Combination HIV prevention for female sex workers: what is the evidence?

The effect of mobility on HIV-related healthcare access and use for female sex workers: A systematic review

Female sex workers (FSW) experience a high HIV burden and are often mobile. FSW access to HIV-related healthcare is essential for equitable welfare and to reduce new HIV infections. We systematically reviewed the literature on mobility and HIV-related healthcare access and use among FSW. Outcome measures included: HIV/STI testing, STI treatment, PrEP (initiation or adherence), and ART (initiation or adherence). We summarised the results with a narrative synthesis. From 7417 non-duplicated citations, nine studies from Canada (3), Guatamala, Honduras (2), India, South Africa, and Vietnam were included. Only one of the studies was designed to address mobility and healthcare access, and only six reported adjusted effect estimates. Mobility was measured over four time-frames (from 'current' to 'ever'), as having lived or worked elsewhere or in another town/province/country. Three studies from Canada, Guatemala, and India found mobility associated with increased odds of poor initial access to healthcare (adjusted odds ratios (AOR) from 1.33, 95% CI 1.02, 1.75, to 2.27, 95% CI 1.09, 4.76), and one from Vietnam found no association (odds ratio (OR): 0.92, 95% CI 0.65, 1.28). The study from South Africa found no association with initiating ART (risk ratio: 0.86, 95% CI 0.65, 1.14). Two studies from Canada and Honduras found increased odds of ART interruption (AOR 2.74, 95% CI 0.89, 8.42; 5.19, 95% CI 1.38, 19.56), while two other studies from Canada and Honduras found no association with detectable viral load (OR 0.84, 95% CI 0.08, 8.33; AOR 0.79, 95% CI 0.41, 1.69). We found that mobility is associated with reduced initial healthcare access and interruption of ART, consistent with literature from the general population. Discordance between effects on adherence and viral load may be due to measurement of mobility. Future research should carefully construct measures of mobility and consider a range of HIV-related healthcare outcomes.

A typology of female sex work in the Metropolitan Region of Santiago, Chile

In Chile, sex work takes place covertly in a variety of venues and locations. Formative research using time-location sampling methods is important in order to understand the nature of this diversity. This study used qualitative methods to develop a typology of female sex work in the Metropolitan Region of Santiago, Chile, using semi-structured interviews, focus groups and ethnographic fieldwork during visits to sex work venues. The study identified seven types of venue, which reflect the context and regulatory framework of the country and the structural vulnerabilities that affect female sex workers in Chile. These venues and locations include: cafés con piernas (coffee with legs); nightclubs, topless bars and cabarets; brothels; hotels; street and highway soliciting; massage parlours; and private residences. Formative research methods were helpful in identifying and characterising the venues and locations in which sex work occurred. Barriers to accessing and mapping specific locations were also identified. Recommendations for addressing these barriers include working with non-governmental organisations to map venues and initiate contact with the populations of interest. A comprehensive typology of sex work in the Metropolitan Region of Santiago, Chile, is an essential element for future time-location sampling and bio-behavioural research in the context of second-generation surveillance for HIV and sexually transmitted infections in Chile.

High Burden of HIV, Syphilis and HSV-2 and Factors Associated with HIV Infection Among Female Sex Workers in Tanzania: Implications for Early Treatment of HIV and Pre-exposure Prophylaxis (PrEP)

This paper estimates population-based prevalence of HIV, syphilis, HSV-2 and factors influencing HIV infection using a national sample of 1914 female sex workers (FSWs) in 7 regions in Tanzania. Additionally, HIV incidence was estimated by comparing biological HIV results with self-reported HIV status. The average HIV prevalence among FSWs in all 7 regions was 28%, ranging from 14% in Tabora to 38% in Shinyanga. HIV incidence was found to be 13 per 100 person-years. Syphilis prevalence was 8% with significantly higher burden found in Iringa (11%), Mbeya (13%), and Shinyanga (12%). Nearly 60% of the study population was infected with HSV-2. The high HIV prevalence and incidence coupled with suboptimal condom use indicate an urgent need to roll out the "Treat-All" approach and provide antiretroviral therapy to FSWs living with HIV regardless of their CD4 count. In addition, antiretroviral-based prevention technologies such as oral pre-exposure prophylaxis and microbicides should be piloted and evaluated.

Microfinance for women at high risk for HIV in Kazakhstan: study protocol for a cluster-randomized controlled trial

BACKGROUND

Among women at high risk for HIV and other sexually transmitted diseases (STIs), gender and economic issues limit the impact of behavioral prevention strategies. Women in Kazakhstan with dual risks of sex trading and drug use face elevated risk for HIV and STIs and may benefit from an economic empowerment intervention which combines HIV-risk reduction (HIVRR) education with financial skills-building and asset-building to promote reduced reliance on sex trading for income.

METHODS/DESIGN

The study employs a two-arm, cluster-randomized controlled trial (c-RCT) design. We will use cluster randomization to assign 350 women in approximately 50 cohorts to a traditional four-session HIV-risk-reduction intervention combined with a six-session financial literacy intervention, enrollment in a 24-session vocational training program and receipt of matched savings (HIVRR+MF); or to the four-session HIV-risk-reduction intervention alone (HIVRR). Repeated behavioral and biological assessments will be conducted at baseline, then at 6, 9, and 15 months post randomization/session 1.

DISCUSSION

This study responds to an identified need in the academic literature for rigorous testing of structural interventions, including combination microfinance and HIV-prevention interventions.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT02406482 . Registered on 30 March 2015.

A randomized trial of cash incentives for sexual behavior change among female sex workers in Dar es Salaam

RATIONALE

Female sex workers (FSW) across the world are at high risk for HIV infection and much work is needed to scale up HIV prevention programs among this group. Conditional cash transfer (CCT) programs have been used successfully in recent years to encourage behavior change. We report the results of a CCT intervention among FSW in Tanzania.

METHODS

We conducted a randomized controlled trial (N = 100) of a CCT intervention among FSW in Dar-es-Salaam, Tanzania in 2013. A respondent-driven sampling approach recruited women and randomized them into two groups based on the value of the cash incentive ($20 vs. $40 per visit). All women received testing for 2 curable sexually transmitted infections (STIs), trichomonas and syphilis, free treatment for those STIs and counseling. Women attended study visits at 0, 2 and 4 months and were tested for STIs and received counseling at each visit. Women testing negative for both STIs at the 2- and 4-month visits received a cash reward.

RESULTS

Eighty-four women were retained in the study through all three visits. Participants reported significant reductions in the number of clients per week, and increases in the proportion of clients that they used condoms with over the course of the study. STI results showed decreases in prevalence from baseline to final study visit for syphilis and trichomonas.

CONCLUSION

While this study was not powered to determine if the incentive resulted in statistically significant increases in condom use or decreases in STI prevalence, the results show the acceptability of the intervention, the feasibility of the recruitment methods, and the ability to retain FSW participants across multiple study visits. A follow-up randomized study with a larger number of participants is planned to test the efficacy of the intervention among high-risk populations of women engaging in transactional sex.

Behavioural interventions promoting condom use among female sex workers in sub-Saharan Africa: a systematic review

The objective of this review was to provide an overview of behavioural interventions promoting condom use amongst female sex workers (FSW) in sub-Saharan Africa. A search of four electronic bibliographic databases from 1990 to September 2016 was carried out. The search was limited to articles published in English. Studies which evaluated behavioural interventions to increase condom use among FSWs were selected and reviewed. Data were extracted on effectiveness, condom use, intervention content, and process outcomes. A total of 20 eligible articles describing 18 interventions in sub-Saharan Africa on HIV prevention with condom use as an outcome measure were identified. Most of the behavioural interventions incorporated a combination of approaches: health education by peers, health workers and project staff, and activities by brothel owners and brothel managers. Most studies showed effectiveness of these interventions on condom use with paying clients. Five studies measuring condom use with regular non-paying partners recorded less consistent condom use with these partners. This review illustrates the existence of sufficient evidence showing the effectiveness of behavioural interventions targeting correct and consistent condom use by FSWs.

Efficacy of multicomponent culturally tailored HIV/ STI prevention interventions targeting foreign female entertainment workers: a quasi-experimental trial

OBJECTIVES

We assessed the efficacy of a multicomponent culturally tailored HIV/STI prevention intervention programme on consistent condom use and STI incidence among foreign Thai and Vietnamese female entertainment workers (FEWs) in Singapore.

