Changes in attitudes, risky practices, and HIV and syphilis prevalence among female sex workers in Brazil from 2009 to 2016

Social and structural determinants associated with the prevalence of sexually transmitted infections among female commercial sex workers in Dhaka City, Bangladesh

Female commercial sex workers (FCSWs) bear higher rates of sexually transmitted infections (STIs) among key populations. The association of structural determinants and STIs among FCSWs was not at the forefront of research earlier in Bangladesh. This study examined how structural factors correlate with the prevalence of STIs at physical/social/economic/policy levels among FCSWs in Dhaka city. 495 FCSWs were screened for HIV, hepatitis B, and syphilis. Structural variables (Individual risks, high-risk sexual behaviors, work environments) were extracted from the previous multi-level study on FCSWs and analyzed in 2020 to determine whether macro/micro-structural factors were associated with STIs. The prevalence of STIs was 43.6% (95% CI: 39.1%-48). Most (n = 207/495) FCSWs were infected with Syphilis or Hepatitis B, only 1.8% had co-infection, and none was positive for HIV. Multiple logistic regression revealed that 'Individual risk' factors like age (≤18 years, adjusted odds ratio = AOR = .28; 18.1-29.9 years, AOR = .57), years in the sex industry (<1 year AOR = .15; 1-5 years, AOR = .39), and condoms as contraceptives (AOR = 2.7) were significantly associated with STIs. Considering 'High-risk behaviors' like monthly coitus with regular clients (AOR = .33), performing no anal sex ever (AOR = .03), and consistent condom use (AOR = .13) were less likely to be associated with STIs (P<0.05), while the association of ever group sex with STIs reported to double (AOR = 2.1). 'Work environment' like sex on roads/parks/shrines/markets (AOR = 2.6) and ever HIV-testing (AOR = 2.5) were significantly linked with STIs. However, micro-level factors like experiencing forced sex in the past year (AOR = 1.79) and condoms collected from hotel boys (AOR = .34) were significantly associated with STIs in the 'Hierarchical- model' with increasing model-power. 'Micro-structural' determinants predominated over 'Macro/policy-level factors' and profoundly influenced STIs. FCSWs need comprehensive and integrated interventions to promote accurate condom use perception, eliminate risky sexual behaviors, and provide quality reproductive health care. Necessary steps at the policy level are urgently needed to decriminalize commercial sex work.

Determinants of gestational syphilis among women attending prenatal care programs in the Brazilian Amazon

Background

There was a high proportion of pregnant women who were attending prenatal care who were not tested for syphilis or tested but not treated, among priority countries. The coverage for prenatal care visits, syphilis screening, and treatment are priority indicators for monitoring of the elimination of syphilis. The aim was to determine the factors associated with gestational syphilis among postpartum women who were in a prenatal care program in the Brazilian Amazon.

Methods

An unmatched case-control study was conducted at the hospital in Brazil. Data collection was carried out from November 2020 to July 2021 during hospitalization using a pretested structured questionnaire. The criteria for selection of cases and control followed the guidelines established by the Ministry of Health of Brazil; postpartum women with a laboratory diagnosis based on treponemal and/or nontreponemal tests, symptoms of syphilis or asymptomatic, treatment or not treated, and in a prenatal care program. Gestational syphilis cases were identified as women who tested positive for syphilis, and those who tested negative were controls, at minimally one prenatal care visit, childbirth, and/or the puerperium. The sample size encompassed 59 cases and 118 controls (1: 2 ratio of cases to controls). Data were analyzed using Minitab 20^® and BioEstat 5.3^® software. The odds ratio was calculated by multiple logistic regression.

