Association between condom use and use of other contraceptive methods among female sex workers in Swaziland: a relationship-level analysis of condom and contraceptive use

ART coverage and viral suppression among female sex workers living with HIV in eThekwini, South Africa: Baseline findings from the Siyaphambili study

In South Africa >60% of female sex workers (FSW) are living with HIV, the majority of whom are not virally suppressed. Identifying multi-level determinants of viral suppression is central to developing implementation strategies to promote retention in HIV care and viral suppression among FSW with unmet treatment needs. Adult cisgender FSW living with HIV for ≥6 months, conducting sex work as their primary source of income, and residing in Durban (South Africa) were enrolled into the Siyaphambili Study, a sequential multiple assignment randomized trial. Baseline viral load and CD4 were assessed, and an interviewer-administered survey was conducted, capturing socio-demographic, reproductive and sexual history and behaviors, vulnerabilities, substance use, mental health, and stigma. We assessed baseline determinants of viral suppression (<50 copies/mL) using bivariate and multivariable robust poisson regression, considering associations across the individual, network, environmental and macrostructural levels. From June 2018 -March 2020, 1,644 women were screened, with 1,391 eligible FSW living with HIV enrolled. The analyses were conducted among the 1,373 participants with baseline data. Overall, 65% (889/1,373) of participants were reported to be on antiretroviral therapy and 38% (520/1,373) were virally suppressed. In the multivariable model, FSW who experienced a lack of housing in the prior six months were less likely to be virally suppressed (aPR: 0.72, 95%CI 0.56-0.91), while older FSW (aPR: 1.46 95%CI: 1.16-1.83 for 30-39 years old vs. 18-29 years old; aPR: 2.15 95%CI: 1.64-2.80 for 40+ years vs. 18-29 years old) and FSW reporting hormonal or long-acting contraception use were more likely to be virally suppressed (aPR: 1.19 95% CI: 1.00-1.43). We found vulnerability to be high among FSW living with HIV in South Africa and identified individual and structural determinants associated with viral suppression. Taken together these results suggest optimizing HIV treatment outcomes necessitates supporting younger sex workers and addressing housing instability. Trial registration: NCT03500172.

Adjusting for hidden biases in sexual behaviour data: a mechanistic approach

Background

Two required inputs to mathematical models of sexually transmitted infections are the average duration in epidemiological risk states (e.g., selling sex) and the average rates of sexual partnership change. These variables are often only available as aggregate estimates from published cross-sectional studies, and may be subject to distributional, sampling, censoring, and measurement biases.

Methods

We explore adjustments for these biases using aggregate estimates of duration in sex work and numbers of reported sexual partners from a published 2011 survey of female sex worker in Eswatini. We develop adjustments from first principles, and construct Bayesian hierarchical models to reflect our mechanistic assumptions about the bias-generating processes.

Results

We show that different mechanisms of bias for duration in sex work may "cancel out" by acting in opposite directions, but that failure to consider some mechanisms could over- or underestimate duration in sex work by factors approaching 2. We also show that conventional interpretations of sexual partner numbers are biased due to implicit assumptions about partnership duration, but that unbiased estimators of partnership change rate can be defined that explicitly incorporate a given partnership duration. We highlight how the unbiased estimator is most important when the survey recall period and partnership duration are similar in length.

Conclusions

While we explore these bias adjustments using a particular dataset, and in the context of deriving inputs for mathematical modelling, we expect that our approach and insights would be applicable to other datasets and motivations for quantifying sexual behaviour data.

HIV- and sex work-related stigmas and quality of life of female sex workers living with HIV in South Africa: a cross-sectional study

BACKGROUND

Environmental quality of life (QoL) assesses individually perceived factors such as physical safety and security, accessibility, quality of healthcare, and physical environment. These factors are particularly relevant in the context of sex work and HIV, where stigma has been identified as an important barrier across several prevention and treatment domains. This study aims to examine the association between different types of HIV- and sex work-related stigmas and environmental QoL among female sex workers (FSW) living with HIV in Durban, South Africa.

METHODS

We conducted cross-sectional analyses using baseline data from the Siyaphambili randomized controlled trial. FSW who reported sex work as their primary source of income and had been diagnosed with HIV for ≥ 6 months were enrolled from June 2018-March 2020, in eThekwini, South Africa. We evaluated the association between environmental QoL, dichotomizing the environmental domain score collected by the WHO Quality of Life HIV Brief (WHOQOL-HIV BREF) questionnaire at the median, and stigma using modified robust Poisson regression models. Five stigma subscales were assessed: sex work-related (anticipated, enacted, or internalized stigma) and HIV-related (anticipated or enacted stigma).