METHODS

We conducted a quasi-experimental pretest and post-test intervention trial with a comparison group. We recruited 220 participants (115 Vietnamese and 105 Thai) for the comparison group, followed by the intervention group (same number) from the same sites which were purposively selected after a 3-month interval period. Both groups completed a self-administered anonymous questionnaire and STI testing for cervical gonorrhoea and Chlamydia, as well as pharyngeal gonorrhoea at baseline and 6-week follow-up. The peer-led intervention consisted of behavioural (HIV/STI education and condom negotiation skills), biomedical (STI screening and treatment services) and structural components (access to free condoms). We used the mixed effects Poisson regression model accounting for clustering by establishment venue to compute the adjusted risk ratio (aRR) of the outcomes at follow-up.

RESULTS

At follow-up, the intervention group was more likely than the comparison group to report consistent condom use for vaginal sex with paid (aRR 1.77; 95% CI 1.71 to 1.83) and casual (aRR 1.81; 95% CI 1.71 to 1.91) partners. For consistent condom use for oral sex, this was aRR 1.50; 95% CI 1.23 to 1.82 with paid and aRR 1.54; 95% CI 1.22 to 1.95 with casual partners. STI incidence at follow-up was significantly lower in the intervention (6.8 per 100 FEWs) than the comparison (14.8 per 100 FEWs) group (aRR 0.42; 95% CI 0.32 to 0.55).

CONCLUSIONS

This trial was effective in promoting consistent condom use for vaginal and oral sex as well as reducing STI incidence among the foreign Thai and Vietnamese FEWs in Singapore. The feasibility of scaling up the interventions to all entertainment establishments in Singapore should be assessed.

Key Programme Science lessons from an HIV prevention 'Learning Site' for sex workers in Mombasa, Kenya

Objectives

In 2013, Kenya’s National AIDS and STI Control Programme established a Learning Site (LS) in Mombasa County to support and strengthen capacity for HIV prevention programming within organisations working with sex workers. A defining feature of LS was the use of a Programme Science approach throughout its development and implementation. We provide an overview of the key components of LS, present findings from 23 months of programme monitoring data, and highlight key Programme Science lessons from its implementation and monitoring.

Methods

Routine monitoring data collected from September 2013 through July 2015 are presented. Individual-level service utilisation data were collected monthly and indicators of interest were analysed over time to illustrate trends in enrolment, programme coverage and service utilisation among sex workers in Mombasa County.

Results

Over the monitoring period, outreach programme enrolment occurred rapidly; condom distribution targets were met consistently; rates of STI screening remained high and diagnoses declined; and reporting of and response to violent incidents increased. At the same time, enrolment in LS clinics was relatively low among female sex workers, and HIV testing at LS was low among both female and male sex workers.

Conclusion

Lessons learnt from operationalising the Programme Science framework through the Mombasa LS can inform the development and implementation of similar LS in different geographical and epidemiological contexts. Importantly, meaningful involvement of sex workers in the design, implementation and monitoring processes ensures that overall programme performance is optimised in the context of local, ‘on-the-ground’ realities. Additionally, learnings from LS highlight the importance of introducing enhanced monitoring and evaluations systems into complex programmes to better understand and explain programme dynamics over time.

Let's talk about sex work in humanitarian settings: piloting a rights-based approach to working with refugee women selling sex in Kampala

Although it is well known that refugees engage in sex work as a form of livelihood, stigma and silence around this issue persist within humanitarian circles. As a result, these refugees' sexual and reproductive health and rights, and related vulnerabilities, remain overlooked. Their protection and health needs, which are significant, often go unmet at the field level. In 2016, the Women's Refugee Commission and Reproductive Health Uganda partnered to pilot a peer-education intervention tailored to meet the needs of refugee women engaged in sex work in Kampala. Findings from the pilot project suggest the feasibility of adapting existing rights-based and evidence-informed interventions with sex workers to humanitarian contexts. Findings further demonstrate how taking a community empowerment approach can facilitate these refugees' access to a range of critical information, services and support options - from information on how to use contraceptives, to referrals for friendly HIV testing and treatment, to peer counselling and protective peer networks.

Risk factors for HIV infection among female sex workers in Bangui, Central African Republic

Objective

The aims of the study were i) to categorize female sex workers (FSW) according to socio-anthropologic criteria in Bangui; ii) to examine the association between a selection of demographic and risk variables with the different categories of female sex work as outcome, and iii) to investigate factors associated with HIV status.

Methods

A cross-sectional questionnaire survey was conducted to describe the spectrum of commercial sex work in Bangui among 345 sexually active women. After collection of social and behavioral characteristics, each woman received a physical examination and a blood sample was taken for biological analyses, including HIV testing. The relationships between sociodemographic characteristics, behavioral variables involved in high risk for HIV as well as biological results were investigated by bivariate analysis in relationship with FSW categories as main outcomes, and by bivariate analysis followed by multivariate logistic regression analysis in relationship with HIV as the main outcome. The strength of statistical associations was measured by crude and adjusted Odds ratios (OR) and their 95% confidence intervals.

Results

The typology of FSW comprised six different categories. Two groups were the “official” professional FSW primarily classified according to their locations of work [i) “kata“(18.55%) representing women working in poor neighborhoods of Bangui; ii) “pupulenge” (13.91%) working in hotels and night clubs to seek white men]. Four groups were “clandestine” nonprofessional FSW classified according to their reported main activity [i) “market and street vendors” (20.86%); ii) “schoolgirls or students” (19.13%) involved in occasional transactional sex (during holidays); iii) “housewives or unemployed women” (15.65%); iv) “civil servants” (11.88%) working as soldiers or in the public sector]. The overall prevalence of HIV-1 was 19.12% (66/345). HIV varied according to FSW categories. Thus, among professional FSW, the HIV prevalence was 6-fold higher in "kata" than "pupulenge" (39.13% versus 6.30%; P = 0.001). Among nonprofessional FSW, the "vendors" showed the highest HIV prevalence (31.91%), which was higher than in "students" (6.10%; P = 0.001), "civil servants" (9.83%; P = 0.005), and "housewives" (13.00%; P = 0.01). In bivariate analysis, the following variables showed statistically significant association with risk for HIV infection: nationality; age of first sexual intercourse; self-assessment of HIV risk; knowledge of HIV status; anal sex practice with last clients; irregular condom use in last week; consumption of alcohol; other psycho-active substances; past history of STIs; HBs Ag; HSV-2 and bacterial vaginosis. However, the variable “sex workers categories” dichotomized into professional versus nonprofessional FSW was no longer associated with HIV. In multivariate logistical regression analysis, HIV infection was strongly associated with nationality (15.65% versus 3.77%) [adjusted OR (aOR) 3.39: 95% CI:1.25–9.16, P<0.05]; age of first sexual intercourse (21.10% versus 14.00%) (aOR 2.13: 95% CI: 1.03–4.39, P<0.05); anal sex practice with last clients (43.40% versus 11.50%) (aOR 4.31: 95% CI:2.28–8.33, P<0.001); irregular condom use in past week (33.50% versus 3.00%) (aOR 5.49: 95% CI:1.89–15.98, P<0.001); alcohol consumption before sex (34.70% versus 7.80%) (aOR 2.69: 95% CI:1.22–4.96, P<0.05); past history of STIs (41.00% versus 10.80%) (aOR 2.46: 95% CI:1.22–4.97, P<0.05) and bacterial vaginosis (29.80% versus 4.29%) (aOR 6.36: 95% CI: 2.30–17.72, P<0.001).

Conclusion

Our observations highlight the high level of vulnerability for HIV acquisition of both poor professional “kata” and nonprofessional “street vendor” FSW categories. These categories should be particularly taken into account when designing specific prevention programs for STIs/HIV control purposes.

HIV Prevention Among Women Who Use Substances And Report Sex Work: Risk Groups Identified Among South African Women

This cross-sectional study presents baseline data from women (n = 641) in a community-based randomized trial in Pretoria, South Africa. Women were eligible if they reported recent alcohol or other drug (AOD) use and condomless sex. Latent class analyses were conducted separately for those who reported sex work and those who did not. Among those who reported sex work, a Risky Sex class (n = 72, 28%) and Low Sexual Risk class (n = 190, 73%) emerged. Those in the Risky Sex class were more likely to report that their last episode of sexual intercourse was with their boyfriend (vs. a client/other partner) compared with the Low Sexual Risk class (p < 0.001). Among participants who did not report sex work, a Drug-Using, Violence-Exposed, and Impaired Sex class (n = 53; 14%) and Risky Sex and Moderate Drinking class (n = 326; 86%) emerged. The findings suggest that interventions for women who engage in sex work should promote safer sexual behavior and empowerment with main partners. Women who use AODs, experience physical or sexual violence, and have impaired sex may be a key population at risk for HIV and should be considered for tailored behavioral interventions in conjunction with South Africa's plan to disseminate HIV prevention methods to vulnerable women.

TRIAL REGISTRATION

ClinicalTrials.gov registration NCT01497405.