Results

One hundred and seventy-seven postpartum women were included in the study, 59 cases and 118 controls. Among all participants, 95.5% (169) were tested for syphilis in any trimester during pregnancy and at the delivery and 4.5% (8) were tested in the maternity only, at the time childbirth and/or puerperium. The final multiple logistic regression model evidenced that cases had higher odds compared to controls if they had past history of sexually transmitted infections (AOR: 55.4; p: 0.00), difficulty talking about condom use with their sexual partner (AOR: 4.92; p: 0.01), one to six prenatal care visits (AOR: 4.93; p: 0.01), had not received a sexually transmitted infections test result in the maternity hospital (AOR: 4.09; p: 0.04), lower monthly income (AOR: 4.32; p: 0.04), or one to three miscarriages (AOR: 4.34; p: 0.01).

Conclusion

The sociodemographic, programmatic, obstetric, and sexual factors are associated with gestational syphilis among postpartum women.

HIV incidence estimates by sex and age group in the population aged 15 years or over, Brazil, 1986-2018

INTRODUCTION

HIV incidence estimates are essential to monitor the progress of prevention and control interventions.

METHODS

Data collected by Brazilian surveillance systems were used to derive HIV incidence estimates by age group (15-24; 25+) and sex from 1986 to 2018. This study used a back-calculation method based on the first CD4 count among treatment-naïve cases. Incidence estimates for the population aged 15 years or over were compared to Global Burden of Disease Study (GBD) estimates from 2000 to 2018.

RESULTS

Among young men (15-24 years), HIV incidence increased from 6,400 (95% CI: 4,900-8,400), in 2000, to 12,800 (95% CI: 10,800-15,900), in 2015, reaching incidence rates higher than 70/100,000 inhabitants and an annual growth rate of 3.7%. Among young women, HIV incidence decreased from 5,000 (95% CI: 4,200-6,100) to 3,200 (95% CI: 3,000-3,700). Men aged ≥25 years and both female groups showed significant annual decreases in incidence rates from 2000 to 2018. In 2018, the estimated number of new infections was 48,500 (95% CI: 45300-57500), 34,800 (95% CI: 32800-41500) men, 13,600 (95% CI: 12,500-16,000) women. Improvements in the time from infection to diagnosis and in the proportion of cases receiving antiretroviral therapy immediately after diagnosis were found for all groups. Comparison with GBD estimates shows similar rates for men with overlapping confidence intervals. Among women, differences are higher mainly in more recent years.

CONCLUSIONS

The results indicate that efforts to control the HIV epidemic are having an impact. However, there is an urgent need to address the vulnerability of young men.

Usual source of healthcare and use of sexual and reproductive health services by female sex workers in Brazil

The fact of having a usual source of care can improve access to health services and preventive activities. The article aimed to estimate the proportion of factors associated with usual source of care among female sex workers. This was a socio-behavioral survey with 4,328 female sex workers, ≥ 18 years, in 12 Brazilian cities. Female sex workers were recruited by the respondent-driven sampling method (RDS). A descriptive profile was performed of the female sex workers who had usual source of care and the association was analyzed between usual source of care and indicators of access to HIV prevention and reproductive health. As effect measure, the study used adjusted odds ratio (OR) in a logistic regression model. The data were weighted by the RDS-II estimator. 71.5% of the female sex workers reported having a usual source of care, and of these, 54.3% cited primary healthcare (PHC) as their main usual source of care. Among female sex workers 18-24 years of age, there was an association between usual source of care and having a Pap smear test (OR = 2.27; 95%CI: 1.66-3.12), seven or more prenatal visits (OR = 2.56; 95%CI: 1.30-5.03), and the use of a contraceptive method (OR = 1.64; 95%CI: 1.09-2.46). Among female sex workers ≥ 25 years, there was an association between usual source of care and attending talks on sexually transmitted infections (STIs) (OR = 1.45; 95%CI: 1.12-1.89), prior knowledge of post-exposure prophylaxis (OR = 1.32; 95%CI: 1.02-1.71), and history of Pap smear test (OR = 1.92; 95%CI: 1.54-2.40). The study's results showed that female sex workers have PHC as their main usual source of care. usual source of care can also positively impact care and activities in reproductive health and prevention of HIV and STIs in this population group.

