Why do female sex workers disengage from targeted reproductive and sexual health services? Experiences from the Sisters with a Voice programme in Zimbabwe

Background

The Sisters programme provides HIV and sexual and reproductive health services for female sex workers (FSW) in Zimbabwe. Many engage with these services only once, while others disengage after repeated visits. Little is known about reasons for disengagement and the extent of service needs after disengaging.

Methods

Programme staff used site- and age-stratified random sampling to identify 1,200 programme records of FSWs who attended one of four Sisters clinics at least once between January 2018 and June 2019, and had no evidence of a further visit before September 2020. Outreach workers attempted to contact these FSWs via home visits, phone tracing and contacting peer educators. We calculated the proportion of FSWs successfully contacted, the level of ongoing engagement in sex work, expressed unmet need for Sisters services and the proportion of FSWs who subsequently made a return visit to the programme. We explored sociodemographic factors associated with these outcomes.

Results

Of 1169 FSWs for whom contact was attempted, peer educators or others provided evidence in relation to 16 FSWs thought to have died. Of the 45% (504/1169) of FSWs who were successfully contacted, 37% (188/504) were no longer engaged in sex work, although 83% (156/188) reported that they were still in need of services. Reasons given for disengaging included having migrated (40%; 200/504); work commitments (16%; 79/504) and accessing services elsewhere (10%; 51/504). 62% of FSWs (313/504) said they were still active in sex work, among whom 23% (73/313) revisited the programme within 3 months of contact. FSWs living with HIV were less likely to re-engage with the programme (adjusted odds ratio 0.41, 95% CI 0.20–0.83). Age and site were associated with no longer being in sex work, while other factors showed no strong association.

Conclusions

These findings highlight the need for robust outreach and re-engagement strategies that accommodate the mobility and evolving circumstances of FSWs. In particular, programmes that promote peer-led, community-based microplanning—supported by integrated data management systems—can help address stigma, frequent relocation, and financial constraints that hinder continuous care. By tailoring services to both active and former FSWs, health systems can ensure that essential sexual and reproductive health services remain accessible, even when FSWs exit sex work. Such differentiated approaches ultimately strengthen continuity of care, reduce service gaps, and support broader public health goals by improving health equity and outcomes for this high-risk population.