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

McMahon, Shannon A.; Musoke, Daniel Kibuuka; Wachinger, Jonas; Nakitende, Aidah; Amongin, Jocelyn; Nanyiri, Esther; Turcotte-Tremblay, Anne-Marie; Oldenburg, Catherine E.; Bärnighausen, Till; Ortblad, Katrina F

doi:10.1080/09540121.2020.1837722

Cited by 11 publications

(10 citation statements)

References 23 publications

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“…These findings highlight the complexity of utilizing word-of-mouth peer systems to disseminate intervention information, thereby emphasizing the need for intervention evaluations. While peer instruction on HIVST use was intended by the intervention, direct peer assistance conducting HIVST (e.g., timing, and interpreting HIVST results) was not intended and may pose risk of testing coercion or involuntary HIV status disclosure [ 15 ]. Furthermore, word-of-mouth peer networks were also prone to the quick spread of misinformation surrounding HIV risk and HIVST.…”

Section: Discussionmentioning

confidence: 99%

“…A randomized implementation trial in this setting found that peer-delivered oral-fluid HIV self-testing (HIVST) significantly increased recent and repeat HIV testing among FSWs compared to standard facility-based testing [ 4 ]. Additionally, FSWs in this trial described peer-delivered HIVST as desirable because it increased privacy, convenience (including time and cost), sense of control, and confidentiality [ 15 , 16 ]. Although this model of peer delivery has been found to be appropriate among FSWs in this setting, little is known about how FSW social support structures (e.g., informational, instrumental, and emotional support) influence the delivery and uptake of peer-delivered HIV prevention interventions.…”

Section: Introductionmentioning

confidence: 99%

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

McGowan

Roche

Nakitende³

et al. 2022

BMC Public Health

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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.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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

McGowan

Roche

Nakitende³

et al. 2022

BMC Public Health

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“…In one study on which the first author collaborated, data revealing unintended consequences emerged from the field during the data collection. Consequently, the research team was compelled to address the issue even though it was not in their initial objectives [65]. Researchers in this situation may have to re-analyze their data to meet this new objective, which ultimately may turn out to be more timeconsuming and costly.…”

Section: Validate the Classification Of Intended Versus Unintended Comentioning

confidence: 99%

“…The level of desirability can vary when the perceptions of decision-makers are compared with those of street-level workers, who have different goals and needs. Operationalizing these concepts imposes difficult choices on research teams, but examples of how to do it are available in the literature [48][49][50]65].…”

Section: Determine the Study's Perspectivementioning

confidence: 99%

The unintended consequences of COVID-19 mitigation measures matter: practical guidance for investigating them

Turcotte-Tremblay

Gali

Ridde

2021

BMC Med Res Methodol

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Background COVID-19 has led to the adoption of unprecedented mitigation measures which could trigger many unintended consequences. These unintended consequences can be far-reaching and just as important as the intended ones. The World Health Organization identified the assessment of unintended consequences of COVID-19 mitigation measures as a top priority. Thus far, however, their systematic assessment has been neglected due to the inattention of researchers as well as the lack of training and practical tools. Main text Over six years our team has gained extensive experience conducting research on the unintended consequences of complex health interventions. Through a reflexive process, we developed insights that can be useful for researchers in this area. Our analysis is based on key literature and lessons learned reflexively in conducting multi-site and multi-method studies on unintended consequences. Here we present practical guidance for researchers wishing to assess the unintended consequences of COVID-19 mitigation measures. To ensure resource allocation, protocols should include research questions regarding unintended consequences at the outset. Social science theories and frameworks are available to help assess unintended consequences. To determine which changes are unintended, researchers must first understand the intervention theory. To facilitate data collection, researchers can begin by forecasting potential unintended consequences through literature reviews and discussions with stakeholders. Including desirable and neutral unintended consequences in the scope of study can help minimize the negative bias reported in the literature. Exploratory methods can be powerful tools to capture data on the unintended consequences that were unforeseen by researchers. We recommend researchers cast a wide net by inquiring about different aspects of the mitigation measures. Some unintended consequences may only be observable in subsequent years, so longitudinal approaches may be useful. An equity lens is necessary to assess how mitigation measures may unintentionally increase disparities. Finally, stakeholders can help validate the classification of consequences as intended or unintended. Conclusion Studying the unintended consequences of COVID-19 mitigation measures is not only possible but also necessary to assess their overall value. The practical guidance presented will help program planners and evaluators gain a more comprehensive understanding of unintended consequences to refine mitigation measures.

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“…HIV self-testing (HIVST), a process in which an individual performs an HIV rapid diagnostic test and interprets the result in private, is highly acceptable, convenient and discreet and may be empowering for SW not accessing traditional HIV testing services [7,8]. This emerging strategy has been shown to significantly increase recent and repeat HIV testing among SW [9,10], and is being scaled up for key populations in high HIV prevalence settings [11]. The WHO also recommends oral pre-exposure prophylaxis (PrEP) for HIV-negative persons at substantial and ongoing HIV risk [12].…”

Section: Introductionmentioning

confidence: 99%

HIV self‐testing and oral pre‐exposure prophylaxis are empowering for sex workers and their intimate partners: a qualitative study in Uganda

et al. 2021

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Introduction: HIV self-testing (HIVST) and oral pre-exposure prophylaxis (PrEP) are complementary, evidence-based, selfcontrolled HIV prevention tools that may be particularly appealing to sex workers. Understanding how HIVST and PrEP are perceived and used by sex workers and their intimate partners could inform prevention delivery for this population. We conducted qualitative interviews to examine ways in which HIVST and PrEP use influence prevention choices among sex workers in Uganda. Methods: Within a randomized trial of HIVST and PrEP among 110 HIV-negative cisgender women, cisgender men and transgender women sex workers (NCT03426670), we conducted 40 qualitative interviews with 30 sex workers and 10 intimate partners (June 2018 to January 2020). Sex worker interviews explored (a) experiences of using HIVST kits; (b) how HIVST was performed with sexual partners; (c) impact of HIVST on PrEP pill taking; and (d) sexual risk behaviours after HIVST. Partner interviews covered (i) introduction of HIVST; (ii) experiences of using HIVST; (iii) HIV status disclosure; and (iv) HIVST's effect on sexual behaviours. Data were analysed using an inductive content analytic approach centering on descriptive category development. Together, these categories detail the meaning of HIVST and PrEP for these qualitative participants. Results: Using HIVST and PrEP was empowering for this group of sex workers and their partners. Three types of empowerment were observed: (a) economic; (b) relational; and (c) sexual health. (i) Using HIVST and PrEP made sex without condoms safer. Sex workers could charge more for condomless sex, which was empowering economically. (ii) Self-testing restored trust in partners' fidelity upon being reunited after a separation. This trust, in combination with condomless sex made possible by PrEP use, restored intimacy, empowering partnered relationships. (iii) HIVST and PrEP enabled sex workers to take control of their HIV prevention efforts and avoid the stigma of public clinic visits. In this way they were empowered to protect their sexual health. Conclusions: In this sample, sex workers' use of HIVST and PrEP benefitted not only prevention efforts, but also economic and relational empowerment. Understanding these larger benefits and communicating them to stakeholders could strengthen uptake and use of combination prevention interventions in this marginalized population.

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

Cited by 11 publications

References 23 publications

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

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

The unintended consequences of COVID-19 mitigation measures matter: practical guidance for investigating them

HIV self‐testing and oral pre‐exposure prophylaxis are empowering for sex workers and their intimate partners: a qualitative study in Uganda

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