Condom use, symptoms of suggestive sexually transmitted infections, and health care seeking among female sex workers in Bangladesh

This article presents a mixed-method cross-sectional study reporting condom use, sexually transmitted infection (STI) symptoms, and care seeking of female sex workers (FSWs) in Dhaka, Bangladesh. A survey of 1228 FSWs, in-depth interviews (n = 24), and key informants' interviews (n = 26) were used for data collection. Among the 1228 FSWs included in this study, 50% of them were illiterate and 39.3% were married, and their mean age was 27.1 years. The consistent use of condoms was reported by 75.6% of the FSWs, 88.7% reported having STI symptoms in the last 6 months, while 91.8% visited one of the drop-in centers for services. FSWs without formal education had lower odds of using condoms consistently (AOR: 0.72; 95% CI: 0.55-0.95), and those working elsewhere than in the streets showed higher odds (AOR: 1.63; 95% CI: 1.23-2.15) to use condoms. Stigma to access health care services, poor knowledge about STI/HIV, and low perceived risk were mentioned as causes of having STI symptoms in the survey as well as in qualitative in-depth interviews. Self-reported condom use, STI symptoms, and care-seeking practices were found to be high among the FSWs. Inconsistent condom use and a high number of sex partners could be the reasons for high levels of STI symptoms. Innovative objectively verifiable approaches should be tested to collect condom use data.

The prevalence and correlates of oral sex among low-tier female sex workers in Zhejiang province, China

Objectives

Oral sex and its associated factors among low-tier female sex workers (FSWs) have not been documented in the Chinese literature. Here, we report this perspective in this group.

Methods

The data were derived from a large cross-sectional study conducted among low-tier FSWs using a structured questionnaire in 21 counties in Zhejiang province, China. The prevalence of oral sex and its associated factors among 2645 low-tier FSWs were analyzed using bivariate and multivariate analysis.

Results

Of all participants, 579 (21.9%) had performed oral sex with clients over the previous month. Multivariate analysis revealed that oral sex is related to being unmarried, low income, early initiation of commercial sex, having conducted commercial sex in more counties, longer duration of commercial sex, larger number of clients, ever having engaged in anal sex, less use of condoms and oral contraceptives during the previous month, low rate of adoption for contraception at the present time, and STI-related symptoms during the previous half year.

Conclusion

Oral sex practitioners among low-tier FSWs in China are at a higher risk of STI, HIV, and unwanted pregnancy compared to those who did not engage in oral sex. Behavioral interventions carried out among low-tier FSWs should specifically target low-tier FSWs who practice oral sex, should carefully take into account the characteristics of these FSWs, provide risk awareness education and training for condom use negotiation, and promote the availability of condom and reproductive health care, timely diagnosis, and treatment of STIs.

Factors associated with knowledge and use of hiv prevention strategies among female sex workers in 12 brazilian cities

This article aims to Identify factors associated with knowledge and use of combined HIV prevention strategies among female sex workers (FSW). Cross-sectional epidemiological study, using the Respondent Driven Sampling (RDS) method. Descriptive analyzes were performed after adjustments required by the RDS method. To investigate factors associated with knowledge of PEP and PrEP and use of the female condom, Poisson regression was applied, using odds ratio as an association measure. FSW not affiliated with NGOs, who did not receive informational material on prevention and / or participated in lectures in the last six months and who do not identify themselves as FSW in healthcare service facilities have less knowledge about PEP and PrEP and use the female condom less frequently. In general, FSW do not have sufficient knowledge and access to combined HIV prevention methods to take advantage of their benefits. We believe that the adoption of different models of care for FSW in partnership with NGOs can be an effective strategy for expanding knowledge and use of HIV prevention methods in Brazil.

Prevalence of syphilis in female sex workers in three countryside cities of the state of Pará, Brazilian Amazon

Background

Syphilis is a sexually transmitted infection (STI) transmitted from person to person mainly by sexual intercourse or through vertical transmission during pregnancy. Female sex workers (FSWs) are exposed especially to syphilis infection, and besides all the efforts to control the spread of STIs, syphilis prevalence is still rising, mainly occurring in low-income countries. This study aimed to investigate the syphilis prevalence, demographic characteristics and sexual habits among FSWs in the Amazon region of Brazil.

