Socio-demographic characteristics
All IDI and FGD participants were healthy female, aged between 20 and 37 years.
The majority (eight) of the IDI participants attained secondary level education, six studied up to seven years of primary school, while only one stopped in fourth year. Besides sex work, a few IDI participants engaged in other income-generating activities such as hairdresser, barmaid, petty business, and master of ceremony responsible for overseeing social events. Half of the FGD participants were educated for up to four years of secondary education, and another half stopped after seven years of primary school.
Themes and sub-themes
Two themes emerged from the thematic content analysis: the ‘Apparent risk’ of acquiring HIV infection before enrolling in the HIV vaccine and Pre-Exposure Trial and the ‘Balancing the perceived risk’ of acquiring HIV infection and preventive measures after enrolling in the HIV vaccine and Pre-Exposure Trial. Each theme is supported by subsequent sub-themes, as described in Table 1.
Theme 1: Apparent risk of acquiring HIV infection before enrolling in HIV vaccine and pre-exposure prophylaxis trial
Engaging in risky sexual practices
Monetary-driven condomless sex
Before enrolling in the HIV vaccine study, many participants reported practising condomless sex to meet the client’s wishes as well as the desire to get more money. They said it was very tempting to practice sex without using condoms because they depended on the sex work as their primary source of income. One participant said:
I used to have sex without protection with people who had a large amount of money, I used to focus on the amount of money that I would be paid; if the money was good enough, I went with them without a condom (P10, IDI).
Condomless sex due to a prolonged relationship with one client
Many participants said they stopped using condoms with permanent clients [a client who was viewed as a husband; could live and have unlimited sexual intercourse with the FSW]. They reasoned that those long-term relationships with male clients provided assurance of faithfulness and that the client could not be living with HIV. One participant narrated:
You know we women, after seeing a man for the first time, the second time, and the third time, think that I am used to this one, I mean you believe that he is not infected (P15, IDI).
Despite the expressed fact that participants were aware of HIV prevention methods, they said sometimes they practiced condomless sex to fulfil the clients’ preferences. Some men disliked condoms:
Not all men want to use protection; some want without condoms, I did have education on how to protect myself against infection, but I used to do it [condomless] while my conscience told me that I was at risk and it increased my fear; (P11, IDI)
Inability to protect against HIV transmission
The participants reported a lack of seriousness when it comes to protecting themselves against HIV transmission. They perceived themselves at risk of acquiring HIV infection before enrolling in the vaccine trial because of sex work without using condom. They suspected that even if they were careful, their clients could have unprotected sex with women living with HIV and in turn transmit the infection to them. Some of the participants complained about not knowing the routes of HIV transmission and identifying healthy clients. They also engaged in unprotected sex because the clients paid them well.
One participant emphasized:
In many cases the people we have sex with without condom give us good payment. So there is a time we say, to hell with! (IDI, P1).
Encountering limited knowledge of HIV preventive measures
Limited knowledge of HIV prevention methods, including PrEP
Participants said they lacked knowledge about HIV prevention including PrEP. They reported seeing people in the community taking prophylaxis but they did not know from where they got them. As a result, they exposed themselves to the risk of acquiring HIV infection without knowing where to get the preventive medicines. They said:
I didn’t know what does preventive medicine helps. I mean I didn’t know anything, even when I see a person taking the medicine, I was among people who would say that she is HIV positive, and other myths. I used to see people in the street taking preventive medicines but didn’t know where they get them (P7, IDI).
Some of the participants argued that they were at risk of HIV infection because of a lack of education on prevention. They lamented that a limited understanding of preventive measures was a big problem for many of them:
I did not have education on how to protect myself against infection [HIV]. So I used to do it [sex] while my conscious tells me that I am at risk, and that increased my fear (P10, IDI).
I was at a high risk of getting HIV infection because I did not have education; I was doing things [unprotected sex] that I didn’t understand (P11, IDI).