Cross-sectional study of female sex workers in Soweto, South Africa: Factors associated with HIV infection

INTRODUCTION

In South Africa, the rate of HIV in the sex worker (SW) population is exceedingly high, but critical gaps exist in our understanding of SWs and the factors that make them vulnerable to HIV. This study aimed to estimate HIV prevalence among female sex workers (FSWs) in Soweto, South Africa, and to describe their sexual behavior and other factors associated with HIV infection.

METHODS

A cross-sectional, respondent-driven sampling (RDS) recruitment methodology was used to enroll 508 FSWs based in Soweto. Data were collected using a survey instrument, followed by two HIV rapid tests. Raw and RDS adjusted data were analyzed using a chi-squared test of association and multivariate logistic regression to show factors associated with HIV infection.

FINDINGS

HIV prevalence among FSWs was 53.6% (95% CI 47.5-59.9). FSWs were almost exclusively based in taverns (85.6%) and hostels (52.0%). Less than a quarter (24.4%) were under 25 years of age. Non-partner violence was reported by 55.5%, 59.6% of whom were HIV-infected. Advancing age, incomplete secondary schooling, migrancy and multiple clients increased the likelihood of HIV acquisition: >30 years of age was associated with a 4.9 times (95% CI 2.6-9.3) increased likelihood of HIV; incomplete secondary schooling almost tripled the likelihood (AOR 2.8, 95% CI 1.6-5.0); being born outside of the Gauteng province increased the likelihood of HIV 2.3 times (95% CI 1.3-4.0); and having more than five clients per day almost doubled the likelihood (AOR 1.9, 95% CI 1.1-3.2).

CONCLUSION

Our findings highlight the extreme vulnerability of FSWs to HIV. Advancing age, limited education and multiple clients were risk factors associated with HIV, strongly driven by a combination of structural, biological and behavioral determinants. Evidence suggests that interventions need to be carefully tailored to the varying profiles of SW populations across South Africa. Soweto could be considered a microcosm of South Africa in terms of the epidemic of violence and HIV experienced by the SW population, which is influenced by factors often beyond an individual level of control. While describing a hitherto largely undocumented population of FSWs, our findings confirm the urgent need to scale up innovative HIV prevention and treatment programs for this population.

The effect of prevention methods on reducing sexual risk for HIV and their potential impact on a large-scale: a literature review

A spectrum of diverse prevention methods that offer high protection against HIV has posed the following challenge: how can national AIDS policies with high coverage for prevention and treatment make the best use of new methods so as to reverse the current high, and even rising, incidence rates among specific social groups? We conducted a narrative review of the literature to examine the prevention methods and the structural interventions that can have a higher impact on incidence rates in the context of socially and geographically concentrated epidemics. Evidence on the protective effect of the methods against sexual exposure to HIV, as well as their limits and potential, is discussed. The availability and effectiveness of prevention methods have been hindered by structural and psychosocial barriers such as obstacles to adherence, inconsistent use over time, or only when individuals perceive themselves at higher risk. The most affected individuals and social groups have presented limited or absence of use of methods as this is moderated by values, prevention needs, and life circumstances. As a result, a substantial impact on the epidemic cannot be achieved by one method alone. Programs based on the complementarity of methods, the psychosocial aspects affecting their use and the mitigation of structural barriers may have the highest impact on incidence rates, especially if participation and community mobilization are part of their planning and implementation.

The Peer and Non-peer: the potential of risk management for HIV prevention in contexts of prostitution

Sex workers have been the protagonists and focus of HIV prevention campaigns and research since the late 1980s in Brazil. Through a review of national and international literature, combined with a history of sex workers' involvement in the construction of the Brazilian response, this article explores the overlaps and disconnects between research and practice in contexts of prostitution over the past three decades. We review the scientific literature on the epidemiology of HIV among sex workers and prevention methodologies. We conclude that although research focus and designs often reinforce the idea that sex workers' vulnerability is due to their sexual relationships with clients, their greatest vulnerability has been found to be with their nonpaying intimate partners. Few studies explore their work contexts and structural factors that influence safe sex practices with both types of partners. The negative effects of criminalization, stigma, and exclusively biomedical and peer education-based approaches are well documented in the scientific literature and experiences of sex worker activists, as is the importance of prevention programs that combine empowerment and human rights-based approach to reduce HIV infection rates. We conclude that there is a need for actions, policies, and research that encompass the environment and context of sex workers' lives and reincorporate the human rights and citizenship frame that dominated the Brazilian response until the end of the 2000s. As part of HIV prevention efforts, female sex workers need to be considered above all as women, equal to all others.

Sex workers as peer health advocates: community empowerment and transformative learning through a Canadian pilot program

Background

Social marginalization and criminalization create health and safety risks for sex workers and reduce their access to health promotion and prevention services compared to the general population. Community empowerment-based interventions that prioritize the engagement of sex workers show promising results. Peer-to-peer interventions, wherein sex workers act as educators of their colleagues, managers, clients and romantic partners, foster community mobilization and critical consciousness among sex workers and equip them to exercise agency in their work and personal lives.

Methods

A pilot peer health education program was developed and implemented, with and for sex workers in one urban centre in Canada. To explore how the training program contributed to community empowerment and transformative learning among participants, the authors conducted qualitative interviews, asked participants to keep personal journals and to fill out feedback forms after each session. Thematic analysis was conducted on these three data sources, with emerging themes identified, organized and presented in the findings.

Results

Five themes emerged from the analysis. Our findings show that the pilot program led to reduced internalized stigma and increased self-esteem in participants. Participants’ critical consciousness increased concerning issues of diversity in cultural background, sexual orientation, work experiences and gender identity. Participants gained knowledge about how sex work stigma is enacted and perpetuated. They also became increasingly comfortable challenging negative judgments from others, including frontline service providers. Participants were encouraged to actively shape the training program, which fostered positive relationships and solidarity among them, as well as with colleagues in their social network and with the local sex worker organization housing the program. Resources were also mobilized within the sex worker community through skills building and knowledge acquisition.

Conclusion

The peer education program proved successful in enhancing sex workers’ community empowerment in one urban setting by increasing their knowledge about health issues, sharing information about and building confidence in accessing services, and expanding capacity to disseminate this knowledge to others. This ‘proof of concept’ built the foundation for a long-term initiative in this setting and has promise for other jurisdictions wishing to adapt similar programs.

Electronic supplementary material

The online version of this article (10.1186/s12939-017-0655-2) contains supplementary material, which is available to authorized users.

Sex Work Criminalization Is Barking Up the Wrong Tree

There is a notable shift toward more repression and criminalization in sex work policies, in Europe and elsewhere. So-called neo-abolitionism reduces sex work to trafficking, with increased policing and persecution as a result. Punitive "demand reduction" strategies are progressively more popular. These developments call for a review of what we know about the effects of punishing and repressive regimes vis-à-vis sex work. From the evidence presented, sex work repression and criminalization are branded as "waterbed politics" that push and shove sex workers around with an overload of controls and regulations that in the end only make things worse. It is illustrated how criminalization and repression make it less likely that commercial sex is worker-controlled, non-abusive, and non-exploitative. Criminalization is seriously at odds with human rights and public health principles. It is concluded that sex work criminalization is barking up the wrong tree because it is fighting sex instead of crime and it is not offering any solution for the structural conditions that sex work (its ugly sides included) is rooted in. Sex work repression travels a dead-end street and holds no promises whatsoever for a better future. To fight poverty and gendered inequalities, the criminal justice system simply is not the right instrument. The reasons for the persistent stigma on sex work as well as for its present revival are considered.

Efficacy of Human Immunodeficiency Virus/Sexually Transmitted Infection Prevention Interventions Targeting Female Entertainment Workers: A Systematic Review and Meta-analysis

Female entertainment workers (FEWs) working in karaoke lounges, bars, pubs, nightclubs, discotheques, dance halls, massage parlours, restaurants (as hostesses or singers) and beer gardens are at high risk for human immunodeficiency virus (HIV)/sexually transmitted infection (STI). The aim of the systematic review and meta-analysis is to evaluate the efficacy of HIV/STI intervention programmes targeting FEWs. Among the 14 included studies, majority were in Asia and targeted native FEWs. Most studies were quasi-experimental and the overall quality was relatively low. While most studies employed only behavioural strategies, structural interventions were the least common. In studies with structural interventions, there was a preference for behavioural and biomedical-based outcome measurements rather than structural-related indicators. FEWs in the intervention group were significantly more likely to report condom use with paying (odds ratio OR 1.7; 95% CI 1.0-2.9, p 0.04), but not with regular (OR 1.0; 95% CI 0.8-1.3, p 0.84) partner than the control/comparison group post-intervention.

