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

(2022) 22:589 Boisvert Moreau et al. BMC Public Health https://doi.org/10.1186/s12889-022-12917-3 Open Access RESEARCH HIV self‑testing implementation, distribution and use among female sex workers in Cotonou, Benin: a qualitative evaluation of acceptability and feasibility Marianne Boisvert Moreau1,2*, Frédéric D. Kintin3,4, Septime Atchekpe3,4,5, Georges Batona6, Luc Béhanzin1,3,4,7, Fernand A. Guédou1,3,4, Marie‑Pierre Gagnon1,8,9 and Michel Alary1,2,10 Abstract 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: com‑ munity-based, facility-based and secondary distribution. In this qualitative study, we explored the elements influenc‑ ing 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 inter‑ ested 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 unreli‑ ability, 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 HIVpositive 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 sur‑ roundings. 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. Keywords: HIV, HIV self-testing, Female sex workers, Acceptability, Feasibility, Theoretical Domains Framework, Benin *Correspondence: 1 Centre de recherche du CHU de Québec – Université Laval, Québec, QC, Canada Full list of author information is available at the end of the article © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativeco mmons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Boisvert Moreau et al. BMC Public Health (2022) 22:589 Background Despite progress in the last decades, sub-Saharan Africa remains the region of the world that carries the highest human immunodeficiency virus (HIV) burden. In this region, sex work is an important driver of the epidemic [1] and female sex workers (FSWs) have a heavy burden of HIV, with a prevalence estimated to be at least 12 times higher than for women of the general population [2]. In West and Central Africa, in 2019, 4.9 million people were living with HIV, 240,000 were newly infected and 140,000 died of conditions related to the acquired immunodeficiency syndrome (AIDS) [3]. The Joint United Nations Programme on HIV/AIDS (UNAIDS) data indicate that among all people living with HIV in West and Central Africa at the end of 2019, only 68% knew their serological status [3]. Benin is not spared by the HIV epidemic. In this country, 75,000 people were living with HIV and 3,500 were newly infected in 2019 [4]. As in most West African countries, the HIV epidemic is concentrated among key populations in Benin. Beninese FSWs have a disproportionate burden of HIV, with an estimated prevalence of 8.5% in 2019, between eight and nine times higher than for the general population, among which the prevalence was 1.0% the same year [4]. In Benin, transactional sex is the driving force of the HIV epidemic [5]. FSWs represent the main core group in the local HIV transmission dynamics, and their clients act as a bridging population, transmitting the infection from the core group of FSWs to their sexual partners [5]. Beninese FSWs are particularly vulnerable to HIV acquisition and transmission due to the nature of the work, its practice in precarious conditions, the obstacles to condom use and the inequitable access to appropriate health services [6]. FSWs generally have little control over these factors, due to social marginalization and sex work criminalization [6]. HIV testing is the first step of the HIV care cascade and the entry point to HIV treatment and support services. According to the most recent UNAIDS targets, by 2025, within all sub-populations and age groups, 95% of all people living with HIV should know their status, 95% of those diagnosed should receive antiretroviral treatment, and 95% of those on treatment should achieve viral suppression [7]. However, in Benin, FSWs knowledge of their serological status remains insufficient. In a 2017 national surveillance survey, the percentage of FSWs who had been tested for HIV in the past 12 months was 59.2% in Benin and 66.1% in Cotonou [8]. Qualitative and quantitative studies carried out on the issue of HIV testing among FSWs in Benin reveal the existence of personal factors that hinder their use of testing in formal health centers [9–11]. Fear or (...truncated)