Also, the participants stated that before joining the study they had limited knowledge about the condoms’ expiring dates. They said that clients could just tell them that they had the condom, and they engaged in sexual intercourse while not being sure about the condom’s viability. One participant said:
You might find someone carrying an expired condom of 2010. Yes, you see it has required quality; you see but you use it without knowing [the expiring date]; hence, ending up infected because you have not read the expiring date. I have come to know these issues [condom expiring date] at Muhimbili [Trial site] (P1, IDI).
Lack of knowledge about the HIV testing schedule
The lack of knowledge about the HIV testing was reported as one of the gaps in HIV prevention. The participants reported that before joining the study, they were less knowledgeable about HIV testing issues including the schedules. They did not know when to test and after how long they should do the test. One participant said:
In the beginning, I didn’t know about HIV well; after how many months are you supposed to test [re-test] for HIV, I didn’t know that [re-test for HIV]. (P7, IDI).
Theme 2: Balancing the perceived risk of acquiring HIV infection and use of preventive measures after enrolling in the HIV vaccine and pre-exposure prophylaxis trial
Perceived reduced risk of HIV due to knowledge gained
Gained knowledge of HIV prevention
After participating in the HIV vaccine trial, testimonies emerged on improved FSW’s knowledge regarding HIV prevention. They embraced the knowledge gained on the meaning of HIV infection, how HIV is transmitted, and available prevention methods. They said:
The risk [HIV infection] is there, but currently [after joining the trial] not much because I am using Pills [PrEP]… the pills make me feel comfortable…I mean it [knowledge about HIV] has greatly changed (P5, IDI).
I am using PrEP, and I know that PrEP are pills which prevent HIV infection 100%. Even if the virus will be attacking, its attack would be different if you are using PrEP (P11, IDI).
I cannot have sex with a client without condom because I know the meaning of HIV, and how it is transmitted. I know the importance of condom, So there is a difference between now and in the beginning [before joining the trial] (P13, IDI).
They declared that although the risk of acquiring HIV was still there even after participating in the study, it was not that much because they were using pills [PrEP] that made them feel protected. They reasoned that the pills made them feel free and comfortable to continue with their sex work even to those clients who refused to use condoms.
Now I don’t think I am at risk because I use the preventive pills [PrEP] even if I skip the pill in a day, I don’t think it will be dangerous [acquire HIV] (P15, IDI).
To be honest, the study has helped me; first of all the study has removed the fear, second it has removed me from the risk because now I have self-awareness (P11, IDI).
Increased knowledge of self-protection
The participants’ confidence in self-protection increased because they felt that they had gained adequate knowledge about HIV prevention and had all the essential protective gear.
Now I am not at risk because I have received an education, and I know how to use this and that [protection such as condom and PrEP] so that I cannot get HIV infection (P8, IDI).
They emphasized how important it was to carry condoms with them. One participant said:
Now I am not at risk of getting the infection because I have protective gear and I am good… now I use condoms, condoms to me now are like a teacher who cannot go to school without a stick and a pen (P6, IDI).
They said they were taught all about HIV and that education increased their knowledge on not having sex haphazardly because they could acquire the HIV infection. The free condoms provided at the study site were essential to support the participants in self-protection:
Now I am confident; I know that I have taken my pills [PrEP], although we were advised not to have much confidence [having sex without protection], and that is why we were advised to use condoms (P14, IDI).
The benefits of joining the study were evidenced by the reduction of risk perceptions among the participants. Some participants reported that they became more careful by avoiding having sex with clients without condoms. They emphasized that if the clients refused to use condoms, they asked them to go for HIV tests:
Since I joined the study and received education and know the importance of my health, I cannot have sex without a condom…so even if you show me three hundred thousand shillings without a condom. I would say no, or if you want sex without a condom, we have to go and check our health [HIV status] (P10, IDI).
The risk of getting HIV infection was considered low because the participants felt confident that they could abandon the clients who would refuse to use condoms:
I also protect myself and the person that I have sex with, …I trust myself and when I meet a person I dare to tell him that, I cannot have sex with you without a condom because I know the meaning of HIV and how is it transmitted (P13, IDI)
The benefits of condoms were well known because of the experience of prevention of infections such as Sexually Transmitted Infections (STIs), HIV, and unplanned pregnancies. One participant emphasised and said:
I always carry condom because it prevents against STIs, HIV and unplanned pregnancies like the child I am taking care of myself; now I am preventing unplanned pregnancies…When I go to my business, I know that I must protect myself (P10, IDI)
The provision of free prophylaxis at the study site increased confidence in not getting HIV infection among the participants. Many participants appreciated being given protection such as PrEP and condoms.
