Introduction. Female sex workers, especially women who are injection drug users, are particularly vulnerable to HIV in St. Petersburg, Russia. Factors that influence the utilization of services by this marginalized population have not been adequately explored. The objective of this mixed-methods study was to gain a better understanding of the facilitators and barriers to accessing HIV services for female sex workers. The research was guided by the theoretical perspectives of the Health Belief Model and Structural Violence.

Methods. Fieldwork in St. Petersburg consisted of participant observations of HIV services, and 29 in-depth, semi-structured interviews and 152 structured interviews with female sex workers. Qualitative data were coded in Atlas.ti and multivariable logistic regression was performed using SAS 9.2 to determine which factors were associated with recent HIV testing.

Results. The mixed-methods findings showed that perceived barriers to getting an HIV test revolved around fear of learning the results, worrying that other people would think they were sick, and the distance needed to travel to obtain services. Quantitative data demonstrated that if a female sex worker reported knowing someone who has HIV then she was more likely to have had a recent HIV test [OR=6.31, 95%CI (1.06, 37.44)]. The results of this study revealed that female sex workers experience stigma, discrimination, and physical violence. Participants discussed the fear or being treated poorly by health care providers because of their status as sex workers, drug users, and HIV-infected. Results from the quantitative data analysis indicated that female sex workers who perceived stigma associated with HIV to be high were less likely to have received a recent HIV test [OR=0.90, 95% CI (0.84, 0.97)]. There are structural barriers embedded within the health care and state system that participants struggle to negotiate with, and in many cases are limited by their social marginalization to access the care they need.

Conclusions. Results from this study highlight the need to improve access to HIV services for marginalized populations, further expand outreach services for sex workers on the streets and in brothels, address stigma in the health care system, and develop innovative ways to provide support to marginalized populations in negotiating the utilization of HIV services.