West African female sex workers in Mali: reduction in HIV prevalence and differences in risk profiles of sex workers of differing nationalities of origin

The impact of past HIV interventions and diagnosis gaps on new HIV acquisitions, transmissions, and HIV-related deaths in Côte d'Ivoire, Mali, and Senegal

OBJECTIVES

To estimate the epidemiological impact of past HIV interventions and the magnitude and contribution of undiagnosed HIV among different risk groups on new HIV acquisitions in Côte d'Ivoire, Mali and Senegal.

DESIGN

HIV transmission dynamic models among the overall population and key populations [female sex workers (FSW), their clients, and MSM].

METHODS

Models were independently parameterized and calibrated for each set of country-specific demographic, behavioural, and epidemiological data. We estimated the fraction of new HIV infections over 2012-2021 averted by condom use and antiretroviral therapy (ART) uptake among key populations and non-key populations, the direct and indirect contribution of specific groups to new infections [transmission population-attributable fraction (tPAF)] over 2012-2021 due to prevention gaps, and the distribution of undiagnosed people with HIV (PWH) by risk group in January 2022 and their tPAF over 2022-2031.

RESULTS

Condom use and ART may have averted 81-88% of new HIV infections over 2012-2021 across countries, mostly due to condom use by key population. The tPAF of all key populations combined over 2012-2021 varied between 27% (Côte d'Ivoire) and 79% (Senegal). Male key populations (clients of FSW and MSM) contributed most to new infections (>60% in Mali and Senegal) owing to their higher HIV prevalence and larger prevention gaps. In 2022, men represented 56% of all PWH with an undiagnosed infection in Côte d'Ivoire (male key populations = 15%), 46% in Mali (male key populations = 23%), and 69% in Senegal (male key populations = 55%). If HIV testing and ART initiation rates remain at current levels, 20% of new HIV infections could be due to undiagnosed key populations living with HIV in Côte d'Ivoire over 2022-2031, 53% in Mali, and 65% in Senegal.

CONCLUSION

Substantial HIV diagnosis gaps remain in Western Africa, especially among male key populations. Addressing these gaps is key to impacting the HIV epidemics in the region and achieving the goal of ending AIDS by 2030.

Mobility and HIV care engagement: a research agenda

INTRODUCTION

Mobility is common and an essential livelihood strategy in sub-Saharan Africa (SSA). Mobile people suffer worse outcomes at every stage of the HIV care cascade compared to non-mobile populations. Definitions of mobility vary widely, and research on the role of temporary mobility (as opposed to permanent migration) in HIV treatment outcomes is often lacking. In this article, we review the current landscape of mobility and HIV care research to identify what is already known, gaps in the literature, and recommendations for future research.

DISCUSSION

Mobility in SSA is closely linked to income generation, though caregiving, climate change and violence also contribute to the need to move. Mobility is likely to increase in the coming decades, both due to permanent migration and increased temporary mobility, which is likely much more common. We outline three central questions regarding mobility and HIV treatment outcomes in SSA. First, it is unclear what aspects of mobility matter most for HIV care outcomes and if high-risk mobility can be identified or predicted, which is necessary to facilitate targeted interventions for mobile populations. Second, it is unclear what groups are most vulnerable to mobility-associated treatment interruption and other adverse outcomes. And third, it is unclear what interventions can improve HIV treatment outcomes for mobile populations.

CONCLUSIONS

Mobility is essential for people living with HIV in SSA. HIV treatment programmes and broader health systems must understand and adapt to human mobility, both to promote the rights and welfare of mobile people and to end the HIV pandemic.

Structural determinants of HIV/STI prevalence, HIV/STI/sexual and reproductive health access, and condom use among immigrant sex workers globally

OBJECTIVE

Given stark health inequities among precarious and criminalized workers, we aimed to apply a structural determinants framework to systematically review evidence on HIV/sexually transmitted infection (STI) prevalence, access to HIV/STI/SRH services, and condom use among im/migrant sex workers (ISWs) globally.

METHODS

Systematic search of peer-reviewed studies published in English (2009-2019). Eligible studies reported HIV/STI, access to HIV/STI/SRH services, and/or condom use outcomes and/or lived experiences among ISWs. Quantitative and qualitative data were synthesized using a structural determinants framework.

RESULTS

Of 425 studies screened, 29 studies from 15 countries were included. HIV prevalence ranged from 0.3 to 13.6% and varied across settings, with highest prevalence among undocumented ISWs in a high-income country (Portugal). Precarious immigration status was a structural factor associated with poorer HIV/STI outcomes, whereas qualitative narratives showed ISWs' lived experiences as strongly shaped by policing and stigma. Despite disparities, in some settings, HIV and STI prevalence were lower and odds of condom use with clients were higher among ISWs relative to non-im/migrant sex workers. This review identified a paucity of research on SRH and male and gender-diverse ISWs. Across legislative settings, criminalization of SW and im/migrant status, policing, and migration-related marginalization were prominent structural barriers to ISWs' HIV/STI/SRH access.

CONCLUSION

This review identified important inequities and variation in HIV/STI prevalence among ISWs globally. Our findings highlight impacts of the intersections of migration and criminalization, and suggest a need to reform criminalized sex work laws; address punitive policing and immigration enforcement; enable safer indoor work environments; and expand community-based interventions towards promoting HIV/STI/SRH access and health equity among ISWs.

