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Age Matters: Determinants of sexual and reproductive health vulnerabilities amongst young women who sell sex (16-24 years) in Zimbabwe. Soc Sci Med 2020; 270:113597. [PMID: 33360151 DOI: 10.1016/j.socscimed.2020.113597] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 10/29/2020] [Accepted: 12/06/2020] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Female sex workers bear a disproportionate burden of HIV and other poor sexual and reproductive health (SRH) outcomes which has led to the tailoring of SRH interventions to mitigate risk. Understanding of the SRH vulnerabilities of young women who sell sex (YWSS) (16-24 years) in Southern Africa is under-represented in research which may result in a mismatch in current SRH interventions and service design. OBJECTIVE This paper is based on a sub-analysis of a qualitative study investigating the SRH of young women who sell sex (16-24 years) in Zimbabwe. We explored the differences in dynamics of SRH vulnerability amongst YWSS within the 16-24 year age band. METHODS In-depth interviews (IDIs) were conducted amongst key informants (n = 4), health care providers (n = 5), and peer educators (n = 16). Amongst YWSS, we conducted IDIs (n = 42) and focus group discussions (n = 30). Transcripts were inductively coded for emergent themes and categories. RESULTS Age and life stage determinants led to key differences in SRH vulnerabilities between younger (16-19 years) and older YWSS (20-24 years). These determinants emerged in the following ways: 1) distancing of younger participants from a "sex worker" identity leading to difficulties in identification and limiting intervention reach, 2) inexperience in dealing with clients and immature cognitive development leading to greater exposure to risk, and 3) the subordinate social position and exploitation of young participants within sex worker hierarchies or networks and lack of protective networks. CONCLUSIONS We highlight the presence of a diverse group of vulnerable young women who may be missed by sex worker programme responses. In future intervention planning, there is need to consider the age-related needs and vulnerabilities within a spectrum of young women involved in a wide range of transactional relationships to ensure that services reach those most vulnerable to poor SRH outcomes.
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Nikpay S, Otaghi M, Azami M, Karimi M, Abdi J. Trichomonas Vaginalis Infection Among Women Attending Laboratory Centers in Ilam, Iran. Infect Disord Drug Targets 2020; 20:98-101. [PMID: 30652653 DOI: 10.2174/1871526519666190117120705] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 01/06/2019] [Accepted: 01/07/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Trichomoniasis is known as a common venereal disease. It is estimated that 180 million people in the world are infected with this disease. The present study was conducted to estimate the prevalence of (Trichomonas vaginalis) T. vaginalis among women who were referred to the central laboratory in Ilam. METHODS In this cross-sectional study, 481 women with suspicious symptoms of trichomoniasis were selected during the first six months of 2015 in the central laboratory and Shahid Mostafa laboratory in Ilam, Iran. All patients were referred to the labs by gynecologists. Sterile swabs were used to collect direct smears. The results and questionnaire data were entered into SPSS version 16 and were analyzed using chi-square test and Fisher's exact test. RESULTS Direct smear of T. vaginalis demonstrated seven positive cases (1.5%). The highest and the lowest percentages of T. vaginalis infection in women were related to the 45-50 and 20-30 years age groups, respectively. Illiterate women had the highest percentage of infection. No significant relationship was found between the level of education and trichomoniasis infection in women (p = 0.085). The highest infection rate was associated with the use of ectopic contraceptive methods (condoms). CONCLUSION The prevalence of T. vaginalis was low among women in Ilam but was high among women who have used tubal ligation and condom to prevent pregnancy. Therefore, more attention is required from healthcare centers for appropriate education to women about the proper use of protective equipment.
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Affiliation(s)
- Sasan Nikpay
- Student Research Committee, Ilam University of Medical Sciences, Ilam, Iran
| | - Masoumeh Otaghi
- Assistant Professor of Nursing, Nursing & Midwifery Faculty, Ilam University of Medical Sciences, Ilam, Iran
| | - Milad Azami
- Student Research Committee, Ilam University of Medical Sciences, Ilam, Iran
| | - Marzieh Karimi
- Student Research Committee, Ilam University of Medical Sciences, Ilam, Iran
| | - Jahangir Abdi
- Department of Parasitology, School of Medicine, Ilam University of Medical Sciences, Ilam, Iran
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Abstract
BACKGROUND HIV took off rapidly in Zimbabwe during the 1980s. Yet, between 1998 and 2003, as the economy faltered, HIV prevalence declined abruptly and without clear explanation. METHODS We reviewed epidemiological, behavioural, and economic data over three decades to understand changes in economic conditions, migrant labour and sex work that may account for observed fluctuations in Zimbabwe's HIV epidemic. Potential biases related to changing epidemic paradigms and data sources were examined. RESULTS Early studies describe rural poverty, male migrant labour and sex work as conditions facilitating HIV/sexually transmitted infection (STI) transmission. By the mid-1990s, as Zimbabwe's epidemic became more generalized, research focus shifted to general population household surveys. Yet, less than half as many men than women were found at home during surveys in the 1990s, increasing to 80% during the years of economic decline. Other studies suggest that male demand for sex work fell abruptly as migrant workers were laid off, picking up again when the economy rebounded after 2009. Numbers of clients reported by sex workers, and their STI rates, followed similar patterns reaching a nadir in the early 2000s. Studies from 2009 describe a return to more active sex work, linked to increasing client demand, as well as a revitalized programme reaching sex workers. CONCLUSION The importance of the downturn in migrant labour and resultant changes in sex work may be underestimated as drivers of Zimbabwe's rapid HIV incidence and prevalence declines. Household surveys underrepresent populations at the highest risk of HIV/STI acquisition and transmission, and these biases vary with changing economic conditions.
