HIV Self-Testing & Female Sex Workers: An Exploration of Delivery Models, Test Performance, and Behavioral Change in Sub-Saharan Africa

Abstract

Female sex workers (FSWs) are a priority population for HIV prevention interventions, yet they face barriers to HIV testing that may be addressed by HIV self-testing. The effectiveness of HIV self-testing among FSWs may depend on how self-tests are delivered and how well FSWs can interpret self-test results. Knowledge of HIV status, acquired through testing, may uniquely affect FSWs’ sexual behaviors because of their economic incentives for many sexual partners and the provision of condomless sex. A cluster-randomized controlled trial was conducted among FSWs in Kampala, Uganda to measure the effect of HIV self-testing delivery models on recent and repeat HIV testing. Groups of one peer educator and eight FSWs were 1:1:1 randomized to: (1) direct provision of HIV self-tests, (2) provision of coupons for free facility collection of HIV self-tests, or (3) referral to standard-of-care HIV testing services. Participants in the intervention arms received two self-tests or coupons, one shortly after enrollment and another three months later. Participants completed baseline, one-month, and four-month assessments. At four months, participants in the intervention arms interpreted images of self-test results. Individual longitudinal data and linear regression models with individual fixed effects were used to measure the effect of HIV status knowledge on FSWs’ sexual behaviors. FSWs in the HIV self-testing intervention arms were significantly more likely to test and re-test for HIV compared to those in the standard-of-care arm. The delivery of HIV self-tests mattered; direct provision was more effective than facility collection. Misinterpretation of HIV self-test results was common despite pre-test training and two opportunities to self-test. Knowledge of HIV status did not affect FSWs’ number of clients, but knowledge of HIV-negative status significantly increased FSWs’ consistent condom use with clients. HIV self-testing can help Kampala-based FSWs regularly test for HIV. For the best HIV testing outcomes, FSWs should receive self-tests directly from a peer educator and support should be available for interpretation of self-test results. Knowledge of HIV-negative status an additional HIV prevention intervention for FSWs. Ministries of health should consider targeted HIV testing interventions for FSWs to reduce population HIV transmission.