Sustained changes in sexual behavior by female sex workers after completion of a randomized HIV prevention trial

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.

Sexual behaviour, changes in sexual behaviour and associated factors among women at high risk of HIV participating in feasibility studies for prevention trials in Tanzania

INTRODUCTION

Risk reduction towards safer behaviour is promoted after enrolment in HIV prevention trials. We evaluated sexual behaviour, changes in sexual behaviour and factors associated with risky behaviour after one-year of follow-up among women enrolled in HIV prevention trials in Northern Tanzania.

METHODS

Self-reported information from 1378 HIV-negative women aged 18-44 enrolled in microbicide and vaccine feasibility studies between 2008-2010,was used to assess changes in behaviour during a 12-month follow-up period. Logistic regression with random intercepts was used to estimate odds ratios for trends in each behaviour over time. A behavioural risk score was derived from coefficients of three behavioural variables in a Poisson regression model for HIV incidence and thereafter, dichotomized to risky vs less-risky behaviour. Logistic regression was then used to identify factors associated with risky behaviour at 12 months.

RESULTS

At baseline, 22% reported multiple partners, 28% were involved in transactional sex and only 22% consistently used condoms with non-regular partners. The proportion of women reporting multiple partners, transactional sex and high-risk sex practices reduced at each 3-monthly visit (33%, 43% and 47% reduction in odds per visit respectively, p for linear trend <0.001 for all), however, there was no evidence of a change in the proportion of women consistently using condoms with non-regular partners (p = 0.22). Having riskier behaviours at baseline, being younger than 16 years at sexual debut, having multiple partners, selling sex and excessive alcohol intake at baseline were strongly associated with increased odds of risky sexual behaviour after 12 months (p<0.005 for all).

CONCLUSION

An overall reduction in risky behaviours over time was observed in HIV prevention cohorts. Risk reduction counselling was associated with decreased risk behaviour but was insufficient to change behaviours of all those at highest risk. Biological HIV prevention interventions such as PrEP for individuals at highest risk, should complement risk reduction counselling so as to minimize HIV acquisition risk.

Effectiveness of a multilevel intervention to reduce violence and increase condom use in intimate partnerships among female sex workers: cluster randomised controlled trial in Karnataka, India

Introduction

Samvedana Plus is a multilevel intervention working with sex workers, their intimate partners (IPs) and communities to reduce intimate partner violence (IPV) and to increase condom use within intimate relationships of sex workers in Northern Karnataka, India.

Methods

A cluster randomised controlled trial in 47 villages. Female sex workers with IPs in the last 6 months were eligible for baseline (2014), midline (2016) and endline (2017) surveys. 24 villages were randomised to Samvedana Plus and 23 to a wait-list control. Primary outcomes among sex workers included experience of physical and/or sexual IPV or severe physical/sexual IPV in the last 6 months and consistent condom use with their IP in past 30 days. Analyses adjusted for clustering and baseline cluster-level means of outcomes.

Result

Baseline (n=620) imbalance was observed with respect to age (33.9 vs 35.2) and IPV (31.4% vs 45.0%). No differences in physical/sexual IPV (8.1% vs 9.0%), severe physical/sexual IPV (6.9% vs 8.7%) or consistent condom use with IPs (62.5% vs 57.3%) were observed by trial arm at end line (n=547). Samvedana Plus was associated with decreased acceptance of IPV (adjusted OR (AOR)=0.62, 95% CI 0.40 to 0.94, p=0.025), increased awareness of self-protection strategies (AOR=1.73, 95% CI=1.04-2.89, p=0.035) and solidarity of sex workers around issues of IPV (AOR=1.69, 95% CI=1.02-2.82, p=0.042). We observed an increase in IPV between baseline (25.9%) and midline (63.5%) among women in Samvedana Plus villages but lower in comparison villages (41.8%-44.3%) and a sharp decrease at end line in both arms (~8%).

Conclusion

We found no evidence that Samvedana Plus reduced IPV or increased condom use, but it may impact acceptance of IPV, increase knowledge of self-protection strategies and increase sex worker solidarity. Inconsistencies in reported IPV undermined the ability of the trial to assess effectiveness.

Trial registration number

NCT02807259.

