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

Acceptability, feasibility and potential of an intervention using secret Facebook groups to complement existing HIV prevention strategies among female sex workers in Cameroon, a randomized pilot study

This randomized pilot project evaluated an intervention promoting health care literacy around HIV, pre-exposure prophylaxis (PrEP), and stigma reduction using private social media groups that complemented existing HIV prevention services among female sex workers (FSWs) in Cameroon. The intervention was 12 HIV and sexual health videos tailored to FSWs that were released over 8 weeks through a secret Facebook group platform. In-person surveys were administered before, after the intervention, and three months later. No HIV seroconversions were detected; all participants completed follow-up and agreed to recommend the intervention to a coworker. Although the intervention was assessed to be acceptable and feasible to implement, poor internet connectivity was a key barrier. In time-series analysis, the intervention group participants reported improved PrEP interest, PrEP knowledge, and condom use along with reduced PrEP and HIV-related stigma, but no impact on sex-work related stigma or social cohesion. Similar results occurred in the control group. Cross-contamination and small pilot study size might have hindered the ability to detect the differential impact of this intervention. As communications technology increases in Cameroon, it is essential to learn more about FSWs preferences on the use of social media platforms for HIV prevention strategies.

The epidemiology of HIV infection among female sex workers in Nairobi, Kenya: A structural determinants and life-course perspective

High HIV prevalence among female sex workers (FSWs) is heavily influenced by structural determinants (e.g. criminalisation of sex work; violence) and significant life events (e.g. orphanhood, teenage pregnancy). This study aims to understand the epidemiology of HIV among FSWs in Nairobi, Kenya using a structural determinants and life-course perspective. Baseline cross-sectional survey data were collected June-December 2019 for the Maisha Fiti study with 1003 FSWs (aged 18-45 years). Odds ratios and 95% confidence intervals were estimated using multivariable logistic regression with a hierarchical modelling approach. HIV prevalence was 28.0%, and increased with age (<25 years 5.7%, 25-34 years 19.0%, ≥35 years 40.6%). In adjusted analyses, HIV seroprevalence was associated with childhood and adolescence including violence from militia or soldiers (AOR = 1.60; 95%CI:1.00-2.53), young age at sexual debut (≤15 years old vs. ≥18 years AOR = 0.57; 95%CI:0.39-0.84) and teenage pregnancy (AOR = 1.37; 95%CI:1.00-1.88). For adulthood the factors included lower SES score (lowest vs. highest tertile AOR = 0.63; 95%CI:0.40-0.98); reduced housing insecurity (AOR = 0.52; 95%CI:0.54-0.79); lower alcohol/drug use score (AOR = 0.44; 95%CI:0.31-0.61); and a longer duration of selling sex (0-5 years vs. ≥11 years AOR = 2.35; 95%CI:1.44-3.82). Among HIV-negative FSWs, prevalence of HIV risk factors was high (recent hunger 32.3%; internalised 67.7% and experienced 66.0% sex work stigma; recent police arrest 30.1%; recent physical or sexual violence 65.6%, condomless last sex intimate partner 71.1%; harmful alcohol or substance use 49.1%). Only 24.6% of HIV-negative FSWs reported taking PrEP. Taken together, adverse events in childhood and adolescence were associated with increased odds of living with HIV, and were more strongly associated with HIV serostatus than adulthood structural or behavioural risk factors. HIV-negative FSWs remain at high risk of HIV acquisition. This study highlights the importance of addressing adverse events throughout the life course to reduce HIV risk, and the need to continue multi-level HIV prevention and treatment efforts.

HIV prevalence and risk behaviors among female sex workers in Togo in 2017: a cross-sectional national study

Background

The HIV epidemic remains an important public health challenge for the sub-Saharan region. Female Sex Workers (FSW) in this region are among the most vulnerable of the key population groups with HIV prevalence as high as twice that of the general population. The aim of this study was to estimate HIV prevalence and explore sexual risk behaviors among FSW in Togo.

Methods

A cross-sectional study using a Respondent Driven Sampling method was conducted across the six regions of country among FSW in 2017. A comprehensive questionnaire was used to explore socio-demographic characteristics, sexual history, HIV knowledge, and sexual behaviors. HIV rapid tests were used to assess HIV infection.

Results

A total of 1,036 FSW, with a median age of 26 years old [interquartile range (IQR): 22–33], participated in the study, with 49.2% (n = 510) of them having reached secondary school. Median age at first sexual intercourse was 20 years old [IQR: 17–25] and estimated number of clients per week was of 5 [IQR: 3–10]. A total of 936 (95.6%) reported the use of a condom during last sexual intercourse with a client and 493 (47.6%) reported the use of a condom during their last sexual intercourse with a partner or husband. HIV prevalence was 13.2% [95% CI: 11.2 – 15.4], and was associated with age (being between 26 and 32 years old; aOR = 4.5; 95% CI: [2.4 – 9.1], p < 0.0001) and ≥ 33 years old; aOR = 6.4; 95% CI [3.5 – 12.7], p < 0.0001), education level (being in primary school or less; aOR = 1.7; 95% CI: [1.1–2.6]; p = 0.012) and the number of partners per week (more than 2 and 3 partners; aOR = 2.5; 95% CI [1.2—5.2]; p = 0.014).

