Applying human-centered design approaches to identify barriers to continuous engagement in HIV/ART services among female sex workers and develop service prototypes to promote service uptake in Myanmar

BACKGROUND: 'Since 2018, HIV/ART drop-in centers under the Targeted Outreach Program (TOP) which provides HIV related health services in Myanmar have experienced low repeated HIV testing rates, delays in ART initiation and high loss-to-follow-up after initiation among female sex workers (FSWs). This study aimed to identify FSWs' barriers to engagement in care and continuous engagement in HIV testing and treatment and design interventions to improve their service utilization in Yangon, Mandalay and Myitkyina.
METHODS: 'Human-centered design (HCD) methodology was applied to gather insights from TOP clients who did not come for repeated HIV testing, delayed ART initiation and loss-to-follow-up. Because of COVID-19 pandemic, semi-structured qualitative interviews were conducted via telephone in September 2020 with 23 respondents. Inspiration and ideation phases were completed. Findings were used to design service prototypes which addressed barriers to access regular HIV/ART services. 13 FSWs were interviewed again to obtain opinions on the prototypes.
RESULTS: 'Frequent workplace migration, prioritizing jobs, inability to go outside freely without brothel managers' permission, fixed clinic opening hours and worrying about breach of confidentiality prevented FSWs from receiving regular testing and treatment. Transportation reimbursement failing to cover actual transportation charges deterred them from visiting the centers regularly. Difficulties in disclosing HIV status, low risk perception of disease, lack of comprehensive information on treatment resources and fear of consequences of positive HIV results such as being discriminated by colleagues and owners made FSWs delay initiating ART and lost to follow-up. Based on these findings, three prototypes were developed: 1) making services more FSW friendly with facilities such as transportation arrangement, flexible opening hours and teleconsultation with doctors and counsellors; 2) advocating brothel managers and authorities through information sessions to reduce FSW's social and occupational challenges; 3) establishing a communication channel which provides health education, treatment sources, regular reminders for HIV/ART services and psychological support to help them manage consequences of positive HIV results. FSWs welcomed the idea of getting more FSW friendly services.
CONCLUSIONS: 'Despite COVID-19 pandemic, applying HCD approach enabled us gain insights into FSW daily lives and barriers in receiving HIV/ART services through interactive discussions and design customized prototypes.

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