In the past decade, sub-Saharan Africa, the region most affected by HIV/AIDS, has witnessed a decline in overall HIV incidence of over 25%.1 In Benin, HIV prevalence estimates went from 2.0% in 2002 to 1.2% in 2012.2 Among female sex workers (FSWs), the prevalence decreased significantly from 40.6% in 1999 to 26.5% a decade later, thanks to the preventive interventions prioritizing FSWs and their clients.3,4 To bolster this downward trend, FSWs need sustained resource allocation and greater attention from programs or interventions to reduce sub-Saharan Africa's HIV burden.5–8
Promoting and improving FSWs' access to regular voluntary counseling and testing is a key component in fighting HIV/AIDS in sub-Saharan Africa.3 The growing importance of testing follows a paradigm shift, specifically from that of “testing for survival,” assuming that with appropriate counseling and treatment, an infected individual can live a longer and healthier life, to the “testing for prevention” paradigm, presenting new ways to address the problem. These approaches include the prevention of mother-to-child transmission, “treatment as prevention,” which is the early treatment of HIV-infected individuals to prevent transmission and pre-exposure prophylaxis administered to uninfected people at very high risk of HIV infection, such as FSWs or individual having an HIV positive partner. Although highly promising, these preventive approaches are mainly dependent on access to and use of testing and care services.
However, improving FSWs' access to and use of testing services is challenging. Indeed, these women often work and live in a context characterized by gender inequity, violence, exploitation, vulnerability, stigmatization, mobility, and poverty.5,9–11 Therefore, the traditional clinical and public health avenues to promote regular testing and care for HIV and sexually transmitted infections (STIs), based on the availability of free testing and care services or on mass media for health education and testing awareness, sometimes fail to have a significant or lasting impact on this atypical population.7,9,12,13 Thus, the use of various outreach strategies for FSWs in recent decades, in addition to the clinical and public health interventions, has had considerable success, despite the particular environmental, psychosocial, cultural, and socioeconomic context of sex work.5,10,14
Outreach strategies frequently used with FSWs, which have here been evaluated specifically for their potential to improve regular testing behavior can be divided into 3 main categories: (1) community mobilization interventions,5,10,15–17 (2) community worker-based and peer educator–based interventions,5,9,10,18–24 and (3) advanced strategies for testing and care.11,25,26 In Benin,“Projet SIDA-1/2/3” (from 1992 to 2006), hereinafter referred to as SIDA-3, a leading intervention and quantitative research program aiming to reduce HIV/STI infections among FSWs, tested a multifaceted strategy, including all of those outreach activities.4,27–29 The presence of the SIDA-3 interventions in the research area will allow documenting retrospectively the potential effect of some outreach interventions on HIV testing behavior as self-reported by FSWs. The SIDA-3 program design, methodology, results, and its outreach components have been described in detail elsewhere.29
Community mobilization interventions' main objective is to transform a group of individuals into a collective entity.30 Community mobilization (transformative communication, behavior change communication, support/empowerment groups, etc.) mainly aims to improve knowledge and self-efficacy, promote social transformation, increase autonomy, reduce violence, and decrease HIV risk-taking, primarily through the empowerment of FSWs.9,16,18 However, this kind of strategy works mainly when administered by peers or well-accepted community workers and requires good access to prevention methods and care so that the promoted behavior can be effectively adopted.18,30
Community worker- and peer-educator–based interventions have proven useful in knowledge improvement, behavioral changes, and lowering the rate of infection.9,21,22,31 Those strategies' impact stems from their greater proximity to the community.22 Indeed, they more easily achieve a relationship of trust with the communities, allowing open discussions on sensitive issues, and greater access to hidden populations, such as the women who resort to sex work occasionally or in a more clandestine fashion, who are otherwise difficult to reach.22 They can work in group sessions or in a one-to-one approach. Moreover, their proximity allows them to distribute condoms and awareness/education tools remind FSWs to go to the health center, refer FSWs with HIV/STI symptoms, and escort FSWs to the health center, and this also enables them to get back in touch with HIV positive FSWs otherwise lost to follow-up.21,23 The effectiveness of this strategy depends partly on good access to care.18,21,22,32
Finally, outreach clinics or other advanced strategies for testing and care include home-/work-based testing/care for HIV/STIs offered either by professional or lay health care workers (HCWs) through regular or rapid HIV tests and periodic presumptive treatment and syndromic case management for curable STIs.11,25,26,31,33 These strategies considerably improve access to care that normally entails distance and travel costs and help reduce the barrier to care utilization resulting from fear of being recognized as a FSW by other community members or the apprehension of stigmatization and marginalization that might be encountered in clinics.11,25,26,31 This strategy might be needed when community-based sexual health promotion activities or community worker and peer educator approaches have motivated a change in behavior like getting regular HIV testing but individuals are still reluctant to take action because of the above-mentioned accessibility barriers.