Conclusions

HIV prevalence and sexual risk behaviors remain high among FSW in Togo, despite prevention efforts aimed at curbing this trend. Other factors, such as access and availability of condoms, the social and legal environment in which FSW operate, should be considered for HIV prevention strategies in this population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13690-022-00851-0.

High HIV Prevalence and Low HIV-Service Engagement Among Young Women Who Sell Sex: A Pooled Analysis Across 9 Sub-Saharan African Countries

BACKGROUND

Epidemiological data are needed to characterize the age-specific HIV burden and engagement in HIV services among young, marginalized women in sub-Saharan Africa.

SETTING

Women aged ≥18 years who reported selling sex were recruited across 9 countries in Southern, Central, and West Africa through respondent driven sampling (N = 6592).

METHODS

Individual-level data were pooled and age-specific HIV prevalence and antiretroviral therapy (ART) coverage were estimated for each region using generalized linear mixed models. HIV-service engagement outcomes (prior HIV testing, HIV status awareness, and ART use) were compared among women living with HIV across age strata (18-19, 20-24, and ≥25 years) using generalized estimating equations.

RESULTS

By age 18%-19%, 45.4% [95% confidence interval (CI): 37.9 to 53.0], 5.8% (95% CI: 4.3 to 7.8), and 4.0% (95% CI: 2.9 to 5.4) of young women who sell sex were living with HIV in Southern, Central, and West Africa respectively. Prevalence sharply increased during early adulthood in all regions, but ART coverage was suboptimal across age groups. Compared with adult women ≥25, young women aged 18-19 were less likely to have previously tested for HIV [prevalence ratio (PR) 0.76; 95% CI: 0.72 to 0.80], less likely to already be aware of their HIV status (PR 0.48; 95% CI: 0.35 to 0.64), and less likely to be taking ART (PR 0.67; 95% CI: 0.59 to 0.75).

CONCLUSIONS

HIV prevalence was already high by age 18-19 in this pooled analysis, demonstrating the need for prevention efforts that reach women who sell sex early in their adolescence. ART coverage remained low, with women in the youngest age group the least engaged in HIV-related services. Addressing barriers to HIV service delivery among young women who sell sex is central to a comprehensive HIV response.

Unmet Need for Family Planning and Experience of Unintended Pregnancy Among Female Sex Workers in Urban Cameroon: Results From a National Cross-Sectional Study

Female sex workers (FSWs) in Cameroon have unmet need for effective contraception, and experience of unintended pregnancy and pregnancy termination is common. Reducing barriers to accessing high-quality, voluntary family planning services in FSW-focused community services is a key strategy to promote client-centered care, promote informed choice, reduce unintended pregnancies, and improve quality of life for FSWs.

Background:

Female sex workers (FSWs) in Cameroon commonly have unmet need for contraception posing a high risk of unintended pregnancy. Unintended pregnancy leads to a range of outcomes, and due to legal restrictions, FSWs often seek unsafe abortions. Aside from the high burden of HIV, little is known about the broader sexual and reproductive health of FSWs in Cameroon.

Methods:

From December 2015 to October 2016, we recruited FSWs aged ≥18 years through respondent-driven sampling across 5 Cameroonian cities. Cross-sectional data were collected through a behavioral questionnaire. Modified-robust Poisson regression was used to approximate adjusted prevalence ratios (aPR) for TOP and current use of effective nonbarrier contraception.

Results:

Among 2,255 FSWs (median age 28 years), 57.6% reported history of unintended pregnancy and 40.0% reported prior TOP. In multivariable analysis, TOP history was associated with current nonbarrier contraceptive use (aPR=1.23, 95% confidence interval [CI]=1.07, 1.42); ever using emergency contraception (aPR=1.34, 95% CI=1.17, 1.55); >60 clients in the past month (aPR=1.29, 95% CI= 1.07, 1.54) compared to ≤30; inconsistent condom use with clients (aPR=1.17, 95% CI=1.00, 1.37); ever experiencing physical violence (aPR=1.24, 95% CI=1.09, 1.42); and older age. Most (76.5%) women used male condoms for contraception, but only 33.2% reported consistent condom use with all partners. Overall, 26.4% of women reported currently using a nonbarrier contraceptive method, and 6.2% reported using a long-acting method. Previous TOP (aPR=1.41, 95%CI=1.16, 1.72) and ever using emergency contraception (aPR=2.70, 95% CI=2.23, 3.26) were associated with higher nonbarrier contraceptive use. Recent receipt of HIV information (aPR=0.72, 95% CI=0.59, 0.89) and membership in an FSW community-based organization (aPR=0.73, 95% CI=0.57, 0.92) were associated with lower use nonbarrier contraceptive use.

