Table 2 Coding tree of the potential barriers and facilitators of regular syphilis and HIV testing

Barriers

Low perceived severity

Syphilis is not like HIV, one can live with syphilis, hard to test for it unless sick, syphilis not a big issue, only fear HIV.

32

Misconception

FSW think you can’t just go and test for syphilis when you have no signs.

33

Internalized stigma

Fear of being seen at the clinic

I fear finding people I know at the clinic as they could know my work.

6

Fear of Peers spreading information of one’s status

My friends may see the medical form and spread information if I am positive for syphilis and other STI.

7

Provider practices

Syndromic STI management

Sometimes you ask for syphilis test, and they simply ask you the signs and write you medicine.

42

Non-emphasis of syphilis testing

Doctors only encourage us to test for HIV.

30

Disrespectful and judgmental questioning

I felt small and shamed, the health worker asked me what I was doing when I asked for a syphilis test, I was asked who told me I had syphilis and whether I was a doctor, I was embarrassed

15

Uncaring attitudes & perceived low quality of care

The care is not good at government hospital, doctors are too busy to attend to us, I spend the whole day at the hospital just to take an HIV test

19

Unavailability of supplies

Lack of syphilis testing kits

Unless you are pregnant it is not easy to be tested for syphilis at public hospitals, no syphilis testing kits

35

High cost

At least for HIV you can find many cheap testing services, but testing for syphilis is expensive in private clinics

20

Stigma and discrimination

We FSW when we visit public hospitals health workers just look at us, once they realize you are a sex worker no one wants to attend to you.

44

Unfavorable clinic working hours

Facilitators

Fears and concerns

Inability to bear children due to syphilis and other STIs

I test for all STIs because I want to get married, I want to bear children at some point, syphilis may affect your uterus and fail to bear children

7

Attracting and satisfying clients

In this job you have to be healthy and strong, syphilis and other STI reduces your capacity to satisfy clients, you lose clients.

30

Worry that syphilis and other STI increase HIV acquisition risk

Syphilis can make you easily get HIV.

25

Psychological fear of contracting HIV

Start imaging things until at test, I cannot settle until I test, test regularly to get psychological relief.

20

Suddenly becoming sick and being unable to provide for significant others

Suddenly becoming sick and stop working for my children, I am in this job for my children I have to test every month or 3 months, I can’t allow myself to become sick no one will look after my children.

35

Social influence

Influence of a regular male partner/boyfriend

Boyfriend insists on STI and HIV testing whenever we meet.

7

Client demand for unprotected sex

Whenever a client requests for unprotected sex.

4

Knowledge of the benefits of early treatment

Syphilis heals better if it has not spread widely in the body.

Habit and prior testing while pregnant

Now my habit to test every 3 months for HIV, during pregnancy it was a must to test for syphilis and HIV I test for them together, I keep a diary to ensure I test every 3 months for HIV

40

Self-efficacy

It is easy to test every 3 months for HIV, developed courage to test every 3 months for HIV

44

Doubts over negative test results

I have messed up a lot but am always told I am HIV negative, I don’t trust test results from outreaches, I doubt a drop of blood from a finger can give true results

10

Use of post-exposure prophylaxis

To get PEP after unprotected sex, after being forced into live sex to obtain PEP

5

Presence of specific or NGO clinics offering both STI and HIV testing

I go to specific clinics for FSW that test HIV and other STIs, at Reproductive health Uganda with small money you are tested for HIV, syphilis, and Hepatitis

32

Availability of many testing facilities

Easy to test for HIV because there are many testing clinics unlike syphilis

48