Bridging the access gaps in HIV services for female sex workers who use drugs with person-centred DSD models in Nairobi, Kenya: lessons learnt

The Bar Hostess Empowerment & Support Programme (BHESP) was established in 1998 in Nairobi, Kenya, to provide a voice for women vulnerable to sexual and gender-based violence to influence policy, reduce HIV acquisitions, support access to justice and reduce stigma and discrimination. BHESP operates for and by female sex workers (FSWs), women having sex with women and women using drugs and bar hostesses, many of whom live in informal settlements. BHESP engages their clients in HIV prevention, treatment and support services; gender and human rights awareness; legal services; advocacy and economic empowerment opportunities.

In 2020, BHESP observed that FSWs using drugs were alienated from accessing the current service delivery models due to community stigma, cultural and religious barriers. Consistent with BHESP's principles of community action, human rights and an evidence-based response that puts the client at the centre of service delivery, FSWs who use drugs, peer educators, outreach workers, support group coordinators and clinicians were convened to lead the development, implementation and evaluation of tailored interventions to improve access for FSWs who use drugs. This was carried out in three parts: a community needs assessment; participatory processes and stakeholder consultations; and continuous monitoring and evaluation.

BHESP initiated this process by conducting a comprehensive community needs assessment with FSWs who use drugs to understand their diverse needs and challenges at each point of service delivery, including experiences of stigma, violence or geographic isolation (hidden sex workers). This individualized approach ensured that differentiated service delivery (DSD) models were tailored to the specific needs and circumstances of the FSW community.

BHESP organized community forums, focus group discussions and stakeholder meetings where FSWs and other key stakeholders, including clinicians, could contribute their perspectives, share experiences and co-design solutions. By fostering collaboration and dialogue among diverse stakeholders, BHESP ensured that DSD models were informed by a holistic understanding of the social, cultural and structural factors influencing access to healthcare for FSWs who use drugs. The participants evaluated the unique individual needs of the clients and worked consultatively to come up with a mix of models that would best address those needs. This collaborative approach also enhanced the ownership and sustainability of DSD interventions within the community.

BHESP established robust monitoring and evaluation mechanisms to assess the effectiveness and impact of DSD models on the health outcomes and wellbeing of FSWs who use drugs. This involved tracking key indicators related to service utilization, health status and client satisfaction, as well as conducting regular assessments of programme implementation fidelity and quality. BHESP also solicited feedback from FSWs who use drugs and other stakeholders through surveys, focus groups and feedback forms to identify areas for improvement and adaptation. By continuously monitoring and evaluating DSD interventions, BHESP was able to identify emerging needs, gaps or challenges within the FSW who use the drug community and adjust approaches accordingly. This iterative process of learning and adaptation ensured that DSD models remained responsive to the evolving needs and preferences of FSWs who use drugs, ultimately enhancing the effectiveness and sustainability of the healthcare service delivery provided by BHESP.

Recognizing the intersectional nature of substance use within the FSW community, BHESP conducted targeted training sessions for healthcare providers, peer navigators and other stakeholders to raise awareness about the unique challenges faced by FSWs who use drugs and the importance of adopting a harm reduction approach. These sensitization efforts included workshops, seminars and peer-led discussions that addressed stigma, discrimination and misconceptions surrounding drug use among FSWs. BHESP also facilitated dialogue between FSWs who use drugs and service providers to foster mutual understanding and empathy. Challenges in this process included entrenched stigma, resistance to harm reduction principles and misconceptions about drug use and sex work. However, through persistent advocacy and evidence-based education, BHESP was able to gradually shift attitudes and perceptions among service providers, leading to increased acceptance and support for harm reduction interventions. The impact of the sensitization process was profound, as evidenced by improved access to non-judgemental healthcare services, increased utilization of harm reduction tools such as needle and syringe programmes, opioid substitution therapy (methadone and buprenorphine), medication to prevent deaths from opioid overdose (naloxone) and safer sex supplies, and enhanced trust and collaboration between FSWs who use drugs and service providers. For FSWs who use drugs, opioid agonist therapy has been particularly beneficial as it provides a stable foundation for recovery, allowing them to focus on other aspects of their lives, such as addressing social and economic inequities contributing to their involvement in sex work. Ultimately, the sensitization efforts undertaken by BHESP not only addressed immediate barriers to care for FSWs who use drugs but also contributed to broader shifts in policy and practice within the healthcare system, paving the way for more inclusive and effective service delivery for other key and priority populations facing similar intersectional challenges.

This person-centred and collaborative approach to the design of tailored interventions improved access to essential healthcare services for FSWs who use drugs and empowered them to actively participate in shared decision-making processes affecting their health and wellbeing. The interventions developed via this participatory approach consisted of peer-operated services, tailored clinic days and specific monthly theme days to advocate for gender-responsive harm reduction services (see Table 1). It was recognized that a single service delivery model would not effectively address the diverse and individualized needs of all FSWs who use drugs. For example, there was a significantly higher uptake of opioid agonist therapy among clients who accessed services via the tailored clinic days. Service delivery was also adapted to virtual spaces during the COVID-19 pandemic restrictions to ensure the continuation of services and has been maintained due to the ongoing need for virtual spaces. Since the implementation of these interventions in February 2021 until December 2023, 1214 newly identified FSWs who use drugs who had been until then disconnected from health services have accessed services among which 43 (3.5%) are living with HIV and 42 (98%) of these were successfully linked to antiretroviral therapy (ART), of which 37 (88%) are now virally suppressed (see Table 1 for results disaggregated by service type).

BHESP recommends community-led, person-centred DSD models specifically tailored for FSWs who use drugs as it individualizes client's management and improves their health outcomes. A mix of DSD models ensures that services are accessible and acceptable to FSWs who use drugs and address the unique challenges they face.

The authors affirm that they have no competing interests relevant to the content of this work.

This work is the result of collaborative efforts and extensive consultations among the authors, contributing to the comprehensive compilation of the manuscript.

No external funding was received for the completion of this work or the preparation of this manuscript.