Methods

A cross-sectional study was carried out including 184 FSWs from 3 countryside cities of the state of Pará, Amazon region of Brazil. A venereal disease research laboratory test and an indirect immunoenzyme assay to test antibodies against Treponema pallidum were used for screening syphilis infection, while sexual habits and demographic data information were collected through a semi-structured questionnaire. Data was analyzed comparing groups with/without syphilis. Poisson regression models were used to estimate the reasons of prevalence (RP).

Results

The overall prevalence of syphilis was 14.1% (95% CI = 9.8–17.8). FSWs had between 15 and 56 years of age, most were unmarried (65.7%), had attended less than 8 years of formal education (64.1%), had between 10 and 20 partners per week (64.1%), and reported no previous history of STIs (76.1%) and regular use of condom (52.7%). Low level of education attending up to the primary school (RP adjusted = 3.8; 95% CI = 1.4–9.2) and high frequency of anal sex during the past year (RP adjusted = 9.3; 95% CI = 3.5–28.7) were associated with a higher prevalence of syphilis.

Conclusions

A high prevalence of syphilis among FSWs in the Brazilian Amazon region was identified, showing that syphilis is more likely to be transmitted in FSW working in low-income areas, which is attributed to the low level of education. Anal intercourse was found as a risk factor associated with syphilis. Health programs focused on risk populations appear as a rational way to control syphilis spread, which is a rising problem in Brazil and in other several countries.

A More Understanding about AIDS: Design and Assessment of Validity and Reliability of Several New Scales

Introduction: Given the high cost of AIDS, research on high-risk behaviors associated with AIDS is an essential requirement today. Therefore, the present study aimed to construct and standardize tests associated with AIDS-related risky behaviors. Methods: To assess the validity of the questionnaires, the experts' viewpoints from different domains were qualitatively and quantitatively included. Additionally, to assess the reliability of the questionnaires, a sample of 31 subjects was selected and then examined on two separate occasions in a fortnight's time. Then, the validity and reliability of the instruments were assessed in a sample of 475 subjects. Results: The results of exploratory factor analysis showed that for AIDS health literacy and AIDS risk perception questionnaires two factors are extractable; while for the questionnaires of self-efficacy in controlling risk behavior and controlling risk behavior associated with AIDS one factor is extractable. Finally, 14 items were approved for each of the AIDS health literacy and self-efficacy in controlling risk behavior questionnaires; while 13 items were approved for each of the controlling risk behavior associated with AIDS and AIDS risk perception questionnaires. Each of the four questionnaires had a good internal consistency (Cronbach's Alpha > 0.70). Interclass Correlation Coefficient (ICC) amounts related to the test-retest reliability were greater than 0.80, which indicates the reliability of the instruments. Conclusion: According to the results of the present study, it was concluded that all four AIDS-related questionnaires enjoyed acceptable validity and reliability.

Application of the Respondent-Driven Sampling methodology in a biological and behavioral surveillance survey among female sex workers, Brazil, 2016

INTRODUCTION

Respondent-Driven Sampling (RDS) has been used in surveys with key populations at risk of HIV infection, such as female sex workers (FSW). This article describes the application of the RDS method among FSW in 12 Brazilian cities, during a survey carried out in 2016.

METHODOLOGY

A biological and behavioral surveillance study carried out in 12 Brazilian cities, with a minimum sample of 350 FSW in each city. Tests were performed for HIV, syphilis, and hepatitis B and C infections. A social-behavioral questionnaire was also applied.

RESULTS

The sample was comprised of 4,328 FSW. For data analysis, the sample was weighted according to each participant's network size (due consideration to the implications of RDS complex design and to the effects of homophilia are recommended).

