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HIV and Contraceptive Service Integration for Female Sex Workers

New toolkits offer guidance for improvement

Key populations, including female sex workers, face barriers to health care access that include stigma, criminalization, and gender-based violence. In many cases, these barriers can be mitigated by peer educators, who bring valuable insight and may engender trust with clients.

Female sex workers are among the priority populations that are the focus of the Meeting Targets and Maintaining Epidemic Control (EpiC) project, funded by the United States Agency for International Development (USAID) and the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). Because HIV and family planning services are critical and, too often, unmet needs for female sex workers, USAID and PEPFAR endorse integrated delivery.

“The barriers that sex workers face regarding access to health services can be mitigated by peer educators because of the valuable perspective they bring.”

Agness John, an FHI 360 senior technical officer for HIV programs in Tanzania

The stigma associated with sex work is a primary reason that peer educators and their lived experiences are irreplaceable. Peers educators often know the locations of sex workers, and they will not discriminate or pass judgment in the way that some providers may. Given these factors, they have a unique opportunity to counsel and meet the needs of their peers who are trying to prevent sexually transmitted infections (STIs) and prevent or plan pregnancy. Training developed specifically for peer educators positions them to have the greatest impact when counseling clients.

Data show that many female sex workers who would like to prevent pregnancy are not using a contraceptive method. Those in low- and middle-income countries in Africa have higher rates of unmet family planning need than the general population. Among surveyed sex workers, 30% in Madagascar had an unmet need for family planning, and 70% in Cote d’Ivoire had experienced an unplanned pregnancy.

Female condom. Photo Credit: U.S. Food and Drug Administration.
Credit: U.S. Food and Drug Administration.

PEPFAR’s Country Operational Plans call for integration of family planning and HIV services, including the provision of pre-exposure prophylaxis (PrEP), and note that a one-stop shop is particularly important for reaching key population members with services they need. Likewise, technical guidance from the Global Fund to Fight AIDS, Tuberculosis and Malaria advocates for focused efforts to integrate high-quality HIV and family planning services and to address discrimination.

To strengthen integration efforts, FHI 360 published The Peer Educator Tool for Informing Female Sex Workers about Contraceptive Options. Developed through the EpiC and Linkages across the Continuum of HIV Services for Key Populations Affected by HIV (LINKAGES) projects with funding from USAID, EpiC teams are beginning to use the toolkit (Figure 1).

Making Options Clear

The toolkit, designed for peer educators who work with HIV programs, has a user guide, peer educator tool, and session plan. It provides tangible processes and resources for peer educators to present basic information on a range of contraceptive options, encourage clients to determine their needs, and explain how to obtain each method. The properties of contraceptive options are described, and a skills checklist gives peer educators a way to assess their practices for empathetically and respectfully interacting with clients.

When used properly, the tool supports positive interaction between the peer educator and female sex worker by facilitating eye contact, providing easy-to-understand and relevant information, and enabling confidential discussions.

The Contraceptive Services for Female Sex Workers—Training Module for Clinicians is designed to orient clinicians to the special needs and concerns of female sex workers seeking contraceptive services. It includes a facilitator manual and slide presentation. The toolkit focuses on reasons they may prefer certain methods and how to provide nonjudgmental, informed-choice counseling. The learning objectives include:

  • Sensitizing clinicians to gender norms and how those norms affect female sex workers.
  • Considering barriers that female sex workers face to contraception and how to address those barriers.
  • Providing counseling and care that is supportive and nonjudgmental.
  • Explaining how HIV status and sexually transmitted infections (STIs) affect eligibility for some methods.
  • Demonstrating the ability to counsel female sex workers about protection against pregnancy, HIV, and STIs.
Agnes Safina, an HIV testing counselor. Credit: USAID in Africa.
Agnes Safina, an HIV testing counselor. Credit: USAID in Africa.

The training is meant to be modified based on the method mix of the country or program and requires five to six hours. It is interactive, with pre- and post-training knowledge assessments, group discussions, presentations, and role-playing.

Female sex workers may lack time or resources to access health services. They may have to travel to find work, or may have experienced discrimination from providers. Having one location for high-quality information and counseling can make it easier for them to access care.

The broad adoption of the toolkits by HIV programs will translate into improved health and quality of life for women who are reached, explained Rose Wilcher, Director of Knowledge Management and Structural Interventions of the HIV Division at FHI 360.

“The HIV and pregnancy prevention needs of women, especially female sex workers, are inextricably linked,” she said. “Women want fully integrated sexual and reproductive health information and services that meet their needs and fulfill their rights. These tools are designed to help providers—from community-based peer outreach workers to health facility-based clinicians—do just that.”

Hannah Webster

Technical Officer, FHI 360

Hannah Webster, MPH, is a Technical Officer in the Global Health, Population, and Research department at FHI 360. In her role, she contributes to project operations, technical communication and knowledge management. Her areas of specialization include public health, research utilization, equity, gender and sexual and reproductive health.

Sarah Muthler

Science Writer, Research Utilization, FHI 360

Sarah Muthler, MPH, MS, is a science writer in the Research Utilization division at FHI 360. In her role, she researches, writes, edits, and coordinates production of reports, briefs, blogs, and other content. Her areas of specialization include reproductive health and family planning, HIV, and gender equity.