HIV self-testing implementation, distribution and use among female sex workers in Cotonou, Benin: a qualitative evaluation of acceptability and feasibility.

BACKGROUND: In Benin, the burden of HIV is disproportionately high among female sex workers (FSWs). HIV testing and knowledge of status are starting points for HIV treatment and prevention interventions. Despite the importance given to testing services in HIV control, its uptake among FSWs remains suboptimal in Benin. HIV self-testing (HIVST) may be useful for increasing testing rates in FSWs. METHODS: We conducted a pilot study of the distribution of saliva-based HIVST among FSWs in Cotonou and its surroundings, Benin. The HIVST promotion and distribution model included three complementary strategies: community-based, facility-based and secondary distribution. In this qualitative study, we explored the elements influencing HIVST implementation, distribution and use among FSWs. We assessed HIVST acceptability and feasibility in this population. We conducted 29 semi-structured individual interviews with FSWs. Data were interpreted with a thematic analysis method, using the Theoretical Domains Framework. RESULTS: Only two FSWs (6.9%) were aware of HIVST before participating in the study. All participants were interested in using HIVST if available in Benin. Many advantages of HIVST were mentioned, including: autonomy, privacy, accessibility, time saving, and the fact that it is a painless test. Barriers to the use of HIVST included: the fear of unreliability, the lack of psychological support and medical follow-up and the possibility of result dissimulation. Participants thought HIVST was easy to use without assistance. HIVST enabled linkage to care for a few FSWs in denial of their HIV-positive status. No case of suicide or violence associated with HIVST was reported. HIVST secondary distribution within FSWs social network was well received. FSWs' boyfriends and clients showed interest in using the device. Some FSWs reported using HIVST to practice serosorting or to guide their decisions regarding condom use. CONCLUSIONS: Our study shows a very high level of acceptability for HIVST among FSWs in Cotonou and its surroundings. Results also demonstrate the feasibility of implementing HIVST distribution in Benin. HIVST should be implemented in Benin quickly and free of charge for all individuals at risk of HIV. HIVST offer should be integrated with comprehensive sexual health and prevention services.

Overview and factors associated with pregnancies and abortions occurring in sex workers in Benin.

BACKGROUND: Behavioural and structural factors related to sex work, place female sex workers (FSWs) at high risk of maternal mortality and morbidity (MMM), with a large portion due to unintended pregnancies and abortions. In the African context where MMM is the highest in the world, understanding the frequency and determinants of pregnancy and abortion among FSWs is important in order to meet their sexual and reproductive health needs. METHODS: Data from two Beninese cross-sectional surveys among FSWs aged 18+ (2013, N = 450; 2016, N = 504) were merged. We first performed exploratory univariate analyses to identify factors associated with pregnancy and abortion (p < 0.20) using Generalized Estimating Equations with Poisson regression and robust variance. Multivariate analyses first included all variables identified in the univariate models and backward selection (p ≤ 0.05) was used to generate the final models. RESULTS: Median age was 39 years (N = 866). The proportion of FSWs reporting at least one pregnancy during sex work practice was 16.4%, of whom 42.3% had more than one. Most pregnancies ended with an abortion (67.6%). In multivariate analyses, younger age, longer duration in sex work, previous HIV testing, having a boyfriend and not using condoms with him were significantly (p < 0.05) associated with more pregnancies. CONCLUSION: One FSW out of five had at least one pregnancy during her sex work practice. Most of those pregnancies, regardless of their origin, ended with an abortion. Improving access to various forms of contraception and safe abortion is the key to reducing unintended pregnancies and consequently, MMM among FSWs in Benin.

Violence, condom breakage, and HIV infection among female sex workers in Benin, West Africa.

OBJECTIVE: To examine the relationship between violence, condom breakage, and HIV prevalence among female sex workers (FSWs). METHODS: Data were obtained from the 2012 cross-sectional integrated biological and behavioral survey conducted in Benin. Multivariable log-binomial regression was used to estimate the adjusted prevalence ratios of HIV infection and condom breakage in relation to violence toward FSWs. A score was created to examine the relationship between the number of violence types reported and HIV infection. RESULTS: Among the 981 women who provided a blood sample, HIV prevalence was 20.4%. During the last month, 17.2%, 13.5%, and 33.5% of them had experienced physical, sexual, and psychological violence, respectively. In addition, 15.9% reported at least 1 condom breakage during the previous week. There was a significant association between all types of violence and HIV prevalence. The adjusted prevalence ratios of HIV were 1.45 (95% confidence interval [95% CI], 1.05-2.00), 1.42 (95% CI, 1.02-1.98), and 1.41 (95% CI, 1.08-1.41) among those who had ever experienced physical, sexual, and psychological violence, respectively. HIV prevalence increased with the violence score (P = 0.002, test for trend), and physical and sexual violence were independently associated with condom breakage (P = 0.010 and P = 0.003, respectively). CONCLUSIONS: The results show that violence is associated with a higher HIV prevalence among FSWs and that condom breakage is a potential mediator for this association. Longitudinal studies designed to analyze this relationship and specific interventions integrated to current HIV prevention strategies are needed to reduce the burden of violence among FSWs.

Développement et implantation d'une intervention ciblée encourageant le dépistage régulier du VIH chez les travailleuses du sexe au Bénin : application du protocole d' intervention mapping.