RESULTS

Among 1373 FSW, the median environmental QoL was 10.5 out of 20 [IQR: 9.0-12.5; range 4.0-19.0], while the median overall QoL was 3 out of 5 [IQR: 2-4; range 1-5]. One-third of FSW (n = 456) fell above the median environmental QoL score, while 67% were above the median overall QoL (n = 917). Reporting anticipated sex work stigma was associated with lower environmental QoL (adjusted prevalence ratio [aPR] 0.74 [95% CI 0.61, 0.90]), as was severe internalized sex work stigma (aPR: 0.64, 95% CI 0.48, 0.86). Reporting enacted HIV stigma versus none was similarly associated with lower environmental QoL (aPR: 0.65, 95% CI 0.49, 0.87). Enacted sex work stigma and anticipated HIV stigma were not statistically associated with environmental QoL.

CONCLUSIONS

This study highlights the need to consider the impact of multiple stigmas on FSW's non-HIV related clinical outcomes, including safety and physical well-being. Moreover, these results suggest that addressing underlying structural risks may support the impact of more proximal HIV prevention and treatment interventions. Trial registration NCT03500172 (April 17, 2018).

Intentional abortion and its associated factors among female sex workers in Iran: Results from national bio-behavioral surveillance-2020

Purpose

In addition to estimating the prevalence of intentional abortion in Iranian female sex workers (FSWs), this study identified related factors using the data of a national study.

Methods

This cross-sectional study utilizes the third round of integrated bio-behavioral surveillance-III data in Iranian FSWs in December 2019 and August 2020, and 1515 Participants were selected in 8 geographically diverse cities in Iran. Logistic regression was performed using unweighted analysis to identify factors associated with intentional abortion. Stata software (version 14), respondent-driven sampling analyses, and R (version 4.1.2) was used for data analysis.

Results

From 1390 participants with valid responses to the abortion question, 598 (37.3%; 95% CI: 32.43, 42.11%) reported intentional abortion during their life. According to the age groups, the highest prevalence of abortion was in the age group of 31 to 40 years (42.60%). In the multivariate logistic regression model, the marital status (divorced women (AOR = 2.05, 95% CI: 1.29, 3.27), concubines (AOR = 1.78, 95% CI: 1.02, 3.11)), work experience in brothels (AOR = 1.39, 95% CI: 1.04, 1.84), the type of sex (AOR = 2.75, 95% CI: 1.35, 5.58), the history of sexual violence (AOR = 1.54, 95% CI: 1.19, 2.01), and alcohol consumption (AOR = 1.53, 95% CI: 1.18, 2.01) were significantly associated with a history of intentional abortion.

Conclusion

Intentional abortion’s prevalence among Iranian FSWs has been much higher than that of the general female population in Iran, which is an alarming issue in the public health of this group and needs more effective interventions. In addition, alcohol consumption, working in a brothel, and being divorced are essential factors in increasing abortions among sex workers.

Intimate Relationships and HIV Infection Risks Among Shan Female Sex Workers From Myanmar in Chiang Mai, Thailand: A Qualitative Study

This study aimed to investigate HIV risks among female sex workers (FSWs) who were from the Shan ethnic group, and how they relate to complex relationships with inconsistent condom use. The study was conducted using in-depth interviews with 17 Shan FSWs (aged 18-45 years old) in Chiang Mai. Intimate relationships between participants and regular clients/steady partners were found to facilitate inconsistent condom use. Participating Shan FSWs sustained intimacy with regular clients not only for economic ends but also for emotional support. Gender norms and male power dominated condom use decision making. Some participants lacked proper HIV preventive knowledge regarding condom breakage and HIV risks. Effective intervention and proper HIV preventive practices should address these intimate contexts. Capacity building among women would assist FSWs to make choices that protect them from HIV/STDs infections. Couples-based HIV interventions addressing emotional intimacy is an urgent need for HIV communication and service delivery in Thailand.

Barriers to condom use among key populations in Namibia

Key populations (KPs), particularly female sex workers (FSWs) and men who have sex with men (MSM), are at increased risk for HIV. Namibia is a global priority for HIV prevention interventions. Marginalized communities must be provided effective and culturally appropriate means to prevent HIV, namely condom use. This cross-sectional analysis of data collected by The Society for Family Health was conducted from 2016 to 2017 in Namibia. Demographics and consistent condom use (CCU) barriers were analyzed among 621 FSWs, MSM, and Other KPs. From the data, 37% FSWs, 24% MSM, and 28% Other KPs were HIV-positive. One-quarter of FSWs and Other KPs reported CCU, while 46% MSM reported CCU. Consistent condom users were more likely to be HIV-negative, have achieved a higher education and use condom-compatible lubricant (CCL). In a multivariate model, higher education, being HIV-negative, and always using CCL remained independent correlates of CCU. Substance use and condom unavailability were the most commonly identified barriers to CCU. FSWs reported client-focused reasons for not using condoms. To the best of our knowledge, this is the first peer-reviewed study assessing condom use behavior and associated factors among FSWs and MSM in Namibia.

Is knowledge of HIV status associated with sexual behaviours? A fixed effects analysis of a female sex worker cohort in urban Uganda

INTRODUCTION

Female sex workers (FSWs) have strong economic incentives for sexual risk-taking behaviour. We test whether knowledge of HIV status affects such behaviours among FSWs.