Although promising in Benin and for all sub-Saharan countries facing similar challenges regarding the regular use of testing and counseling services adding one or several of those outreach interventions to the existing biomedical and clinical activities always implies greater expense and energy expenditure for a given intervention program. Thus, the intervention must suit the characteristics and acceptability criteria of the targeted communities and fulfill their specific needs to avoid wasting resources due to technical inefficiency.7,12,33,34
The objective of this article is to examine the potential of 3 different categories of outreach intervention to increase the use of testing services in Benin. To do this, we have developed our analysis around 3 central questions: (1) What are the Beninese FSW population's specific needs regarding testing services that would justify the use of an adjunct outreach intervention? (2) What is the general appreciation of outreach interventions according to FSWs and HCWs who experienced them in their work with FSWs? and (3) What factors, present in our study population, may impede the use of the different outreach intervention?
These analyses are based on ethnographic fieldwork in Benin from June to December 2012 as part of the study Health Equity for FSWs, a quantitative and qualitative inquiry exploring sexual behavior and history of STIs and the context of sex work and issues related to sexual and reproductive health of FSW. The qualitative study took place in 10 municipalities covering 7 departments (Table 1). HCW participants were recruited from the same areas except Ouidah because the adapted center of that region was not functioning at the moment of the study. Four of these municipalities have experienced outreach components of project SIDA-3.
FSWs were recruited in varied sex work venues, regardless of whether they were professional sex workers (main source of revenue) often working in brothels, or occasional or clandestine sex workers (hereafter called occasional FSWs) on the street, in hotels, or in buvettes (a snack bar serving soft and/or alcoholic beverages) where some work initially as waitresses. Women were identified and approached by the community workers and peers educators who work directly with those women on a daily basis. HCWs were also chosen to represent a variety of health workers, including doctors, nurses, midwives and community workers.
Individual semistructured interviews of about 1 hour were conducted by Benin researchers with each participant, using interview grids to lead exchanges. They covered the context of sex work, sexual and reproductive health, HIV testing, and use of health care services, medical history related to HIV and STIs, knowledge, and health needs. For HCWs, we added questions about their work with FSWs and the problems they regularly encounter. When applicable, the participant's local dialect was used.
The data were extracted from the verbatim record of both FSWs and HCWs for the analysis to highlight: (1) the needs prompting the use of each type of outreach intervention according to the theoretical effect of each one, (2) the opinion of FSWs and HCWs on those outreach interventions, and (3) the presence of favorable conditions for those interventions' optimal effects. The conceptual framework used is summarized in Table 2. Results are presented separately for FSWs and HCWs.
Sixty-six FSWs and 24 HCWs were interviewed. Most participating FSWs were either professional FSWs working mainly in brothels (62%) or occasional FSWs working primarily as waitresses in buvettes (21%). Table 1 shows the baseline sociodemographic characteristics of the participating FSWs. HCWs interviewed were working with FSWs as nurses (8), midwives (6), community workers (5), doctors (3), and auxiliary nurses (2). In all groups, occasional or overt, the majority of FSWs (65%) were foreign-born (Table 1).
Specific Needs Justifying the Use of an Outreach Intervention
Less than half of all FSW participants (46%) reported being tested for HIV regularly, at least once every 6 months, although more (both professional and occasional) were tested in the SIDA-3 intervention areas (Table 3). Thirty-three women (50%) reported being tested only occasionally during a prenatal consultation, after the onset of STI symptoms, through special testing activities or before having unprotected sex with a regular partner. More than a quarter of the women (26%) said they did not know their current HIV status, because they had never been tested for HIV or their test results did not seem clear to them or because they have not been tested recently. This was truer of clandestine FSWs than overt FSWs. There were fewer professional FSWs presenting an unknown status in the SIDA-3 intervention areas (9%) than elsewhere (23%).
FSWs' Needs and Problems Regarding Voluntary Testing
Participants offered several explanations for why they do not get tested regularly. Among the most frequently cited were lack of personal motivation to get tested and limited access to health care. The lack of personal motivation to be tested stems from fear of receiving a possible positive result or the fact they were not feeling sick and did not see the importance of being tested (30%). In addition, lack of access to health care and the negative perception of the quality of care were mentioned by 43% of participating FSWs as an important barrier to HIV testing. This woman explained:
“They don't even have drugs there. They only give us some paracetamol or expired drugs. What can we do with these?! […] It's a community worker from [name of NGO] that led me there, but I'm not going to go anymore. I refuse. Hmmm…” (Professional FSW, Porto-Novo).