Lack of full citizenship rights linked to heightened client condom refusal among im/migrant sex workers in Metro Vancouver (2010-2018)

In Canada, im/migrant sex workers face stigma, health access barriers, and overlapping marginalisation, with end-demand law reforms in 2014 postulated to exacerbate these inequities. Yet, little quantitative evidence on how immigration status shapes HIV/STI risk exists. Drawing on community-based longitudinal cohort data (AESHA, 2010-2018), we used multivariable confounder models with logistic regression to model (1) the independent effect of precarious immigration status (any status revocable under criminal charges: permanent residency/temporary residency/undocumented) on client condom refusal, and (2) the moderating effect of precarious status on the relationship between condom refusal and exposure to end-demand law reform (2015-2018). Over this 8-year study involving 758 sex workers in Metro Vancouver, 16.0% were im/migrants, of whom 57% had precarious immigration status at baseline. 16.5% of participants experienced client condom refusal. Precarious immigration was associated with increased odds of facing condom refusal (adjusted odds ratio [AOR] 2.53, 95% confidence interval [CI] 1.37-4.68), and these odds were heightened post-end-demand law reforms (AOR 4.35, 95%CI 1.21-15.66). Our findings suggest that lack of citizenship rights may enhance barriers to safer sex negotiation and increase HIV/STI risk among sex workers, highlighting the need for sex work and immigration policy reforms.

Impact of time perspectives on texting intervention to reduce HIV/STI transmission among female sex workers in Tijuana and Ciudad Juarez, Mexico

Text messages may sustain post-counseling gains in behavioral improvements and reduce HIV/STI incidence. However, their effectiveness may depend on the messages' time perspective and characteristics of the individual. We evaluated the impact of time perspective on a text messaging intervention designed to maintain improvements in safer sex practices among drug-using and non-drug-using female sex workers (FSWs) in Tijuana (n = 141) and Cd. Juarez (n = 129), Mexico. FSWs received the efficacious Mujer Segura intervention, and were randomized to receive safer sex maintenance text messages with either a short-term or future-oriented time perspective. The outcome was HIV/STI incidence rate over 6-month follow-up. In Tijuana, combined HIV/STI incidence density was lower among FSWs in the FUTURE group (31.67 per 100 py) compared to women in the SHORT-TERM group (62.40 per 100 py). Conversely, in Cd. Juarez, HIV/STI incidence density was lower (although non-significant) among FSWs in the SHORT-TERM group (19.80 per 100 py) compared to those in the FUTURE group (35.05 per 100 py). These findings suggest that future-oriented text messages may sustain post-counseling improvements in sexual risk behavior among FSWs, but findings may vary by FSWs' characteristics (e.g., drug use), and by region and context.

War-Related Abduction and History of Incarceration Linked to High Burden of HIV Among Female Sex Workers in Conflict-Affected Northern Uganda

OBJECTIVE

Sex workers (SWs) in sub-Saharan Africa face a disproportionate HIV burden and growing concerns of severe human rights violations. Given the dearth of evidence on the burden and correlates of HIV among SWs in sub-Saharan Africa, particularly within conflict-affected settings, we examined the relationship between structural determinants (eg, war-related abduction, incarceration) and HIV infection among conflict-affected SWs in Northern Uganda.

DESIGN

Cross-sectional community-based research study among female SWs in conflict-affected Gulu, Northern Uganda.

METHODS

Interview questionnaires and voluntary HIV testing were conducted with participants recruited through SW/peer-led outreach and time-location sampling from 2011 to 2012. HIV prevalence was calculated, and bivariable and multivariable logistic regression was used to identify independent associations with HIV seroprevalence.

RESULTS

Of 400 SWs, 135 (33.75%) were HIV seropositive; of whom one-third were new/previously undiagnosed HIV infections. In multivariable analysis, after adjusting for age of sex work entry and education, lifetime incarceration (adjusted odds ratio: 1.93, 95% confidence interval: 1.17 to -3.20) was independently associated with HIV seroprevalence, and history of wartime abduction (adjusted odds ratio: 1.62, 95% confidence interval: 1.00 to 2.63) was marginally associated (P = 0.051).

CONCLUSIONS

This study documented a high rate of undiagnosed HIV infections and associations between war-related human rights violations, incarceration, and a heavy HIV burden among SWs in conflict-affected Northern Uganda. These findings highlight the serious harms of conflict and criminalization of marginalized women in sub-Saharan African contexts. SW-led interventions that address conflict experiences and policy shifts to promote a rights-based approach to HIV prevention and care remain critically needed.

Scaling-up HIV responses with key populations in West Africa

BACKGROUND

Despite decades of HIV responses in pockets of West and Central Africa (WCA), the HIV response with key populations remains an understudied area. Recently, there has been a proliferation of studies highlighting epidemiologic and behavioral data that challenge attitudes of complacency among donors and country governments uncomfortable in addressing key populations.

METHODS

The articles in this series highlight new studies that provide a better understanding of the epidemiologic and structural burden facing key populations in the WCA region and how to improve responses through more effective targeting.

RESULTS

Key populations face pervasive structural barriers including institutional and sexual violence and an intersection of stigma, criminalization, and marginalization as sexual minorities. Despite decades of smaller interventions that have shown the importance of integrated services for key populations, there remains incongruent provision of outreach or testing or family planning pointing to sustained risk. There remains an incongruent resource provision for key populations where they shoulder the burden of HIV and their access to services alone could turn around HIV epidemics within the region.

CONCLUSIONS

These proximal and distal determinants must be addressed in regional efforts, led by the community, and resourced for scale, targeting those most at risk for the acquisition and transmission of HIV. This special issue builds the knowledge base for the region focusing on interventions that remove barriers to service access including treatment uptake for those living with HIV. Better analysis and use of data for strategic planning are shown to lead to more effective targeting of prevention, care, and HIV treatment programs with key populations. These articles further demonstrate the immediate need for comprehensive action to address HIV among key populations throughout the WCA region.