What is stopping sex workers from testing for syphilis?

Researchers in Uganda have interviewed sex workers about their experiences testing for syphilis and for HIV to identify common barriers that could be addressed to encourage regular testing.

What is the research about?

Interviews with 48 female sex workers were conducted in 4 Ugandan cities (Arua, Kampala, Mbale, and Mbarara). The women were asked what stops them from testing for syphilis and HIV, and the things that encourage them to do so.

Why is this research important?

Globally, female sex workers are 30-times more likely to get HIV than other people. They also experience high rates of sexually transmitted infections (STIs), including syphilis.

The World Health Organization recommends that female sex workers should test for syphilis every 3 to 6 months and for HIV every 6 to 12 months. But HIV testing rates tend to be higher than syphilis testing rates, even though both are still behind globally agreed targets to end the AIDS epidemic by 2030 and end the STI epidemic by 2040.

Offering sex workers dual syphilis and HIV testing – which is when one test can detect both syphilis and HIV – could increase screening for both conditions. But there is a lack of knowledge on what stops sex workers from testing for syphilis, as research tends to focus on HIV.

What did they find out?

Barriers that stop sex workers testing

1. Public health providers’ attitudes

Sex workers described healthcare workers as having uncaring, unfriendly and judgemental attitudes. They often made sex workers wait longer than other people for services.

These things were an issue in relation to HIV testing, but participants still felt it was easier to ask for an HIV test than a syphilis test. Asking for a syphilis test was more likely to attract embarrassing, disrespectful and critical responses from healthcare workers.

The range of HIV testing options meant sex workers could choose to get an HIV test from clinics that were more friendly and responsive, which encouraged regular HIV testing. But there was less choice with syphilis testing.

2. Stigma

Many sex workers were scared of being seen at a HIV or sexual health clinic. Sometimes, this stopped them from testing for HIV and syphilis. People were worried that rumours would be spread about their health and they would lose customers and income.

3. Lack of syphilis testing

Participants in each city reported being prescribed antibiotics for STIs without being tested, even after they had requested a test. Unlike HIV testing, healthcare workers in public health facilities rarely mentioned syphilis testing unless the sex worker they were attending to was pregnant.

4. Frequent stock outs of syphilis test kits and high cost of syphilis tests

A lack of syphilis test kits in public health facilities and the high cost of syphilis testing in private clinics also discouraged regular syphilis testing. HIV testing kits were more likely to be available in public clinics. In private clinics, HIV tests were cheaper than other STI tests.

Factors that encourage sex workers to test

1. Staying healthy

Sex workers felt motivated to test for HIV and syphilis due to fears and concerns about staying healthy, their ability to work and family responsibilities.

Knowledge that syphilis increased the risk of getting HIV, and the mistaken beliefs that it causes infertility and reduces a sex workers’ ability to satisfy their customers all motivated sex workers to test for syphilis.

2. Emotional well-being

Sex workers can earn more for having condomless sex, but this caused many to worry about getting HIV. Regular HIV testing addressed this by providing peace of mind (if the test was HIV-negative). The same cycle of fear and relief did not exist in relation to syphilis testing.

Some sex workers expressed doubts over the accuracy of HIV-negative test results. The desire to confirm HIV test results, get peace of mind or access treatment led to regular testing at various health facilities.

3. Risk perception

HIV was viewed as a serious health threat, and testing allowed either peace of mind or access to lifesaving treatment that also prevented further transmission. Syphilis was seen as a less serious threat, and there was a widespread misconception that you should only test for it if you developed symptoms.

4. Dual syphilis/HIV testing in friendly clinics

Some participants reported testing for syphilis and HIV when pregnant. Others said they tested for both in specialist clinics for female sex workers and clinics run by non-governmental organisations. These clinics offered integrated STI and HIV services, shorter waiting times, and had friendly and caring healthcare workers.

What does this mean for HIV services?

There is a need to make sex workers aware that they should regularly test for syphilis and other STIs, not just HIV. This could be done by designing community-led awareness and empowerment campaigns that provide sex workers with the facts on syphilis. (For example, the need to regularly test for syphilis rather than wait for symptoms, as some people with syphilis are asymptomatic.)

Yet again, this study shows the need to sensitise healthcare workers in public facilities. This could be done through community-led training sessions designed to stop health workers stigmatising and discriminating against sex workers when they come for HIV and syphilis tests or any service.

National guidelines in Uganda currently recommend dual syphilis and HIV testing for pregnant women and their partners. If this was extended to include female sex workers, and enough syphilis testing kits were provided, it could help to change the attitudes of health providers and improve testing uptake for both conditions.