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Dubbink JH, Verweij SP, Struthers HE, Ouburg S, McIntyre JA, Morré SA, Peters RP. Genital Chlamydia trachomatis and Neisseria gonorrhoeae infections among women in sub-Saharan Africa: A structured review. Int J STD AIDS 2018; 29:806-824. [PMID: 29486628 DOI: 10.1177/0956462418758224] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Chlamydia trachomatis and Neisseria gonorrhoeae constitute major public health problems among women, but the burden of infection in sub-Saharan Africa is poorly documented. We conducted a structured review of the prevalence and incidence of genital, oral and anal C. trachomatis and N. gonorrhoeae infection in women in sub-Saharan Africa. We searched Medline, EMBASE and Web of Science over a 10-year period for studies on epidemiology of genital, oral and anal chlamydial infection and gonorrhoea in women in all countries of sub-Saharan Africa. We assessed geographic and demographic differences in prevalence and incidence of infection; weighted mean prevalence estimates were calculated with a random-effect model. A total of 102 study results were included, with data available for 24/49 of sub-Saharan countries. The weighted prevalence of chlamydial infection was lower among women in community-based studies (3.9%; 95% CI: 2.9-5.1%) than for women recruited at primary healthcare facilities (6.0%; 95% CI: 4.2-8.4%, p < 0.001); the same was observed for gonorrhoea (2.2%; 95% CI: 1.2-4.0% vs. 4.2%; 95% CI: 3.2-5.6%, p < 0.001). Prevalence of Chlamydia among sex workers was 5.5% (95% CI: 4.2-7.3%) and gonorrhoea 7.6% (95% CI: 5.4-11%). Seven studies reported on incidence which varied between 0.75-28 and 2.8-17 per 100 person-years-at-risk for chlamydial infection and gonorrhoea, respectively. Only two studies reported on anal infections and one on oral infection. This overview underscores the considerable incidence and prevalence of genital C. trachomatis and N. gonorrhoeae in women in different settings in sub-Saharan Africa. Better control strategies are warranted to reduce the burden of infection and to prevent long-term complications of these infections.
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Affiliation(s)
- Jan Henk Dubbink
- 1 Anova Health Institute, Johannesburg, South Africa.,2 Department of Medical Microbiology & Infection Control, Laboratory of Immunogenetics, VU University Medical Center, Amsterdam, the Netherlands.,3 Faculty of Health, Medicine & Life Sciences, Department of Genetics and Cell Biology, Institute for Public Health Genomics (IPHG), Research School GROW (School for Oncology & Developmental Biology), University of Maastricht, Maastricht, the Netherlands
| | - Stephan P Verweij
- 2 Department of Medical Microbiology & Infection Control, Laboratory of Immunogenetics, VU University Medical Center, Amsterdam, the Netherlands
| | - Helen E Struthers
- 1 Anova Health Institute, Johannesburg, South Africa.,4 Division of Infectious Diseases & HIV Medicine, Department of Internal Medicine, University of Cape Town, Cape Town, South Africa
| | - Sander Ouburg
- 2 Department of Medical Microbiology & Infection Control, Laboratory of Immunogenetics, VU University Medical Center, Amsterdam, the Netherlands
| | - James A McIntyre
- 1 Anova Health Institute, Johannesburg, South Africa.,5 School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Servaas A Morré
- 2 Department of Medical Microbiology & Infection Control, Laboratory of Immunogenetics, VU University Medical Center, Amsterdam, the Netherlands.,3 Faculty of Health, Medicine & Life Sciences, Department of Genetics and Cell Biology, Institute for Public Health Genomics (IPHG), Research School GROW (School for Oncology & Developmental Biology), University of Maastricht, Maastricht, the Netherlands
| | - Remco Ph Peters
- 1 Anova Health Institute, Johannesburg, South Africa.,6 Department of Medical Microbiology, University of Pretoria, Pretoria, South Africa
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Marks M, Bottomley C, Tome H, Pitakaka R, Butcher R, Sokana O, Kako H, Solomon AW, Mabey DC. Mass drug administration of azithromycin for trachoma reduces the prevalence of genital Chlamydia trachomatis infection in the Solomon Islands. Sex Transm Infect 2016; 92:261-5. [PMID: 26888658 PMCID: PMC4893086 DOI: 10.1136/sextrans-2015-052439] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 01/23/2016] [Indexed: 11/30/2022] Open
Abstract
Objectives Chlamydia trachomatis is the most common bacterial sexually transmitted infection and is frequently asymptomatic; ocular C. trachomatis strains cause trachoma. Mass drug administration (MDA) of azithromycin for trachoma might also reduce the prevalence of genital C. trachomatis. In a survey conducted in the Solomon Islands in 2014, prior to MDA, the prevalence of genital C. trachomatis was 20.3% (95% CI 15.9% to 25.4%). We conducted a survey to establish the impact of MDA with azithromycin on genital C. trachomatis. Methods Women attending three community outpatient clinics, predominantly for antenatal care, 10 months after MDA with azithromycin given for trachoma elimination, were enrolled in this survey. Self-taken high vaginal swabs were for C. trachomatis and Neisseria gonorrhoeae using the BD Probetec strand displacement assay. Results 298 women were enrolled. C. trachomatis infection was diagnosed in 43 women (14.4%, 95% CI 10.6% to 18.9%) and N. gonorrhoeae in 9 (3%, 95% CI 1.4% to 5.7%). The age-adjusted OR for C. trachomatis infection was consistent with a significant decrease in the prevalence of C. trachomatis following MDA (OR 0.58, 95% CI 0.37 to 0.94, p=0.027). There was no change in the prevalence of N. gonorrhoeae between following MDA (OR 0.51, 95% CI 0.22 to 1.22, p=0.13). Conclusions This study demonstrated a 40% reduction in the age-adjusted prevalence of genital C. trachomatis infection following azithromycin MDA for trachoma elimination.