Sex Work Criminalization Is Barking Up the Wrong Tree

There is a notable shift toward more repression and criminalization in sex work policies, in Europe and elsewhere. So-called neo-abolitionism reduces sex work to trafficking, with increased policing and persecution as a result. Punitive "demand reduction" strategies are progressively more popular. These developments call for a review of what we know about the effects of punishing and repressive regimes vis-à-vis sex work. From the evidence presented, sex work repression and criminalization are branded as "waterbed politics" that push and shove sex workers around with an overload of controls and regulations that in the end only make things worse. It is illustrated how criminalization and repression make it less likely that commercial sex is worker-controlled, non-abusive, and non-exploitative. Criminalization is seriously at odds with human rights and public health principles. It is concluded that sex work criminalization is barking up the wrong tree because it is fighting sex instead of crime and it is not offering any solution for the structural conditions that sex work (its ugly sides included) is rooted in. Sex work repression travels a dead-end street and holds no promises whatsoever for a better future. To fight poverty and gendered inequalities, the criminal justice system simply is not the right instrument. The reasons for the persistent stigma on sex work as well as for its present revival are considered.

Estimating the number of female sex workers in Côte d'Ivoire: results and lessons learned

OBJECTIVE

To report on the results of three size estimations of the populations of female sex workers (FSW) in five cities in Côte d'Ivoire and on operational lessons learned, which may be relevant for key population programmes in other parts of the world.

METHODS

We applied three methods: mapping and census, capture-recapture and service multiplier. All were applied between 2008 and 2009 in Abidjan, San Pedro, Bouaké, Yamoussoukro and Abengourou.

RESULTS

Abidjan was the city with the highest number of FSW by far, with estimations between 7880 (census) and 13 714 (service multiplier). The estimations in San Pedro, Bouaké and Yamoussoukro were very similar, with figures ranging from 1160 (Yamoussoukro, census) to 1916 (San Pedro, capture-recapture). Important operational lessons were learned, including strategies for mapping, the importance of involving peer sex workers for implementing the capture-recapture and the identification of the right question for the multiplier method.

CONCLUSIONS

Successful application of three methods to estimate the population size of FSW in five cities in Côte d'Ivoire enabled us to make recommendations for size estimations of key population in low-income countries.

Sexual and reproductive health outcomes among female sex workers in Johannesburg and Pretoria, South Africa: Recommendations for public health programmes

BACKGROUND

The sexual and reproductive health (SRH) status of female sex workers is influenced by a wide range of demographic, behavioural and structural factors. These factors vary considerably across and even within settings. Adopting an overly standardised approach to sex worker programmes may compromise its impact on some sub-groups in local areas.

METHODS

Records of female sex workers attending clinic-, community-, or hotel-based health services in Johannesburg (n = 1422 women) and Pretoria (n = 408 women), South Africa were analysed. We describe the population's characteristics and identified factors associated with sexual and reproductive health outcomes, namely HIV status; previous symptomatic sexually transmitted infection (STI); modern contraceptive use and number of child dependents.

RESULTS

The women in Johannesburg were less likely than those in Pretoria to have HIV (42.2% vs 52.9%), or previous symptomatic STIs (44.3% vs. 8.3%), and were 1.4 fold less likely to have child dependents (20.1% vs. 15.3%). About 43% of women in Johannesburg were Zimbabwean and 40% in Pretoria. Of concern, only about 15% of women in both sites were using modern contraceptives. Johannesburg women were also more likely to access health services at a hotel (85.0% vs. 80.6%) or clinic (5.7% vs. 0.5%), to have completed secondary education (57.1% vs. 36.0%), and moved house more than twice during the past year (19.6 vs. 2.0%). In both cities, risk of HIV rose rapidly with age (23.8%-58.2% vs. 22.0%-64.8%). Of interest, HIV prevalence was considerably higher in those with consistent condom use with one's main partner than inconsistent users.

CONCLUSIONS

Sex worker populations are heterogeneous. Local health programmes must prioritise services that reflect the variety and complexity of sex worker needs and behaviours, and should be designed in consultation with sex workers. Segmenting sex worker populations according to age, country of origin and place of service delivery, and training healthcare providers accordingly, could help prevent new HIV infections, improve adherence to antiretroviral treatment and increase uptake of SRH services.

Systematic review of sex work interventions in sub-Saharan Africa: examining combination prevention approaches

OBJECTIVE

The incidence of HIV and sexually transmitted infections is disproportionately high among sex workers (SW). We aimed to update the evidence on the effectiveness of SW interventions in sub-Saharan Africa and to provide more insights into combination prevention.

METHODS

The Systematic review followed PRISMA guidelines in a search of PUBMED and POPLINE for peer-reviewed literature published between 1 January 2000 and 22 July 2016 (registration number on PROSPERO: CRD42016042529). We considered cohort interventions, randomised controlled trials and cross-sectional surveys of SW programmes. A framework was used in the description and mapping of intervention to desired outcomes.

RESULTS

Twenty-six papers(reporting on 25 studies) were included. A strategy that empowered peer educator leaders to steer community activities showed a twofold increase in coverage of behaviour change communication and utilisation of health facility among SW. Brief alcohol harm reduction effort demonstrated a significant effect on sexual violence and engagement in sex trading. A risk reduction counselling intervention among drug-injecting SW showed an effect on alcohol, substance use and engagement in sex work. No study on a promising intervention like PrEP among SWs was found. We observed that interventions that combined some structural components, biomedical and behavioural strategies tend to accumulate more desired outcomes.

CONCLUSION

The evidence base that can be considered in intervention designs to prevent HIV in SW in SSA is vast. The health sector should consider interventions to reduce binge alcohol intake and intravenous drug use among sex workers. Programmes should staunchly consider multicomponent approaches that explore community-based structural approaches.

Zambian Peer Educators for HIV Self-Testing (ZEST) study: rationale and design of a cluster randomised trial of HIV self-testing among female sex workers in Zambia

BACKGROUND

HIV testing and knowledge of status are starting points for HIV treatment and prevention interventions. Among female sex workers (FSWs), HIV testing and status knowledge remain far from universal. HIV self-testing (HIVST) is an alternative to existing testing services for FSWs, but little evidence exists how it can be effectively and safely implemented. Here, we describe the rationale and design of a cluster randomised trial designed to inform implementation and scale-up of HIVST programmes for FSWs in Zambia.

METHODS

The Zambian Peer Educators for HIV Self-Testing (ZEST) study is a 3-arm cluster randomised trial taking place in 3 towns in Zambia. Participants (N=900) are eligible if they are women who have exchanged sex for money or goods in the previous 1 month, are HIV negative or status unknown, have not tested for HIV in the previous 3 months, and are at least 18 years old. Participants are recruited by peer educators working in their communities. Participants are randomised to 1 of 3 arms: (1) direct distribution (in which they receive an HIVST from the peer educator directly); (2) fixed distribution (in which they receive a coupon with which to collect the HIVST from a drug store or health post) or (3) standard of care (referral to existing HIV testing services only, without any offer of HIVST). Participants are followed at 1 and 4 months following distribution of the first HIVST. The primary end point is HIV testing in the past month measured at the 1-month and 4-month visits.

ETHICS AND DISSEMINATION

This study was approved by the Institutional Review Boards at the Harvard T.H. Chan School of Public Health in Boston, USA and ERES Converge in Lusaka, Zambia. The findings of this trial will be presented at local, regional and international meetings and submitted to peer-reviewed journals for publication.

TRIAL REGISTRATION NUMBER

Pre-results; NCT02827240.

Meeting the Reproductive Health Needs of Female Key Populations Affected by HIV in Low- and Middle-Income Countries: A Review of the Evidence

Female sex workers and other women at high risk of acquiring HIV have the right to sexual and reproductive health, including the right to determine the number and timing of pregnancies. We conducted a literature review to examine the data that exist regarding the family planning and reproductive health needs of female key populations, the underlying determinants of these populations' vulnerability to poor reproductive health outcomes, and the obstacles they face in accessing high-quality reproductive health services. Findings indicate that female key populations experience high rates of unmet need for family planning and safer conception services, unintended pregnancies, sexual violence, and abortion, and that they practice inconsistent condom use. Restrictive policy environments, stigma and discrimination in health care settings, gender inequality, and economic marginalization restrict access to services and undermine the ability to safely achieve reproductive intentions. We offer recommendations for structural, health system, community, and individual-level interventions that can mitigate the effects of these barriers and improve reproductive health outcomes.

