A short history of HIV prevention programs for female sex workers in Ghana: lessons learned over 3 decades

The effect on HIV transmission and cost-effectiveness of programmes for female sex workers in East, Central, and Southern Africa: a modelling study

BACKGROUND

HIV prevalence and incidence has declined in East, Central, and Southern Africa (ECSA), but remains high among female sex workers (FSWs). Sex worker programmes have the potential to considerably increase access to HIV testing, prevention, and treatment. We aimed to quantify these improvements by modelling the potential effect of sex worker programmes at two different intensities on HIV incidence and key health outcomes, and assessed the programmes' potential cost-effectiveness in order to help inform HIV policy decisions.

METHODS

Using a model previously used to review policy decisions in ECSA, we assumed a low-intensity sex worker programme had run from 2010 until 2023; this resulted in care disadvantages among FSWs being reduced, and also increased testing, condom use, and willingness to take pre-exposure prophylaxis (PrEP). After 2023, three policy options were considered: discontinuation, continuation, and a scale-up of the programme to high-intensity, which would have a broader reach, and higher influences on condom use, antiretroviral therapy (ART) adherence, testing, and PrEP use. Outputs of the key outcomes (the percentage of FSWs who were diagnosed with HIV, on ART, and virally suppressed; the percentage of FSWs with zero condomless partners, and HIV incidence) were compared in 2030. The maximum cost for a sex worker programme to be cost-effective was calculated over a 50-year time period and in the context of 10 million adults. The cost-effectiveness analysis was conducted from a health-care perspective; costs and disability-adjusted life-years were both discounted to present US$ values at 3% per annum.

FINDINGS

Compared with continuing a low-intensity sex worker programme until 2030, discontinuation of the programme was calculated to result in a lower percentage of FSWs diagnosed (median 88·75% vs 91·37%; median difference compared to continuation of a low-intensity programme [90% range] 2·03 [-4·49 to 10·98]), a lower percentage of those diagnosed currently taking ART (86·35% vs 88·89%; 2·38 [-3·69 to 13·42]), and a lower percentage of FSWs on ART with viral suppression (87·49% vs 88·96%; 1·17 [-6·81 to 11·53]). Discontinuation of a low-intensity programme also resulted in an increase in HIV incidence among FSWs from 5·06 per 100 person-years (100 p-y; 90% range 0·52 to 22·21) to 4·05 per 100 p-y (0·21 to 21·15). Conversely, comparing a high-intensity sex worker programme until 2030 with discontinuation of the programme resulted in a higher percentage of FSWs diagnosed (median 95·81% vs 88·75; median difference compared to discontinuation [90% range] 6·36 [0·60 to 18·63]), on ART (93·93 vs 86.35%; median difference 7·13 [-0·65 to 26·48]), and with viral suppression (93·21% vs 87·49; median difference 7·13 [-0·65 to 26·48]). A high-intensity programme also resulted in HIV incidence in FSWs declining to 2·23 per 100 p-y (0·00 to 14·44), from 5·06 per 100 p-y (0·52 to 22·21) if the programme was discontinued. In the context of 10 million adults over a 50-year time period and a cost-effectiveness threshold of US$500 per disability-adjusted life-year averted, $34 million per year can be spent for a high-intensity programme to be cost-effective.

INTERPRETATION

A sex worker programme, even with low-level interventions, has a positive effect on key outputs for FSWs. A high-intensity programme has a considerably higher effect; HIV incidence among FSW and in the general population can be substantially reduced, and should be considered for implementation by policy makers.

FUNDING

Wellcome Trust.

Screening for Resistant Bacteria, Antimicrobial Resistance Genes, Sexually Transmitted Infections and Schistosoma spp. in Tissue Samples from Predominantly Vaginally Delivered Placentae in Ivory Coast and Ghana