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Affiliation(s)
- M Marks
- Faculty of Infectious and Tropical Diseases, Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK Hospital for Tropical Diseases, University College London Hospitals NHS Trust, London, UK
| | - C Bottomley
- Department of Infectious Diseases Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - H Tome
- Nursing Division, Honiara City Council, Honiara, Solomon Islands
| | - R Pitakaka
- National Referral Hospital, Honiara, Solomon Islands
| | - R Butcher
- Faculty of Infectious and Tropical Diseases, Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
| | - O Sokana
- Eye Health Department, Ministry of Health and Medical Services, Honiara, Solomon Islands
| | - H Kako
- Department of STI and HIV Prevention, Ministry of Health and Medical Services, Honiara, Solomon Islands
| | - A W Solomon
- Faculty of Infectious and Tropical Diseases, Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK Hospital for Tropical Diseases, University College London Hospitals NHS Trust, London, UK
| | - D C Mabey
- Faculty of Infectious and Tropical Diseases, Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK Hospital for Tropical Diseases, University College London Hospitals NHS Trust, London, UK
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Elmes J, Nhongo K, Ward H, Hallett T, Nyamukapa C, White PJ, Gregson S. The price of sex: condom use and the determinants of the price of sex among female sex workers in eastern Zimbabwe. J Infect Dis 2015; 210 Suppl 2:S569-78. [PMID: 25381377 PMCID: PMC4231645 DOI: 10.1093/infdis/jiu493] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Higher prices for unprotected sex threaten the high levels of condom use that contributed to the decline in Zimbabwe's human immunodeficiency virus (HIV) epidemic. To improve understanding of financial pressures competing against safer sex, we explore factors associated with the price of commercial sex in rural eastern Zimbabwe. METHODS We collected and analyzed cross-sectional data on 311 women, recruited during October-December 2010, who reported that they received payment for their most-recent or second-most-recent sex acts in the past year. Zero-inflated negative binomial models with robust standard errors clustered on female sex worker (FSW) were used to explore social and behavioral determinants of price. RESULTS The median price of sex was $10 (interquartile range [IQR], $5-$20) per night and $10 (IQR, $5-$15) per act. Amounts paid in cash and commodities did not differ significantly. At the most-recent sex act, more-educated FSWs received 30%-74% higher payments. Client requests for condom use significantly predicted protected sex (P < .01), but clients paid on average 42.9% more for unprotected sex. CONCLUSIONS Within a work environment where clients' preferences determine condom use, FSWs effectively use their individual capital to negotiate the terms of condom use. Strengthening FSWs' preferences for protected sex could help maintain high levels of condom use.
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Affiliation(s)
| | - Kundai Nhongo
- Biomedical Research and Training Institute, Avondale, Zimbabwe
| | - Helen Ward
- Department of Infectious Disease Epidemiology
| | - Timothy Hallett
- MRC Centre for Outbreak Analysis and Modelling NIHR Health Protection Research Unit in Modelling Methodology, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London
| | | | - Peter J White
- MRC Centre for Outbreak Analysis and Modelling NIHR Health Protection Research Unit in Modelling Methodology, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London Modelling and Economics Unit, Centre for Infectious Disease Surveillance and Control, Public Health England, London, United Kingdom
| | - Simon Gregson
- Department of Infectious Disease Epidemiology Biomedical Research and Training Institute, Avondale, Zimbabwe
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The case for transmissible antivirals to control population-wide infectious disease. Trends Biotechnol 2014; 32:400-5. [PMID: 25017994 DOI: 10.1016/j.tibtech.2014.06.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Revised: 06/09/2014] [Accepted: 06/10/2014] [Indexed: 01/08/2023]
Abstract
Infectious disease control faces significant challenges including: how to therapeutically target the highest-risk populations, circumvent behavioral barriers, and overcome pathogen persistence and resistance mechanisms. We review a recently proposed solution to overcome these challenges: antivirals that transmit by 'piggybacking' on viral replication. These proposed antivirals, termed 'therapeutic interfering particles' (TIPs), are engineered molecular parasites of viruses that are designed to steal replication resources from the wild type virus. Depriving viruses of crucial replication machinery, TIPs would reduce viral loads. As obligate parasites, TIPs would transmit via the same risk factors and transmission routes as wild type viruses, automatically reaching high-risk populations, and thereby substantially limiting viral transmission even in resource-poor settings. Design issues and ethical/safety considerations of this proposed intervention are discussed.
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Dhana A, Luchters S, Moore L, Lafort Y, Roy A, Scorgie F, Chersich M. Systematic review of facility-based sexual and reproductive health services for female sex workers in Africa. Global Health 2014; 10:46. [PMID: 24916010 PMCID: PMC4070634 DOI: 10.1186/1744-8603-10-46] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Accepted: 04/07/2014] [Indexed: 12/19/2022] Open
Abstract
Background Several biological, behavioural, and structural risk factors place female sex workers (FSWs) at heightened risk of HIV, sexually transmitted infections (STIs), and other adverse sexual and reproductive health (SRH) outcomes. FSW projects in many settings have demonstrated effective ways of altering this risk, improving the health and wellbeing of these women. Yet the optimum delivery model of FSW projects in Africa is unclear. This systematic review describes intervention packages, service-delivery models, and extent of government involvement in these services in Africa. Methods On 22 November 2012, we searched Web of Science and MEDLINE, without date restrictions, for studies describing clinical and non-clinical facility-based SRH prevention and care services for FSWs in low- and middle-income countries in Africa. We also identified articles in key non-indexed journals and on websites of international organizations. A single reviewer screened titles and abstracts, and extracted data from articles using standardised tools. Results We located 149 articles, which described 54 projects. Most were localised and small-scale; focused on research activities (rather than on large-scale service delivery); operated with little coordination, either nationally or regionally; and had scanty government support (instead a range of international donors generally funded services). Almost all sites only addressed HIV prevention and STIs. Most services distributed male condoms, but only 10% provided female condoms. HIV services mainly encompassed HIV counselling and testing; few offered HIV care and treatment such as CD4 testing or antiretroviral therapy (ART). While STI services were more comprehensive, periodic presumptive treatment was only provided in 11 instances. Services often ignored broader SRH needs such as family planning, cervical cancer screening, and gender-based violence services. Conclusions Sex work programmes in Africa have limited coverage and a narrow scope of services and are poorly coordinated with broader HIV and SRH services. To improve FSWs’ health and reduce onward HIV transmission, access to ART needs to be addressed urgently. Nevertheless, HIV prevention should remain the mainstay of services. Service delivery models that integrate broader SRH services and address structural risk factors are much needed. Government-led FSW services of high quality and scale would markedly reduce SRH vulnerabilities of FSWs in Africa.