HCWs' Needs and Problems Faced During Interventions With FSWs
Participating HCWs highlighted different problems regularly encountered in their work with FSWs. These problems stem from FSWs' general attitude and behavior in the clinic. Talking about the main characteristics of FSWs that may impede the consultation process, 44% of HCWs cited the fact that these women, mostly occasional FSWs, do not like disclosing their occupation or being recognized as FSWs in clinics, a situation that may affect the adaptation of the care provided to the reality of FSWs:
“You know, those women don't come here to us like that! It is during the interview that we detect that they are doing the sex work. […] They come in private like any regular user for a simple infection. They don't like it when we know they are doing this work there. Because they are working clandestinely, […] they will never come to tell us it's that work they do…never!”(Nurse, Cotonou).
In addition, participating HCWs reported problems with their high mobility (difficulties with follow-up) and communication challenges, with migrant FSWs speaking foreign languages (36%).
Appreciation of Outreach Components of SIDA-3
During interviews, half of FSW participants spontaneously cited 1 or more outreach strategies as contributing greatly to enhancing their own positive testing behavior.
Community mobilization interventions were mentioned by 15 women (23%) as an efficient driver for their testing behavior. However, among these 15 women, 12 cited one or more other outreach facilitators, in addition to the community mobilization interventions, as also responsible for improving testing awareness and empowerment. The majority of them evoked the direct solicitation by peer educators and community workers, who, in addition to carrying out other group-based community mobilization activities, come to the sites to personally encourage every woman to get tested for HIV. This strategy was reported by nearly half (47%) of all FSWs undergoing regular testing as a major motivation in their behavior:
“Some people [peer educators] came here to sensitize us. They gave us a referral slip and asked us to go to the medical center for testing and health care” (Occasional FSW, Bohicon).
Finally, the facilitators mentioned included advanced testing strategies, such as home-/work-based testing. For 12% of the women, advanced strategies were the only opportunity and main motivation to undergo an HIV test. These women explained:
“I once did the test, because it is the doctors who came here to do the screening. It was not my doing I got tested; it is because of the doctors who came up to us” (Professional, FSW, Dassa-Zoumè).
“Some health agents from [name of hospital] also came to do the test in the house here. The last test we did was about three months ago.” (Professional FSW, Cotonou).
These women asked for additional peer-based outreach activities or advanced strategies for testing. Some outreach strategies were also cited by HCWs as effective in improving their proximity to FSWs and making testing and the provision of care easier for these highly mobile women. Those outreach strategies are the advanced strategies (meeting at the sites of prostitution or at the home of the FSW) (24%) and collaboration with peer educators and community workers for community outreach (16%). Despite these interventions' great popularity among FSWs, 40% of HCWs interviewed noted and explicitly deplored the general reduction in outreach activities, alongside with frequent stockouts in HIV testing reagents that have happened since the termination of project SIDA-3.
Factors That May Impede the Use of the Different Outreach Interventions
The overall social cohesion or community capacity was rather poor in our study areas according to their social characteristics. For instance, among FSW participants, 74% changed their work location at least once in the past year. Occasional FSWs are extremely mobile (86%), staying on a given site only briefly, usually for around 6 months, before moving to another location. Thirty six percent of participants described the relationship between FSWs at work as being rather negative, regardless of the type of site, and 60% of participating FSWs reported experiencing violence on sites and among themselves.
To ensure progress in the fight against HIV/AIDS, regular voluntary testing is essential. This study examined the appropriateness and limitations of different outreach activities as adjunct tools to increase the use of HIV-testing services in predicting the future use of preventive interventions based on the administration of antiretroviral drugs like treatment as prevention or pre-exposure prophylaxis.3 These activities were analyzed in the light of the main FSW characteristics and needs relative to HIV testing. There was also an attempt to evaluate the interest manifested spontaneously by them, and by HCWs, toward different types of outreach activities, either by evoking positive experiences of those activities from SIDA-3 or by requesting them as potential solutions.
About the Needs That Justifies the Use of an Adjunct Outreach Intervention
FSW and HCW narratives allowed us to identify 3 main factors or needs that apparently hinder the development of appropriate HIV testing behavior among women tested only sporadically. They confirm the findings of other studies conducted in a similar context.9,21,35–39 Those negative factors can be positioned along a continuum of health care behaviors, with each stage of this continuum presenting its own challenges: fear and lack of motivation to decide to accept treatment; lack of accessibility to care when the decision to accept it has been made; and a perceived lack of quality of care at the health care center.