Single Mothers and Female Sex Workers in Zambia Have Similar Risk Profiles

The aim of the study was to compare reproductive health and high-risk behaviors in female sex workers (FSWs) and single mothers (SMs) in Zambia's two largest cities, Lusaka and Ndola. FSWs were invited from known community hot spots, and sexually active HIV- SMs were referred from infant vaccination services for free and anonymous screening and treatment for HIV and other sexually transmitted infections (STIs) and long acting reversible contraception. A subset completed an interviewer-administered survey. From 2012 to 2016, 1,893 women (1,377 FSWs and 516 HIV- SMs) responded to referrals. HIV prevalence was 50% in Lusaka and 33% in Ndola FSWs. Positive syphilis serology (rapid plasmin reagin) was found in 29%-31% of HIV+ FSWs and 9%-12% of HIV- FSWs and SMs. Trichomonas was more common in Ndola (11%-12%), compared with Lusaka (3%-7%). Antiretroviral therapy (ART) use among HIV+ FSWs was 9%-15%. In all groups, consistent condom use (8%-11%) and modern contraceptive use (35%-65%) were low. Low literacy and reported coercion at first sexual intercourse were common in both FSWs and SMs, as was alcohol use during sex among FSWs. Zambian FSWs and SMs have low condom use and high HIV/STI and unplanned pregnancy risk. Many FSWs and half of SMs are ≥25 years of age, and thus too old for HIV prevention services targeting "adolescent girls and young women" (aged 15-24). Tailored and targeted reproductive health services are needed to reduce HIV, STI, and unplanned pregnancy in these vulnerable women.

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.

Female sex workers experiences of using contraceptive methods: a qualitative study in Kenya

Background

Female Sex Workers (FSWs) are predisposed to a broad range of social, sexual and reproductive health problems such as sexually transmitted infections (STIs)/HIV, unintended pregnancy, violence, sexual exploitation, stigma and discrimination. Female sex workers have unmet need for contraceptives and require comprehensive Sexual and Reproductive Health (SRH) prevention interventions. Existing programs pay little attention to the broad sexual and reproductive health and rights of these women and often focus on HIV and other STIs prevention, care and treatment while neglecting their reproductive health needs, including access to family planning methods. The aim of this study is, therefore, to explore the experiences of female sex workers with using existing contraceptive methods, assess individual and health facility-level barriers and document inter-partner relationship in the use of contraceptives.

Methods

We focus on women aged 15–49, who reported current sex work, defined as ‘providing sexual services in exchange for money or other material compensation as part of an individual’s livelihood.’

Results

Findings reveal that while some FSWs know about modern contraceptives, others have limited knowledge or out rightly refuse to use contraceptives for fear of losing clients. The interaction with different client types act as a barrier but also provide an opportunity for contraceptive use among FSWs. Most FSWs recognize the importance of dual protection for HIV/STI and pregnancy prevention. However, myths and misconceptions, fear of being tested for HIV at the family planning clinic, wait time, and long queues at the clinics all act in combination to hinder uptake of contraceptives.

Conclusions

We recommend a targeted approach to address the contraceptive needs of FSWs to help remove barriers to contraceptive uptake. We also support the introduction of counseling services to provide information on the benefits of non-barrier contraceptive methods and thereby enhance dual use for both pregnancy and STI/HIV prevention.

Behavioural interventions promoting condom use among female sex workers in sub-Saharan Africa: a systematic review

The objective of this review was to provide an overview of behavioural interventions promoting condom use amongst female sex workers (FSW) in sub-Saharan Africa. A search of four electronic bibliographic databases from 1990 to September 2016 was carried out. The search was limited to articles published in English. Studies which evaluated behavioural interventions to increase condom use among FSWs were selected and reviewed. Data were extracted on effectiveness, condom use, intervention content, and process outcomes. A total of 20 eligible articles describing 18 interventions in sub-Saharan Africa on HIV prevention with condom use as an outcome measure were identified. Most of the behavioural interventions incorporated a combination of approaches: health education by peers, health workers and project staff, and activities by brothel owners and brothel managers. Most studies showed effectiveness of these interventions on condom use with paying clients. Five studies measuring condom use with regular non-paying partners recorded less consistent condom use with these partners. This review illustrates the existence of sufficient evidence showing the effectiveness of behavioural interventions targeting correct and consistent condom use by FSWs.

Systematic review of sex work interventions in sub-Saharan Africa: examining combination prevention approaches

OBJECTIVE

The incidence of HIV and sexually transmitted infections is disproportionately high among sex workers (SW). We aimed to update the evidence on the effectiveness of SW interventions in sub-Saharan Africa and to provide more insights into combination prevention.

METHODS

The Systematic review followed PRISMA guidelines in a search of PUBMED and POPLINE for peer-reviewed literature published between 1 January 2000 and 22 July 2016 (registration number on PROSPERO: CRD42016042529). We considered cohort interventions, randomised controlled trials and cross-sectional surveys of SW programmes. A framework was used in the description and mapping of intervention to desired outcomes.