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Affiliation(s)
| | | | | | | | | | | | - Matthew Chersich
- Centre for Health Policy, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
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Chico RM, Hack BB, Newport MJ, Ngulube E, Chandramohan D. On the pathway to better birth outcomes? A systematic review of azithromycin and curable sexually transmitted infections. Expert Rev Anti Infect Ther 2013; 11:1303-32. [PMID: 24191955 PMCID: PMC3906303 DOI: 10.1586/14787210.2013.851601] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
The WHO recommends the administration of sulfadoxine-pyrimethamine (SP) to all pregnant women living in areas of moderate (stable) to high malaria transmission during scheduled antenatal visits, beginning in the second trimester and continuing to delivery. Malaria parasites have lost sensitivity to SP in many endemic areas, prompting the investigation of alternatives that include azithromycin-based combination (ABC) therapies. Use of ABC therapies may also confer protection against curable sexually transmitted infections and reproductive tract infections (STIs/RTIs). The magnitude of protection at the population level would depend on the efficacy of the azithromycin-based regimen used and the underlying prevalence of curable STIs/RTIs among pregnant women who receive preventive treatment. This systematic review summarizes the efficacy data of azithromycin against curable STIs/RTIs.
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Affiliation(s)
- R Matthew Chico
- London School of Hygiene and Tropical Medicine Keppel Street, London, WC1E 7HT,UK
| | - Berkin B Hack
- Brighton and Sussex Medical School,Brighton, East Sussex, BN1 9PX,UK
| | - Melanie J Newport
- Brighton and Sussex Medical School,Brighton, East Sussex, BN1 9PX,UK
| | - Enesia Ngulube
- London School of Hygiene and Tropical Medicine Keppel Street, London, WC1E 7HT,UK
| | - Daniel Chandramohan
- London School of Hygiene and Tropical Medicine Keppel Street, London, WC1E 7HT,UK
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Cowan FM, Mtetwa S, Davey C, Fearon E, Dirawo J, Wong-Gruenwald R, Ndikudze T, Chidiya S, Benedikt C, Busza J, Hargreaves JR. Engagement with HIV prevention treatment and care among female sex workers in Zimbabwe: a respondent driven sampling survey. PLoS One 2013; 8:e77080. [PMID: 24143203 PMCID: PMC3797143 DOI: 10.1371/journal.pone.0077080] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Accepted: 09/06/2013] [Indexed: 11/18/2022] Open
Abstract
Objective(S) To determine the HIV prevalence and extent of engagement with HIV prevention and care among a representative sample of Zimbabwean sex workers working in Victoria Falls, Hwange and Mutare. Design Respondent driven sampling (RDS) surveys conducted at each site. Methods Sex workers were recruited using respondent driven sampling with each respondent limited to recruiting 2 peers. Participants completed an interviewer-administered questionnaire and provided a finger prick blood sample for HIV antibody testing. Statistical analysis took account of sampling method. Results 870 women were recruited from the three sites. HIV prevalence was between 50 and 70%. Around half of those confirmed HIV positive were aware of their HIV status and of those 50-70% reported being enrolled in HIV care programmes. Overall only 25-35% of those with laboratory-confirmed HIV were accessing antiretroviral therapy. Among those reporting they were HIV negative, 21-28% reported having an HIV test in the last 6 months. Of those tested HIV negative, most (65-82%) were unaware of their status. Around two-thirds of sex workers reported consistent condom use with their clients. As in other settings, sex workers reported high rates of gender based violence and police harassment. Conclusions This survey suggests that prevalence of HIV is high among sex workers in Zimbabwe and that their engagement with prevention, treatment and care is sub-optimal. Intensifying prevention and care interventions for sex workers has the potential to markedly reduce HIV and social risks for sex workers, their clients and the general population in Zimbabwe and elsewhere in the region.
