HIV self-testing leads to positive sexual behaviour change among Zambian sex workers, according to new study.
Zambian sex workers accessing HIV self-tests reported less risky sexual behaviour and increased control over their sexual health – an unintended positive outcome associated with a peer-led self-testing intervention for female sex workers.
The results come from a secondary analysis of the Zambian Peer Educators for HIV Self-Testing (ZEST) trial – a randomised control trial which compared two peer-led HIV self-test distribution methods with the standard-of-care for HIV testing. It found that the women reported fewer clients per night and less non-client sexual partners, revealing that the provision of these kits positively impacted sexual behaviour change.
ZEST was initially designed to see if HIV self-testing could play a role in addressing gaps in HIV testing coverage for female sex workers, who traditionally experience difficulties coming forward for testing because of stigma or logistical challenges.
The trial was one of the first to report on the effectiveness and safety of an HIV self-testing intervention among female sex workers. Most previous studies concentrated on HIV self-testing delivery among men who have sex with men, and largely in Europe and North America.
965 women were recruited by peer educators and assigned to three study arms over four months. Study participants received either, (1) direct distribution of HIV self-testing kits by a peer educator; (2) the receipt of a coupon from a peer educator for the collection of an HIV self-test at a participating pharmacy or medical clinic; or (3) standard of care – where they were referred to HIV testing without the offer of HIV self-testing. All women received regular visits and HIV counselling from the peer educators.
The median age of the women participating in the study was 25, and had engaged in sex work for a median time of five years. All had self-reported as HIV-negative or unknown status at the start of the study. Few of the study participants had regular access to free condoms while working. All participants had access to a 24-hour help line if they needed help with testing, counselling of their results, or if they needed to report any adverse effects, such as intimate partner violence.
The primary outcomes of the trial were that HIV self-tests were a safe, effective and acceptable HIV prevention intervention for female sex workers in Zambia. But sexual behaviour data was also collected regarding the number of clients and non-client partners which were measured at baseline, one, and four months. The secondary analysis revealed that the number of clients decreased over time in all arms from baseline to one and four months. At four months, participants reported significantly fewer clients per night in the direct delivery arm (-0.78 mean difference), and the coupon arm (-0.71 mean difference), compared to the standard-of-care arm. Compared to the standard-of-care arm, sexual partners outside of clients also decreased in the direct delivery model (-3.19 mean difference) and in the coupon arm (-1.84 mean difference).
While the specific mechanisms that may drive the reduction in partners was not assessed, the authors pointed to several plausible pathways that could have occurred independently of simply knowing one’s status. Notably, as HIV self-tests are a user-controlled intervention, it could increase the perceptions of control over one’s situation, increasing sense of agency or empowerment which could affect the number of sexual partners they have. As most women engage in sex work for economic reasons, the authors note that women may also be able to charge more for a sex act if they can prove their HIV-negative status using the self-tests.
A concern with HIV self-testing is that sexual risk-taking behaviour could increase following a negative test. But they found no evidence of increased risk-taking – in fact, the participants reporting a HIV-negative test result also reported fewer clients and non-client partners overall.
The authors conclude: “In this setting in Zambia, sexual behaviour changes among FSW [female sex workers] following HIV self-testing does not appear to be a concern, and thus, should not limit expansion of HIV self-testing programmes. There may be positive behavioural benefits of HIV self-testing related to reduced HIV risk-taking among FSW.”