Medical complications during pregnancy have been frequently reported from Western Africa with a particular importance of infectious complications. Placental tissue can either become the target of infectious agents itself, such as, e.g., in the case of urogenital schistosomiasis, or be subjected to contamination with colonizing or infection-associated microorganisms of the cervix or the vagina during vaginal delivery. In the retrospective cross-sectional assessment presented here, the quantitative dimension of infection or colonization with selected resistant or pathogenic bacteria and parasites was regionally assessed. To do so, 274 collected placental tissues from Ivory Coastal and Ghanaian women were subjected to selective growth of resistant bacteria, as well as to molecular screening for beta-lactamase genes, Schistosoma spp. and selected bacterial causative agents of sexually transmitted infections (STI). Panton-Valentine-negative methicillin-resistant Staphylococcus aureus (MRSA) was grown from 1.8% of the tissue samples, comprising the spa types t008 and t688, as well as the newly detected ones, t12101 (n = 2) and t12102. While the culture-based recovery of resistant Enterobacterales and nonfermentative rod-shaped Gram-negative bacteria failed, molecular assessments confirmed beta-lactamase genes in 31.0% of the samples with multiple detections of up to four resistance genes per sample and blaCTX-M, blaIMP, blaGES, blaVIM, blaOXA-58-like, blaNDM, blaOXA-23-like, blaOXA-48-like and blaKPC occurring in descending order of frequency. The beta-lactamase genes blaOXA-40/24-like, blaNMC_A/IMI, blaBIC, blaSME, blaGIM and blaDIM were not detected. DNA of the urogenital schistosomiasis-associated Schistosoma haematobium complex was recorded in 18.6% of the samples, but only a single positive signal for S. mansoni with a high cycle-threshold value in real-time PCR was found. Of note, higher rates of schistosomiasis were observed in Ghana (54.9% vs. 10.3% in Ivory Coast) and Cesarean section was much more frequent in schistosomiasis patients (61.9% vs. 14.8% in women without Schistosoma spp. DNA in the placenta). Nucleic acid sequences of nonlymphogranuloma-venereum-associated Chlamydia trachomatis and of Neisseria gonorrhoeae were recorded in 1.1% and 1.9% of the samples, respectively, while molecular attempts to diagnose Treponema pallidum and Mycoplasma genitalium did not lead to positive results. Molecular detection of Schistosoma spp. or STI-associated pathogens was only exceptionally associated with multiple resistance gene detections in the same sample, suggesting epidemiological distinctness. In conclusion, the assessment confirmed considerable prevalence of urogenital schistosomiasis and resistant bacterial colonization, as well as a regionally expected abundance of STI-associated pathogens. Continuous screening offers seem advisable to minimize the risks for the pregnant women and their newborns.

Characterizing Sociostructural Associations With New HIV Diagnoses Among Female Sex Workers in Cameroon

BACKGROUND

Female sex workers (FSW) are disproportionately affected by HIV in Cameroon, with an estimated 23.6% HIV prevalence. Given the unavailability of HIV incidence data, to better understand associations with acquiring HIV we assessed the prevalence and associations with new HIV diagnoses among FSW in Cameroon.

METHODS

In 2016, FSW were recruited through respondent-driven sampling from 5 cities for a biobehavioral survey. Participants self-reporting living with HIV or with an indeterminate test status were excluded from analysis. New diagnoses were defined as testing HIV-positive when participants self-reported HIV-negative or unknown status. A multivariable modified Poisson regression model was developed to assess determinants of new HIV diagnosis (referent group: HIV-negative) using key covariates; adjusted prevalence ratios (aPR) are reported if statistically significant (P < 0.05).

RESULTS

Overall 2255 FSW were recruited. Excluding participants who self-reported living with HIV (n = 297) and indeterminate test results (n = 7), 260/1951 (13.3%) FSW were newly diagnosed with HIV. Variables significantly associated with new HIV diagnosis were: no secondary/higher education [aPR: 1.56, 95% confidence interval (CI): 1.12 to 2.15], 5+ dependents compared with none (aPR: 2.11, 95% CI: 1.01 to 4.40), 5+ years involved in sex work compared with <1 year (aPR: 2.84, 95% CI: 1.26 to 6.42), history of incarceration (aPR: 2.13, 95% CI: 1.13 to 3.99), and low social capital (aPR: 1.53, 95% CI: 1.12 to 2.10). Higher monthly income (>250,000 FCFA vs. <50,000 FCFA) was associated with lower prevalence of new HIV diagnosis (aPR: 0.22, 95% CI: 0.05 to 0.86).

CONCLUSIONS

There are significant sociostructural factors that seem to potentiate risk of HIV infection and delay diagnosis among FSW in Cameroon. Initiatives to build social capital and integrate services such as pre-exposure prophylaxis and HIV self-testing into HIV programs may reduce new infections and decrease time to diagnosis and treatment.