Cet article présente le processus suivi pour développer et implanter une intervention ciblée encourageant les femmes travailleuses du sexe (TS) à se faire dépister régulièrement pour le virus de l'immunodéficience humaine (VIH) dans les services de santé adaptés au Bénin. Le modèle de planification d' intervention mapping (IM) de Bartholomew et al. (2006), structuré en six étapes, a servi de référence pour guider le développement et l'implantation de l'intervention. Une analyse des besoins a été réalisée à partir d'une revue de littérature et d'une étude basée sur la théorie du comportement planifié, d'Ajzen (1991). Cette analyse a permis d'identifier les déterminants associés au comportement sur lesquels ont porté les actions de changement. Les méthodes et stratégies d'intervention ont été basées sur des théories et adaptées aux besoins des femmes TS. Les résultats consistent en une intervention de neuf mois visant à couvrir plus de 1200 femmes TS, en impliquant divers acteurs (intervenants communautaires, agents de santé et pairs éducatrices). La perception de contrôle comportemental, la norme descriptive, les connaissances, l'attitude et l'intention d'adopter le dépistage régulier du VIH constituent les cibles d'action. L'intervention comporte des activités visant des changements individuels et environnementaux à travers diverses méthodes comme le counseling motivationnel, l'éducation par les pairs, le modeling, la communication persuasive, le renforcement de capacités et la réorganisation des services cliniques. L'IM a permis de structurer et d'implanter avec transparence une intervention ciblée visant l'adoption d'un comportement favorable à la santé chez les femmes TS. Les enjeux rencontrés et les leçons tirées de l'application de l'IM en contexte africain francophone peuvent inspirer les planificateurs et professionnels pour améliorer leurs interventions en promotion de la santé.

[Quality of disease management of sexually transmitted diseases: investigation of care in six countries in West Africa]. / Qualité de la prise en charge des maladies sexuellement transmises: enquête auprés des soignants de six pays de l'Afrique de l'Quest.

OBJECTIVES: the objectives of this study were, in healthcare facilities in six countries in West Africa, to: (1) estimate the proportion of patients consulting for sexually transmitted diseases (STDs) for whom an adequate case history was taken and who received an appropriate physical examination and effective treatement (prevention indicator PI6); (2) to determine the percentage of patients who were given advice on condom use and notification of sexual partners for STD treatment (prevention indicator PI7); (3) to determine the level of knowledge of healthcare workers concerning STD case management; and (4) to compare reported and observed behaviour regarding STD case management by healthcare workers. MATERIAL AND METHOD: this descriptive study was carried out in 240 health care facilities in six countries: Benin, Burkina Faso, Côte d'Ivoire, Guinea, Mali, and Senegal, using the WHO protocol for PI6 and PI7 indicators to evaluate the quality of management of urethral discharge and genital ulcers, as well as an extension of this protocol to evaluate STD syndromes specific to women, namely vaginal discharge and pelvic inflammatory disease. Healthcare workers were observed during STD consultations, and thereafter interviewed. Up to five observations per healthcare worker were carried out over a period of three days spent at each health care facility. Criteria for an adequate case history were inclusion of questions on the nature, time of initiation and duration of symptoms, and for physical examination, visualisation and examination of genital organs for discharge and lesions. Treatments prescribed were judged as effective when in conformity with national algorithms for syndromic STD management. The PI6 indicator was estimated as the proportion of cases where an adequate case history was taken, an appropriate physical examination carried out and effective treatment prescribed. The PI7 score corresponded to the percentage of patients who received advice on condom use and partner notification for treatment. In order to control for intra-healthcare-worker correlation, the SUUDAN software was used for the computation of 95% confidence intervals of the proportions, obtained from univariate analysis in EPI-INFO, and for the comparison of the PI6 and PI7 scores by country, sex, marital status and symptoms of the patient, as well as by level of qualification of the healthcare workers, using the khi2 test. RESULTS: overall, 613 observations and 504 interviews of 263 healthcare workers were carried out. The majority of STD patients were female (57.1%) and unmarried (53.0%). Healthcare workers were most frequently doctors (33.6%) and the most common complaint was vaginal discharge (42.2%). Intercountry variation was observed for all these variables. An adequate case history was taken in 84.6% of cases and an adequate physical examination carried out in 60.8% of cases. Healthcare workers gave a diagnosis in conformity with national syndromic STD management algorithms in 35.3% of cases, while effective treatment was given to 14.1% of patients. Patients were encouraged to use condoms in 19.5% of cases and to advise their partners to seek treatment in 50.8% of cases; this advice was given more frequently to men than to women. PI6 and PI7 scores were respectively 9.9% (95% CI: 6.9%; 12.9%) and 15.4% (95% CI: 11.4%; 19.2%). Healthcare workers' knowledge of effective STD treatment regimes was low. Practices reported during interviews with regard to STD patients were comparable to observed behaviour with regard to case history-taking and physical examination, but not for diagnosis and treatment nor for condom promotion or partner notification advice. CONCLUSION: the results of this study demonstrate the low quality of STD management in the six countries evaluated, which may be explained by the lack of availability of examination material, the inadequate knowledge of healthcare workers, as well as the infrequent promotion of STD prevention methods, particularly in women.