HIV self-testing services for female sex workers, Zimbabwe and Malawi

Objective To present findings from implementation and scale-up of human immunodeficiency virus (HIV) self-testing programmes for female sex workers in Malawi and Zimbabwe, 2013–2018. Methods In Zimbabwe, we carried out formative research to assess the acceptability and accuracy of HIV self-testing. During implementation we evaluated sex workers’ preferences for and feasibility of distribution of test kits before the programme was scaled-up. In Malawi, we conducted a rapid ethnographic assessment to explore the context and needs of female sex workers and resources available, leading to a workshop to define the distribution approach for test kits. Once distribution was implemented, we conducted a process evaluation and established a system for monitoring social harm. Findings In Zimbabwe, female sex workers were able to accurately self-test. The preference study helped to refine systems for national scale-up through existing services for female sex workers. The qualitative data helped to identify additional distribution strategies and mediate potential social harm to women. In Malawi, peer distribution of test kits was the preferred strategy. We identified some incidents of social harm among peer distributors and female sex workers, as well as supply-side barriers to implementation which hindered uptake of testing. Publication: Bulletin of the World Health Organization; Type: Research Article ID: BLT.18. 223560 Page 2 of 23 Conclusion Involving female sex workers in planning and ongoing implementation of HIV self-testing is essential, along with strategies to mitigate potential harm. Optimal strategies for distribution and post-test support are contextspecific and need to consider existing support for female sex workers and levels of trust and cohesion within their communities. Introduction Female sex workers are a marginalized group who are disproportionately affected by human immunodeficiency virus (HIV) infection. Despite reduction in HIV infections in the general population, the prevalence and incidence of HIV among female sex workers remain extremely high. In sub-Saharan Africa the proportion of HIV infection in the general female population that is attributable to sex work is estimated to be 17.8% (upper to lower estimates obtained from sensitivity analysis: 13.6–22.1%). Due to multiple barriers, female sex workers underuse HIV services, including HIV testing services. Increasing the engagement of female sex workers in HIV testing services is the first step towards prevention and care services that will minimize health inequity. Increasing timely initiation of antiretroviral therapy (ART) should reduce morbidity for these women and onward HIV transmission to partners and clients of sex workers. Self-testing for HIV may be particularly appropriate for female sex workers as an additional testing option. Female sex workers need, and often desire, frequent re-testing and typically have high knowledge of HIV. HIV self-testing has been shown to be acceptable and feasible for female sex workers and to increase the uptake of testing. Self-testing may improve the efficiency of testing among both female sex workers and health-care providers. Modelling studies in Zimbabwe demonstrated that increasing HIV testing among female sex workers could be one of the most cost–effective uses of HIV self-testing. Secondary distribution of kits to other female sex workers and sexual partners is also feasible. A study in Uganda showed that, similar to general populations, HIV test sensitivity among female sex workers can be low when test kits are distributed without support for carrying out the self-test. A concern for this high HIV-incidence population is the limited analytical sensitivity of HIV self-testing for detecting early infection in female sex workers, especially among those taking pre-exposure prophylaxis. HIV self-testing may facilitate testing among sex workers’ peer and sexual networks, but this may also make the method more prone to coercive misuse than other testing strategies. The feasibility of scaling-up HIV self-testing programmes for female sex workers is of interest to national HIV programmes. However, the optimal models for distributing kits Publication: Bulletin of the World Health Organization; Type: Research Article ID: BLT.18. 223560 Page 3 of 23 and providing support for women needing confirmatory testing remain undefined, and balancing the potential risks and benefits of self-testing is needed in this context. We have conducted HIV self-testing implementation research among female sex workers in Malawi and Zimbabwe. Zimbabwe has one of the few nationally scaled programmes for female sex workers in Africa (Sisters with a Voice), established in 2009. The Sisters clinics are co-located within government services in convenient, discreet locations, with staff trained to maintain a friendly and non-judgemental environment. Services are supported by a network of peer educators. To date over 65 000 women have received services nationwide. The National HIV/AIDS Programme in Malawi, by contrast, has focused on meeting general population needs through public clinic-based services that exemplify a public health approach. There has been little focus on the specific needs of key populations in Malawi until dedicated funding for services for female sex workers became available in 2015. We present and compare findings from programmes for implementation of HIV selftesting for female sex workers in these two countries. We discuss similarities and differences, lessons learnt, knowledge gaps and the feasibility of scaling-up HIV self-testing programming for female sex workers. Methods The settings for the studies in Malawi and Zimbabwe are shown in Box 1. In Table 1 we summarize the research methods and dates in the development of HIV self-testing programmes by the three phases: (i) formative assessment, (ii) implementation and (iii) scaleup. All research was reviewed and approved by the relevant institutional review boards for each country. Formative assessment phase In Zimbabwe, the formative research initially aimed to assess the acceptability and accuracy of HIV self-testing. From November to December 2013 we surveyed a representative sample of female sex workers from 14 sites nationally and asked about the hypothetical acceptability of HIV self-testing. Additional formative research in August to September 2015 aimed to evaluate self-testing accuracy among a convenience sample of female sex workers attending a Sisters clinic in Harare for HIV testing. Women were provided with validated pictorial instructions for use and a video demonstration. Self-test results were compared with confirmatory test results conducted by a health-care provider. Publication: Bulletin of the World Health Organization; Type: Research Article ID: BLT.18. 223560 Page 4 of 23 In Malawi, little existing information was available on the population and lifestyle of female sex workers. Our formative research therefore aimed to explore the context and needs of female sex workers and to define the distribution approach for HIV self-testing. We conducted a rapid ethnographic assessment of female sex workers from January to June 2016. This assessment was followed by a participatory workshop in September 2016 with various stakeholders, including female sex workers, to present the results of formative research and invite input on the proposed peer-distribution model. Implementation phase As a first step towards implementation of routine HIV self-testing in Zimbabwe, we conducted an observational study from November 2015 to April 2016 of all female sex workers who presented at the Sisters clinic in Harare. We assessed their preferences for HIV self-testing versus standard provider-delivered testing. We also carried out in-depth interviews with women selected from among those who opted for self-testing, to explore their preferences around distribution and support strategies. In Malawi the peer-distribution model proposed in the formative research was implemented, whereby self-testing kits are distributed by other sex workers. During the implementation phase, from February 2017 to July 2017, we conducted a descriptive analysis of the uptake of self-testing kits and use of post-test support. We explored the acceptability and feasibility of the peer-distribution model though a process evaluation with focus group discussions with female sex workers and peer distributors. Once self-testing distribution was initiated, we established a parallel system for social harm monitoring and reporting through cross-sectional surveys and event diary reporting by female sex workers who received test kits, carried out from February 2017 to November 2017. Scale-up phase To date, only Zimbabwe has scaled-up HIV self-testing services, starting in October 2016. Distribution via community outreach began in September 2017, and secondary distribution of self-test kits for sexual partners was introduced in October 2017. We analysed routine programme data through September 2018 to describe uptake of self-testing by female sex workers, and the number of self-test kits which female sex workers accepted for secondary distribution to their regular partners or clients. During this period, we explored additional approaches to HIV self-testing service provision in Zimbabwe through focus group discussions with stakeholders, including female sex workers, peer educators and service providers. Publication: Bulletin of the World Health Organization; Type: Research Article ID: BLT.18. 223560 Page 5 of 23 Results Formative assessment phase