METHODS

We used longitudinal data from a FSW cohort in urban Uganda, which was formed as part of an HIV self-testing trial with four months of follow-up. Participants reported perceived knowledge of HIV status, number of clients per average working night, and consistent condom use with clients at baseline, one month, and four months. We measured the association between knowledge of HIV status and FSWs' sexual behaviours using linear panel regressions with individual fixed effects, controlling for study round and calendar time.

RESULTS

Most of the 960 participants tested for HIV during the observation period (95%) and experienced a change in knowledge of HIV status (71%). Knowledge of HIV status did not affect participants' number of clients but did affect their consistent condom use. After controlling for individual fixed effects, study round and calendar month, knowledge of HIV-negative status was associated with a significant increase in consistent condom use by 9.5 percentage points (95% CI 5.2 to 13.5, p < 0.001), while knowledge of HIV-positive status was not associated with a significant change in consistent condom use (2.5 percentage points, 95% CI -8.0 to 3.1, p = 0.38).

CONCLUSIONS

In urban Uganda, FSWs engaged in safer sex with clients when they perceived that they themselves were not living with HIV. Even in communities with very high HIV prevalence, the majority of the population will test HIV-negative. Our results thus imply that expansion of HIV testing programmes may serve as a behavioural HIV prevention measure among FSWs.

Consistent condom use among highly effective contraceptive users in an HIV-endemic area in rural Kenya

Background

Women of reproductive age are at the highest risk of both HIV infection and unintended pregnancy in sub-Saharan Africa. Highly effective contraceptives (HECs) such as hormonal injectable and implants are widely used in this region. HECs are effective for preventing pregnancies. However, unlike condoms, HECs offer no protection against HIV. Dual-method use, or the use of condoms with HECs, is an ideal option to reduce HIV risk but is infrequently practiced. Rather, women tend not to use condoms when they use HECs and increase their HIV risk from their sexual partners. However, it remains unknown whether HIV status affects such tendency. Given the increasing popularity of HECs in sub-Saharan Africa, this study examined the association between the use of HECs and condom use among HIV-positive and negative women.

Methods

A cross-sectional study was conducted among 833 sexually active women aged 18–49 years, recruited from six clinics in Siaya county, Kenya. From March to May 2017, female research assistants interviewed the women using a structured questionnaire. Multiple logistic regression analysis was conducted to examine the association between HEC use and consistent condom use in the past 90 days, adjusting for potential confounders. It was also examined with regular partners (husbands or live-in partners) and non-regular partners, separately. In addition, a sub-sample analysis of HIV-negative or unknown women was conducted.

Results

In total, 735 women were available for the analysis. Among the women, 231 (31.4%) were HIV-positive. HIV-positive women were more likely to use HECs than HIV-negative or status unknown women (70.1% vs. 61.7%, p = 0.027). HEC use was significantly associated with decreased condom use with a regular partner (adjusted odds ratio (AOR) = 0.25; 95% CI 0.15–0.43, p<0.001) and a non-regular partner (AOR = 0.25; 95% CI 0.11–0.58, p = 0.001). However, compared with HIV-negative or status unknown women, HIV-positive women were more likely to use HECs and condoms consistently with a regular partner (AOR = 6.54, 95% CI 2.15–20.00, p = 0.001). Other factors significantly associated with consistent condom use included partner’s positive attitude toward contraception, partner’s HIV-positive status, high HIV risk perception, and desire for children in the future.

Conclusion

Dual-method use was limited among HIV-negative women and women who had HIV-negative partners due to inconsistent condom use. The use of HECs was significantly associated with decreased condom use, regardless of partner type and their HIV status. Due to this inverse association, HIV-negative women may increase their HIV risk from their sexual partners. Therefore, interventions should be strengthened to reduce their dual risks of HIV infection and unintended pregnancy by promoting dual-method use. Family planning services should strengthen counseling on the possible risk of HIV infection from their sexual partners and target not only women but also their partners, who may play a key role in condom use.

Development and reliability of metrics to characterize types and sources of stigma among men who have sex with men and female sex workers in Togo and Burkina Faso

Background

Stigma is a multifaceted concept that potentiates Human Immunodeficiency Virus and sexually transmitted infection acquisition and transmission risks among key populations, including men who have sex with men (MSM) and female sex workers (FSW). Despite extensive stigma literature, limited research has characterized the types and sources of stigma reported by key populations in Sub-Saharan Africa.

Methods

This study leveraged data collected from 1356 MSM and 1383 FSW in Togo and Burkina Faso, recruited via respondent-driven sampling. Participants completed a survey instrument including stigma items developed through systematic reviews and synthesis of existing metrics. Using exploratory factor analysis with promax oblique rotation, 16 items were retained in a stigma metric for MSM and 20 in an FSW stigma metric. To assess the measures’ convergent validity, their correlations with expected variables were examined through bivariate logistic regression models.

