Strategies to Identify and Reach Young Women Who Sell Sex With HIV Prevention and Care Services: Lessons Learnt From the Implementation of DREAMS Services in Two Cities in Zimbabwe

"Achieving the ambitious goal to end the AIDS epidemic by 2030 requires that programs identify and reach populations at high risk of HIV."

In many countries, including Zimbabwe, selling sex is criminalised, making young women who sell sex (YWSS) particularly hidden and hard to reach with HIV prevention and care services. The success of peer referral approaches in reaching high-risk hidden populations has been noted in many populations, including in West and Central Africa. Between 2016 and 2019, the Determined, Resilient, Empowered, AIDS-free, Mentored and Safe (DREAMS) Partnership aimed to reduce the risk of HIV acquisition among vulnerable populations of adolescent girls and young women, including YWSS, in 10 sub-Saharan African countries. This paper describes a study of 2 peer referral methods, peer outreach and respondent-driven sampling (RDS), used to refer YWSS for DREAMS services in Zimbabwe, and it compares the characteristics and engagement of YWSS referred to these services by each method to assess which strategy reached more YWSS.

In Zimbabwe, DREAMS was implemented in 6 districts in Bulawayo, Chipinge, Gweru, Makoni, Mazowe, and Mutare. To increase economic well-being, YWSS were offered economic empowerment programmes, including vocational skills training, financial literacy training, savings and lending support, and services to support access to education, including cash transfers and educational subsidies. DREAMS services for YWSS were accessible through the Sisters with a Voice programme (Sisters), in addition to other implementing partners. Sisters is a national sex worker programme that was established in Zimbabwe in 2009 on behalf of the Ministry of Health and Child Care, and the National AIDS Council. Briefly, Sisters provides free condoms and contraception, HIV testing and counseling, syndromic management of sexually transmitted infections (STIs), health education, and legal advice supported by a network of peer educators.

This study was conducted in 2 districts/cities (Bulawayo and Mutare) that were selected as part of DREAMS impact evaluation from the 6 districts where DREAMS was being implemented. A cohort of YWSS was recruited using RDS and followed-up for 24 months to determine the impact of DREAMS on HIV incidence among YWSS in these 2 cities compared to the incidence among YWSS in 4 towns where DREAMS was not implemented and YWSS only had access to Sisters services.

To identify, reach, and refer YWSS for DREAMS, the researchers used peer outreach, which is a programmatic approach, and RDS, which is a sampling method designed to reach a representative sample of the network of key populations, between January 2017 and July 2018 and between April and July 2017, respectively, in 2 cities in Zimbabwe. More specifically:

• For peer outreach, the researchers initiated recruitment to DREAMS via 18 trained and age-matched peer educators using youth-tailored community mobilisation. Peer educators received a monthly incentive of US$15. The peer educators are trained to build rapport with other YWSS and mobilise them for HIV prevention and care services using 21 activity packs, organised into 6 modules relating to social asset building, HIV prevention, condom promotion and provision, gender norms, basic financial literacy, and sexual violence prevention. These materials were designed in consultation with YWSS and experts and were piloted and evaluated among a sample of YWSS. Peer educators were recruited in 2016 and worked in the DREAMS programme until 2018. Peer educators included 10 who self-identified as female sex workers and 8 who did not. All were 18 to 20 years old and had some secondary school education or higher. Their duties involved identifying hotspots and adolescent girls and young women through word of mouth. Peer educators would meet with young women, talk to them about DREAMS services, and offer them a referral slip.
• For RDS, the researchers conducted detailed mapping to understand sex work typology and geography, and then they purposively selected 10 "seed" participants in each city to initiate RDS for DREAMS referrals. Each "seed" was interviewed and given 2 recruitment coupons to pass on to YWSS in her social network. YWSS who received a coupon were given 2 coupons on completion of survey activities to pass on to 2 further YWSS they knew, who sold sex in that location, and who had not previously been recruited to the survey. With RDS, the number of coupons given to each recruiter is limited to reduce the likelihood of overrepresentation of participants with more extensive networks. The recruitment process happened over 6 waves until the desired sample size of about 600 YWSS was achieved in each city. YWSS were given an incentive of US$3 for participating in the survey themselves and an additional US$2 for each peer recruited.

The paper describes the characteristics and service engagement of YWSS who accessed DREAMS services by each referral approach and assesses the association of these characteristics with referral approach using the chi-square test. Analysis was performed with and without restricting the period when RDS took place.

Overall, 5,386 and 1,204 YWSS were referred for DREAMS services through peer outreach and RDS, respectively. However, YWSS referred through RDS were more likely to access DREAMS services compared to YWSS referred through peer outreach (501/1,204, 41.6% vs 930/5,386, 17.3%; P<.001). Regardless of referral approach, YWSS who accessed DREAMS had similar education levels, and a similar proportion tested HIV negative and reported not using a condom at the last sex act. A higher proportion of YWSS accessing DREAMS through RDS were aged 18-19 years (167/501, 33.3% vs 243/930, 26.1%; P=.004) and more likely to be aware of their HIV status (395/501, 78.8% vs 396/930, 42.6%; P<.001) compared to those accessing DREAMS services through peer outreach. The incremental cost per YWSS recruited was US$7.46 for peer outreach and US$52.81 for RDS.

Reflecting on the findings, the researchers note that, among women who accessed DREAMS services, those referred by RDS were younger, appeared to be better engaged with services, had previously tested for HIV, and knew their status. By contrast, peer outreach identified more YWSS who had never been tested for HIV and were unaware of their HIV status. The fact that a higher proportion of previously unengaged YWSS accessed DREAMS services through peer outreach than through RDS is possibly due to the level of training that peer educators received, coupled with the tailored community mobilisation activities and materials used. Although the differences in ever testing between recruitment approaches were not significant (76% vs 88%), when programmes are aiming to ensure that all those who are vulnerable are reached, optimising referral approaches by using a combination of approaches is likely important.

Notably, YWSS who reported having at least one close friend were more likely to access DREAMS services compared to those who did not have a close friend, emphasising the importance of building social cohesion among disempowered communities to optimise their uptake of HIV prevention and care.

In conclusion, peer outreach and RDS approaches can reach and refer high-risk but different groups of YWSS for HIV services; using both approaches will likely improve reach.