Acceptability of microbicidal vaginal rings and oral pre-exposure prophylaxis for HIV prevention among female sex workers in a high-prevalence US city

Biomedical HIV prevention tools including oral pre-exposure prophylaxis (PrEP) and vaginal microbicidal rings hold unique value for high-risk women who may have limited capacity for condom negotiation, including the key populations of sex workers and drug users. Commercial sex is a PrEP indicator in CDC guidelines, yet little is known about female sex workers' (FSWs) knowledge of and attitudes toward PrEP or the recently developed monthly vaginal microbicide rings. We describe knowledge and attitudes toward PrEP and microbicide rings in a sample of 60 mostly drug-using FSWs in Baltimore, Maryland, a high HIV-prevalence US city. Just 33% had heard of PrEP, but 65% were interested in taking daily oral PrEP and 76% were interested in a microbicide vaginal ring; 87% were interested in at least one of the two methods. Results suggest method mix will be important as biomedical tools for HIV prophylaxis are implemented and scaled up in this population, as 12% were interested in PrEP but not vaginal rings, while 19% were interested in vaginal rings but not in PrEP. Self-efficacy for daily oral adherence was high (79%) and 78% were interested in using PrEP even if condoms were still necessary. Women who had experienced recent client-perpetrated violence were significantly more interested in PrEP (86% vs 53%, p = 0.009) and microbicidal rings (91% vs 65%, p = 0.028) than women who had not recently experienced violence. No differences were observed by demographics nor HIV risk behaviors, suggesting broad potential interest in daily PrEP and monthly-use vaginal microbicides in this high-risk population.

Engagement in the HIV care cascade and barriers to antiretroviral therapy uptake among female sex workers in Port Elizabeth, South Africa: findings from a respondent-driven sampling study

BACKGROUND

Female sex workers (FSWs) are disproportionately affected by HIV, even in the context of broadly generalised HIV epidemics such as South Africa. This has been observed in spite of the individual and population-level benefits of HIV treatment. We characterise the HIV care cascade among FSWs and relationships with antiretroviral therapy (ART) use.

METHODS

FSWs ≥18 years were recruited through respondent-driven sampling into a cross-sectional study in Port Elizabeth, South Africa. Participants completed questionnaires and received HIV and syphilis testing; CD4 counts were assessed among women living with HIV. Engagement in the HIV care cascade is described, and correlates of self-reported ART use among treatment-eligible previously diagnosed FSWs were estimated using robust Poisson regression.

RESULTS

Between October 2014 and April 2015, 410 FSWs participated in study activities. Overall, 261/410 were living with HIV (respondent-driven sampling-weighted prevalence 61.5% (95% bootstrapped CI 54.1% to 68.0%)). Prior diagnosis of HIV was relatively high (214/261, 82%); however, ART coverage among FSWs living with HIV was 39% (102/261). In multivariate analyses, FSWs were less likely to be on ART if they had not disclosed their HIV status to non-paying partners (adjusted prevalence ratio (aPR) 0.43, 95% CI 0.22 to 0.86, where the reference is FSWs without non-paying partners), and also if they engaged in mobile healthcare services (aPR 0.71, 95% CI 0.57 to 0.89).

CONCLUSIONS

HIV testing and awareness of HIV status were high, but substantial losses in the cascade occur at treatment initiation. Given that FSWs engaged in mobile HIV testing and peer education programmes have unmet HIV treatment needs, models of decentralised treatment provision such as mobile-based ART care should be evaluated.

PrEP implementation research in Africa: what is new?

INTRODUCTION

Of the two million new HIV infections in adults in 2014, 70% occurred in sub-Saharan Africa. Several African countries have already approved guidelines for pre-exposure prophylaxis (PrEP) for individuals at substantial risk of HIV as part of combination HIV prevention but key questions remain about how to identify and deliver PrEP to those at greatest need. Throughout the continent, individuals in sero-discordant relationships, and members of key populations (sex workers, men who have sex with men (MSM), transgender women and injection drug users) are likely to benefit from the availability of PrEP. In addition, adolescent girls and young women (AGYW) are at substantial risk in some parts of the continent. It has been estimated that at least three million individuals in Africa are likely to be eligible for PrEP according to WHO's criteria. Tens of demonstration projects are planned or underway across the continent among a range of countries, populations and delivery settings.

DISCUSSION

In each of the target populations, there are overarching issues related to (i) creating demand for PrEP, (ii) addressing supply-side issues and (iii) providing appropriate and tailored adherence support. Critical for creating demand for PrEP is the normalization of HIV prevention. Community-level interventions which engage opinion leaders as well as empowerment interventions for those at highest risk will be key. Critical to supply of PrEP is that services are accessible for all, including for stigmatized populations. Establishing accessible integrated services provides the opportunity to address other public health priorities including the unmet need for HIV testing, contraception and sexually transmitted infections treatment. National policies need to include minimum standards for training and quality assurance for PrEP implementation and to address supply chain issues. Adherence support needs to recognize that social and structural factors are likely to have an important influence. Combining interventions that build self-efficacy, empowerment and social cohesion, with evidence-based individualized adherence support for PrEP, are most likely to be effective.

CONCLUSIONS

Efficacy of tenfovir-based PrEP is proven but many issues related to implementation remain unclear. Here, we have summarized some of the important implementation questions that need to be assessed as PrEP is rolled out across Africa.

Prevalence of HIV Among U.S. Female Sex Workers: Systematic Review and Meta-analysis

Although female sex workers are known to be vulnerable to HIV infection, little is known about the epidemiology of HIV infection among this high-risk population in the United States. We systematically identified and critically assessed published studies reporting HIV prevalence among female sex workers in the United States. We searched for and included original English-language articles reporting data on the prevalence of HIV as determined by testing at least 50 females who exchanged sexual practices for money or drugs. We did not apply any restrictions on date of publication. We included 14 studies from 1987 to 2013 that reported HIV prevalence for a total of 3975 adult female sex workers. Only two of the 14 studies were conducted in the last 10 years. The pooled estimate of HIV prevalence was 17.3 % (95 % CI 13.5-21.9 %); however, the prevalence of HIV across individual studies varied considerably (ranging from 0.3 to 32 %) and statistical heterogeneity was substantial (I(2) = 0.89, Q = 123; p < 0.001). Although the variance across the 14 studies was high, prevalence was generally high (10 % or greater in 11 of the 14 included studies). Very few studies have documented the prevalence of HIV among female sex workers in the United States; however, the available evidence does suggest that HIV prevalence among this vulnerable population is high.

Strategies for reducing police arrest in the context of an HIV prevention programme for female sex workers: evidence from structural interventions in Karnataka, South India

Introduction

Female sex workers (FSWs) frequently experience violence in their work environments, violating their basic rights and increasing their vulnerability to HIV infection. Structural interventions addressing such violence are critical components of comprehensive HIV prevention programmes. We describe structural interventions developed to address violence against FSWs in the form of police arrest, in the context of the Bill and Melinda Gates Foundation's India AIDS Initiative (Avahan) in Karnataka, South India. We examine changes in FSW arrest between two consecutive time points during the intervention and identify characteristics that may increase FSW vulnerability to arrest in Karnataka.

Methods

Structural interventions with police involved advocacy work with senior police officials, sensitization workshops, and integration of HIV and human rights topics in pre-service curricula. Programmes for FSWs aimed to enhance collectivization, empowerment and awareness about human rights and to introduce crisis response mechanisms. Three rounds of integrated behavioural and biological assessment surveys were conducted among FSWs from 2004 to 2011. We conducted bivariate and multivariate analyses using data from the second (R2) and third (R3) survey rounds to examine changes in arrests among FSWs over time and to assess associations between police arrest, and the sociodemographic and sex work-related characteristics of FSWs.

Results

Among 4110 FSWs surveyed, rates of ever being arrested by the police significantly decreased over time, from 9.9% in R2 to 6.1% in R3 (adjusted odds ratio (AOR) [95% CI]=0.63 [0.48 to 0.83]). Arrests in the preceding year significantly decreased, from 5.5% in R2 to 2.8% in R3 (AOR [95% CI]=0.59 [0.41 to 0.86]). FSWs arrested as part of arbitrary police raids also decreased from 49.6 to 19.5% (AOR [95% CI]=0.21 [0.11 to 0.42]). Certain characteristics, including financial dependency on sex work, street- or brothel-based solicitation and high client volumes, were found to significantly increase the odds of arrest for participants.

Conclusion

Structural interventions addressing police arrest of FSWs are feasible to implement. Based on our findings, the design of violence prevention and response interventions in Karnataka can be tailored to focus on FSWs, who are disproportionately vulnerable to arrest by police. Context-specific structural interventions can reduce police arrests, create a safer work environment for FSWs and protect fundamental human rights.

Factors associated with consistent condom use and STIs among foreign female entertainment workers: results from a cross-sectional survey in Singapore

OBJECTIVES

We assessed the prevalence of consistent condom use and laboratory-confirmed STIs among foreign female entertainment workers (FEWs) who engaged in paid or casual sex in Singapore and the factors associated with these characteristics.