Results

One factor, experienced stigma, included actions that were carried out by multiple types of perpetrators and included being arrested, verbally harassed, blackmailed, physically abused, tortured, or forced to have sex. Other factors were differentiated by source of stigma including healthcare workers, family and friends, or police. Specifically, stigma from healthcare workers loaded on two factors: experienced healthcare stigma included being denied care, not treated well, or gossiped about by healthcare workers and anticipated healthcare stigma included fear of or avoiding seeking healthcare. Stigma from family and friends included feeling excluded from family gatherings, gossiped about by family, or rejected by friends. Stigma from police included being refused police protection and items related to police confiscation of condoms. The Cronbach’s alpha ranged from 0.71–0.82. Median stigma scores, created for each participant by summing the number of affirmative responses to each stigma item, among MSM were highest in Ouagadougou and among FSW were highest in both Ouagadougou and Bobo-Dioulasso. Validation analyses demonstrated higher stigma was generally significantly associated with suicidal ideation, disclosure of involvement in sex work or same-sex practices, and involvement in organizations for MSM or FSW.

Conclusions

Taken together, these data suggest promising reliability and validity of metrics for measuring stigma affecting MSM and FSW in multiple urban centers across West Africa.

The Prevalence and Correlates of Physical and Sexual Violence Affecting Female Sex Workers in Swaziland

Female sex workers (FSW) have a heightened vulnerability to violence and negative sexual/reproductive health outcomes. Limited research has examined how experiencing physical and sexual violence (PSV) mediates risk for poor health outcomes among FSW in Swaziland. The present analyses aim to contribute to literature linking violence with poor health outcomes, high-risk behaviors, and reduced health service-seeking among FSW. Data were analyzed from a cross-sectional study conducted in Swaziland between July and September 2011 with 325 adult women who reported exchanging sex for money, goods, or favors in the last 12 months, recruited through respondent-driven sampling (RDS). Logistic regression was used to assess the relationship between PSV and ancillary violence/abuse exposures, risk behaviors, and sexual/reproductive and mental health outcomes. PSV was conceptualized as either ever having been beaten up as a result of selling sex or ever being forced to have sex since the age of 18, or both. Prevalence of PSV in this sample was 59.0% in crude estimation, and 48.4% (95% confidence interval [CI]:[39.2,57.6]) with RDS weighting. Separate RDS-weighted estimates of being beaten up as a result of sex work and ever being forced to have sex were 32.4% (95%CI=[24.4,40.4]) and 33.1% (95%CI =[25.0,41.2%]), respectively. Experiencing PSV was associated with being blackmailed (adjusted odds ratio [aOR]= 1.93, 95%CI= [1.07,3.52]), non-injection drug use in the last 12 months (aOR= 1.84, 95%CI= [1.02,3.33]), and feeling afraid to seek health services as a result of selling sex (aOR = 1.74, 95%CI= [1.01,2.99]). Given these findings, violence prevention strategies should be prioritized in programs that address Swazi FSW health, empowerment, and safety.

High pregnancy incidence and low contraceptive use among a prospective cohort of female entertainment and sex workers in Phnom Penh, Cambodia

BACKGROUND

While HIV and unintended pregnancies are both occupational risks faced by female sex workers, the epidemiology of pregnancy and its drivers in this population remains understudied. This includes Cambodia, where the drivers of pregnancy among female entertainment and sex workers (FESW) remain unknown. The current study aimed to examine factors associated with incident pregnancy, as well as describe contraceptive use among FESW in Phnom Penh, Cambodia.

METHODS

This analysis drew from the Young Women's Health Study (YWHS)-2, a 12-month observational cohort of 220 FESW aged 15-29 years, conducted between August 2009 and August 2010. Interviewer-administered questionnaires were conducted at baseline and quarterly thereafter, alongside HIV and pregnancy testing. Bivariate and multivariable extended Cox regression analysis was used to examine correlates of incident pregnancy.

RESULTS

At baseline, 6.8% of participants were pregnant, and only 10.8% reported using hormonal contraceptives, with 11.3% reporting an abortion in the past 3 months. Pregnancy incidence was high, at 22/100 person-years (95% CI: 16.3-30.1). In multivariable analysis, younger age (19-24 years versus 25-29 years) (Adjusted Hazards Ratio (AHR): 2.28; 95% Confidence Interval (CI) 1.22-4.27), lower income (400,000-600,000 Riel (≤150$USD) versus > 600,000 Riel (> 150$USD)) (AHR 2.63; 95% CI 1.02-6.77) positively predicted pregnancy, while higher self-reported condom self-efficacy were associated with reduced pregnancy incidence (AHR 0.89; 95% CI 0.81-0.98).

CONCLUSIONS

Results document high incidence of pregnancy and unmet reproductive health needs among FESWs in Cambodia. Findings point to an urgent need for multi-level interventions, including venue-based HIV/STI and violence prevention interventions, in the context of legal and policy reform. High pregnancy incidence in this population may also undermine recruitment and retention into HIV prevention intervention trials. The exploration of innovative and comprehensive sex worker-tailored sexual and reproductive health service models, also as part of HIV prevention intervention trials, is warranted.

