Feasibility of HIV self-testing among female sex workers in Iran: the SELFii study


BACKGROUND: The HIV epidemic in Iran may be shifting from injection to sexual transmission, presenting challenges to reach new key populations at high risk. Considering severe stigma, discrimination, and criminalization, female sex workers' (FSW) in Iran face barriers to HIV testing at health facilities. New testing strategies such as HIV self-testing (HIVST) present a possible solution. We assessed the feasibility of HIVST among FSW in two cities of Iran.
METHODS: Through peer-referral sampling from 3/2019-8/2020, 492 FSW (aged 18 years or older who sold sex in the last month) in Tehran and Isfahan were invited by 18 peer-educators to use HIVST. We collected data on their experiences in using HIVST, test outcomes, and feasibility of reporting results through peer-educators.
RESULTS: Of 492 FSW participants, 54% were age 30-49 years, 44% used a condom at last sex, and 60% had never tested for HIV. The most common places where FSW used the HIVST were at home (43%), followed by hotspots for sex work or houses that temporarily served as brothels (20%), and public places (18%). Most FSW were assisted by a peer-educator to do the HIVST (76%). Two FSW (0.4%) self-reported a positive HIVST result to a peer-educator; both were referred and received confirmatory testing by the health system. At follow-up, 33% of FSW reported using a condom at last sex; 32% reported no sexual contact after the HIVST. Half (50%) of FSW reported high stress to learn if they are positive before testing; 17% reported stress after the HIVST. Three-fourths (75%) reported the HIVST was easy to use; 83% will recommend it to other FSW. A majority of FSW (54%) were willing to pay up to $2 USD for the HIVST.
CONCLUSIONS: Our study found that HIVST can be distributed by peer-educators to FSW, with high acceptability for use at sex-work venues or at home. Most accepted the assistance of peers to perform the test and record results. The issue of stress reported by some FSW needs further exploration to address this potential barrier. We found no indication that the self-test results increased condomless sex.