Acquired confidence in performing HIV test
After enrolling in the study, the participants reported that they gained confidence about performing an HIV test. They did not fear testing for HIV, and envisioned themselves as being more careful as compared to before they enrolled in the study. They said:
I don’t fear testing for HIV, and I have confidence now compared to the beginning… the study has helped me; first of all, the study has removed the fear, (P11, IDI).
The confidence in HIV testing after enrolling in the trial provided the participants with assurance of their health status. They acknowledged the frequency of taking HIV tests at the trial sites helped to reduce their fear.
The belief that the study products (vaccines and PrEP) protect against HIV
Compliance with HIV preventive measures
The knowledge gained during the study increased compliance with HIV preventive measures including PrEP. They perceived themselves at low risk of acquiring HIV infection because they used PrEP. Some were confident that full use of PrEP protects them from HIV infection.
They evidenced that using PrEP pills could prevent HIV infection 100 per cent.
When we use the pills even if we suffer from minor injuries, we are sure that we have immunity in our bodies. That is why we request that the size of the pills should be reduced and the pills be made available (P8, FGD 2).
Other participants emphasized the benefits of PrEP during their sex work. They said that when taking the pills for seven days consecutively, it could stay in the body and hence provide effective protection even if they have sex without a condom with a person living with HIV. They also described that PrEP had resolved the risk of condom-less sex that was practised before joining the study.
When you get a client who tells you that he doesn’t want to use condoms and that he will pay you more money, you will not refuse it, you will accept it. So when I take the medicine, I know that I have taken my pill [PrEP] in the morning and now I am free (FGD 6, P6).
Exposure to unprotected sex using unreliable preventive methods
After participating in the study some participants continued to expose themselves to the risk of acquiring HIV infection despite the availability of modern preventive methods. They used locally perceived preventive methods without condoms as exemplified below:
I had sex with a man without a condom, and when I suffered from itching I took hot water and put it there [in the vagina]; when I felt fresh, I went and had sex with another client, and I didn’t advise them to put on condoms, I didn’t use condoms a lot (P6, IDI)
Some continued to engage in unsafe sex by relying on the physical inspection of the clients as an assurance of their HIV status:
I don’t have an HIV infection now, then I meet a client who has bruises [minor injuries] then I can get an infection eeh, so even if you [client] say you will pay me a large amount of money when we go in the room I must inspect you, that is the first thing I will do. (P10, IDI)
Many participants believed that they had been given a preventive vaccine in the study. Some of them felt more protected because they received both the vaccine and PrEP. Some also relied on their individual beliefs against the risk of acquiring HIV infection:
I believe I am at risk but not much…Still, I have the vaccine in my body now; I still use the pills. So, I trust myself that I am not a great risk… So I believe that I can’t get the infection (P15, IDI)
I trust myself because I still have the vaccine in my body, so I know the vaccine will help me also, it is not a hundred percent; we live by hope, as I have told you, and hope helps. (P14, IDI)
The use of combined HIV preventive methods was reported to increase confidence in self-protection among the participants. They reasoned that it would be difficult to get HIV because they used condoms, and pills, and sometimes they used lubricants to prevent bruises and regular health check-ups. Some participants were cautious that they might still be at risk of acquiring HIV in the future.
I am not at risk of getting HIV. One of the reasons is that I use condom; second, I believe in pills [PrEP] that I am using; third sometimes I use lubricant to prevent bruises… (P13, IDI).
Overall, the participants believed that the trial products would protect them. However, potentially some participants might be re-engaged in risky sexual practices including condomless sex to get more money from the clients. Having the ‘belief’ that trial products [HIV prophylactic vaccine plus TAF and TDF as Pre-Exposure prophylaxis] will protect them and the need for money, means condomless sex.