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Affiliation(s)
- Frances M. Cowan
- Infection and Population Health, University College London, London, United Kingdom
- Zimbabwe AIDS Prevention Project Trust, Harare, Zimbabwe
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe
- * E-mail:
| | - Sibongile Mtetwa
- Zimbabwe AIDS Prevention Project Trust, Harare, Zimbabwe
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe
| | - Calum Davey
- Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Elizabeth Fearon
- Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jeffrey Dirawo
- Zimbabwe AIDS Prevention Project Trust, Harare, Zimbabwe
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe
| | | | - Theresa Ndikudze
- Deutsche Gesellschaft für Internationale Zusammenarbeit (GmbH), Bonn, Germany
| | - Samson Chidiya
- United Nations Population Fund (UNFPA), Harare, Zimbabwe
| | | | - Joanna Busza
- Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - James R. Hargreaves
- Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Priority interventions to reduce HIV transmission in sex work settings in sub-Saharan Africa and delivery of these services. J Int AIDS Soc 2013; 16:17980. [PMID: 23462140 PMCID: PMC3589546 DOI: 10.7448/ias.16.1.17980] [Citation(s) in RCA: 103] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Revised: 09/17/2012] [Accepted: 10/24/2012] [Indexed: 12/04/2022] Open
Abstract
Introduction Virtually no African country provides HIV prevention services in sex work settings with an adequate scale and intensity. Uncertainty remains about the optimal set of interventions and mode of delivery. Methods We systematically reviewed studies reporting interventions for reducing HIV transmission among female sex workers in sub-Saharan Africa between January 2000 and July 2011. Medline (PubMed) and non-indexed journals were searched for studies with quantitative study outcomes. Results We located 26 studies, including seven randomized trials. Evidence supports implementation of the following interventions to reduce unprotected sex among female sex workers: peer-mediated condom promotion, risk-reduction counselling and skills-building for safer sex. One study found that interventions to counter hazardous alcohol-use lowered unprotected sex. Data also show effectiveness of screening for sexually transmitted infections (STIs) and syndromic STI treatment, but experience with periodic presumptive treatment is limited. HIV testing and counselling is essential for facilitating sex workers’ access to care and antiretroviral treatment (ART), but testing models for sex workers and indeed for ART access are little studied, as are structural interventions, which create conditions conducive for risk reduction. With the exception of Senegal, persistent criminalization of sex work across Africa reduces sex workers’ control over working conditions and impedes their access to health services. It also obstructs health-service provision and legal protection. Conclusions There is sufficient evidence of effectiveness of targeted interventions with female sex workers in Africa to inform delivery of services for this population. With improved planning and political will, services – including peer interventions, condom promotion and STI screening – would act at multiple levels to reduce HIV exposure and transmission efficiency among sex workers. Initiatives are required to enhance access to HIV testing and ART for sex workers, using current CD4 thresholds, or possibly earlier for prevention. Services implemented at sufficient scale and intensity also serve as a platform for subsequent community mobilization and sex worker empowerment, and alleviate a major source of incident infection sustaining even generalized HIV epidemics. Ultimately, structural and legal changes that align public health and human rights are needed to ensure that sex workers on the continent are adequately protected from HIV.
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Labbé AC, Pépin J, Khonde N, Dzokoto A, Méda H, Asamoah-Adu C, Mayaud P, Mabey D, Demers E, Alary M. Periodical Antibiotic Treatment for the Control of Gonococcal and Chlamydial Infections Among Sex Workers in Benin and Ghana. Sex Transm Dis 2012; 39:253-9. [DOI: 10.1097/olq.0b013e318244aaa0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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13
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Periodic presumptive treatment of curable sexually transmitted infections among sex workers: a systematic review. AIDS 2012; 26:437-45. [PMID: 22095197 DOI: 10.1097/qad.0b013e32834ed991] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Unprotected sex work remains a major driver of HIV/sexually transmitted infection (STI) epidemics in many countries. STI treatment can lower disease burden, complications and prevalence of HIV cofactors. Periodic presumptive treatment (PPT) has been used with sex workers to reduce their high burden of largely asymptomatic STIs. The objective of this review is to assess benefits and harms of PPT among female sex workers. METHODS We searched MEDLINE for studies related to sex work and STIs during 1990-2010, extracted data from eligible studies in duplicate and conducted meta-analysis by study design using random effects models. RESULTS Two thousand, three hundred and fifteen articles were screened, 18 studies met inclusion criteria and 14 were included in meta-analyses. One published randomized controlled trial (RCT) reported significant reductions of gonorrhoea (Neisseria gonorrhoeae) [rate ratio (RR) 0.46, 95% confidence interval (CI) 0.31-0.68] and chlamydia (Chlamydia trachomatis) (RR 0.38, 95%CI 0.26-0.57), but no effect on serologic syphilis (RR 1.02, 95%CI 0.54-1.95). Similar results were seen for N. gonorrhoeae and C. trachomatis in pooled analyses, including data from one unpublished RCT and across study designs, and correlated with initial prevalence (R(2) = 0.155). One observational study reported genital ulcer disease (GUD) declines in sex workers, and two reported impact among male client populations for N. gonorrhoeae [odds ratio (OR) 0.60, 95% CI 0.38-0.94], C. trachomatis (OR 0.47, 95% CI 0.31-0.71) and GUD (OR 0.21, 95% CI 0.11-0.42). No studies reported evidence of risk compensation or antibiotic resistance. CONCLUSION PPT can reduce prevalence of gonorrhoea, chlamydia and ulcerative STIs among sex workers in whom prevalence is high. Sustained STI reductions can be achieved when PPT is implemented together with peer interventions and condom promotion. Additional benefits may include impact on STI and HIV transmission at population level.
