The relationship between health worker stigma and uptake of HIV counseling and testing and utilization of non-HIV health services: the experience of male and female sex workers in Kenya

ABSTRACT

The barrier HIV-stigma presents to the HIV treatment cascade is increasingly documented; however less is known about female and male sex worker engagement in and the influence of sex-work stigma on the HIV care continuum. While stigma occurs in all spheres of life, stigma within health services may be particularly detrimental to health seeking behaviors. Therefore, we present levels of sex-work stigma from healthcare workers (HCW) among male and female sex workers in Kenya, and explore the relationship between sex-work stigma and HIV counseling and testing. We also examine the relationship between sex-work stigma and utilization of non-HIV health services. A snowball sample of 497 female sex workers (FSW) and 232 male sex workers (MSW) across four sites was recruited through a modified respondent-driven sampling process. About 50% of both male and female sex workers reported anticipating verbal stigma from HCW while 72% of FSW and 54% of MSW reported experiencing at least one of seven measured forms of stigma from HCW. In general, stigma led to higher odds of reporting delay or avoidance of counseling and testing, as well as non-HIV specific services. Statistical significance of relationships varied across type of health service, type of stigma and gender. For example, anticipated stigma was not a significant predictor of delay or avoidance of health services for MSW; however, FSW who anticipated HCW stigma had significantly higher odds of avoiding (OR = 2.11) non-HIV services, compared to FSW who did not. This paper adds to the growing evidence of stigma as a roadblock in the HIV treatment cascade, as well as its undermining of the human right to health. While more attention is being paid to addressing HIV-stigma, it is equally important to address the key population stigma that often intersects with HIV-stigma.

KEYWORDS:

• Stigma
• discrimination
• healthcare utilization
• male sex workers
• female sex workers
• health care workers

Acknowledgements

We greatly appreciate study participants taking the time to be interviewed and sharing their personal experiences with the research team. We also thank study coordinator Rahma Hassan for her leadership in coordinating the interviewer training, data collection, and data cleaning, and Paul Waweru Ngugi (Kenya National Bureau of Statistics) for his invaluable support in data cleaning and analysis. We gratefully acknowledge the following individuals who interviewed respondents and ensured data were collected ethically and rigorously: Caroline Gakii, Claudette Jollebo, Tabitha Kinyanjui, Benard Maingi, Timothy Matingi, Mwikali Manga’ti, Charles Mutuku, Lukas Constant Nthei, David Brian Ochar, Aketch Charles Otieno, Joseph James Otieno, Caroline Sumbeiywo, and Savatia Juliet. We are grateful for the leadership and staff of our partner organizations and for their assistance during data collection, specifically John Mathenge from Health Options for Young Men on HIV, AIDS and STIs; Peninah Mwangi from the Bar Hostess Empowerment and Support Program; Thomas Odhiambo from Keeping Alive Society’s Hope; and Caroline Kemunto from Survivors. This study would not have been possible without the hard work of a talented research team including Joshua Kimani, Daniel Mwai, and Tom Oneko and the support of HPP country director Stephen Muchiri and Laura McPherson. We are also grateful for the support of Helgar Musyoki and Martin Sirengo of the National AIDS & STI Control Program.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

The study was funded by the U.S. Agency for International Development (USAID) and the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) through funding to the Health Policy Project [agreement number AID-OAA-A-10-00067]. The content of this publication is the sole responsibility of the authors and does not necessarily reflect the views or policies of U.S. Agency for International Development or the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), and does not imply endorsement by the U.S. Government. Additional support for analysis was provided by RTI, International.