Association between non-barrier modern contraceptive use and condomless sex among HIV-positive female sex workers in Mombasa, Kenya: A prospective cohort analysis

Background

As access to antiretroviral therapy in sub-Saharan Africa continues to expand, more women with HIV can expect to survive through their reproductive years. Modern contraceptives can help women choose the timing and spacing of childbearing. However, concerns remain that women with HIV who use non-barrier forms of modern contraception may engage in more condomless sex because of their decreased risk of unintended pregnancy. We examined whether non-barrier modern contraceptive use by HIV-positive female sex workers was associated with increased frequency of recent condomless sex, measured by detection of prostate-specific antigen (PSA) in vaginal secretions.

Methods

Women who were HIV-positive and reported transactional sex were included in this analysis. Pregnant and post-menopausal follow-up time was excluded, as were visits at which women reported trying to get pregnant. At enrollment and quarterly follow-up visits, a pelvic speculum examination with collection of vaginal secretions was conducted for detection of PSA. In addition, women completed a structured face-to-face interview about their current contraceptive methods and sexual risk behavior at enrollment and monthly follow-up visits. Log-binomial generalized estimating equations regression was used to test for associations between non-barrier modern contraceptive use and detection of PSA in vaginal secretions and self-reported condomless sex. Data from October 2012 through September 2014 were included in this analysis.

Results

Overall, 314 women contributed 1,583 quarterly examination visits. There was minimal difference in PSA detection at contraceptive-exposed versus contraceptive-unexposed visits (adjusted relative risk [aRR] 1.28, 95% confidence interval [95% CI] 0.93–1.76). There was a higher rate of self-reported condomless sex at visits where women reported using modern contraceptives, but this difference was not statistically significant after adjustment for potential confounding factors (aRR 1.59, 95% CI 0.98–2.58).

Conclusion

Non-barrier methods of modern contraception were not associated with increased risk of objective evidence of condomless sex.

Non-barrier contraceptive use and relation to condom use behaviour by partner type among female sex workers in Andhra Pradesh, India

OBJECTIVE

The study assessed non-barrier contraceptive use among female sex workers (FSW) in Andhra Pradesh, India and relation to inconsistent condom use among commercial and non-commercial male sexual partners.

METHODS

FSW at least 18 years of age (n=2338) were recruited through respondent-driven sampling for an HIV risk survey. Analysis was restricted to women of childbearing age (n=2197). Crude and adjusted logistic regression models were used to assess non-barrier contraceptive use and relation to inconsistent condom use with husbands or regular male partners (i.e. non-clients), regular clients and occasional clients.

RESULTS

Non-barrier methods of contraception included contraceptive pills (3.8%) and sterilisation (68.4%). In logistic regression models adjusted for relevant demographics, FSW using contraceptive pills were more likely to report inconsistent condom use with a regular client (past week) [adjusted odds ratio (AOR) 2.2, 95% confidence interval (CI) 1.2-4.0] and with an occasional client (past week) (AOR 2.6, 95% CI 1.6-5.3), as well as accepting more money for sex without a condom (past 30 days) (AOR 2.5, 95% CI 1.5-4.3). No significant associations were found between pill use and inconsistent condom use among women's non-client partners, potentially related to small sample sizes within these subgroups. Reporting sterilisation, which was more common among FSW who were older in age, was not associated with inconsistent condom use with client or non-client sexual partners.

CONCLUSIONS

Findings document potential unmet need for modern, spacing contraceptives (i.e. pill, intrauterine device), but also indicate the importance for family planning services, particularly those promoting modern contraceptive methods to be provided alongside HIV prevention among FSW in Andhra Pradesh, India.

Lifetime Abortion of Female Sex Workers in Iran: Findings of a National Bio-Behavioural Survey In 2010

Introduction

Unintended pregnancies and abortion may be considered as occupational hazards for female sex workers (FSWs). As our understanding of contraceptive and abortion practices of Iranian FSWs is very limited, this study tries to assess the dynamics of contraception and abortion among this sub-population.

Methods

This survey was conducted in 2010, by recruiting 872 FSWs through facility-based sampling from 21 sites in 14 cities in Iran. Data were collected through face-to-face interviews using a pilot-tested standardized risk assessment questionnaire. We applied the logistic regression model to investigate the correlates of induced abortion among FSWs.

Results

Of the 863 participants with valid responses to the abortion variable, 35.3% (95% CI: 32.1–38.6) acknowledged ever induced abortion and the annual rate of abortion was estimated at 20.7 per 1000 women. Around 31.2% of FSWs reported no usual contraceptive use, 32.6% barrier method, 23.6% non-barrier modern contraception methods, and 12.5% dual protection. In our multivariable model, older age (Adjusted Odds Ratio (AOR) = 1.74, 95% Confidence Interval (CI): 1.02, 2.96), group sex (AOR = 1.92, 95% CI: 1.10, 3.35), history of travel for sex work (AOR = 1.55, 95% CI: 1.09, 2.20), sexual violence (AOR = 1.77, 95% CI: 1.25, 2.50), STIs in last year (AOR = 1.53, 95% CI: 1.09, 2.14), and accessing family planning services (AOR = 1.76, 95% CI: 1.24, 2.49) were significant predictors of lifetime abortion.