Love, power, resilience and vulnerability: relationship dynamics between female sex workers in Ghana and their intimate partners

Little is known about female sex workers' daily lives or emotional relationships. Using relational-cultural theory, this study explored the relationship dynamics between sex workers and their intimate partners in Kumasi, Ghana. We collected qualitative data from 37 male intimate partners through 24 in-depth interviews and two focus group discussions (FGDs) with 13 male partners. We also conducted three FGDs with 20 women involved in sex work. Relationships between sex workers and their intimate partners were mutual, reciprocal and transactional. Male partners provided protection for financial support, a place to sleep and intimacy. Both men and women described their relationships in terms of friendship, love and a hopeful future. Women were reluctant to quit sex work because they depended on it for income. Most respondents did not use condoms in these romantic relationships, citing trust, love, faithfulness and commitment. Both men and women described high levels of violence in their relationships. The context of sex work heightens vulnerability but also appears to facilitate resilience and creative coping strategies. The relational dynamics between sex workers and their intimate partners in Ghana merit further exploration to examine the extent to which women involved in sex work hold and exert power within these relationships.

Using qualitative and community-based engagement approaches to gain access and to develop a culturally appropriate STI prevention intervention for foreign female entertainment workers in Singapore

Background

There is an increasing global movement of foreign female entertainment workers (FEWs), a hard-to-reach population vulnerable to HIV/STIs. This paper described the needs assessment phase before intervention implementation where the socio-organisation, sexual risk behaviours and access to health services of foreign FEWs in Singapore were explored. We also highlighted how qualitative inquiry, census enumeration technique and community-based engagement approaches were used to gain access and to develop a culturally appropriate STI prevention intervention.

Methods

In-depth interviews, observations, informal conversational interviews, mystery client and critical incident technique were used. We estimated the size of FEW population using the census enumeration technique. The findings were used to inform intervention development and implementation.

Results

We estimated 376 Vietnamese and 330 Thai FEWs in 2 geographical sites where they operated in Singapore. Their reasons for non-condom use included misconceptions on the transmission and consequences of STI/HIV, low risk perception of contracting HIV/STI from paid/casual partner, lack of skills to negotiate or to persuade partner to use condom, unavailability of condoms in entertainment establishments and fear of the police using condom as circumstantial evidence. They faced difficulties in accessing health services due to fear of identity exposure, stigmatisation, cost and language differences. To develop the intervention, we involved FEWs and peer educators, and ensured that the intervention was non-stigmatising and met their needs. To foster their participation, we used culturally-responsive recruitment strategies, and ensured that the trial was anonymous and acceptable to the FEWs. These strategies were effective as we achieved a participation rate of 90.3%, a follow-up rate of 70.5% for the comparison and 66.8% for the intervention group. The interventions group reported a significant increase in consistent condom use with a reduction in STI incidence compared to no significant change in the comparison group.

Conclusions

The qualitative inquiry approaches to gain access, to foster participation and to develop a culturally appropriate intervention, along with the census enumeration technique application to estimate the FEW population sizes has led to successful intervention implementation as well as safer sexual behaviour and STI incidence reduction.

Trial registration

ClinicalTrials.gov, NCT02780986. Registered 23 May 2016 (retrospectively registered).

Electronic supplementary material

The online version of this article (10.1186/s12992-018-0358-5) contains supplementary material, which is available to authorized users.

Genital Chlamydia trachomatis and Neisseria gonorrhoeae infections among women in sub-Saharan Africa: A structured review

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.

Getting the balance right: Scaling-up treatment and prevention

The goals of the international response to control the HIV epidemic include high antiretroviral therapy (ART) coverage with HIV viral suppression, as well as reduction of new infections. ART use at individual and population levels reduces HIV morbidity and mortality and likely reduces HIV incidence. HIV viral suppression requires high levels of ART adherence, which necessitates support through behavioural and structural interventions to optimise effectiveness of the use of ART for prevention. Many people living with HIV remain unaware that they are HIV-infected, and HIV transmission risk is high during early infection, therefore ART expansion should be accompanied by other interventions in order to achieve the promise of treatment for prevention. Biomedical and behavioural prevention efforts focused on HIV-uninfected individuals at substantial risk of HIV acquisition are also needed to control the epidemic. Maintaining prevention programming is essential during the scale up of ART to reduce HIV transmission.

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.