Background: Criminalization of sex work is thought to be a major structural driver of the HIV epidemic among female sex workers (FSW). Incarceration may lead to marginalization, which can reduce access to healthcare and HIV prevention services. Here, we investigated the association between incarceration history and recent HIV testing among FSW in three transit towns in Zambia.
Methods: A quantitative questionnaire was conducted among FSW without known HIV infection in Livingstone, Chirundu, and Kapiri Mposhi, Zambia. Participants were eligible if they were 18 years or older, reported exchanging sex for money or goods at least once in the past month, and were self-reported HIV uninfected or status unknown. Participants were asked if they had ever been arrested or incarcerated, if they had ever had an HIV test, and if so, months since their last test. Logistic regression models were used to determine the association between incarceration history and HIV testing, adjusting for sociodemographic characteristics.
Results: Of 965 participants enrolled, median age was 25 years (interquartile range 21-30 years), 722 (75.3%) were literate, and 560 (59.0%) reported a monthly income of < 500 ZMK (~USD$50). Most (760, 79.5%) reported ever testing for HIV and 617 (65.1%) reported testing for HIV in the previous 12 months. More than one-quarter (275, 28.5%) had a history of incarceration. Most (89.8%) of women reporting incarceration reported that it was related to their engagement in sex work. In an adjusted model, incarceration was associated with 38% reduced odds of HIV testing in the previous year (aOR=0.61, 95% CI 0.45-0.83, P=0.002).
Conclusions: FSW with a history of incarceration significantly less frequently reported recent HIV testing. In this population, incarceration may increase barriers to HIV testing, possibly through increased marginalization or fear of disclosure of sex worker status or police harassment for HIV testing. This may contribute to the disproportionate burden of HIV in this population. Decriminalization of sex work may increase accessibility of HIV testing, and could have profound effects on the HIV epidemic among FSW in Zambia.