Despite the efforts by Ministry of Health Uganda (MoH) and patterns to reach FSWs, very few FSWs have been reached with the HIV prevention interventions and the HIV prevalence has remained high among this category of key population. We assessed the preference and uptake of the current community-based HIV testing services delivery models that are used to reach FSW along Malaba-Kampala high way and identified challenges faced during the implementation of the models., a Malaba-Kampala high way, is a major busy high way from Mombasa-Kenya that links Uganda to other countries such as Rwanda, Tanzania, and Burundi with many hotspots and identified challenges associated with the models. Based on the assessment, we identified answers to the following research questions: What is the preference and uptake of different current community-based HIV testing services delivery models among FSWs along Malaba- Kampala highway? and what are the challenges in the different community-based HIV testing service delivery models used to reach FSWs along Malaba- Kampala highway?
Methods
Study setting
We conducted the study at hot spot areas along the Malaba-Kampala highway in six districts namely, Busia, Tororo, Bugiri, Iganga, Jinja, and Kampla. We defined hot spots as geographical locations where high risk activities such as pick-up points or places where the actual execution of sex work takes place or are concentrated. The hot spot areas included: Malaba-Tororo highway, Malaba-Busia highway, Iganga, Bugiri, Jinja, and Kampala. We selected Malaba-Kampala highway based on the fact that it is one of the major highways in Uganda where a lot of sex work occurs.
Study design
We conducted a cross-sectional study using both quantitative and qualitative data collection methods: We assessed the preference and uptake of the different community-based HIV testing service delivery models based on two indicators, that’s, the proportion of FSWs who had an HIV test in the last 12 months (June 2015–July 2016) and the proportion of FSWs who were positive and linked into care (Table
1).
Table 1
Indicators used to assess the preference and uptake of different community-based HIV testing service delivery models
Definition of the indicator | The proportion of female sex workers who have had an HIV test in the last 12 months and know the results through the different community model |
Target | All sampled female sex workers along Malaba-Kampala highway |
Numerator | The number of female sex workers who have had an HIV test in the last 12 months and know their status. |
Denominators | All female sex workers interviewed |
HIV Positive female sex workers immediately linked to care through the different model |
Definition of the indicator | The proportion of HIV positive female sex workers linked to care in the last 12 months through the different models. Immediate linkage means a newly identified HIV+ female sex worker who has been referred and enrolled into care. It is recommended that an HIV + individual is enrolled within 7 days at the same health facility of identification or within 30 days if referred to another health facility |
Target | All positive HIV female sex workers who tested in the different models |
Numerator | The number of positive HIV female sex workers linked to care by the different models |
Denominator | All HIV positive female sex workers who tested in the different models |
Ministry of Health Uganda provides the policy guidance and standards for health services and facilities. Ministry of Health Uganda acknowledges that HIV programmes for Most At Risk Populations (MARPs) along the transport corridors are critical in prevention and control of HIV. The community-based HIV testing models that target FSWs were established in 2009 and these include: Static facility services (clinics in hot spot areas), outreaches, and peer to peer mechanism.
Static facility based services
These are located along hotspot areas where FSWs can easily go and access HIV testing services without incurring high travel costs. They are stocked with free commodities like condoms, water based lubricants, HIV testing kits, STI drugs, and supplies for HIV/AIDS care. These facilities are open daily and have at least three service providers. These health workers are informed and are in contact with referral health facilities for the services they cannot offer. Female Sex workers consult service providers without any appointment through centre visits or phone calls.
Outreach posts and sites
Services are provided in a variety of settings in the community, either as outreach to community sites or through mobile vans or tents. Each of the health facility serving a given hot spot area makes an annual worker plan and health workers move out to these hot spots at least once a week. The team has got at least four health workers that include a clinician, nurse, lab personnel, counselor, and the mobilization is done by the peers. These services are temporary, but regular in community sites where FSWs operate and reside such as entertainment centers like bars, clubs, and lodges. Extra space is created by provision of tents or mobile vans stationed in high risk places. Outreach posts and sites on average operate 4 to 8 days in a month.
Peer to peer mechanism
Here, two FSWs are selected by their colleagues, trained and equipped with knowledge on HIV and skills to reach peers by Most-At-Risk-Population Initiative (MARPI) or any comprehensive HIV partner who is in charge of the region such as The Aids Support Organization (TASO), Regional Health Integration to Enhance Services in East Central Uganda (RHITE-EC) with the guidance of the district and health facility where the peers are attached. The trained FSWs then share information provided to them by the health workers, encourage their colleagues to seek HCT services, distribute condoms, and link them to care. These Peers are paid for the mobilization done by the responsible pattern like MARPI through the heath facility staff or the focal person for KPs to which the peers are attached.
HIV Counselling and Testing services are being provided through drop in centre (safe space either in the community or attached to the facility which key population like Female Sex Workers use as entry point to access services or a congregation point to discuss issues pertaining to their health and welfare and other social issues)) which are located in the hot spot, outreaches are being carried to hot spot areas which include bars, brothels, and the peers do provide HCT testing using the self testing kits. HIV Counselling and Testing services are being provided by the public health facilities that have the drop in centres. The government of Uganda provides the testing kits and NGO & CSO such as MARPI, TASO, Infectious Diseases Institute (IDI) with funding from President’s Emergency Plan For AIDS Relief (PEPFAR) or Global Fund pays allowance for the health workers, Peers, and facilitation for transport and space during outreaches.
