It’s Not Easy to Ask Peers and Partners to Test: Perspectives of Female Sex Workers, Their Networks, and Experts on Social Network-Based HIV Testing in Tehran

Abstract

Objectives The World Health Organization recommends social network-based HIV testing (SNHT) to increase HIV testing coverage and improve early diagnosis, particularly among key populations. Although SNHT has shown promising outcomes, implementing this strategy remains challenging. This study explores multilevel barriers to implementing SNHT in Tehran by exploring the perspectives of female sex workers (FSWs), their clients, pimps, healthcare providers and community leaders.Methods In this qualitative study, 42 key stakeholders, including FSWs, pimps, clients, and healthcare and community experts, were purposively selected and interviewed between 2022 and 2023. Interviews were transcribed verbatim and analyzed using Braun and Clarke’s thematic analysis, with rigor ensured according to Lincoln and Guba’s trustworthiness criteria.Results The study identified multilevel barriers to implementing social network-based strategies for HIV testing among FSWs. At the contextual level, these included a restrictive policy environment, HIV-related social stigma, restrictive occupational norms, and gender norms. At the network structural level, barriers included episodic and pleasure-based interaction with clients, non-intimate and work-based interaction patterns among peers, inadequate knowledge and misperceptions of HIV risk within FSW networks, and low trust in healthcare services. Together, these factors contributed to women’s anticipation of negative reactions from network members to HIV testing invitations.Conclusions This study highlights how barriers at different levels limit FSWs’ ability to discuss and invite members of their social networks to undergo HIV testing. SNHT may face challenges in contexts where concerns about stigma, confidentiality, violence, and potential social, economic, and legal consequences affect communication about HIV testing. Social network-based interventions for HIV testing may need to move beyond individual behavior change and address broader network and structural barriers.