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Braunstein SL, Ingabire CM, Geubbels E, Vyankandondera J, Umulisa MM, Gahiro E, Uwineza M, Tuijn CJ, Nash D, van de Wijgert JHHM. High burden of prevalent and recently acquired HIV among female sex workers and female HIV voluntary testing center clients in Kigali, Rwanda. PLoS One 2011; 6:e24321. [PMID: 21949704 PMCID: PMC3176231 DOI: 10.1371/journal.pone.0024321] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2011] [Accepted: 08/07/2011] [Indexed: 11/21/2022] Open
Abstract
Objectives To estimate HIV prevalence and risk factors in population-based samples of female sex workers (FSW) and female voluntary counseling and testing (VCT) clients in Rwanda. Methods We conducted a cross-sectional survey of 800 FSW and 1,250 female VCT clients in Rwanda, which included interviewing and testing for HIV-1/2, HSV-2 and pregnancy, and BED-CEIA and Avidity Index (AI) to identify recent infections among HIV-infected women. Results Prevalence of HIV-1, HSV-2, and pregnancy were 24% (95% CI: 21.0–27.0), 59.8% (56.4–63.2), and 7.6% (5.8–9.5) among FSW, and 12.8% (10.9–14.6), 43.2% (40.4–46.0), and 11.4% (9.7–13.3) among VCT clients, respectively. Thirty-five percent of FSW and 25% of VCT clients had never been HIV tested. Per national guidelines, 33% of newly HIV-diagnosed FSW and 36% of VCT clients were already eligible for ART based on CD4<350 cells/µl. Condom use at last sex was higher among FSW (74%) than VCT clients (12%). In age and district of residence-adjusted models, HIV-1 seropositivity was associated with HSV-2 co-infection; recent treatment for sexually transmitted infection (STI); genital symptoms; forced sex; imprisonment; widowhood; and alcohol consumption. Eleven percent of FSW and 12% of VCT clients had recently acquired HIV-1 per BED-CEIA and AI. HSV-2 infection and recent STI treatment were associated with recent HIV infection in both groups, and being married and vaginal cleansing were associated with recent infection before last sex among VCT clients. Conclusions This population-based survey reveals a high HIV prevalence and incidence among FSW and female VCT clients in Kigali, the scale of which is masked by the low general-population HIV prevalence in Rwanda. HIV/STI and family planning services should be strengthened.
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Affiliation(s)
- Sarah L Braunstein
- Mailman School of Public Health, Columbia University, New York, New York, United States of America.
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High Human Immunodeficiency Virus Incidence in a Cohort of Rwandan Female Sex Workers. Sex Transm Dis 2011; 38:385-94. [DOI: 10.1097/olq.0b013e31820b8eba] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Autonomous targeting of infectious superspreaders using engineered transmissible therapies. PLoS Comput Biol 2011; 7:e1002015. [PMID: 21483468 PMCID: PMC3060167 DOI: 10.1371/journal.pcbi.1002015] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2010] [Accepted: 01/17/2011] [Indexed: 12/15/2022] Open
Abstract
Infectious disease treatments, both pharmaceutical and vaccine, face three universal challenges: the difficulty of targeting treatments to high-risk ‘superspreader’ populations who drive the great majority of disease spread, behavioral barriers in the host population (such as poor compliance and risk disinhibition), and the evolution of pathogen resistance. Here, we describe a proposed intervention that would overcome these challenges by capitalizing upon Therapeutic Interfering Particles (TIPs) that are engineered to replicate conditionally in the presence of the pathogen and spread between individuals — analogous to ‘transmissible immunization’ that occurs with live-attenuated vaccines (but without the potential for reversion to virulence). Building on analyses of HIV field data from sub-Saharan Africa, we construct a multi-scale model, beginning at the single-cell level, to predict the effect of TIPs on individual patient viral loads and ultimately population-level disease prevalence. Our results show that a TIP, engineered with properties based on a recent HIV gene-therapy trial, could stably lower HIV/AIDS prevalence by ∼30-fold within 50 years and could complement current therapies. In contrast, optimistic antiretroviral therapy or vaccination campaigns alone could only lower HIV/AIDS prevalence by <2-fold over 50 years. The TIP's efficacy arises from its exploitation of the same risk factors as the pathogen, allowing it to autonomously penetrate superspreader populations, maintain efficacy despite behavioral disinhibition, and limit viral resistance. While demonstrated here for HIV, the TIP concept could apply broadly to many viral infectious diseases and would represent a new paradigm for disease control, away from pathogen eradication but toward robust disease suppression. We introduce a proposed intervention against infectious diseases that extends and optimizes the recognized benefit of ‘transmissible immunization’ that occurs with live-attenuated vaccines such as Oral Polio Vaccine (OPV), the vaccine chosen for the worldwide polio eradication campaign. The intervention proposed here is based upon Therapeutic Interfering Particles (TIPs) that are engineered to replicate only in the presence of the wildtype pathogen and act to inhibit the growth of the pathogen. Therefore TIPs ‘piggyback’ on the pathogen, leading to two important differences from live-attenuated vaccines: TIPs can only transmit from individuals already infected with wildtype pathogen, and TIPs could only revert to virulence in individuals already carrying the wild-type pathogen. Intriguingly, because TIPs spread between individuals using the same transmission routes as the pathogen, they automatically find their way to the populations at greatest risk of infection, thus circumventing the unsolved problem of how to identify superspreaders and target them for preventive measures. Based on clinical-trial data, we analyze the impact that TIP intervention would have on HIV/AIDS in sub-Saharan Africa and show that TIPs could lower HIV/AIDS prevalence more effectively than vaccines or drugs alone and, in fact, would effectively complement these other interventions.
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Bruce E, Bauai L, Masta A, Rooney PJ, Paniu M, Sapuri M, Keogh L, Kaldor J, Fairley CK. Effects of periodic presumptive treatment on three bacterial sexually transmissible infections and HIV among female sex workers in Port Moresby, Papua New Guinea. Sex Health 2011; 8:222-8. [DOI: 10.1071/sh10049] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2010] [Accepted: 10/12/2010] [Indexed: 11/23/2022]
Abstract
Background
Sexually transmissible infections (STI) are common in female sex workers (FSW). Aim: To determine if 3-monthly periodic presumptive treatments (PPT) would reduce the prevalence of STI in FSW. Methods: In a cohort study conducted between November 2003 and September 2004, FSW were enrolled, counselled and interviewed. Informed consent was obtained. Testing by using polymerase chain reaction (PCR) for Chlamydia trachomatis (Ct), Neisseria gonorrhoeae (Ng) and Trichomonas vaginalis (Tv), and serology for HIV were performed at baseline and final follow-up visits. Each FSW received 3-monthly oral amoxicillin, probenecid, a combination of amoxicillin and clavulanic acid, and azithromycin. Tinidazole was administered once. Results: The cohort consisted of 129 FSW at baseline and 71 at final follow-up visit. Of these 71 FSW, there was a significant decline in the proportion with positive PCR results for Ct from 38% to 16% (P = 0.001), Ng from 56% to 23% (P = <0.001) and Tv from 62% to 30% (P = <0.001) between baseline and the final follow-up visit. HIV prevalence increased from 15% to 21% (P = 0.125). Conclusions: PPT was statistically effective in reducing STI but rates rebounded rapidly. Several new HIV infections occurred. If PPT is to be very effective in FSW where the prevalence of STI is so high, then 100% condom use with clients and regular sexual partners (RSP), and high rates of notification of RSP would be required if low incidence and prevalence of STI were to be achievable.