METHODS

A cross-sectional survey, using time-location sampling, was conducted on 220 FEWs (115 Vietnamese and 105 Thai) in 2015. For multivariable analysis, we used a mixed-effects Poisson regression model with backward stepwise approach to account for clustering by venue and to obtain the adjusted prevalence ratios (aPRs) of factors associated with consistent condom use and STI positivity, respectively.

RESULTS

Consistent condom use with paid or casual partners in the past month was 39.6% and 36.2% for vaginal and oral sex, respectively. The prevalence of STI (cervical chlamydia, cervical gonorrhoea or pharyngeal gonorrhoea) positivity was 13.6%. In multivariable analysis, consistent condom use for both vaginal and oral sex increased with high self-perceived risk of getting STI/HIV (vaginal: aPR 2.09; 95% CI 1.26 to 3.46; oral: aPR 2.41; 95% CI 1.23 to 4.69) and condom negotiation (vaginal: aPR 3.74; 95% CI 2.07 to 6.75; oral: aPR 2.81; 95% CI 1.51 to 5.26). STI positivity decreased with consistent condom use for vaginal sex (aPR 0.22; 95% CI 0.07 to 0.75) and increased with number of sexual partners (aPR 1.43; 95% CI 1.07 to 1.92).

CONCLUSION

In addition to advocating for policy decisions to provide a safer work environment, behavioural interventions on condom negotiation skills and condom use and biomedical interventions on STI/HIV testing and treatment interventions are needed among the FEWs in Singapore.

TRIAL REGISTRATION NUMBER

NCT02780986; pre-results.

Repeat Use of Post-exposure Prophylaxis for HIV Among Nairobi-Based Female Sex Workers Following Sexual Exposure

As ART-based prevention becomes available, effectively targeting these interventions to key populations such as female sex workers (FSW) will be critical. In this study we analyze patterns of repeated post-exposure prophylaxis (PEP) access in the context of a large FSW program in Nairobi. During close to 6000 person-years of follow-up, 20 % of participants (n = 1119) requested PEP at least once and 3.7 % requested PEP more than once. Repeat PEP users were younger, had a higher casual partner volume, and were more likely to use condoms with casual and regular partners, have a regular partner, and test for HIV prior to enrolment. Barriers to PEP included stigma, side effects, and lack of knowledge, suggesting repeated promotion may be required for higher rates of uptake. A small subset of FSW, potentially those with heightened risk perception, showed a higher frequency of PEP use; these individuals may be most amenable to rollout of pre-exposure prophylaxis.

Preferences for ARV-based HIV prevention methods among men and women, adolescent girls and female sex workers in Gauteng Province, South Africa: a protocol for a discrete choice experiment

INTRODUCTION

For the past few decades, condoms have been the main method of HIV prevention. Recent advances in antiretroviral (ARV)-based prevention products have substantially changed the prevention landscape, yet little is known about how popular these products will be among potential users, or whether new methods might be used in conjunction with, or instead of, condoms. This study will use a discrete choice experiment (DCE) to (1) explore potential users' preferences regarding HIV prevention products, (2) quantify the importance of product attributes and (3) predict the uptake of products to inform estimates of their potential impact on the HIV epidemic in South Africa. We consider preferences for oral pre-exposure prophylaxis; a vaginal microbicide gel; a long-acting vaginal ring; a SILCS diaphragm used in concert with gel; and a long-acting ARV-based injectable.

METHODS AND ANALYSIS

This study will gather data from 4 populations: 200 women, 200 men, 200 adolescent girls (aged 16-17 years) and 200 female sex workers. The DCE attributes and design will be developed through a literature review, supplemented by a thematic analysis of qualitative focus group discussions. Extensive piloting will be carried out in each population through semistructured interviews. The final survey will be conducted using computer tablets via a household sample (for women, men and adolescents) and respondent-driven sampling (for female sex workers), and DCE data analysed using a range of multinomial logit models.

ETHICS AND DISSEMINATION

This study has been approved by the University of the Witwatersrand Human Research Ethics Committee and the Research Ethics Committee at the London School of Hygiene and Tropical Medicine. Findings will be presented to international conferences and peer-reviewed journals. Meetings will be held with opinion leaders in South Africa, while results will be disseminated to participants in Ekurhuleni through a public meeting or newsletter.

The Use of Female Sex Workers Among Men in Nepal: Prevalence, STIs/HIV-Related Risk Behaviors, and Gender Ideology

Heterosexual sex involving female sex workers (FSWs) is widely documented for its role in facilitating the spread of sexually transmitted infections (STIs)/HIV. Critical to such studies, and increasingly considered essential to HIV prevention efforts, is the gender constructs and power dynamics within relationships. However, little efforts have been made, which focus on male clients of FSWs, particularly on the relationship between gender ideologies and men’s sexual contact with FSWs, within the Nepali context. The present study aims to fill this critical gap by assessing the prevalence of use of FSWs and its association with STIs/HIV-related risk behaviors and gender ideologies among Nepali men. We used data from the nationally representative Nepal Demographic Health Survey (NDHS) 2011. For the purpose of analyses, we included a sample of 4,121 men, aged 15–49 years. During data analyses, we used multivariate logistic regression models, adjusted for the following variables: age, region, residence, religion, educational level, wealth index, employment status, and cigarette smoking status. Of the total sample, approximately 5% reported the use of FSWs in their lifetime. In regression models, men who had sex with FSWs were more likely to report a history of STIs [adjusted odds ratio (aOR): 3.03; 95% confidence interval (CI): 1.69–5.43; P < 0.001], not using condom all the time (aOR: 1.31; 95% CI: 1.05–2.12; P = 0.010), more than one sexual partner (aOR: 3.75; 95% CI: 2.18–5.23; P < 0.001), and have had early sexual debut (aOR: 2.60; 95% CI: 1.85–3.67; P < 0.001). Respondents reporting the endorsement of violence against wives (aOR: 1.65; 95% CI: 1.01–2.84; P = 0.04) and male sexual entitlement (aOR: 1.63; 95% CI: 1.21–2.32; P = 0.001) were significantly more likely to report sexual contact with FSWs. Our findings highlight the need to develop and implement specifically tailored interventions toward male clients of FSWs, with a particular emphasis on promoting equitable gender roles and beliefs.

Association between treatment for gonorrhoea and chlamydia and lower condom use in a cross-sectional study of female sex workers in southern India

OBJECTIVES

To assess whether having received grey packets containing treatment for gonorrhoea and chlamydia was associated with condom use among female sex workers (FSWs) in 5 districts of southern India covered by the Avahan programme where both periodic presumptive treatment (PPT) and syndromic management were used to control these sexually transmitted infections (STIs) among FSWs.

SETTING

Cross-sectional study of FSWs recruited in the field in 5 districts of southern India (Bangalore, Belgaum, Bellary, Guntur and Mumbai) in 2006-2007.

PARTICIPANTS

1378 self-identified FSWs out of 1442 were approached to participate in the study (participation rate: 95.6%). The only exclusion criterion was to be aged <18 years.

PRIMARY AND SECONDARY OUTCOME MEASURES

Consistent condom use (CCU) with new or occasional clients, and with the most recent repeat client as assessed using a questionnaire administered through face-to-face interviews.

RESULTS

Using the Poisson regression to model the association between the number of grey packets received in the past 3-12 months and reported CCU, adjusting for factors associated with condom use and other potential confounders in our data, CCU was lowest among FSWs who had received ≥3 grey packets in the past 3-12 months with their new or occasional clients (adjusted prevalence ratio (APR): 0.70, 95% CI 0.57 to 0.84, p<0.001) and with the most recent repeat client (APR 0.63, 95% CI 0.51 to 0.78, p<0.001). Tests for trends showed that CCU with both types of clients decreased with the number of grey packets received (p<0.001).

CONCLUSIONS

Since we could not distinguish grey packets used for PPT from those given for syndromic management, these results could be either due to a perception of protection conferred by PPT or by the fact that inconsistent condom users are more at risk for STIs. Further research on the potential disinhibiting effect of PPT is warranted.

Promoting male partner HIV testing and safer sexual decision making through secondary distribution of self-tests by HIV-negative female sex workers and women receiving antenatal and post-partum care in Kenya: a cohort study

BACKGROUND

Increased uptake of HIV testing by men in sub-Saharan Africa is essential for the success of combination prevention. Self-testing is an emerging approach with high acceptability, but little evidence exists on the best strategies for test distribution. We assessed an approach of providing multiple self-tests to women at high risk of HIV acquisition to promote partner HIV testing and to facilitate safer sexual decision making.