Personal motivation factors leading to the decision to not use HIV testing services reflect both a general lack of awareness about the importance of getting tested and insufficient support in going through the testing process.5,10,15–17 Thus, they highlight the need for outreach interventions with health promotion/education provided by community workers and/or peer educators.5,10,15–17 Results also showed that half of the participating FSWs specifically referred to direct solicitation by community workers and peer educators for HIV testing, confirming previous findings that it is an effective means to enhance their own positive testing behavior.4
Additionally, it seems clear that some structural barriers related to access to health care and fear of stigmatization impede positive testing behavior among FSWs who are aware of the importance of testing uptake, a situation that emphasizes the urgent need to implement advanced strategies for testing and care.11,25,26 Outreach services involving advanced strategies were suggested by both FSWs and HCWs as an effective way to overcome lack of access to HIV testing. Significantly, for some women, this was the only opportunity for testing uptake, and several women explicitly said they had lacked the necessary motivation both to overcome the distance and lack of time and to conquer the fear of stigma that arises with a visit to the clinic where they might be revealed as sex workers.
For their part, HCWs mentioned problems principally tied to a lack of access for occasional FSWs and the establishment of a relationship of trust with those women for long-term follow-up. These problems appeared clearly as HCWs stated that FSWs do not openly disclose their sex work and are very mobile, constantly moving to new locations, or coming from foreign countries. Here again, community workers and peer-based interventions appear to be an appropriate solution.5,9,10,18–24 Moreover, a third of all HCWs specifically evoked peer-based interventions along with the advanced strategies as facilitators to support their clinical work with FSWs.
Many of the needs mentioned above seem to be addressed by these outreach and proximity strategies (Table 4). Indeed, they function as much in terms of improved knowledge transfer about testing activities as they do in providing better support for women who can be less motivated to get tested and offering them greater access to care.
General Appreciation of Outreach Interventions
Our qualitative study indicates a marked difference between the self-reported testing behavior and HIV status knowledge of professional FSWs recruited from the SIDA-3 areas and those from elsewhere. FSWs from the SIDA-3 areas reported better testing behavior. These results are consistent with the quantitative analysis of the effects of SIDA-3 on the use of testing services and HIV prevalence in areas covered by this project4 and with other similar setting, which had community mobilization activities provided by fieldworkers and peer educators as principal outreach components.19
On this point, half of the FSW participants confirmed their appreciation of at least 1 outreach strategies during interviews. HCWs, for their part, mainly evoked the advanced strategies and their collaboration with peer educators and community workers for community outreach as good outreach interventions and specifically ask for more of those interventions. However, the results also exposed some potential limitations of these types of outreach strategies in this specific setting (Table 5).
About the Factors That Might Impedes the Use of Outreach Interventions
Community mobilization interventions are more effective in socially cohesive groups or those with community capacity; this may facilitate bonding and empowerment.30,37 Even if those strategies might also serve to enhance social cohesion9,18 and create a more favorable and supportive environment,5,19,39 they are more successfully implemented in stable groups that already possess good social relationships, sufficient interpersonal trust, reciprocity, and a certain sense of community belonging.30 Our data, however, depicted a more torn social fabric because of the high rate of immigrant women, bad relationships and violence among FSWs, the occasional and clandestine sex work, and, above all, high mobility. Therefore, such group-based approaches might be less appropriate.
Regarding community worker- and peer-based interventions, as reported in other studies, the lack of access to high quality services appeared to be a major limitation.18,21,32 Even if these direct solicitation activities seemed to enhance FSWs' testing attitude and intended behavior, our results suggest that ultimately, some women were disappointed as they perceived a major difference in the depicted services and quality of the actual clinical offer, which suffers from testing reagent and other consumable shortages.29 In addition, it may have a negative impact on the relationship of trust between the women and the outreach actors (peer educators or community workers) who promote the use of these services.9,18,32
The advanced strategy could help mitigate some limitations of the peer-based approach by improving the testing service offer.11,26 Therefore, by providing good access and appropriate care, community workers and peer educators may keep their privileged access to provide health education and counseling to the key population, in both occasional and professional FSWs' usual workplaces.
In summary, to increase the use of testing services, an outreach strategy based on community workers or peer educators, paired with improved access to testing services, either by means of an advanced strategy or by strengthening the capacity and accessibility of health centers, would be well suited to this context largely characterized by violence, vulnerability, stigma, and mobility and would be welcomed by both the FSWs and HCWs.
The authors are indebted to the interviewers whose dedication made this study possible. Above all, they wish to thank all the participants in this study for their time and openness to share their experiences.
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