“I wanted evidence that my status had changed, so that is why I tested”: experiences with HIV self-testing among female sex workers in Malawi

Maximising HIV testing among female sex workers (FSWs) is an established global health priority. HIV self-testing (HIVST) seems to have the potential to address issues of confidentiality, privacy and convenience among this key population. HIVST, however, may result in unintended consequences as its implementation unfolds in a complex sex work context characterised by unequal power relations, stigma and high HIV prevalence. This study aimed to explore the experiences of FSWs with HIVST in the context of retesting and antiretroviral usage in Blantyre, Malawi. We used an ethnographic approach to understand meanings and views around HIV self-testing and retesting. We found high levels of retesting, especially among those on antiretroviral, two of which received ‘false negative’ results. We identified three broad narratives: (1) retesting in response to experiences in the sex work context, (2) retesting driven by the desire to self-monitor HIV negative status, and (3) retesting in the hope of sero-reversion. The experiences of these women indicate that the implementation of HIV self-testing in the context of sex work is complex with potential for unintended harms such as coercive testing. HIVST programmes must include clear and appropriate messaging to reduce retesting while on ART and ensure effective strategies are in place to address FSW concerns and anxieties about the accuracy of their HIV positive test results.