Conclusions:

Experience of unintended pregnancies and TOP is common among FSWs in Cameroon. Given the low use of nonbarrier contraceptive methods and inconsistent condom use, FSWs are at risk of repeat unintended pregnancies. Improved integration of client-centered, voluntary family planning within community-led HIV services may better support the sexual and reproductive health and human rights of FSWs consistent with the United Nations Declaration of Human Rights.

Factors associated with alcohol use before sex among HIV-negative female sex workers in Zambia

Female sex workers (FSWs) are at high risk of HIV infection. Alcohol use prior to sex can compound this risk. We investigated the factors associated with having sex under the influence of alcohol among Zambian FSWs. Community health workers and peer FSWs recruited 331 HIV-negative FSWs in Lusaka and Ndola. In a cross-sectional survey, we asked FSWs how often they had sex under the influence of alcohol in the previous month and categorised responses as ‘always’ and ‘not always’. The adjusted odds ratios (AORs) of always having sex under the influence of alcohol were higher among FSWs who charged clients medium (AOR: 2.20, 95% confidence interval [CI]: 1.04–4.68) and low fees (AOR: 2.65, 95% CI: 1.26–5.60) for sex versus high fees; received 9–19 (AOR: 2.37, 95% CI: 1.15–4.91) and 20 or more clients per month (AOR: 3.06, 95% CI: 1.47–6.37) versus up to 8 clients per month; and never used condoms versus always used condoms with clients (AOR: 4.21, 95% CI: 1.53–11.55). FSWs who always used alcohol before sex appeared more likely to engage in riskier sex and charge clients lower fees. Interventions for financial empowerment and alcohol risk reduction should complement existing HIV prevention interventions for FSWs.

Characterising unmet HIV prevention and treatment needs among young female sex workers and young men who have sex with men in Cameroon: a cross-sectional analysis

BACKGROUND

In Cameroon, female sex workers (FSWs) and men who have sex with men (MSM) carry disproportionately high burdens of HIV. Despite specific vulnerabilities and health needs, young key populations remain understudied and underserved in Cameroon owing to legal, ethical, and social challenges. We aimed to assess and compare HIV-related behavioural and structural risks and coverage of HIV prevention and treatment services between young and older key populations to inform implementation strategies.

METHODS

FSWs and MSM aged 18 years or older were recruited through respondent-driven-sampling for a biobehavioural survey carried out in five Cameroonian cities. Prevalence of HIV, risk, stigma, and health service engagement were compared between young (18-24 years) and older (≥25 years) key populations. Multivariable Poisson regression models, disaggregated by key population, were constructed to estimate prevalence ratios (PR) by age group for HIV service engagement.

FINDINGS

Participants were recruited between Nov 30, 2015, and Oct 12, 2016. Among FSWs, 724 (32%) of 2255 were aged 18-24 years, and median age of first transactional or compensated sex was 22 years (IQR 19-28). Among MSM, 840 (63%) of 1323 were aged 18-24 years, and median age of first anal sex was 18 years (IQR 17-21). RDS-adjusted HIV prevalence was 8·5% (95% CI 4·7-15·2) among young FSWs and 12·9% (9·5-18·2) among young MSM. HIV viral suppression (<1000 copies per mL) was evident in 24 (43%) of 56 young and 292 (61%) of 479 older FSWs (p=0·0091) and 40 (34%) of 119 of young and 64 (42%) of 153 older MSM (p=0·17). Young FSWs were less likely than older FSWs to report recent peer education (PR 0·65, 95% CI 0·48-0·88), or membership of an FSW community-based organisation (PR 0·69, 0·55-0·86) and were more likely to report untreated sexually transmitted infection symptoms in the past year (PR 1·29, 1·03-1·61). Young MSM were less likely than older MSM to report an HIV test in the past year (PR 0·88, 0·78-0·98), recent peer education (PR 0·77, 0·62-0·95) and receipt of free condoms (PR 0·77, 0·67-0·89). By key population, condom use and recent experiences of stigma and violence were similar between age groups (p>0·05).

INTERPRETATION

Young key populations have similar behavioural and structural risks to older populations but have lower coverage of HIV preventive and treatment services. Achieving an AIDS-free generation in Cameroon and elsewhere in the region necessitates overcoming social and legal challenges and delivering innovative, evidence-based, and human rights-affirming HIV prevention and treatment interventions for young key populations.

FUNDING

PEPFAR, USAID.