METHODS

In this cohort study, HIV-negative women aged 18-39 years were recruited at two sites in Kisumu, Kenya: a health facility with antenatal and post-partum clinics and a drop-in centre for female sex workers. Participants gave informed consent and were instructed on use of oral fluid based rapid HIV tests. Participants enrolled at the health facility received three self-tests and those at the drop-in centre received five self-tests. Structured interviews were conducted with participants at enrolment and over 3 months to determine how self-tests were used. Outcomes included the number of self-tests distributed by participants, the proportion of participants whose sexual partners used a self-test, couples testing, and sexual behaviour after self-testing.

FINDINGS

Between Jan 14, 2015, and March 13, 2015, 280 participants were enrolled (61 in antenatal care, 117 in post-partum care, and 102 female sex workers); follow-up interviews were completed for 265 (96%). Most participants with primary sexual partners distributed self-tests to partners: 53 (91%) of 58 participants in antenatal care, 91 (86%) of 106 in post-partum care, and 64 (75%) of 85 female sex workers. 82 (81%) of 101 female sex workers distributed more than one self-test to commercial sex clients. Among self-tests distributed to and used by primary sexual partners of participants, couples testing occurred in 27 (51%) of 53 in antenatal care, 62 (68%) of 91 from post-partum care, and 53 (83%) of 64 female sex workers. Among tests received by primary and non-primary sexual partners, two (4%) of 53 tests from participants in antenatal care, two (2%) of 91 in post-partum care, and 41 (14%) of 298 from female sex workers had positive results. Participants reported sexual intercourse with 235 (62%) of 380 sexual partners who tested HIV-negative, compared with eight (18%) of 45 who tested HIV-positive (p<0·0001); condoms were used in all eight intercourse events after positive results compared with 104 (44%) after of negative results (p<0·0018). Four participants reported intimate partner violence as a result of self-test distribution: two in the post-partum care group and two female sex workers. No other adverse events were reported.

INTERPRETATION

Provision of multiple HIV self-tests to women at high risk of HIV infection was successful in promoting HIV testing among their sexual partners and in facilitating safer sexual decisions. This novel strategy warrants further consideration as countries develop self-testing policies and programmes.

FUNDING

Bill & Melinda Gates Foundation.

Effect of Physical Violence on Sexually Transmitted Infections and Treatment Seeking Behaviour among Female Sex Workers in Thane District, Maharashtra, India

BACKGROUND

Violence against sex workers can heighten their vulnerability to HIV and other sexually transmitted infections (STIs). Evidence suggests the risk of acquiring STI/HIV infections among female sex workers (FSWs) who have experienced violence to be almost three-times higher than FSWs, who have not experienced violence. Moreover, an experience of physical and sexual violence makes it difficult for them to negotiate safer sex with their partners and often act as a barrier to utilization of prevention services.

METHODS

This study utilizes data from 2785 FSWs aged 18 years and above who participated in a cross-sectional behavioural study conducted during 2013-14 in Thane district, Maharashtra. A probability-based two-stage cluster sampling method was used for data collection. This study assesses the effect of physical violence on self-reported STI symptoms (any STI and multiple STIs) and treatment seeking for the last STI symptom using propensity score matching method.

RESULTS

About 18% of sampled FSWs reported physical violence at the time of the survey. The likelihood of experiencing such violence was significantly higher among FSWs who solicited clients at public places, engaged in other economic activities apart from sex work, had savings, and reported high client volume per week. FSWs experiencing violence were also inconsistent condom users while engaging in sex with regular partners and clients. The average adjusted effect of violence clearly depicted an increase in the risk of any STI (11%, p<0.05) and multiple STIs (8%, p<0.10) and reduction in treatment seeking (10%, p<0.05).

CONCLUSIONS

This study demonstrates a significant effect of physical violence on reporting of any STI symptom and treatment seeking. Findings call for the immediate inclusion of strategies aimed to address violence related challenges in HIV prevention program currently being provided at Thane district. Such strategies would further help in enhancing the access to tailored STI prevention and care services among FSWs in the district.

Underage and underserved: reaching young women who sell sex in Zimbabwe

Young women who sell sex (YWSS) in Southern Africa are highly vulnerable to HIV, as the risks of being young and female in a high prevalence setting coalesce with those of commercial sex. YWSS are less able to negotiate safe sex, more likely to have higher risk partners, and less likely to use available health services compared to older sex workers. In Zimbabwe's national HIV programme for sex workers, fewer than 1% of clients were 15-29. We developed monthly interactive workshops for YWSS based on an Activity Pack consisting of 21 sessions organised into six modules. The aim was to encourage YWSS' interaction with each other, build their trust, confidence and skills, and encourage uptake of clinical services. We conducted a process evaluation to assess programme strengths, identify challenges, and recommend changes. This paper presents findings synthesising programme records with qualitative data and discusses feasibility, acceptability, and outputs during the pilot phase. In total, 143 YWSS attended meetings and most were from the target 15-19-year-old age group. Participants enjoyed the sessions and reported improved cooperation, willingness to negotiate with clients, and self-reflection about their futures. Staff found facilitating sessions easy and activities clear and appropriate. Challenges included identifying appropriate referrals, initial recruitment of women in some sites, and managing participants' requests for financial compensation. The number of clients aged 15-19 increased at sex worker clinics in all sites. This programme is the first to target YWSS in Zimbabwe to address their disproportionately low service use. It proved feasible to staff and acceptable to participants over a one-year period. Given enhanced vulnerability of YWSS, this programme provides one workable model for reaching this underserved group.

The HIV Care Continuum among Female Sex Workers: A Key Population in Lilongwe, Malawi

OBJECTIVE

The HIV care continuum among female sex workers (FSW), a key population, has not been well characterized, especially within the generalized epidemics of sub-Saharan Africa. This was the first study to characterize the HIV care continuum among FSW in Lilongwe, Malawi.

METHODS

From July through September 2014, we used venue-based sampling to enroll 200 adult FSW in Lilongwe, Malawi into a cross-sectional evaluation assessing HIV care continuum outcomes. Seropositive FSW, identified using HIV rapid testing, received rapid CD4 counts in addition to viral loads using dried blood spots. We calculated proportions of HIV-infected FSW who had history of care, were on ART, and had suppressed viral load and we used Poisson regression to estimate the associations of demographic characteristics and transmission risk behaviors with each outcome.

RESULTS

HIV seroprevalence was 69% (n = 138). Among all FSW the median age was 24 years (IQR: 22-28). Among the 20% who were newly diagnosed and reported previously testing negative, the median time since last HIV test was 11 months (interquartile range: 3-17). The majority (69%) of HIV-infected FSW had a history of HIV care, 52% reported current ART use, and 45% were virally suppressed. Of the FSW who reported current ART use, 86% were virally suppressed. Transmission risk behaviors were not associated with continuum outcomes.

CONCLUSIONS

FSW in Lilongwe were predominately young and have a high HIV prevalence. Only half of HIV-infected FSW reported current ART use, but the majority of those on ART were virally suppressed. To reduce ongoing transmission and improve health outcomes, increased HIV testing, care engagement, and ART coverage is urgently needed among FSW. Universal testing and treatment strategies for all FSW in Malawi must be strongly considered.

Systematic review and meta-analysis of community and facility-based HIV testing to address linkage to care gaps in sub-Saharan Africa

HIV testing and counselling is the first crucial step for linkage to HIV treatment and prevention. However, despite high HIV burden in sub-Saharan Africa, testing coverage is low, particularly among young adults and men. Community-based HIV testing and counselling (testing outside of health facilities) has the potential to reduce coverage gaps, but the relative impact of different modalities is not well assessed. We conducted a systematic review of HIV testing modalities, characterizing community (home, mobile, index, key populations, campaign, workplace and self-testing) and facility approaches by population reached, HIV positivity, CD4 count at diagnosis and linkage. Of 2,520 abstracts screened, 126 met eligibility criteria. Community HIV testing and counselling had high coverage and uptake and identified HIV-positive people at higher CD4 counts than facility testing. Mobile HIV testing reached the highest proportion of men of all modalities examined (50%, 95% confidence interval (CI) = 47-54%) and home with self-testing reached the highest proportion of young adults (66%, 95% CI = 65-67%). Few studies evaluated HIV testing for key populations (commercial sex workers and men who have sex with men), but these interventions yielded high HIV positivity (38%, 95% CI = 19-62%) combined with the highest proportion of first-time testers (78%, 95% CI = 63-88%), indicating service gaps. Community testing with facilitated linkage (for example, counsellor follow-up to support linkage) achieved high linkage to care (95%, 95% CI = 87-98%) and antiretroviral initiation (75%, 95% CI = 68-82%). Expanding home and mobile testing, self-testing and outreach to key populations with facilitated linkage can increase the proportion of men, young adults and high-risk individuals linked to HIV treatment and prevention, and decrease HIV burden.

