ICRH Monograph Yves Lafort How to ensure access to adequate HIV and sexual and reproductive health services for female sex workers? : lessons learned from a ‘diagonal’ service delivery model tested in Africa and India


On January 7th 2019 Dr. Yves Lafort succesfully defended his PhD entitled: "How to ensure access to adequate HIV and sexual and reproductive health services for female sex workers? : lessons learned from a ‘diagonal’ service delivery model tested in Africa and India" - Supervisors: Prof. Dr. Wim Delva and Prof. Dr. Matthew Chersisch

Title: "How to ensure access to adequate HIV and sexual and reproductive health services for female sex workers? Lessons learned from a ‘diagonal’ service delivery model tested in Africa and India".

Supervisors: Prof. Dr. Wim Delva and Prof. Dr. Matthew Chersich

Faculty of Medicine and Health Sciences, Ghen University, Department of Public Health and Primary Care, ICRH


Background - Female sex workers (FSWs)     are at disproportional risk for HIV and other adverse sexual and reproductive health (SRH) outcomes, because of having multiple sexual contacts with a variety of partners. However, access to the general health services is hampered by stigmatisation, discrimination and other barriers. Several initiatives have established separate, parallel health services for FSWs, but these are generally small-scale, limited in geographical range and time, have scant government support, and offer only a few services. Our hypothesis was that to ensure appropriate access to a complete package of HIV/SRH services, a ‘diagonal’ approach was needed that combines and links ‘vertical’, FSW-targeted interventions with ‘horizontally’ improving access to the general health services. We tested this hypothesis in four cities in sub-Saharan Africa and India: Durban in South Africa; Tete in Mozambique; Mombasa in Kenya and Mysore in India.
Methods - Applying an implementation research design, we first conducted a thorough situational analysis, developed context-specific interventions, implemented them for 18 months, and evaluated their performance. Pre- and post-intervention, we conducted cross-sectional surveys and interviewed FSWs face-to-face. At baseline, we quantitatively compared HIV/SRH care seeking across the four cities, and at end-line changes in care seeking since baseline in each of the three African cities. In Tete, Mozambique we additionally performed mixed-methods analyses. At baseline, we explored further in-depth barriers to care by comparing the cross-sectional survey results with the findings of focus group discussions with FSWs. We assessed the HIV/SRH service delivery environment through a joint desk review of policy documents; health facility audits; and in-depth interviews with policy makers, health managers, HIV/SRH care providers and HIV/SRH care users. At end-line, we further explored the effect of the intervention by comparing the cross-sectional survey results with findings of focus group discussions with FSWs and peer educators. We assessed the feasibility, acceptability, sustainability and scalability of the intervention through triangulation of the results of a second round of interviews with policy makers, health managers and HIV/SRH care providers; and the analysis of monitored process measures.
Results - At baseline, uptake of HIV/SRH services differed significantly across the four cities and differences remained significant after adjusting for variations in FSWs’ socio-demographic characteristics. Uptake of services was nevertheless sub-optimal in all cities. Across cities, FSWs most commonly sought care at public health facilities. Services specifically targeting FSWs only had a high coverage in Mysore for some services. Private-for-profit clinics were important providers in Mombasa only. The reason for the choice of care provider was mostly convenience-based. Where available, clinics specifically targeting FSWs were more often chosen because of shorter waiting times, perceived higher quality of care, more privacy and friendlier personnel.
In Tete-Mozambique, none of the national policy documents provided guidance for care adapted to the needs of FSWs. Policy makers had different views on the best approach for providing services to FSWs—integrated in the general health services or through parallel services for key populations—and there existed no national strategy. Most basic services were widely available, except for certain family planning methods, cervical cancer screening, services for victims of sexual and gender-based violence, and termination of pregnancy. The public facilities faced serious limitations in term of space, staff, equipment, regular supplies and adequate provider practices. A stand-alone clinic targeting key populations offered a limited range of services to the FSW population in part of the area. In the focus group discussions, FSWs expressed dissatisfaction with the public health services, as a result of being asked for bribes, being badly attended by some care providers, stigmatisation and breaches of confidentiality.
At end-line, we observed a substantial and significant increase in uptake of HIV/SRH services, in all four study sites. In Tete and Mombasa, rise in SRH service use was entirely due to a greater uptake of targeted services. In Tete, FGD participants reported that some facilities had become more FSW-friendly, but barriers such as stock-outs, being asked for bribes and disrespectful treatment persisted. The intervention, as designed, was considered theoretically feasible by all informants, but in practice the expansion of some of the targeted services was hampered by insufficient financial resources, institutional capacity and buy-in from local government and private partners. In terms of acceptability, there was broad consensus on the need to ensure FSWs have access to SRH services, but not on how this might be achieved. Targeted clinical services were no longer endorsed by national government, which now preferred a strategy of making public services friendlier. Stakeholders judged that the piloted model was not fully sustainable, nor scalable, given its dependency on short-term project-based funding, lack of government endorsement for targeted clinical services, and viewing the provision of community activities as a responsibility of civil society.
Conclusion – Our research demonstrated that a ‘diagonal’ service delivery model can effectively increase uptake of services in different settings. The FSW-targeted components had the highest impact on increasing service utilisation, while improving use of general health services appeared harder to achieve. More research is needed to define the best approach to make public health services accessible to FSWs. In the meantime, targeted interventions, including targeted clinical services continue necessary. Each FSW setting is specific with regards to policy environment and available health service providers, and service-delivery model must therefore be context-specific. National policy makers need to endorse this ‘diagonal’ approach and the international community must provide funding where necessary.


The full thesis can be downloaded here

Authors & affiliation: 
Yves Lafort - PhD Ghent University Faculty of Medicine and Health Sciences - ICRH (07/01/2019)
Staff Members: 
Published In: 
ICRH Monographs
Publication date: 
Monday, January 7, 2019