Is knowledge of HIV status associated with sexual behaviours? A fixed effects analysis of a female sex worker cohort in urban Uganda

Abstract

Introduction Female sex workers (FSWs) have strong economic incentives for sexual risk‐taking behaviour. We test whether knowledge of HIV status affects such behaviours among FSWs. Methods We used longitudinal data from a FSW cohort in urban Uganda, which was formed as part of an HIV self‐testing trial with four months of follow‐up. Participants reported perceived knowledge of HIV status, number of clients per average working night, and consistent condom use with clients at baseline, one month, and four months. We measured the association between knowledge of HIV status and FSWs’ sexual behaviours using linear panel regressions with individual fixed effects, controlling for study round and calendar time. Results Most of the 960 participants tested for HIV during the observation period (95%) and experienced a change in knowledge of HIV status (71%). Knowledge of HIV status did not affect participants’ number of clients but did affect their consistent condom use. After controlling for individual fixed effects, study round and calendar month, knowledge of HIV‐negative status was associated with a significant increase in consistent condom use by 9.5 percentage points (95% CI 5.2 to 13.5, p < 0.001), while knowledge of HIV‐positive status was not associated with a significant change in consistent condom use (2.5 percentage points, 95% CI −8.0 to 3.1, p = 0.38). Conclusions In urban Uganda, FSWs engaged in safer sex with clients when they perceived that they themselves were not living with HIV. Even in communities with very high HIV prevalence, the majority of the population will test HIV‐negative. Our results thus imply that expansion of HIV testing programmes may serve as a behavioural HIV prevention measure among FSWs.

Perceived Knowledge of HIV-Negative Status Increases Condom Use Among Female Sex Workers in Zambian Transit Towns

“…The finding that knowledge of HIV-negative status significantly increases consistent condom use with clients is consistent with the findings from a similar study among a cohort of FSWs in urban Uganda, 35 but it contradicts much of the literature among members of the general population suggesting that knowledge of HIV-negative status does not affect HIV risk-related sexual behaviors. 2,3,[6][7][8][9][10] The suggestion that knowledge of HIV-positive status might also increase consistent condom use with clients is contradictory to the findings from the similar study among the Ugandan FSW cohort (which suggest that knowledge of HIV-positive status may decrease consistent condom use with clients), 35 but it is consistent with literature among members of the general population. 1,2,4,5,7,8,10 The observed increase in consistent condom use following knowledge of HIV-negative status is encouraging, as it indicates that FSWs in this setting are incentivized to engage in behaviors that decrease their risk of HIV acquisition.…”

“…This measurement approach has previously been used in other studies, including a similar study among FSWs in Uganda. 35 Our measurement of knowledge of HIV status in this study is participants' perceived knowledge of HIV status, which may not reflect participants' most recent HIV test result. Among our study participants, perceived HIV status may differ from actual HIV status for reasons including a new HIV risk encounter after recent HIV testing, mistrust of a new HIV testing technology (e.g., self-testing), and participation in an intervention believed to cure HIV infection (e.g., religious ceremony).…”

“…A recent study among an FSW cohort in Kampala, Uganda, for example, found that FSWs in this setting increased condom use with clients when they learned they were not living with HIV (presumably to prevent infection) and decreased condom use with clients when they learned they were living with HIV (presumably to earn more income). 35 With this study, we aim to understand the effect of knowledge of HIV status on HIV risk-related sexual behavior in a different cohort of FSWs that consists of individuals from three different Zambian transit towns: Livingstone, Chirundu, and Kapri Moposi. The FSWs in this setting differ from those in Kampala, because their clientele are primarily transient truck drivers and, at the time of the study, no health services catered to FSWs were available at these locations.…”

“But I Gathered My Courage”: HIV Self-Testing as a Pathway of Empowerment Among Ugandan Female Sex Workers

“…Learning one’s HIV status, whether positive or negative, can be an empowering process, but can also require a fundamental reshaping of one’s social identity. In a population at high HIV risk (such as FSWs in Sub-Saharan Africa), a majority will still test HIV-negative, despite subjective assumptions to the contrary ( Ortblad et al, 2019 ). In the present study, participants expressed fatalism regarding the inevitability of an HIV infection during the baseline interviews, but also surprise and reassurance following a (unexpected) negative test result at follow-up.…”

Unintended uses, meanings, and consequences: HIV self-testing among female sex workers in urban Uganda

“…Our findings are largely consistent with HIVST research in Uganda. Quantitative research with the same cohort of FSWs found that learning one's HIV status led to decreases in the severity of depressive symptoms (Ortblad et al, 2020) and knowledge of an HIVnegative status led to increases in condom use (Ortblad et al, 2019), both factors that may be at least partially explained by the qualitative data showing that HIVST sparked feelings of self-worth, and a desire to live healthy, full lives (Wachinger et al, 2020). A qualitative study among FSWs in Rakai, Uganda, which preempted the distribution of HIVST kits, found that FSWs perceived HIVST as advantageous because it bolsters privacy and convenience, but problematic because it circumvents formal counseling, which is echoed in our data stemming from actual experience (Burke et al, 2017).…”