DISCUSSION

Although RDS methods for obtaining a statistical sample are based on strong statistical assumptions, allowing for an estimation of statistical parameters, with each new application the method has been rethought. In the analysis of whole-sample data, estimators were robust and compatible with those found in 2009. However, there were significant variations according to each city.

CONCLUSION

The achieved sample size was of great relevance for assessing progress and identifying problems regarding the prevention and treatment of Sexually Transmitted Infections. New RDS studies with more time and operational resources should be envisaged. This could further network development.

HIV testing coverage among female sex workers, Brazil, 2016

INTRODUCTION

Knowing the factors associated with periodic HIV testing among female sex workers (FSW) is essential to expand testing coverage and to broaden programs of treatment as prevention.

METHODS

We used data from 4,328 FSWs recruited by the respondent-driven sampling (RDS) method in 12 Brazilian cities in 2016. Data analysis considered the complex sampling design. The prevalence of HIV testing in the last year and periodic HIV test were estimated. Factors associated with regular HIV testing were identified through logistic regression models.

RESULTS

The testing coverage in the last year was 39.3%. Only 13.5% of FSW reported having performed a periodic HIV test in the last year. Among the factors associated with the higher probability of HIV testing in the last year were a better level of education, living with a partner, working indoors, consistent use of condoms, and regular use of public and private health services stood out.

DISCUSSION

Periodic HIV testing allows early diagnosis and immediate treatment of cases, reducing the chances of spreading the infection to the population. However, factors such as stigma and discrimination hinder the use of regular health services.

CONCLUSION

It is necessary to expand awareness campaigns, especially among FSWs with low educational level and greater vulnerability, in order to broaden the perception of risk and the importance of periodic testing, in addition to encouraging regular health care.

Nonoccupational post-exposure prophylaxis for HIV after sexual intercourse among women in Brazil: Risk profiles and predictors of loss to follow-up

Access to antiretroviral-based HIV prevention has been marked by sex asymmetries, and its effectiveness has been compromised by low clinical follow-up rates. We investigated risk profiles of women who received nonoccupational post-exposure prophylaxis (nPEP), as well as the rates and predictive factors of loss to follow-up after nPEP initiation.Retrospective study evaluating 501 women who received nPEP between 2014 and 2015 at 5 HIV centers (testing centers-VCT, outpatient clinics, and infectious diseases hospital). Risk profiles were drawn based on the characteristics of the women and their sexual partners, and then stratified by sociodemographic indicators and previous use of HIV prevention services. Loss to follow-up (LTFU) was defined as not presenting for follow-up visits or for HIV testing after nPEP initiation. Predictors of LTFU were analyzed by calculating adjusted prevalence ratios (aPRs).Approximately 90% of women had sexual encounters that met the criteria established in the Brazilian guidelines for nPEP. Those who declared to be sex workers (26.5%) or drug users (19.2%) had the highest social vulnerability indicators. In contrast, women who had intercourse with casual partners of unknown HIV risk (42.7%) had higher education and less experience with previous HIV testing (89.3%) or nPEP use (98.6%). Of the women who received nPEP after sexual intercourse with stable partners, 75.8% had HIV-infected partners. LTFU rate was 72.8% and predictors included being Black (aPR = 1.15, 95% confidence interval [CI]: 1.03-1.30), using drugs/alcohol (aPR = 1.15, 95% CI: 1.01-1.32) and having received nPEP at an HIV outpatient clinic (aPR = 1.35, 95% CI: 1.20-1.51) or at an infectious diseases hospital (aPR = 1.37, 95% CI: 1.11-1.69) compared with a VCT. The risk of LTFU declined as age increased (aPR 41-59 years = 0.80, 95% CI: 0.68-0.96).Most women who used nPEP had higher socioeconomic status and were not part of populations most affected by HIV. In contrast, factors that contribute to loss to follow-up were: having increased social vulnerability; increased vulnerability to HIV infection; and seeking nPEP at HIV treatment services as opposed to at a VCT.