Designing PrEP and early HIV treatment interventions for implementation among female sex workers in South Africa: developing and learning from a formative research process

Abstract

ObjectivesThe objective of this research was to design relevant, tailored oral pre-exposure prophylaxis (PrEP) and early antiretroviral (ART) interventions for female sex workers (FSWs) in South Africa. This paper examines the methods, process and outcomes of employing an inductive approach to formative research exploring intervention feasibility and acceptability.SettingResearch was conducted in several sex work-related settings including five sites in and around clinics and stakeholder offices.ParticipantsParticipants in this research included stakeholders, experts in the field and FSWs. This included at least 25 separate engagements, 14 local organisations and 8 focus group discussions (FGDs) with 69 participants, in addition to ad hoc meetings.ResultsThe first set of outcomes consisted of five selected methods: (1) stakeholder consultations; (2) site assessments and selection; (3) field observations and mapping; (4) development of supportive structures to encourage retention and intervention adherence; (5) FGDs conducted with FSWs to explore specifics of acceptability. In terms of feasibility, two sites were selected in central Johannesburg and Pretoria out of five considered. The urban site contexts varied, necessitating adjustments to intervention implementation. There was overall support for PrEP and early ART from stakeholders and FSWs. Concerns included potential issues with adherence to PrEP (and early ART), possible reduction in condom use, resistance to antiretrovirals and burden on scarce resources. These concerns indicated where special attention should be focused on education, messaging and programming as well as development of supportive structures.ConclusionsThe inductive approach allowed for a wide range of perspectives, defining population needs and accessibility. This research illustrated how similar sex work environments can vary and how implementation of interventions may not be uniform across contexts. Lessons learnt in details could assist in future project designs and implementation of new interventions where feasibility, social and cultural factors affecting acceptability must be considered.

“The Drug Will Help Protect My Tomorrow”: Perceptions of Integrating PrEP into HIV Prevention Behaviors Among Female Sex Workers in Lilongwe, Malawi

“…Although motivated to use PrEP, participants in our study noted adherence, stigma, and side effects as perceived barriers affecting their uptake and continued PrEP use, which was also found among FSW in Kenya and South Africa (Eakle et al, 2018; Restar et al, 2017). A study of serial interviews with FSW in South Africa also found FSW had concerns regarding adherence, but that over time participants became more committed to adherence PrEP and developed strategies and support systems (Eakle et al, 2019).…”

“…Most participants found PrEP acceptable and were highly motivated to use it. These findings contribute to the growing body of qualitative data indicating that FSW in sub-Saharan with high perceived susceptibility to HIV find PrEP highly acceptable and are hypothetically willing to use it (Eakle et al, 2018; Restar et al, 2017; Van der Elst et al, 2013). Participants in our study described employing a variety of HIV preventive behaviors, including condom use and STI testing, extensive knowledge on HIV, and feeling highly susceptible to HIV.…”

“I am still negative”: Female sex workers’ perspectives on uptake and use of daily pre-exposure prophylaxis for HIV prevention in South Africa

“…It is difficult to assess why participants drop out over time when they do not provide specific reasons themselves. However, based on what we learned here and what was learned in earlier research preparing for the TAPS study [25,26], it is likely that a combination of social dynamics around belief in PrEP and its efficacy (including stigmatization of taking ARVs as a sign of illness), personal risk assessment which may fluctuate over time, personal responsibilities which supersede clinic visits and participation in research, and potential issues with substance use probably contributed to retention. For these reasons and to further unpack the dropout seen in TAPS to help support PrEP programming, additional research is being considered to potentially interview women who were lost to follow up, to determine the reasons.…”

“…Initial interview guides were developed based on findings from a systematic review of qualitative evidence on women’s perspectives on use of female-initiated prevention products in sub-Saharan Africa [23,24], as well as results from formative research conducted in preparation for TAPS [25], including focus group discussions with potential users [26]. The premise and structure of the interview guides were based on the Modified Social-Ecological Model (MSEM) designed by Baral et al [27] to facilitate a holistic and broad inquiry.…”

Exploring acceptability of oral PrEP prior to implementation among female sex workers in South Africa

“…These services include: HIV counselling and testing and condom distribution, NIMART (nurse‐initiated and managed antiretroviral treatment), tuberculosis screening, HPV screening, clinical services for minor ailments, psychosocial support, and referrals to both clinical and legal services. The clinics, services and programme are described in further detail in several other publications, including a detailed account of the formative research conducted during the design of the TAPS project .…”