Discussion
HIV risk reduction, risk-taking behaviors
HOT SPOTS, ARRESTED
In this study, we explored the acceptability of the evidence-based HIV risk reduction component of a combination intervention that also included an economic empowerment component among WESW in Uganda. We explored the expectations and concerns that contributed to their decisions to participate in the overall program, facilitators, and barriers to their participation in the HIV risk reduction sessions, as well as thoughts on different aspects of intervention delivery. WESW’s expectations mainly centered around access to health-related information and resources as well as information around safe sex practices, which shows that the program was highly relevant and appropriate to the needs of this population. For those who expressed concerns about participation -about two-thirds of our sample, these potential benefits ultimately outweighed their initial concerns around enrolment to the program. However, concerns around confidentiality -including disclosure of their engagement in sex work, being arrested, killed, or trafficked for sex work underline the unique vulnerabilities of WESW. These concerns were also identified in other studies as barriers to access to services and underline the need to effectively address them to facilitate access to interventions as well as other health services designed for this population [In addition to being the initial reason for enrolment in the program, the desire to learn more information on HIV/STIs and safer sex practices was the main reason that motivated WESW to continue attending HIV risk reduction sessions. As expected, when WESW find the intervention relevant and applicable to their life circumstances, they are more likely to sustain their participation. Importantly, in addition to content relevance, some WESW also pointed to the fact that being treated respectfully by the facilitators was another factor that facilitated their continued attendance. The same theme emerged when WESW were asked about their feedback on intervention implementation. Stigma WESW experience from service providers is a major factor that interferes with access and retention with health services, including HIV care [In addition to not being stigmatized, WESW appreciated that facilitators were patient and took the time to answer questions, underlining the importance of training facilitators/service providers working with this key population to improve WESW’s engagement and retention in services. As indicated before, the HIVRR facilitators delivering this intervention participated in a one-week training that included sensitization around working with WESW in addition to intervention content and delivery. Finally, WESW also stated that monetary compensation for their time and transport, as well as lunches, made it easier for them to attend the sessions. Costs associated with transportation are widely cited as a barrier to attendance [Barriers to HIVRR session participation included family commitments, work schedules, and other personal reasons which primarily centered around privacy and confidentiality. Many women were also caregivers to children or other members of their families. One participant experienced the loss of an extended family member that interfered with her session attendance. In addition, even though the research team worked closely with WESW and their managers to identify the most convenient times for intervention delivery, work schedules still posed challenges for some WESW. Both family and work commitments are common barriers to participation across a wide range of programs and services [However, there were also challenges unique to the life circumstances of WESW, though mentioned by only a few, including being intoxicated or in jail. Concerns around privacy and confidentiality remained a concern for some WESW during the initial sessions, underlying the need to continuously reinforce the message that all information would be kept confidential as well as put in place safeguards to ensure it. While ensuring privacy and confidentiality is critical in any group intervention, doing so is even more critical for WESW given the high level of stigma, discrimination, and other risks associated with disclosure of sex work [Overall, WESW’s feedback on intervention characteristics was positive. WESW who provided feedback on the group format found it helpful. Being in a group with other WESW not only made them more comfortable to share their experiences, but some WESW stated that it also encouraged some to make changes to their risk-taking behaviors. These findings align with the existing evidence on the benefits of group interventions. The group format for behavioral interventions in the context of HIV prevention utilizes the social interactions among group members to enhance the likelihood of acquiring new information and skills, facilitate behavioral change, and enable the group members to learn with and from each other in a safe environment [Except for a few instances, WESW also expressed satisfaction with the locations where the intervention was delivered, emphasizing their convenience and privacy. Similarly, WESW were also generally satisfied with the day and time when the sessions were delivered. Both the delivery location and timing of the sessions were decided upon in collaboration with WESW and their managers in an attempt to minimize potential obstacles to attendance. As discussed before, WESW’s feedback on facilitators delivering the intervention was also positive and emphasized the attention, care, and respect they conveyed during the sessions.Overall, our findings suggest that the HIV risk reduction component of our combination intervention was appropriate and acceptable to WESW. From a public health point of view, our findings show that WESW experience unique concerns and barriers to enroll and attend interventions that need to be addressed to increase the acceptability of an intervention. Privacy and confidentiality are one such concern that warrants the attention of service providers and/or program implementers working with WESW. Safeguards to ensure privacy and confidentiality should be incorporated both at the time of enrolment as well as throughout the intervention, including the selection of sites where it will be implemented. In addition, interventions targeting WESW should incorporate both content and sensitivity training for facilitators/service providers to improve access and utilization [Results need to be interpreted in light of study limitations. Due to restrictions related to COVID-19 at the time of qualitative data collection, we collected data from a smaller sample of WESW than originally targeted. Relatedly, WESW in the treatment group were underrepresented. Hence, the findings may not fully represent the experiences of WESW who received the combination intervention.Despite these limitations, our study provides important insights into the acceptability of an evidence-based HIV risk reduction intervention among WESW in hot spots in Uganda–a region underserved by evidence-based interventions. Our study is one of the few studies in Uganda, and in SSA, that documents the unique needs and challenges of WESW from their own perspectives when HIV risk reduction programs are provided.