Understanding how social support influences peer-delivered HIV prevention interventions among Ugandan female sex workers: a case study from HIV self-testing

Abstract

Background Female sex workers (FSWs) have tightly connected peer networks and remain at high risk of HIV acquisition. Peer delivery of HIV prevention interventions, such as HIV self-testing (HIVST), is a recommended implementation strategy for increasing intervention uptake and continuation among FSWs. We analyzed qualitative data from a peer-delivered HIVST intervention among FSWs in urban Uganda to understand the ways social support within this peer network can motivate or discourage the uptake of peer-delivered HIVST. Methods Between February and April 2017, we conducted in-depth interviews (IDIs) with FSWs (n = 30) and focus group discussions (FGDs) with FSW peer educators (PEs, n = 5) finishing participation in a four-month randomized implementation trial testing models of peer-delivered HIVST in Kampala. FSW participants were ≥ 18 years old, self-reported exchanging sex for money or goods (past month) and had not recently tested for HIV (past 3 months). FSW PEs either directly distributed HIVST kits to participants or provided coupons exchangeable for HIVST kits from specified healthcare facilities. In the IDIs and FGDs, we asked participants to share their experiences receiving or delivering peer-delivered HIVST, respectively. Using a hybrid deductive and inductive coding approach, we arranged findings along the dimensions of an established social support theory: informational, instrumental, and emotional support. Results The median age of participants was 30 years (IQR: 27–33) and PEs was 33 years (IQR: 29–37). We found that social support within FSW peer networks both motivated and discouraged uptake of peer-delivered HIVST. For example, sharing positive HIVST experiences (informational support), directly delivering HIVST kits (instrumental support), and encouraging linkage to care (emotional support) motivated HIVST uptake among FSWs. Conversely, the spread of misinformation (informational support), limited HIVST kit availability fostering mistrust of PEs (instrumental support), and fear of social exclusion following HIV status disclosure (emotional support) discouraged HIVST uptake among FSWs. Conclusions In Uganda, social support (e.g., informational, instrumental, and emotional support) among FSW peers can work in ways that both motivate and discourage peer-delivered intervention uptake. Future FSW peer-delivered HIV prevention interventions should be designed around the dimensions of social support within FSW peer networks to maximize initial and repeat intervention delivery and uptake.

Enrollment and retention of female sex workers in HIV care in health facilities in Mbarara city

“…It is reported in other studies that peer support with routine medical care is superior to routine clinic follow-up in improving outcomes for people living with HIV. The approach was also recommended as feasible and effective for linking and retaining HIV-positive sex workers to HIV care, which can help HCWs shoulder existing services ( 21 , 22 ).…”

“…HIV counseling is key in the fight against stigma and in improving retention and enrollment in HIV care. With the best counseling services, FSWs reported willingness to start ART ( 21 , 23 ). Therefore, the HCWs, in addition to clinical knowledge, should be equipped with knowledge and skills on how to provide HIV care services to FSWs living with HIV.…”

Findings from the Tushirikiane mobile health (mHealth) HIV self‐testing pragmatic trial with refugee adolescents and youth living in informal settlements in Kampala, Uganda

“…Hence, peer support may be important alongside HIVST for reducing stigma among urban refugee youth who may experience disrupted social networks [ 67 ] and intersecting stigma [ 8 ]. Studies have similarly documented preferences for peer support with HIVST in Uganda, including among gay, bMSM [ 68 , 69 ] and sex workers [ 70 ]. Our findings can inform stigma‐informed approaches to HIVST implementation and trial design.…”

Social Network Strategies to Distribute HIV Self-testing Kits: A Global Systematic Review and Network Meta-analysis

“…Second, more efficient distribution strategies for peer educators should be further explored, considering economic costs and incorporating the dynamics of relationships within the social networks of the target population. Future HIV prevention interventions could be carried out in partnership with the community to identify trusted and knowledgeable peer educators and train them to be most effective [67]. Finally, along with increasing testing for early detection of people living with HIV, emphasis should be placed on increasing access to ART or HIV care among at-risk populations.…”