Conclusions

The reproductive health needs of Iranian FSWs are unmet and around one-third of FSWs reported induced abortion. Scaling-up comprehensive family planning services and empowering FSWs to have safer sex practices may help them to prevent unintended pregnancies and further risk of HIV transmission.

Kenyan female sex workers' use of female-controlled nonbarrier modern contraception: do they use condoms less consistently?

OBJECTIVES

To examine whether nonbarrier modern contraceptive use is associated with less consistent condom use among Kenyan female sex workers (FSWs).

STUDY DESIGN

Researchers recruited 579 FSWs using respondent-driven sampling. We conducted multivariate logistic regression to examine the association between consistent condom use and female-controlled nonbarrier modern contraceptive use.

RESULTS

A total of 98.8% reported using male condoms in the past month, and 64.6% reported using female-controlled nonbarrier modern contraception. In multivariate analysis, female-controlled nonbarrier modern contraceptive use was not associated with decreased condom use with clients or nonpaying partners.

CONCLUSION

Consistency of condom use is not compromised when FSWs use available female-controlled nonbarrier modern contraception.

IMPLICATIONS

FSWs should be encouraged to use condoms consistently, whether or not other methods are used simultaneously.

Implementation and Operational Research: Integration of Family Planning Services in a Peer-Managed HIV Care Clinic Serving Most-at-Risk Populations in Phnom Penh, Cambodia

OBJECTIVE

To assess contraceptive uptake and method choice among women living with HIV (WLHIV) attending an HIV care clinic serving most-at-risk women in Phnom Penh, Cambodia, before and after the implementation of family planning (FP) services.

METHODS

Semistructured questionnaires were administered to clients before (July, 2011) and after (July, 2012) FP service implementation with provision of contraceptive methods (pills, injectables, implants, and intrauterine device [IUD]).

RESULTS

Among 250 and 249 clients interviewed before and after implementation respectively, 24.5% of women reported selling sex for money during the last 6 months before and 35.3% after implementation. Awareness about contraceptive methods significantly increased among clients postimplementation. Among sexually active women, male condom remained the contraceptive method of choice with an overall condom use during the last 6 months at 91% postimplementation vs. 95.6% preimplementation (P = 0.11). Although the use of noncondom FP methods increased but not significantly (16.4% after vs. 12.6% before implementation, P = 0.8), the use of dual method (condom plus another method) remained low and did not significantly increase after implementation (14.8% after vs. 11.0% before, P = 0.28).

CONCLUSIONS

Our results show that FP practices of WLHIV attending an HIV care clinic for most-at-risk populations did not significantly change after integration on-site provision of a wide range of FP methods. Innovative strategies and further research are needed to better understand how to promote the use of noncondom FP methods and prevent unwanted pregnancies and abortions among most-at-risk women and WLHIV.

Advancing the strategic use of HIV operations research to strengthen local policies and programmes: the Research to Prevention Project

In the field of HIV prevention, there is renewed interest in operations research (OR) within an implementation science framework. The ultimate goal of such studies is to generate new knowledge that can inform local programmes and policies, thus improving access, quality, efficiency and effectiveness. Using four case studies from the USAID-funded Research to Prevention (R2P) project, we highlight the strategic use of OR and the impact it can have on shaping the focus and content of HIV prevention programming across geographic and epidemic settings and populations. These case studies, which include experiences from several sub-Saharan African countries and the Caribbean, emphasize four unique ways that R2P projects utilized OR to stimulate change in a given context, including: (1) translating findings from clinical trials to real-world settings; (2) adapting promising structural interventions to a new context; (3) tailoring effective interventions to underserved populations; and (4) prioritizing key populations within a national response to HIV. Carefully crafted OR can bridge the common gap that exists between research-generated knowledge and field-based practice, lead to substantial, real-world changes in national policies and programmes, and strengthen local organizations and the use of data to be more responsive to a given topic or population, ultimately supporting a locally tailored HIV response.

An urgent need for integration of family planning services into HIV care: the high burden of unplanned pregnancy, termination of pregnancy, and limited contraception use among female sex workers in Côte d'Ivoire

BACKGROUND

HIV infection and unintended pregnancy are occupational risks of commercial female sex work (FSW). The burden of unintended pregnancy among FSW including maternal and infant outcomes in the context of HIV is largely unknown.

METHODS

FSW ≥18 years were recruited through respondent driven sampling into a cross-sectional study in Abidjan, Côte d'Ivoire. Participants completed a sociobehavioral questionnaire and HIV counseling and testing. Pregnancy history by HIV status and contraceptive use were described, and Poisson regression used to estimate correlates of termination of pregnancy (TOP).

