Challenges and Facilitators in Scaling Up HIV Testing Among Female Sex Workers: Exploring Multiple Stakeholder Perspectives in Tehran, Iran

HIV testing is essential for early diagnosis and timely linkage to care, particularly among key populations at increased risk of HIV. HIV testing rates among female sex workers (FSWs) in Iran remain low despite the availability of free and confidential HIV testing and counselling services. This study explores the barriers to and facilitators of access to and uptake of HIV testing among FSWs in Tehran. It incorporates the perspectives of multiple stakeholders (FSWs, pimps, and experts) to provide context-specific recommendations for policy and practice aimed at increasing HIV testing uptake in this population. This qualitative study involved 31 in-depth interviews with purposively selected key stakeholders including FSWs, pimps, and key experts in Tehran between October 2022 and February 2023. Interviews were transcribed verbatim and analysed using qualitative content analysis. Lincoln and Guba’s criteria were applied to ensure trustworthiness. Barriers and facilitators to HIV testing were categorised into three groups: (a) Structural and cultural barriers included inadequate policy support, limitations in HIV care services, and restrictive cultural norms. Facilitators included outreach HIV care services and a friendly environment in HIV care centres. (b) At the social network level, barriers included fear of reactions from network members and limited social support. Facilitators included support networks and the positive influence of pimps. (c) At the individual level, barriers included knowledge gaps and misperceptions, work conditions and economic pressures, emotional and psychological barriers, lack of trust, and security concerns. Facilitators included women’s self-care behaviours and commitment to the health of others. This study identifies the multilevel challenges that FSWs face in seeking and accessing HIV testing services in Tehran, from the perspectives of multiple stakeholders. The findings underscore the need for comprehensive, context-specific interventions that address barriers at the structural and cultural, social network, and individual levels, while also using existing supports and facilitators to improve HIV testing uptake among FSWs. The study concludes with targeted recommendations for policy, practice, and future research.