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. 2022 Sep 16;22(1):1166.
doi: 10.1186/s12913-022-08506-0.

Opportunities and considerations for the design of decentralized delivery of antiretroviral therapy for female sex workers living with HIV in South Africa

Carly A Comins  1 , Vijayanand Guddera  2 , Lauren E Parmley  3 , Katherine Young  4 , Mfezi Mcingana  4 , Ntambue Mulumba  4 , Sharmistha Mishra  5   6 , Deliwe R Phetlhu  7 , Harry Hausler  4 , Sheree Schwartz  8 , Stefan Baral  8
Affiliations

Opportunities and considerations for the design of decentralized delivery of antiretroviral therapy for female sex workers living with HIV in South Africa

Carly A Comins et al. BMC Health Serv Res. .

Abstract

Background: In South Africa, 60% of female sex workers (FSW) are living with HIV, many of whom experience structural and individual barriers to antiretroviral therapy (ART) initiation and adherence. Community-based decentralized treatment provision (DTP) may mitigate these barriers. To characterize optimal implementation strategies, we explored preferences for DTP among FSW living with HIV in Durban, South Africa.

Methods: Thirty-nine semi-structured in-depth interviews were conducted with FSW living with HIV (n = 24), and key informants (n = 15) including HIV program implementers, security personnel, and brothel managers. Participants were recruited using maximum variation and snowball sampling. Interviews were conducted in English or isiZulu between September-November 2017 and analyzed using grounded theory in Atlas.ti 8.

Results: DTP was described as an intervention that could address barriers to ART adherence and retention, minimizing transport costs, time and wage loss from clinic visits, and act as a safety net to address FSW mobility and clinic access challenges. Respondents highlighted contextual considerations for DTP and suggested that DTP should be venue-based, scheduled during less busy times and days, and integrate comprehensive health services including psychological, reproductive, and non-communicable disease services. ART packaging and storage were important for community-based delivery, and participants suggested DTP should be implemented by sex work sensitized staff with discrete uniform and vehicle branding.

Conclusions: Incorporating FSW preferences may support implementation optimization and requires balancing of tensions between preferences and feasibility. These data suggest the potential utility of DTP for FSW as a strategy to address those most marginalized from current ART programs in South Africa.

Keywords: Antiretroviral; Differentiated care; Differentiated service delivery; Female sex workers; HIV; South Africa.

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Conflict of interest statement

The authors declare no conflict of interests nor other financial or non-financial competing interests.

Figures

Fig. 1
Fig. 1
Participant preferences surrounding DTP implementation for FSW living with HIV at greatest need
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