RESULTS

From March to July 2014, 466 FSW were enrolled. Unintended pregnancy was common, and 64% of participants had ≥1 TOP. Half of FSW experiencing TOPs did so without a medical professional, resulting in frequent complications. Contraceptive use was lowest among younger FSW, and 37% of 20-24 year olds reported multiple TOPs. FSW with a TOP history reported 19% less consistent condom use with clients than women who never had a TOP (adjusted-prevalence ratio, 0.81; 95% confidence interval: 0.74 to 0.88), whereas use of reliable nonbarrier contraceptive methods was comparable between the groups. Although FSW were engaged in HIV testing and prevention services, only 59% of FSW had received HIV testing before childbirth during their last pregnancy, and 30% of HIV-infected FSW had lost ≥1 children.

CONCLUSIONS

Low contraceptive use and high burden of unintended pregnancy result in poor reproductive outcomes for FSW and avoidable mother-to-child HIV transmission risks. Integration of family planning and antenatal services into HIV prevention and care programs accessed by FSW could enhance reproductive outcomes and HIV prevention goals.

Mothers who sell sex: a potential paradigm for integrated HIV, sexual, and reproductive health interventions among women at high risk of HIV in Burkina Faso

BACKGROUND

Antenatal care is a point of entry into the health system for women across Africa and may facilitate the uptake of HIV services among female sex workers (FSWs). This study aimed to evaluate the determinants of motherhood among FSWs, their sexual risks, and their engagement in health care.

METHODS

A cross-sectional study was conducted from January to July 2013 among FSWs in Ouagadougou and Bobo-Dioulasso, Burkina Faso. The study used respondent-driven sampling for HIV testing and behavioral data collection. Predictors of motherhood and the association of motherhood and sex work dynamics were assessed separately using logistic regression.

RESULTS

Of the 696 women enrolled, the majority of participants (76.6%, n = 533) had at least 1 biological child. Mothers were more likely to have a nonpaying partner [adjusted odds ratio (aOR), 1.73; 95% confidence interval (CI): 1.20 to 2.49], and significantly less likely to currently desire to conceive (aOR, 0.21; 95% CI: 0.13 to 0.33). Motherhood was predictive of having reduced condomless vaginal or anal sex with a new client [age-adjusted odds ratio (aaOR), 0.80; 95% CI: 0.65 to 0.97] in the past 30 days, and increased condomless vaginal or anal sex with a nonpaying partner (aaOR, 1.49; 95% CI: 1.13 to 1.96). Motherhood was prognostic of a higher likelihood of ever being tested for HIV (aaOR, 1.89; 95% CI: 1.55 to 2.31). Motherhood was predictive of reporting limited difficulty when accessing health services (aaOR, 0.15; 95% CI: 0.67 to 0.34).

CONCLUSIONS

Motherhood is common among FSWs. The results indicate that FSWs who are mothers may have more exposure to health care because of seeking antenatal/perinatal services, presenting important opportunities for inclusion in the HIV continuum of care and to prevent vertical transmission.

Strategies for recruiting steady male partners of female sex workers for HIV research

Steady male partners of female sex workers (FSW) are a key population for HIV prevention, but researchers face challenges finding and recruiting this population. We conducted 40 in-depth interviews with FSW and steady male partners of FSW in Santo Domingo, Dominican Republic about how to engage steady male partners in HIV research. Participants cautioned that male partners might be unwilling to participate because of discomfort disclosing intimate information and cultural norms of masculinity. They recommended inviting male partners to research offices, instead of venue-based recruitment, because it was more private and trust-promoting. Most participants suggested that FSW could refer their partners or men could refer their friends who have FSW partners. Participants emphasized that referrals could break down trust-related barriers that prevent male partners from participating. Establishing an environment of respect and trust in the research setting can aid referral processes as individuals who participate communicate their positive experiences to their networks.

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

Sex work occurs in many forms and sex workers of all genders have been affected by HIV epidemics worldwide. The determinants of HIV risk associated with sex work occur at several levels, including individual biological and behavioural, dyadic and network, and community and social environmental levels. Evidence indicates that effective HIV prevention packages for sex workers should include combinations of biomedical, behavioural, and structural interventions tailored to local contexts, and be led and implemented by sex worker communities. A model simulation based on the South African heterosexual epidemic suggests that condom promotion and distribution programmes in South Africa have already reduced HIV incidence in sex workers and their clients by more than 70%. Under optimistic model assumptions, oral pre-exposure prophylaxis together with test and treat programmes could further reduce HIV incidence in South African sex workers and their clients by up to 40% over a 10-year period. Combining these biomedical approaches with a prevention package, including behavioural and structural components as part of a community-driven approach, will help to reduce HIV infection in sex workers in different settings worldwide.

