title: Understanding empowerment and vulnerability through engagement with HIV self-testing among female sex workers in Blantyre, Malawi
Creators: name: Lora, Wezzie Stephanie
Publisher: name: University of Liverpool Repository
Year: 2021

description: My thesis presents a discussion of the concepts of vulnerability and empowerment in research exploring female sex workers’ (FSW) engagement with HIV Self-testing (HIVST). HIVST is regarded as an ‘empowering innovative approach’ to HIV testing; however, there are concerns that HIVST may generate unintended consequences, especially in the context of sex work. Despite optimism around HIVST, no studies exist to date exploring how HIVST ‘empowers’ FSW in settings constrained by political and structural barriers. There is a need to interrogate whether HIVST could increase vulnerability/empowerment among FSW given the existing barriers and the burden of responsibilities of HIV protection. I draw and reflect on a range of theoretical perspectives on sex work, power, vulnerabilities and empowerment and apply them to FSW’s interaction with HIVST in the context of Blantyre, Malawi. I aimed to explore how FSW engage with HIVST and the extent to which this engagement contributes to their vulnerability or provide opportunities for empowerment. I conducted my research in peri-urban Blantyre where HIVST was implemented as part of a large scale study. I used ethnography and participatory research methods to address the following three key research questions: 1) What constitutes FSW’s vulnerability and empowerment, including perceptions of HIV risk in the sex work environment? 2) How does the sex work context shape FSW’s experiences with HIVST and the meaning of empowerment? 3) How does HIVST impact on FSW’s lives in relation to HIV prevention, treatment and care? Overall, I found that FSW exercise limited power across their life course, although their narratives highlighted both their sense of agency and the societal structural forces shaping their decisions to engage and remain in sex work. Whilst FSW clearly exercised agency in entering sex work, this was done in a context of severely constrained choices shaped by gender relations and the global-local political economy. The delivery of HIVST has the potential to increase FSW’s decision making power over when and where to test for HIV. However, the specific power relations and vulnerabilities vary in sex work contexts because, for some, the power to decide to test was not increased; for others, feelings of insecurity and a sense of the need for retesting were amplified. High (re)testing rates among FSW indicate that knowledge of the risk of HIV infection was high, though not translated into HIV prevention. These findings challenge the current narrative that HIVST alone will reduce the HIV testing gap or increase access, treatment and care, and prevent onward HIV transmission. In conclusion, it is important to attend to the complexities of the political economy forces, public and public health discourses, gendered power relations, and FSW’s voices at the site of the intervention. Therefore, implementers should strategically reconsider the delivery model for HIVST, as testing in some sex work locations creates power dynamics leading to coercive testing, and sometimes resulting in resistance from some FSW. As this is the case, HIVST should be implemented in the context of efforts to build wider trusting relationships between providers and FSW and to reduce widespread stigma and unequal power relations.