Your Demand Creation Campaign Strategy

Audience: This is the population that you are looking to target, or speak to, with your PrEP communications campaign.

This segment of female sex workers (FSW) may have entered into sex work to support themselves and their family after being faced with limited opportunities for jobs. Others may have entered into sex work voluntarily as a career opportunity. In both cases, FSW face criminalization, stigma, discrimination, abuse, and, for some, even life-threatening violence.

Not complying with a client’s request, such as having sex without a condom, usually means making the very difficult decision of turning down extra money, but in some cases, such a stance could also result in abuse and violence. Though the ability to provide for herself and her family may give her a sense of liberation, it also comes at a cost; she’s faced with choices that are either incredibly difficult to make given the circumstances or that don’t end up being choices at all.

FSW are facing different degrees of agency loss.

Problem: The core problem you are trying to address.

Some FSW are so accustomed to surrendering their control in situations regarding their sexual health and safety that they may approach HIV prevention with resignation, seeing it as a choice they don’t have any say in.

There are others that strive (and succeed) to maintain control by insisting on using condoms, but the offer of more money to forgo them makes it an incredibly difficult choice and some choose, or feel compelled, to take the extra money.

HIV prevention is a difficult choice (if a choice at all).

Strategic idea: The most powerful idea that can address the problem.

PrEP helps you choose yourself.

Support: Reasons that support the audience’s belief in the strategic idea.

PrEP puts you completely in control of your health:

• You may not be able to insist on condoms, but the choice to protect yourself from HIV with PrEP is entirely yours.
• Taken orally and on your schedule, the only person that needs to know about taking PrEP is you.

PrEP is taken by you, for you (and your family):

• When you take PrEP, you’re ensuring that you stay healthy, strong, and able to support your children.

Considerations:

• When used correctly and consistently, PrEP is proven to be highly effective in reducing one’s risk of acquiring HIV.
• Because PrEP doesn’t protect against STI’s, it should be used together with condoms.
• PrEP does not protect against pregnancy.

Channels: What are the best ways or places to engage with this audience?

• Printed materials: Leaflets and posters, as well as innovative materials such as bookmarks, postcards, and stickers may be used to reach FSW at work hotspots, which include bars, clubs, beaches, bus stops, and on the street. Condom dispensaries may also be effective hotspots for reaching FSW with materials; these include public health facilities, pharmacies, shops, supermarkets, and clubs. 1
• Interpersonal communications (IPC): Fellow sex workers, peer educators, and female community healthcare workers of greater or matched age (when possible) can reach FSW at community-based organizations, social groups, health centers, drop-in centers, work hotspots and condom dispensary locations, and mobile HIV testing sites and clinics. 2
• Mobile and social media: In the 2017 research conducted by OPTIONS in Kenya, the majority of FSW respondents did not have a computer, but two-thirds had access to a smartphone. This means mobile, internet, and social media channels may be viable ways to communicate prevention and implementation messages to FSW. These channels can also be used to communicate clinic information, such as hours of availability and appointments. 3 Materials created for print can be excerpted and repurposed as online content to be shared through social media for greater time- and cost-effectiveness. Mobile and social media outreach also may be used to preface and facilitate face-to-face interaction.
• Digital: A number of FSW may be moving online for work purposes, finding clients on sites such as nairobiraha.com or nairobiescort.com. 2

Tips for Connecting with Your Audience

• Common interests: Many FSW spend their time going to clubs, watching TV, dancing, socializing with friends, and singing. 3
• Where they go for care and information: Most FSW receive health care at government hospitals; they most often go alone. 3 Currently, FSW main sources of information about sexual and reproductive health are radio, TV, health centers, and hospitals. Community health workers and drop-in centers are also preferred information sources. 3
  Of the many FSW that reported awareness of
  PrEP, they had most commonly heard of it via
  word-of-mouth or from a medical professional. 3 When asked how they think PrEP should be communicated to people like themselves, FSW primarily answered radio, TV, and health centers. 3
• Peers are a trusted, existing network: Because FSW face stigma and discrimination from all parts of society, including those (like
  police and healthcare workers) that should be sources of protection, FSW rely heavily on each other. Many have a strong social/peer network and turn to each other for advice, information, discussion, and support 4 Because of the importance of this peer network and the resulting power of peer education, it is important to keep FSW involved in programs and planning. 5 Also, tapping into the community may be an effective way to reach FSW. 4
• Meet where they are: Work and hangout hotspots are critical to planning outreach. Developing a map of hotspots may serve as a helpful guide for planning in-person outreach and mobile clinic interventions. As hotspots shift, make sure to update the map accordingly.
• High mobility is common: Many FSW may migrate in search of work opportunities. They may also work mostly at night. This mobility and irregular schedules may make it difficult for FSW to access healthcare. They may not consistently visit the same clinic or service provider and may find it difficult to attend clinic services during regular office hours. 6
• Educate about the benefits of PrEP, while still encouraging condoms: In one study, FSW respondents initially believed PrEP would be a useful replacement for condoms; they were disappointed to learn that they would still need to use condoms to prevent other STIs. 7 Providers should address the rationale for using PrEP in addition to condoms, for example, explaining that PrEP can protect in case a condom is forgotten, burst, or a FSW is unable to use one. PrEP is also theoretically a person-controlled prevention method, in the sense that a person can use it covertly. Being able to protect yourself without the influence or permission of others is a powerful motivator.

Recommended Tactics

• Make it as accessible and convenient as possible: In addition to discrimination by providers, FSW face a variety of barriers to healthcare access, discouraging them from testing and seeking care. Overcome these barriers by offering flexible hours that cater to irregular schedules and providing information on how to continue on PrEP (or receiving HIV testing and prevention services generally) even if an FSW is unable to return to a particular provider. For example, provide health service referrals to other accessible locations.
• Train providers in sensitivity and confidentiality: Discrimination by healthcare workers is by far the greatest barrier inhibiting FSW from seeking and receiving care. 6 ^, 4 Providers at all levels should be adequately trained in engaging with FSW with sensitivity and confidentiality, and without judgment.
• Contextualize the risks: To effectively educate FSW on the risks of certain behaviors and practices, talk openly with them about the circumstances and context of recent risky behaviors without judgment.
• Emphasize benefits: FSW may be aware of PrEP, but that doesn’t necessarily translate into consideration of using PrEP. FSW may need to learn about the benefits of PrEP use (aside from the purely functional) to drive their interest. 3
• Deliver through peers and influencers: FSW trust and rely on one another for support. Peers and peer educators can give advice on safe sex and condoms and can provide information related to HIV testing. Prevention initiatives that involve sex workers educating their peers have led to increases in protected sex and reduced HIV prevalence. Research has indicated that the most appropriate person to deliver information about STI/HIV to an FSW is an older woman; the second-most appropriate source is a woman of the same age. 8
• Engage about needs: Distribution of condoms and lube, distribution of information, trainings, empowerment activities, wellness support, supportive social events, and parties are things a FSW needs, and may engage her interest. Information and support can be offered one-on-one or in a group setting, in person, or
  online.
• Compare to contraceptives: Normalize and encourage daily adherence to PrEP by comparing it to contraceptive pills. Some FSW like the idea of a daily pill because it is something they control, like contraceptive pills. Drawing the comparison may help normalize PrEP and encourage FSW in the belief that they are capable of daily adherence. 7