Sex workers report unexpected benefits of PrEP and HIV self-testing
Interviews with sex workers in Uganda highlight economic and relationship benefits alongside advantages for sexual health
Interviews with sex workers and their intimate partners in Uganda suggests that being able to take PrEP and self-test for HIV is not only good for sexual health but can have economic and relationship benefits as well.
Between 2018 and 2020, researchers in Kampala interviewed 30 sex workers taking part in an HIV prevention trial, plus 10 people in relationships with sex workers in the trial. None of the sex workers had HIV. All were using PrEP and had access to HIV self-testing kits. They could also offer self-testing kits to partners (clients and intimate).
Among the sex workers, 21 (70%) were cisgender women, six were transgender women and three were cisgender men who have sex with men. The partners’ gender was not reported, but five were in a relationship with a transgender female sex worker, four were in a relationship with a cisgender female sex worker and one was the partner of a male sex worker who has sex with men. The median age of both sex workers and intimate partners was 25.
Sex work was the main source of income for 70% of sex workers. Their median monthly income was US$78, which is around a third less than the national average.
Both PrEP and self-testing kits gave sex workers the power to make more informed decisions about having sex without a condom, which they could charge more money for. Sex workers could earn around four times more for vaginal sex without a condom and double for condomless anal sex.
When clients agreed to take a self-test, sex workers were able to immediately see a positive or negative result. Sex workers could then make an informed decision about having sex without a condom, based on that result.
This unintended economic benefit has the potential to increase HIV self-testing among sex workers. But it could also make sex workers more vulnerable to HIV, as self-testing kits are not always accurate.
Male sex workers found it easier than female sex workers to tell clients who screened positive for HIV about their results. Female sex workers feared violence and loss of income if they told a client they had a positive screen.
Sex workers also reported feeling more able to have condomless sex, and so earn more money, if they were taking PrEP, even if they had not used a self-testing kit on their client. However, some made the point that PrEP would not protect them against other sexually transmitted infections.
Sex workers and their intimate partners said self-testing and PrEP were improving their intimate relationships. Female sex workers said it was common for their partners to work away from home, and they suspected their partners had sex with other people during these times. But repeated negative screens from self-testing kits helped to renew trust in their relationships.
The shared experience of testing together also made self-testing feel normal and brought couples closer. HIV-negative screens motivated both partners to protect themselves from HIV and to stay in their relationship.
Regular self-testing and PrEP also led to some couples having condomless sex, which increased sexual intimacy and pleasure for some.
Getting repeated negative screens from HIV self-tests despite having condomless sex reinforced the sense that PrEP works. Sex workers said this encouraged them to keep taking it.
Being able to self-test for HIV and take PrEP at home made sex workers feel more in control of their HIV prevention choices and enabled them to avoid stigmatising and costly clinic visits.
The study found clear evidence to suggest that the stigma associated with sex work leads people who sell sex to do so in secret. Most sex workers (71%) had not told anyone they sold sex, while only 26% had told their intimate partner. The hidden nature of sex work suggests that home-based interventions, or things that reduce the need for clinic visits, are likely to be popular.