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Pascom ARP, Szwarcwald CL, Júnior AB. Sampling studies to estimate the HIV prevalence rate in female commercial sex workers. Braz J Infect Dis 2010. [DOI: 10.1016/s1413-8670(10)70081-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Shahmanesh M, Wayal S, Cowan F, Mabey D, Copas A, Patel V. Suicidal behavior among female sex workers in Goa, India: the silent epidemic. Am J Public Health 2009; 99:1239-46. [PMID: 19443819 PMCID: PMC2696657 DOI: 10.2105/ajph.2008.149930] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We sought to study suicidal behavior prevalence and its association with social and gender disadvantage, sex work, and health factors among female sex workers in Goa, India. METHODS Using respondent-driven sampling, we recruited 326 sex workers in Goa for an interviewer-administered questionnaire regarding self-harming behaviors, sociodemographics, sex work, gender disadvantage, and health. Participants were tested for sexually transmitted infections. We used multivariate analysis to define suicide attempt determinants. RESULTS Nineteen percent of sex workers in the sample reported attempted suicide in the past 3 months. Attempts were independently associated with intimate partner violence (adjusted odds ratio [AOR] = 2.70; 95% confidence interval [CI] = 1.38, 5.28), violence from others (AOR = 2.26; 95% CI = 1.15, 4.45), entrapment (AOR = 2.76; 95% CI = 1.11, 6.83), regular customers (AOR = 3.20; 95% CI = 1.61, 6.35), and worsening mental health (AOR = 1.05; 95% CI = 1.01, 1.11). Lower suicide attempt likelihood was associated with Kannad ethnicity, HIV prevention services, and having a child. CONCLUSIONS Suicidal behaviors among sex workers were common and associated with gender disadvantage and poor mental health. India's widespread HIV-prevention programs for sex workers provide an opportunity for community-based interventions against gender-based violence and for mental health services delivery.
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Affiliation(s)
- Maryam Shahmanesh
- Centre for Sexual Health and HIV Research, University College London, 3rd floor Mortimer Market Centre, off Caper St, London WC1E 6AU UK.
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Abstract
PURPOSE OF REVIEW Trichomonas vaginalis is the most common curable sexually transmitted infection. Despite a number of serious health consequences including facilitation of HIV transmission, pelvic inflammatory disease and adverse outcomes of pregnancy it remains an under-recognized condition. This review aims to update the reader on the global epidemiology and control of T. vaginalis. RECENT FINDINGS The burden of T. vaginalis infection is found in resource-limited settings and high-risk groups in industrialized settings. Utilization of polymerase chain reaction-based diagnostics has enhanced our understanding of the epidemiology of T. vaginalis both at the population level and in sexual partners. High rates of asymptomatic infection in male partners of infected females and subsequent re-infection have significant implications for control programmes. Further studies investigating the role of T. vaginalis in facilitating HIV transmission has highlighted its significance and the need to develop and implement control interventions. SUMMARY Future research to develop cheap, point-of-care diagnostic tests will allow a greater understanding of T. vaginalis epidemiology. In addition, the effect of treatment on outcome of pregnancy and HIV acquisition requires further study. This will in turn facilitate operational studies evaluating optimal control strategies and their impact on the complications of T. vaginalis.
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Shahmanesh M, Patel V, Mabey D, Cowan F. Effectiveness of interventions for the prevention of HIV and other sexually transmitted infections in female sex workers in resource poor setting: a systematic review. Trop Med Int Health 2008; 13:659-79. [PMID: 18266784 DOI: 10.1111/j.1365-3156.2008.02040.x] [Citation(s) in RCA: 183] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To systematically review the evidence for effectiveness of HIV and sexually transmitted infection (STI) prevention interventions in female sex workers in resource poor settings. METHOD Published and unpublished studies were identified through electronic databases (Cochrane database, Medline, Embase, and Web of Science), hand searching and contacting experts. Randomized-controlled-trials and quasi-experimental studies were included if they were conducted in female sex workers from low and middle income settings; if the exposure was described; if the outcome was externally measurable, it was after the discovery of HIV, and if follow-up was longer than 6 months. A priori criteria were used to extract data. Meta-analysis was not performed due to the heterogeneity of studies. RESULTS Twenty-eight interventions were included. Despite methodological limitations, the evidence suggested that combining sexual risk reduction, condom promotion and improved access to STI treatment reduces HIV and STI acquisition in sex workers receiving the intervention. Strong evidence that regular STI screening or periodic treatment of STIs confers additional protection against HIV was lacking. It appears that structural interventions, policy change or empowerment of sex workers, reduce the prevalence of STIs and HIV. CONCLUSION Rigorous evaluation of HIV/STI prevention interventions in sex workers is challenging. There is some evidence for the efficacy of multi-component interventions, and/or structural interventions. The effect of these interventions on the wider population has rarely been evaluated.
