Regular STI and HIV screening intentions and practices among sex workers in Uganda: the effect of text message reminders and peer education

Abstract

Background: Sex workers are a bridge population; up to 15% of HIV infections and other sexually transmitted infections (STIs) in the general female adult population are attributable to sex work. Secondly, in sub-Saharan Africa, where HIV disproportionately affects women, heterosexual male sex workers (HMSWs) and their female clients, are at high risk of acquiring or transmitting HIV and other STIs. Testing is essential for knowing one’s infection status and obtaining prevention, treatment, and care services, but uptake of STI testing services remains low among sex workers. This study examined the influences of regular STI and HIV screening intentions and practices among sex workers and assessed the effect of text message reminders and peer education on STI testing uptake among female sex workers (FSWs) in Uganda. Methods: this mixed-methods study was conducted across four cities (Arua, Mbale, Mbarara, and Kampala). A cross-sectional survey (questionnaire-based, n=541) was used in the formative phase to describe HIV and syphilis screening intentions, practices, and associated factors among HMSWs and FSWs. This was followed by an explanatory qualitative study using in-depth interviews (n=48) to explore barriers and facilitators of regular syphilis and HIV testing among FSWs. Later a non-randomized pilot quasi-experimental study (n=436) was implemented, with pre-and post-measurement surveys, to assess the effect of bi-monthly text message reminders and weekly peer education sessions on uptake of 3-monthly facility-based syphilis and HIV testing among FSWs. The Integrated Change Model was used to derive the psychosocial variables and themes, i.e., intention, attitude, norms, social influences, and self-efficacy of 3-monthly syphilis and 6-monthly HIV testing. Qualitative data were analyzed using thematic analysis. Chi-square tests and negative binomial regression were used, respectively to compare proportions and estimate the correlates of syphilis and HIV testing at baseline and follow-up. Results: Compared to FSWs, HMSWs had low intentions to undergo HIV testing in the next six months (24% vs. 66%; P= 0.001) and were significantly less likely to have tested for HIV in the prior 12 months (50% vs. 86%; P= 0.001). Non-testing for HIV was significantly associated with low intention to seek HIV testing [adjusted prevalence ratio (aPR) 1.64; 95% confidence interval (CI) 1.35–2.04], the perception that 6-monthly testing was not common or non-normative (aPR 1.33; 95% CI 1.09–1.67), and low self-efficacy (aPR 1.41; 95% CI 1.12–1.79). Relative to FSWs, HMSWs had low intentions to undergo syphilis testing in the next three months (19% vs. 63%; P = 0.001) but both had low syphilis testing rates, as only 14% of FSWs and less than 10% of the HMSWs reported testing three or more times for syphilis in the prior 12 months. Non-testing for syphilis was associated with low intentions to seek a syphilis test, a negative testing attitude, and a perception that 3-monthly testing for syphilis is not common. Sex workers face substantial barriers to accessing HIV/STI testing because of (1) disrespectful, judgmental, and unfriendly provider attitudes; (2) interpersonal and internalized stigma; (3) unfavorable clinic operating hours; (4) non-emphasis of syphilis testing because of policy recommendations for syndromic STI management; and (5) frequent stock outs of syphilis test kits, high cost of syphilis tests, and low perceived severity of syphilis infection. Testing barriers and facilitators overlapped substantially for both infections. Unlike syphilis, the availability of welcoming testing environments and facilities promoted HIV testing. However, in the intervention city, bi-monthly text message reminders and weekly peer education sessions increased the proportion of FSWs reporting testing in the prior three months to 82% (95% confidence interval [CI] 74.0-88.2) for HIV and 81% (95% CI: 73.0-87.0) for syphilis at follow-up, relative to 57% for HIV and 35% for syphilis at baseline. Compared to the baseline in the control city, the proportion testing for HIV was unchanged (52% vs. 54%) but decreased for syphilis (26% vs. 39%). Conclusions and recommendations: HMSWs had low STI/HIV testing intentions and practices that were associated with negative testing attitudes, low self-efficacy, and low descriptive norms. Both FSWs and HMSWs had low syphilis testing intentions and practices. Sex workers still face challenges in accessing STI and HIV testing services. Multilevel interventions targeting the FSWs, the providers and policy guidelines are still required to increase access to dual syphilis and HIV testing among FSWs in Uganda. Bi-monthly text message reminders with weekly peer education sessions increased uptake of 3-monthly syphilis and HIV testing among FSWs. HIV and STI control programs should consider utilizing bi-monthly text message reminders, with weekly peer education sessions, to promote periodic testing for syphilis and HIV among FSWs. however, extending the dual syphilis and HIV testing approach to sex workers, implementing interventions targeting both health care providers and sex workers, and designing and adopting messages that emphasize dual testing may improve the testing uptake for both infections at public health facilities. Future studies should also evaluate the HIV burden and strategies to increase testing uptake among HMSWs.