Assuring access to topical mosquito repellents within an intensive distribution scheme: a case study in a remote province of Cambodia

Background

The public health value of a vector control tool depends on its epidemiological efficacy, but also on its ease of implementation. This study describes an intensive distribution scheme of a topical repellent implemented in 2012 and 2013 for the purpose of a cluster-randomized trial using the existing public health system. The trial aimed to assess the effectiveness of repellents in addition to long-lasting insecticidal nets (LLIN) and occurred in a province of Cambodia. Determinants for accessibility and consumption of this tool were explored.

Methods

135 individuals were appointed to be repellent distributors in 57 villages. A 2-weekly bottle exchange programme was organized. Distributors recorded information regarding the amount of bottles exchanged, repellent leftover, and reasons for not complying in household data sheets. Distributor-household contact rates and average 2-weekly consumption of repellent were calculated. Household and distributors characteristics were obtained using questionnaires, surveying 50 households per cluster and all distributors. Regression models were used to explore associations between contact and consumption rates and determinants such as socio-economic status. Operational costs for repellent and net distribution were obtained from the MalaResT project and the provincial health department.

Results

A fourfold increase in distributor-household contact rates was observed in 2013 compared to 2012 (median₂₀₁₂ = 20 %, median₂₀₁₃ = 88.9 %). Consumption rate tripled over the 2-year study period (median₂₀₁₂ = 20 %, median₂₀₁₃ = 57.89 %). Contact rates were found to associate with district, commune and knowing the distributor, while consumption was associated with district and household head occupation. The annual operational cost per capita for repellent distribution was 31 times more expensive than LLIN distribution (USD 4.33 versus USD 0.14).

Discussion

After the existing public health system was reinforced with programmatic and logistic support, an intense 2-weekly distribution scheme of a vector control tool over a 2-year period was operated successfully in the field. Lack of associations with socio-economic status suggested that the free distribution strategy resulted in equitable access to repellents. The operational costs for the repellent distribution and exchange programme were much higher than LLIN distribution. Such effort could only be justified in the context of malaria elimination where these interventions are expected to be limited in time.

Electronic supplementary material

The online version of this article (doi:10.1186/s12936-015-0960-4) contains supplementary material, which is available to authorized users.

HIV treatment cascade in MSM, people who inject drugs, and sex workers

PURPOSE OF REVIEW

People who inject drugs (PWID), sex workers, and MSM simultaneously bear a high burden of HIV and stigma and discrimination. The purpose of this review was to summarize recent information about the understanding of the HIV care cascade among PWID, sex workers, and MSM populations around the globe.

RECENT FINDINGS

A review of the published literature relating to the care cascade in these three key populations was conducted. Data on the care cascade among key populations are sparse, particularly for PWID and sex workers. In the 12 countries in which a study or report of the care cascade was available stratified by these populations, all three populations have care cascade outcomes that are far below the 90-90-90 target set by the Joint United Nations Programme on HIV/AIDS (UNAIDS) for 2020. Culturally tailored interventions, including colocation of services and peer navigators, can improve care cascade outcomes among key populations.

SUMMARY

Key populations' care cascade outcomes must be included in international reporting metrics to expand cascade data for these groups. Improving care cascade outcomes in these key populations through culturally tailored interventions should be a priority in the coming years.

Sustainability of Evidence-Based Practices for HIV Prevention among Female Sex Workers in Mexico

Objective

This study examined service provider perceptions of requirements for successful sustainment of an efficacious intervention for preventing HIV/AIDS and STIs in female sex workers (FSWs) in Mexico.

Methods

Semi-structured interviews were conducted with 77 leaders and counselors from 12 community-based reproductive health clinics located throughout Mexico participating in a large hybrid effectiveness-implementation randomized controlled trial to scale-up the use of Mujer Segura, a psychoeducational intervention designed to promote condom use and enhance safer sex negotiation skills among FSWs.

Results

Five sets of requirements for sustainment were identified: 1) characteristics of the provider, including competence in delivering the intervention, need for continued technical support and assistance from outside experts, and satisfaction with addressing the needs of this population; 2) characteristics of the clients (i.e., FSWs), including client need and demand for services and incentives for participation; 3) characteristics of the organization, including its mission, benefits, and operations; 4) characteristics of the outer setting, including financial support and relationship with the community-based organization’s central offices, and transportation and security in areas where FSWs live and work; and 5) outcomes associated with the intervention itself, including a reduction of risk through education and increased outreach through referrals from FSWs who received the intervention.

Conclusions

Although the requirements for successful sustainment of interventions like Mujer Segura are consistent with the factors identified in many models of implementation, the results illustrate the importance of local context in assigning priority to these model elements and suggest that the five categories are not discrete entities but interconnected.

Policing the epidemic: High burden of workplace violence among female sex workers in conflict-affected northern Uganda

Sex workers in sub-Saharan Africa experience a high burden of HIV with a paucity of data on violence and links to HIV risk among sex workers, and even less within conflict-affected environments. Data are from a cross-sectional survey of female sex workers in Gulu, northern Uganda (n = 400). Logistic regression was used to determine the specific association between policing and recent physical/sexual violence from clients. A total of 196 (49.0%) sex workers experienced physical/sexual violence by a client. From those who experienced client violence the most common forms included physical assault (58.7%), rape (38.3%), and gang rape (15.8%) Police harassment was very common, a total of 149 (37.3%) reported rushing negotiations with clients because of police presence, a practice that was significantly associated with increased odds of client violence (adjusted odds ratio: 1.61, 95% confidence intervals: 1.03-2.52). Inconsistent condom use with clients, servicing clients in a bar, and working for a manager/pimp were also independently associated with recent client violence. Structural and community-led responses, including decriminalisation, and engagement with police and policy stakeholders, remain critical to addressing violence, both a human rights and public health imperative.

Prevalence and correlates of intimate partner violence in HIV-positive women engaged in transactional sex in Mombasa, Kenya

We evaluated the prevalence and correlates of intimate partner violence (IPV) in the past year by a regular male partner in HIV-positive female sex workers (FSWs) in Mombasa, Kenya. This cross-sectional study included HIV-positive women ≥18 years old who reported engagement in transactional sex at the time of enrolment in the parent cohort. We asked 13 questions adapted from the World Health Organization survey on violence against women about physical, sexual, or emotional violence in the past year by the current or most recent emotional partner (index partner). We used standardised instruments to assess socio-demographic and behavioural characteristics as possible correlates of IPV. Associations between IPV and these correlates were evaluated using univariate and multivariate logistic regression. Overall, 286/357 women (80.4%) had an index partner, and 52/357 (14.6%, 95% confidence interval 10.9%-18.2%) reported IPV by that partner in the past year. In multivariate analysis, women with severe alcohol problems (adjusted odds ratio 4.39, 1.16-16.61) and those experiencing controlling behaviours by the index partner (adjusted odds ratio 4.98, 2.31-10.74) were significantly more likely to report recent IPV. Recent IPV was common in HIV-positive FSWs. Interventions targeting risk factors for IPV, including alcohol problems and partner controlling behaviours, could help to reduce recurrent violence and negative health outcomes in this key population.

Speaking of sex workers: How suppression of research has distorted the United States' domestic HIV response

Sex workers remain a vulnerable population at risk for HIV acquisition and transmission. Research suggests that interventions at the individual level, such as condom distribution, are less effective in preventing HIV among sex workers than structural changes such as allowing safer work settings and reducing the harassment and abuse of sex workers by clients and police. In the US, HIV incidence has not declined in the last decade. This may be due in part to its policy of wilful ignorance about sex work, but the data to resolve the question simply do not exist. Political actions such as PEPFAR's prostitution pledge and a congressional campaign against "waste, fraud and abuse" in research are products of an ideological environment that suppresses research on HIV prevention and treatment needs of sex workers. Even basic prevalence data are missing because there is no "sex worker" category in the US National HIV Behavior Surveillance System. However, international efforts are taking a public health approach and are calling for decriminalization of sex work, as the most effective public health strategy for reducing HIV incidence among sex workers. Although such an approach is not yet politically feasible in the US, some urgent practical policy changes can be implemented to improve data collection and generation of evidence to support HIV prevention and treatment programs targeting sex workers.

Pre-exposure prophylaxis in Southern Africa: feasible or not?

INTRODUCTION

Southern and Eastern Africa bear the brunt of the AIDS epidemic, and current prevention interventions remain inadequate. Antiretroviral-based pre-exposure prophylaxis (PrEP) is gaining momentum as an effective prevention intervention.

DISCUSSION

Discussions have been started on how this strategy could be employed in Africa such that the populations most in need can be reached urgently for the greatest impact. This requires the selection of specific risk groups and service environments in which PrEP can be distributed safely and cost effectively while being mindful of any ethical issues.

CONCLUSIONS

Given the need for an integrated public health approach to this, a number of potential populations and opportunities for PrEP distribution exist and are discussed in this commentary.