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Affiliation(s)
- Maryam Shahmanesh
- Centre for Sexual Health and HIV Research, University College London, London, UK.
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Gregson S, Adamson S, Papaya S, Mundondo J, Nyamukapa CA, Mason PR, Garnett GP, Chandiwana SK, Foster G, Anderson RM. Impact and process evaluation of integrated community and clinic-based HIV-1 control: a cluster-randomised trial in eastern Zimbabwe. PLoS Med 2007; 4:e102. [PMID: 17388666 PMCID: PMC1831737 DOI: 10.1371/journal.pmed.0040102] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2006] [Accepted: 01/22/2007] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND HIV-1 control in sub-Saharan Africa requires cost-effective and sustainable programmes that promote behaviour change and reduce cofactor sexually transmitted infections (STIs) at the population and individual levels. METHODS AND FINDINGS We measured the feasibility of community-based peer education, free condom distribution, income-generating projects, and clinic-based STI treatment and counselling services and evaluated their impact on the incidence of HIV-1 measured over a 3-y period in a cluster-randomised controlled trial in eastern Zimbabwe. Analysis of primary outcomes was on an intention-to-treat basis. The income-generating projects proved impossible to implement in the prevailing economic climate. Despite greater programme activity and knowledge in the intervention communities, the incidence rate ratio of HIV-1 was 1.27 (95% confidence interval [CI] 0.92-1.75) compared to the control communities. No evidence was found for reduced incidence of self-reported STI symptoms or high-risk sexual behaviour in the intervention communities. Males who attended programme meetings had lower HIV-1 incidence (incidence rate ratio 0.48, 95% CI 0.24-0.98), and fewer men who attended programme meetings reported unprotected sex with casual partners (odds ratio 0.45, 95% CI 0.28-0.75). More male STI patients in the intervention communities reported cessation of symptoms (odds ratio 2.49, 95% CI 1.21-5.12). CONCLUSIONS Integrated peer education, condom distribution, and syndromic STI management did not reduce population-level HIV-1 incidence in a declining epidemic, despite reducing HIV-1 incidence in the immediate male target group. Our results highlight the need to assess the community-level impact of interventions that are effective amongst targeted population sub-groups.
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Affiliation(s)
- Simon Gregson
- Department of Infectious Disease Epidemiology, Faculty of Medicine, Imperial College London, London, United Kingdom.
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Cowan FF, Pascoe SJS, Barlow KL, Langhaug LF, Jaffar S, Hargrove JW, Robinson NJ, Latif AS, Bassett MT, Wilson D, Brown DWG, Hayes RJ. Association of genital shedding of herpes simplex virus type 2 and HIV-1 among sex workers in rural Zimbabwe. AIDS 2006; 20:261-7. [PMID: 16511420 DOI: 10.1097/01.aids.0000198086.39831.4a] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Herpes simplex virus type 2 (HSV-2) facilitates sexual acquisition of HIV-1 but data on transmission are less clear. In this study the interaction between genital shedding of HIV-1 and HSV-2 was explored among Zimbabwean sex workers. METHODS Women (n = 214) were interviewed about genital symptoms. Blood samples were analysed for HIV-1 and HSV-2 antibodies, HIV-1 plasma viral load (PVL) and CD4 lymphocyte count and genital swabs for detection of HIV-1 and HSV-2 genital shedding, Chlamydia trachomatis, Neisseria gonorrhoeae and Trichomonas vaginalis, and a cervico-vaginal lavage (CVL) for quantitative measurement of HIV-1 shedding. Shedding analyses were undertaken on women co-infected with HSV-2 and HIV-1. RESULTS A total of 124 women were co-infected with HIV-1 and HSV-2; 58 were infected with HSV-2 alone. Most HIV-1-infected women were co-infected with HSV-2 (95.4%). Genital HIV-1 shedding was detected in 84.3% of co-infected women and was associated with low CD4 cell count and high PVL but not with reported symptoms of genital herpes or genital shedding of HSV-2. There was no difference in HIV-1 shedding among women shedding HSV-2 (79.3%) and women not shedding HSV-2 (83.2%) (P = 0.64). The adjusted odds ratio for HIV-1 shedding between HSV-2 shedders and non-shedders was 0.8 [95% confidence interval (CI), 0.2-3.3]. HIV-1 PVL(log10) and CVL viral load(log10) were correlated (r = 0.38; 95%CI, 0.2-0.5). After adjusting for PVL, genital symptoms and age, HSV-2 shedding had no effect on CVL viral load (P = 0.13). CONCLUSION Rate and quantity of HIV-1 genital shedding do not appear to be altered by presence of HSV-2 genital shedding.
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Affiliation(s)
- Frances F Cowan
- Royal Free and University College Medical School, London, UK.
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Abstract
Sex work is an extremely dangerous profession. The use of harm-reduction principles can help to safeguard sex workers' lives in the same way that drug users have benefited from drug-use harm reduction. Sex workers are exposed to serious harms: drug use, disease, violence, discrimination, debt, criminalisation, and exploitation (child prostitution, trafficking for sex work, and exploitation of migrants). Successful and promising harm-reduction strategies are available: education, empowerment, prevention, care, occupational health and safety, decriminalisation of sex workers, and human-rights-based approaches. Successful interventions include peer education, training in condom-negotiating skills, safety tips for street-based sex workers, male and female condoms, the prevention-care synergy, occupational health and safety guidelines for brothels, self-help organisations, and community-based child protection networks. Straightforward and achievable steps are available to improve the day-to-day lives of sex workers while they continue to work. Conceptualising and debating sex-work harm reduction as a new paradigm can hasten this process.
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Affiliation(s)
- Michael L Rekart
- British Columbia Centre for Disease Control, University of British Columbia, Vancouver V5Z 4R4, BC, Canada.
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