€Œi Decided in My Heart I Have to Complete the Sessionsâ€�: The Experiences of Women Engaged in Sex Work with an Evidence-Based HIV Risk Reduction Intervention in Uganda

Background: The HIV burden remains a critical public health concern and women engaged in sex work (WESW) are at significantly higher risk compared to the general adult population. Similar to other sub-Saharan African countries, Uganda reports high rates of HIV prevalence among WESW. Yet, their experiences with evidence-based comprehensive behavioral HIV risk reduction interventions are understudied.

Methods: Using stratified purposive sampling, we conducted semi-structured in-depth interviews with 20 WESW to explore their experiences with an evidence-based HIV risk reduction intervention implemented as part of a combination intervention tested in a clinical trial in Uganda. Specifically, we explored WESW's initial motivations and concerns for participating in the intervention, barriers and facilitators to attendance, and their feedback on specific intervention characteristics. Interviews were conducted in Luganda, the widely spoken language in the study region by trained research assistants and lasted 38 to 100 minutes. All interviews were audiotaped, transcribed and translated verbatim. Proctor et al.’s conceptualization of implementation outcomes -specifically acceptability and appropriateness- guided the data analysis. We used inductive techniques for the thematic analysis of the data.

Results: WESW’s expectations centered around access to health-related information and resources as well as information about safe sex practices. Concerns around confidentiality, being arrested, killed, or trafficked for sex work were the main concerns raised when considering participation. In addition to being the initial reason for enrolment, the desire to learn more information on HIV/STIs and safer sex practices motivated WESW to continue attending HIV risk reduction sessions. Being treated respectfully by the facilitators was another factor that facilitated their continued attendance. Barriers to HIVRR session participation included family commitments, work schedules, and other personal reasons. There were also challenges unique to WESW, including being intoxicated or in jail. Privacy and confidentiality remained a concern for some WESW during the initial sessions. Overall, WESW's feedback on intervention characteristics was positive. WESW who provided feedback on the group format found it helpful. Except for a few instances, WESW also expressed satisfaction with the location, day and time of the intervention. WESW’s feedback on facilitators emphasized the attention, care, and respect they conveyed.

Conclusions and implications: Study findings suggest that the HIV risk reduction component of our combination intervention was appropriate and acceptable to WESW. Our findings show that WESW experience unique concerns and barriers to enrolling and attending interventions that need to be addressed to increase intervention acceptability. Privacy and confidentiality are one such concern that warrants the attention of service providers working with WESW. Safeguards to ensure privacy and confidentiality should be incorporated both during enrolment and the intervention period. Additionally, interventions targeting WESW should incorporate both content and sensitivity training for facilitators to improve access and utilization. Finally, working closely with WESW in identifying appropriate locations and times may increase the acceptability of an intervention. Our findings also align with existing evidence that proposes the enactment of policies to create a safe and favorable environment for WESW to access and attend programs and services without fear of being arrested, prosecuted, or discriminated against.