Individual level perspectives of HIV recent infection testing among female sex workers in Zimbabwe

Issue: In 2022 the United States President’s Emergency Plan for AIDS Relief released a guidance proposing recency testing to be adopted as a key component of new real-time HIV surveillance systems for resource allocation at a local level (1). In response to this, the Foundation of AIDS Research (amfAR) highlighted their concerns regarding ethical and human rights issues relating to consent, risks of harms, inaccuracy of test results and more (2). Through sharing our learnings we aim to contribute to the debate around individual level utility and ethical concerns, and to understanding how we can further support recency testing in real world settings as informed by the perspectives of those being tested. From June to November 2018, we carried out in-depth interviews with fourteen female sex workers (FSWs) recruited from Zimbabwe’s national Sisters with a Voice sex worker programme. We aimed to explore experiences and perspectives of clinic users to assess the feasibility and utility of integrating a Recent Infection Testing Algorithm into routine programme service delivery for FSWs. Participants were aged 25 to 46 years with interviews taking place in Bulawayo, Gweru, Harare, Karoi, and Mutare. Lessons Learnt: In support of amfAR’s concerns, several participants mentioned the potential physical and psychological harm of receiving their recency results including distress and fear of violence from themselves and/or their partners. However, it is hard to disentangle if these harms are linked to the return of the additional recency test or the positive HIV test. Additionally, participants mentioned several benefits to returning recency results including better understanding of their status and health, and incentive to take their HIV medication. We also found that some participants did not properly understand what recency testing was and some reported that they felt obliged to participate out of a sense of duty. These results highlight issues of consent, where even in healthcare settings with large amounts of trust, a structural power imbalance still exists and patients can feel an increased sense of responsibility for their health and that of their community. Recommendations: There is a need for more community engagement to rightly make patients active agents in their healthcare decisions. We think that the choice of whether patients should receive their recency results should reside with the patients themselves. After providing patients with information regarding the risks of receiving their recency results, they should have the ability to decide what is best for them. By deciding what is best for them without involving them in the decision, we exacerbate power imbalances and risk undermining patient’s trust of programmes.