Reconceptualizing the HIV epidemiology and prevention needs of Female Sex Workers (FSW) in Swaziland

BACKGROUND

HIV is hyperendemic in Swaziland with a prevalence of over 25% among those between the ages of 15 and 49 years old. The HIV response in Swaziland has traditionally focused on decreasing HIV acquisition and transmission risks in the general population through interventions such as male circumcision, increasing treatment uptake and adherence, and risk-reduction counseling. There is emerging data from Southern Africa that key populations such as female sex workers (FSW) carry a disproportionate burden of HIV even in generalized epidemics such as Swaziland. The burden of HIV and prevention needs among FSW remains unstudied in Swaziland.

METHODS

A respondent-driven-sampling survey was completed between August-October, 2011 of 328 FSW in Swaziland. Each participant completed a structured survey instrument and biological HIV and syphilis testing according to Swazi Guidelines.

RESULTS

Unadjusted HIV prevalence was 70.3% (n = 223/317) among a sample of women predominantly from Swaziland (95.2%, n = 300/316) with a mean age of 21(median 25) which was significantly higher than the general population of women. Approximately one-half of the FSW(53.4%, n = 167/313) had received HIV prevention information related to sex work in the previous year, and about one-in-ten had been part of a previous research project(n = 38/313). Rape was common with nearly 40% (n = 123/314) reporting at least one rape; 17.4% (n = 23/314)reported being raped 6 or more times. Reporting blackmail (34.8%, n = 113/314) and torture(53.2%, n = 173/314) was prevalent.

CONCLUSIONS

While Swaziland has a highly generalized HIV epidemic, reconceptualizing the needs of key populations such as FSW suggests that these women represent a distinct population with specific vulnerabilities and a high burden of HIV compared to other women. These women are understudied and underserved resulting in a limited characterization of their HIV prevention, treatment, and care needs and only sparse specific and competent programming. FSW are an important population for further investigation and rapid scale-up of combination HIV prevention including biomedical, behavioral, and structural interventions.

"There is hunger in my community": a qualitative study of food security as a cyclical force in sex work in Swaziland

BACKGROUND

Swaziland has the highest HIV prevalence in the world - 32% of adults are currently living with HIV - and many Swazis are chronically food insecure - in 2011 one in four Swazis required food aid from the World Food Programme. In southern Africa, food insecurity has been linked to high-risk sexual behaviors, difficulty with antiretroviral therapy (ART) adherence, higher rates of mother-to-child HIV transmission, and more rapid HIV progression. Sex workers in Swaziland are a population that is most at risk of HIV. Little is known about the context and needs of sex workers in Swaziland who are living with HIV, nor how food insecurity may affect these needs.

METHODS

In-depth interviews were conducted with 20 female sex workers who are living with HIV in Swaziland. Interviews took place in four different regions of the country, and were designed to learn about context, experiences, and health service needs of Swazi sex workers.

RESULTS

Hunger was a major and consistent theme in our informants' lives. Women cited their own hunger or that of their children as the impetus to begin sex work, and as a primary motivation to continue to sell sex. Informants used good nutrition and the ability to access "healthy" foods as a strategy to manage their HIV infection. Informants discussed difficulty in adhering to ART when faced with the prospect of taking pills on an empty stomach. Across interviews, discussions of CD4 counts and ART adherence intertwined with discussions of poverty, hunger and healthy foods. Some sex workers felt that they had greater trouble accessing food through social networks as result of both their HIV status and profession.

CONCLUSIONS

Informants described a risk cycle of hunger, sex work, and HIV infection. The two latter drive an increased need for 'healthy foods' and an alienation from social networks that offer material and emotional support against hunger. Services and interventions for sex workers which address the pathways through which food insecurity generates vulnerability to HIV and social marginalization, build sex workers collective efficacy to mobilize, consider poverty alleviation, and address social and policy level changes are necessary and likely to have the greatest success.

A cross-sectional evaluation of the prevalence and associations of HIV among female sex workers in the Gambia

To determine HIV prevalence among female sex workers in the Gambia and HIV risk factors, we accrued participants (n = 251) through peer-referral and venue-based recruitment. Blood samples were screened for HIV and participants were administered a questionnaire. Bivariate and multivariate logistic regression identified factors associated with HIV status. Forty respondents (15.9%) were HIV-positive: 20 (8.0%) were infected with HIV-1 only, 10 (4.0%) with HIV-2 only, and 10 (4.0%) with both HIV-1 and HIV-2; 12.5% (n = 5/40) knew their status. Condom usage at last sex was 97.1% (n = 170/175) with new clients and 44.2% (n = 53/120) with non-paying partners. Having a non-paying partner, living with relatives or friends, having felt scared to walk in public, selling sex in multiple locations, and recent depressive symptoms were positively associated with HIV under multivariate regression. Female sex workers have a higher prevalence of HIV compared to the general Gambian population. Interventions should be rights-based, promote safer sex practices and regular testing for female sex workers and linkage to HIV treatment and care with adherence support for those living with HIV. In addition, service providers should consider non-paying partners of female sex workers, improve knowledge and availability of condoms and lubricant, and address safety and mental health needs.