title: "You are wasting our drugs": health service barriers to HIV treatment for sex workers in Zimbabwe.
abstract: BACKGROUND
  Although disproportionately affected by HIV, sex workers (SWs) remain neglected by efforts to expand access to antiretroviral treatment (ART). In Zimbabwe, despite the existence of well-attended services targeted to female SWs, fewer than half of women diagnosed with HIV took up referrals for assessment and ART initiation; just 14% attended more than one appointment. We conducted a qualitative study to explore the reasons for non-attendance and the high rate of attrition.
  
  
  METHODS
  Three focus group discussions (FGD) were conducted in Harare with HIV-positive SWs referred from the 'Sisters with a Voice' programme to a public HIV clinic for ART eligibility screening and enrolment. Focus groups explored SWs' experiences and perceptions of seeking care, with a focus on how managing HIV interacted with challenges specific to being a sex worker. FGD transcripts were analyzed by identifying emerging and recurring themes that were specifically related to interactions with health services and how these affected decision-making around HIV treatment uptake and retention in care.
  
  
  RESULTS
  SWs emphasised supply-side barriers, such as being demeaned and humiliated by health workers, reflecting broader social stigma surrounding their work. Sex workers were particularly sensitive to being identified and belittled within the health care environment. Demand-side barriers also featured, including competing time commitments and costs of transport and some treatment, reflecting SWs' marginalised socio-economic position.
  
  
  CONCLUSIONS
  Improving treatment access for SWs is critical for their own health, programme equity, and public health benefit. Programmes working to reduce SW attrition from HIV care need to proactively address the quality and environment of public services. Sensitising health workers through specialised training, refining referral systems from sex-worker friendly clinics into the national system, and providing opportunities for SW to collectively organise for improved treatment and rights might help alleviate the barriers to treatment initiation and attention currently faced by SW.
authors.affiliation: Zimbabwe AIDS Prevention Project, Department of Community Medicine, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe. sibongile2s@yahoo.co.uk
authors.forename: Sibongile
authors.initials: S
authors.lastname: Mtetwa
authors.forename: Joanna
authors.initials: J
authors.lastname: Busza
authors.forename: Samson
authors.initials: S
authors.lastname: Chidiya
authors.forename: Stanley
authors.initials: S
authors.lastname: Mungofa
authors.forename: Frances
authors.initials: F
authors.lastname: Cowan
mesh_terms: D000293:Adolescent; D000328:Adult; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D005260:Female; D017144:Focus Groups; D015658:HIV Infections / Q000188:drug therapy*; D006297:Health Services Accessibility; D006801:Humans; D008875:Middle Aged; D060386:Sex Workers; D057545:Social Stigma; D055815:Young Adult; D015030:Zimbabwe
chemical_list: D044966:Anti-Retroviral Agents
references.citation: AIDS Patient Care STDS. 2009 Nov;23(11):973-80
references.pmid: 19821725
references.citation: Sex Transm Infect. 2010 Feb;86 Suppl 1:i2-3
references.pmid: 20167726
references.citation: Soc Sci Med. 2009 Oct;69(8):1177-85
references.pmid: 19692165
references.citation: AIDS Behav. 2013 Jul;17(6):2162-72
references.pmid: 23080358
references.citation: Health Educ Res. 2008 Feb;23(1):137-45
references.pmid: 17363361
references.citation: Aust N Z J Public Health. 2010 Oct;34(5):482-6
references.pmid: 21040176
references.citation: Soc Sci Med. 2008 Apr;66(8):1848-62
references.pmid: 18295948
references.citation: AIDS Behav. 2012 May;16(4):920-33
references.pmid: 21750918
references.citation: PLoS One. 2012;7(3):e32627
references.pmid: 22403685
references.citation: AIDS Patient Care STDS. 2009 May;23(5):357-64
references.pmid: 19327099
references.citation: BMC Public Health. 2011 Sep 14;11:700
references.pmid: 21917177
references.citation: Trop Med Int Health. 2010 Jun;15 Suppl 1:16-33
references.pmid: 20586957
references.citation: AIDS. 2007 Jul 11;21(11):1486-7
references.pmid: 17589198
references.citation: BMC Public Health. 2010 Jul 20;10:427
references.pmid: 20646300
references.citation: PLoS Med. 2009 Jan 27;6(1):e11
references.pmid: 19175285
references.citation: J Int Assoc Physicians AIDS Care (Chic). 2002 Spring;1(2):51-2
references.pmid: 12942676
references.citation: BMC Health Serv Res. 2011 Apr 18;11:79
references.pmid: 21501473
references.citation: Lancet. 2011 Jun 11;377(9782):2031-41
references.pmid: 21641026
references.citation: Lancet Infect Dis. 2012 Jul;12(7):538-49
references.pmid: 22424777
references.citation: BMC Public Health. 2011 Sep 14;11:701
references.pmid: 21917178
references.citation: Soc Sci Med. 1997 Jun;44(12):1791-803
references.pmid: 9194241
references.citation: J Int AIDS Soc. 2010 Sep 23;13:37
references.pmid: 20863399
references.citation: N Engl J Med. 2011 Aug 11;365(6):493-505
references.pmid: 21767103
references.citation: Cochrane Database Syst Rev. 2013 Apr 30;(4):CD009153
references.pmid: 23633367
references.citation: J Epidemiol Community Health. 2012 Oct;66 Suppl 2:ii42-48
references.pmid: 22495772
references.citation: AIDS Patient Care STDS. 2009 May;23(5):377-87
references.pmid: 19327098
references.citation: JAMA. 2010 Aug 4;304(5):573-4
references.pmid: 20682941
references.citation: Int J Health Plann Manage. 2011 Jul-Sep;26(3):296-318
references.pmid: 21744381
references.citation: Soc Sci Med. 2009 Oct;69(8):1157-66
references.pmid: 19716639
references.citation: AIDS. 2004 Apr 9;18(6):945-7
references.pmid: 15060443
references.citation: Trop Med Int Health. 2008 Jul;13(7):904-13
references.pmid: 18466183
references.citation: PLoS Med. 2012;9(7):e1001258
references.pmid: 22802738
references.citation: Sex Transm Infect. 2008 Dec;84(7):548-53
references.pmid: 18684855
references.citation: AIDS Care. 2007 Aug;19(7):878-87
references.pmid: 17712691
references.citation: Curr HIV/AIDS Rep. 2010 Nov;7(4):234-44
references.pmid: 20820972