The community-based HIV/AIDS service delivery models along Malaba-Kampala highway are being provided by local governments in partnership with non-government organizations (NGO) and community-based organizations (CBO) such as MARPI, Family Health International (FHI), Aids Information Center (AIC), Uganda Reproductive Health Bureau (URHB), Malaba Kyosimba Onaamya Community Development Association (MAKOCDA), Reach Out Mbuya, IDI. These are funded by PEPFAR or Global fund and are coordinated by the MARPs Network which was formed in 2007 by MoH in partnership with the Uganda Health Marketing group (UHMG).
Study population
We conducted the study among FSWs aged ≥18 years who operated along the Malaba-Kampala highway. We defined SWs as any female aged 18 years and above, who undertakes sexual activity after consenting with a man for money or other items/ benefits as an occupation or as a primary source of livelihood irrespective of site of operation within the last 6 months i.e. street, bars, home, hotel, and other locations and they should have operated along Malaba-Kampala high way for at least 1 year. We interviewed health service providers from six health facilities as key informants which included clinicians, counselors, nurses, and pharmacists at points of care, district political leaders (Resident District Commissioners (RDC) and Secretaries for Health), technical leaders such as District Health Officers or HIV focal persons and focal persons for key populations of Implementing Partners (IP) in all the six districts, and Ministry of Health. At the MoH Uganda level, we engaged the AIDS Control Program (ACP), Uganda AIDS Commission (UAC), and other partners such as, AIDS Information Center (AIC), Uganda Reproductive Health Bureau (URHB). The IPs engaged included MAKOCDA, Reach Out Mbuya, IDI, Mildmay Uganda, TASO Uganda, and the MARPs Network.
Sample size and sampling considerations
Hot spots and Sex workers: We used cluster sampling for hot spot selection. We purposively selected the “hot spots” along the Malaba-Kampala highway. In each hot spot, all the popular bars, streets, and brothel where FSWs operated were taken as a cluster in that district. The actual population of FSWs in the different clusters (hot spots) was not known, so we assumed an equal population in all the selected clusters. The sample size for this cross-sectional study was determined using the Kish leslie formula (Kish leslie, 1965) for single proportion. We recruited a total of 72 FSWs in each cluster (420 FSWs in total) determined based on the calculation. Because FSWs are a hard-to-reach category, we used snowballing approach to reach the 72 needed for each cluster (Ritchie, 2003). We only included FSWs who were residents within the programs (community-based HIV testing service delivery models) defined catchment areas. These FSWs had to have spent ≥ 1 year in the defined catchment area for community-based HIV testing service delivery model prior to the date of interview. This was a consideration for both qualitative and quantitative data collection methods, the participates were asked if they had received HIV services in the past 12 month. Female sex workers who were found to be too sick to respond as judged by the research assistants (RA) and eligible participants who did not consent were excluded from the study.
Service providers, Ministry of Health Uganda, and Implementing Partners: We purposively selected service providers in health facilities that were providing services to FSWs and these included clinicians, counselors, nurses, and pharmacists who worked directly with SWs at selected health facilities within the six districts along the Malaba-Kampala highway. In total, we recruited 12 service providers from six health facilities that were providing services for FSWs in the selected districts. We also purposively selected respondents from MoH Uganda (ACP = 2), IPs including technical officers (MARPs, AIC, Reach Out Mbuya, IDI, Mildmay, and TASO = 12), Politicians (RDCs, and Secretaries for Health = 6), and patrons = 6. We conducted a total of 6 FGDs with SWs (1 at every hot spot). The qualitative questions asked during the assessment focused on factors affecting implementation and suggestions on how to effectively implement HIV services models that are used to reach FSWs. We also explored the experiences, challenges, acceptability of community-based HIV testing service delivery models used to reach FSW.
Data collection
We recruited Research Assistants (RAs) who then recruited FSWs in the company of local contact persons such as peer FSWs, bar owners or brothel managers. We defined local contact persons as a member of the community who had regular interaction with FSWs, peer FSWs or a patron of a bar and other entertainment venues that FSWs usually frequented. The RAs were fluent in both English and the study area local languages and also had prior experience of working with FSWs. We used a semi-structured questionnaire and data abstraction tools (Supplementary material) to obtain information on the proportion of FSWs who had an HIV test in the last 12 months and those who were positive and linked into care under the different models mainly by self report or reviewing their medical record if available. We recruited both male and female RAs to cater for female SWs who were more comfortable with the opposite sex interviewing them. For the busy FSWs, we requested for appointments to match their convenient time.
In-addition, we assessed the respondents’ views on the challenges and factors which are crucial for the success of community-based HIV testing service delivery models using key informant interviews and focus group discussions. We translated the data collection tools into relevant local languages and back translated by other people without prior knowledge of the instrument in order to maintain the original meaning of the questions.
