“They have my number, but they have not called to check up on me”: Exploring trust in the health care system among sex workers living with HIV in Kumasi, Ghana

Sex workers are disproportionately affected by the global HIV epidemic, yet distrust in the health system, driven by stigma and criminalization, hinders early testing and treatment. Despite significant progress, Ghana has fallen behind on the UNAIDS 95–95–95 targets. The unique intersectional experiences of sex workers living with HIV (SWLH) often go underreported, as studies primarily focus on sex work or HIV in isolation. This ethnographic study explores how the intersecting identities and care experiences of SWLH influence trust within the health system in Kumasi, Ghana. Semi-structured interviews were conducted with SWLH (n = 18) and key informants (n = 8). The data was analyzed thematically. Four key themes shaped SWLHs’ trust in the health care system: Communication, Confidentiality, Stigma, and Education. Transparent communication, regular check-ins, and provider attentiveness fostered trust, whereas inconsistent follow-ups and non-consensual testing created barriers. While confidentiality safeguards reassured patients, fears of unintentional disclosure by service providers remained. Stigma, both self-imposed and external, led some participants to avoid care or relocate to other communities. Education was critical to treatment adherence, yet misinformation about HIV persisted, underscoring the need for improved public health messaging. Strengthening trust requires patient-centered approaches, including transparent communication, strict confidentiality, stigma reduction, and comprehensive education. These could be achieved through tailored interventions, including enhanced provider training, peer-led programs, and community-centred awareness campaigns. While this research provides critical insights, further studies are needed to explore regional variations and structural influences on trust. Integrating SWLH voices in policy and program development is essential for creating sustainable, inclusive healthcare solutions. • Trust in health systems among sex workers living with HIV depends on communication, confidentiality, stigma, and education. • Transparent communication and safeguarding confidentiality foster trust in service providers. • Intersectional stigma and misinformation remain key barriers to HIV treatment adherence and care engagement. • Patient-centred programs, stigma training, and community-based interventions are needed to build trust in health systems.