HIV/STI Testing through Culturally Sensitive Mobile Outreach in Metro Vancouver, Canada: Im/Migrant Sex Workers' Experiences and Perspectives

Background: Im/migrant sex workers face inequitable access to sexual health services including voluntary and confidential HIV/STI testing and treatment in Canada; this is often due to intersecting socio-structural barriers, such as end-demand criminalization, punitive immigration policies, and linguistic marginalization. Community-based mobile clinics have shown promise in bridging service gaps to meet the sexual health needs among structurally marginalized groups. This study explores im/migrant sex workers’ experiences of and perspectives on a culturally sensitive, multilingual, and mobile HIV/STI testing model, which was developed as a clinical service component of a community-based longitudinal open cohort study – An Evaluation of Sex workers Health Access (AESHA) – with sex workers in Metro Vancouver, Canada.

Methods: Qualitative semi-structured interviews were conducted individually in Mandarin with 22 indoor im/migrant sex workers between March and August 2023. Participants were primarily recruited during the AESHA cohort study outreach testing, which was conducted at im/migrant sex workers’ workplaces (e.g., massage parlor) or a private and safe location of their choice (e.g., residential home). An interview guide, which was initially developed to gain a comprehensive understanding of sex workers’ experiences with different HIV/STI testing models, was culturally adapted to the work context of Chinese im/migrant sex workers in Vancouver, Canada, and translated into Chinese. Field reflective notes during data collection were taken regularly to complement the interview data with rich contextual nuances. Informed by a socio-structural perspective of health inequities, iterative and reflexive thematic analysis was conducted to understand main factors influencing participants’ experiences of and perspectives on the culturally sensitive, multilingual, and mobile AESHA HIV/STI testing model. To enhance study rigor, we adopted strategies of prolonged engagement, post-analysis member checking, ongoing reflexive note-taking, and regular team consultations.

Findings: Participants (n=22; average age = 46 [34 – 62]) were all women born in China who migrated to Canada during adulthood, whose duration of sex work involvement ranged from one month to 17 years. Most (n=17, 77%) primarily relied on AESHA outreach for HIV/STI testing. Participants identified major strengths of the outreach testing, including cultural and linguistic responsiveness, physical accessibility, operational flexibility, the easing of privacy concerns due to trust building, as well as challenges such as team turnover and limited scope of reach due to operational schedules. Workplace settings and dynamics, including physical-social space, collegial relationship, client reactions, and the complex role of managers, jointly influenced the experiences of and strategies to navigate issues such as confidentiality, privacy protection, as well as their decision-making during the testing process and post-testing treatment. Finally, participants highlighted that peer referrals and managers’ active participation greatly promoted testing access and facilitated the process.

Conclusions: Future development and implementation of tailored mobile testing services with (and led by) im/migrant sex workers should proactively attend to not only language-specific services, but also the workplace dynamics and privacy challenges that arise in indoor sex work venues. Structural policy changes that address the criminalized, oppressive, and inequitable environment that constrains im/migrant sex workers’ resources, services, and rights to sexual health are also needed.