Data management and analysis
We entered and analyzed quantitative data in Epi-info 7. We used descriptive statistics to summarize participants’ demographic characteristics. Categorical variables were described using frequencies and percentages, while continuous variables were summarized using means (±SD) or medians (IQR).
For qualitative data, raw data from FGDs and KIIs– were recorded, translated, transcribed and typed in detail. In addition, field diaries from the data collection process, with records of any events deemed important for the interpretation of the results were also typed out and integrated for the data interpretation and analysis stage. After the data transcripts had been typed, we read through repeatedly to identify the codes and the emerging themes.
We analyzed qualitative data using the Thematic and Template Analysis (TA) approach (King, 2012; Braun & Clarke, 2006). For data management, we used the NVivo 10 software. Guided by the study objectives, the typed data transcripts were entered into the NVivo 10 software after which they were assigned specific codes that related to the theme or pattern they fell under (the template approach). Following this, we then reviewed and related the multiple emerging themes related to the study objectives and research questions for analysis to begin. In addition to use of the software, analysis for qualitative data was further guided by data from the field diaries which helped contextualize the data from verbal/audio sources. The process of coding took place in six phases to create established and meaningful patterns. These phases were: familiarization with data, generating initial codes, searching for themes among codes, reviewing themes, defining and naming themes, and finally writing the report.
Discussion
In this study conducted to assess the preference and uptake of community-based HIV testing service delivery models to FSWs, most of the FSWs had HCT services and were linked to care through static facilities compared to outreaches, and peer to peer mechanisms. Among the three community-based HIV testing service delivery models, FSWs preferred static facilities. Static facilities were preferred for reasons such as ensuring patient confidentiality, and services always being available whenever FSWs desired to have them. Despite the better performance of static facilities, they were also faced with challenges such as long waiting times to obtain services which discouraged some FSWs from accessing HIV testing services.
The limited performance of outreaches and peer to peer mechanisms could be attributed to business owners not willing to have such services conducted in their premises as it would disrupt business. Outreach services were also characterized by lack of trust in the results generated, irregular service provisions, and failure to offer all demanded services such as hepatitis B and syphilis testing to the FSWs.
However, all the models were faced with stock out of HIV test kits, failure to offer FSW friendly services, and stigma and discrimination among the FSWs. In order to reach the population-level impact of HIV prevention, HIV/AIDS programs among FSWs should also offer comprehensive services including how to overcome stigma and discrimination, FSW friendly, and sexually transmitted infection (STI) services. Health service providers should therefore strive to offer comprehensive and integrated health programs for FSWs [
7]. Additionally, there is need to implement the MoH Uganda STI/HIV prevention action plan that recommends screening and treating of all STIs among the MARPs including FSWs [
8].
According to a review conducted by Wilson, HIV/AIDS care programs for FSWs in low and middle income countries lack consistency and quality [
7]. Lack of consistency of outreach programs according to health care providers and documented literature may be due to the fact that most of such programs in low and middle income countries are donor dependent and are therefore prone to such challenges [
7,
9,
10]. Irregular provision of services makes it hard for health workers to be in touch with the FSWs hence making HIV testing and linkage to care a problem. This calls for local political will and increased domestic funding to ensure increased uptake of the FSW HIV testing programs.
The proportion of FSWs who had taken an HIV test is still below the 90–90-90 UNAIDS targets for HIV elimination where we want to have 90% of the people knowing their HIV status [
11]. The prevalence of HIV among the SWs reported by our study is consistent with the national prevalence at 35% [
12]. This prevalence is still high compared to the general populations’ at 6.2% [
11]. Linkage to care is important, of those who were HIV positive, majority were linked to care and more than 90% were on ART. The current national antiretroviral treatment guidelines require that every person including FSW found to be HIV positive should start ART regardless of their CD4 [
13].
Peer educators also reported poor facilitation or no facilitation. For interventions that target FSWs to be successful, there is need to compensate peer educators for the time spent offering services to colleagues in the same business.
Limitations
Our findings should be interpreted based on the biases that are inherent in sampling hard to reach populations and respondent driven sampling. We paid $4 to each of the FSWs as an incentive to participate in the study and also compensate for losses while interacting with the RAs. Given the generally poor economic status of most Ugandans, and the fact that most of the FSWs reported earning $3 or less per transaction act, it is possible that some of the respondents were not FSWs but other categories of persons attracted by the incentive attached to the study. However, chances of recruiting none FSWs were reduced by using RAs who had prior experience in working with the FSW population in Uganda. We also tested the incentive amount while piloting the study tool. Additionally, our study only focused on the number of FSWs who benefited from the different models. We did not do a cost analysis of how much it would cost to reach each female sex worker using the different models.
Acknowledgements
We would like to appreciate the technical support from the Uganda Public Health Fellowship Program and the MoH Uganda AIDS Control Programme during the execution of this study. We also appreciate the RAs’ Tenywa Ronald, Aliwebwa Prossy, Balisanyuka Joseph, and Nakayiza Barbara for their efforts during the data collection process.
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