RESULTS

Twenty-six papers(reporting on 25 studies) were included. A strategy that empowered peer educator leaders to steer community activities showed a twofold increase in coverage of behaviour change communication and utilisation of health facility among SW. Brief alcohol harm reduction effort demonstrated a significant effect on sexual violence and engagement in sex trading. A risk reduction counselling intervention among drug-injecting SW showed an effect on alcohol, substance use and engagement in sex work. No study on a promising intervention like PrEP among SWs was found. We observed that interventions that combined some structural components, biomedical and behavioural strategies tend to accumulate more desired outcomes.

CONCLUSION

The evidence base that can be considered in intervention designs to prevent HIV in SW in SSA is vast. The health sector should consider interventions to reduce binge alcohol intake and intravenous drug use among sex workers. Programmes should staunchly consider multicomponent approaches that explore community-based structural approaches.

A Systematic Review of the Effects of Behavioral Counseling on Sexual Risk Behaviors and HIV/STI Prevalence in Low- and Middle-Income Countries

The purpose of this study was to assess the effectiveness of behavioral counseling interventions in reducing sexual risk behaviors and HIV/STI prevalence in low- and middle-income countries. A systematic review of papers published between 1990 and 2011 was conducted, identifying studies that utilized either a multi-arm or pre-post design and presented post-intervention data. Standardized methods of searching and data abstraction were used, and 30 studies met inclusion criteria. Results are summarized by intervention groups: (a) people living with HIV; (b) people who use drugs and alcohol; (c) serodiscordant couples; (d) key populations for HIV prevention; and (e) people at low to moderate HIV risk. Evidence for the effectiveness of behavioral counseling was mixed, with more rigorously designed studies often showing modest or no effects. Recommendations about the use of behavioral counseling in developing countries are made based on study results and in light of the field's movement towards combination prevention programs.

Prevalence of HIV, sexually transmitted infections, and risk behaviours among female sex workers in Nairobi, Kenya: results of a respondent driven sampling study

We conducted a respondent driven sampling survey to estimate HIV prevalence and risk behavior among female sex workers (FSWs) in Nairobi, Kenya. Women aged 18 years and older who reported selling sex to a man at least once in the past 3 months were eligible to participate. Consenting FSWs completed a behavioral questionnaire and were tested for HIV and sexually transmitted infections (STIs). Adjusted population-based prevalence and 95 % confidence intervals (CI) were estimated using RDS analysis tool. Factors significantly associated with HIV infection were assessed using log-binomial regression analysis. A total of 596 eligible participants were included in the analysis. Overall HIV prevalence was 29.5 % (95 % CI 24.7-34.9). Median age was 30 years (IQR 25-38 years); median duration of sex work was 12 years (IQR 8-17 years). The most frequent client-seeking venues were bars (76.6 %) and roadsides (29.3 %). The median number of clients per week was seven (IQR 4-18 clients). HIV testing was high with 86.6 % reported ever been tested for HIV and, of these, 63.1 % testing within the past 12 months. Of all women, 59.7 % perceived themselves at 'great risk' for HIV infection. Of HIV-positive women, 51.0 % were aware of their infection. In multivariable analysis, increasing age, inconsistent condom use with paying clients, and use of a male condom as a method of contraception were independently associated with unrecognized HIV infection. Prevalence among STIs was low, ranging from 0.9 % for syphilis, 1.1 % for gonorrhea, and 3.1 % for Chlamydia. The data suggest high prevalence of HIV among FSWs in Nairobi. Targeted and routine HIV and STI combination prevention strategies need to be scaled up or established to meet the needs of this population.

Community empowerment and involvement of female sex workers in targeted sexual and reproductive health interventions in Africa: a systematic review

Background

Female sex workers (FSWs) experience high levels of sexual and reproductive health (SRH) morbidity, violence and discrimination. Successful SRH interventions for FSWs in India and elsewhere have long prioritised community mobilisation and structural interventions, yet little is known about similar approaches in African settings. We systematically reviewed community empowerment processes within FSW SRH projects in Africa, and assessed them using a framework developed by Ashodaya, an Indian sex worker organisation.

Methods

In November 2012 we searched Medline and Web of Science for studies of FSW health services in Africa, and consulted experts and websites of international organisations. Titles and abstracts were screened to identify studies describing relevant services, using a broad definition of empowerment. Data were extracted on service-delivery models and degree of FSW involvement, and analysed with reference to a four-stage framework developed by Ashodaya. This conceptualises community empowerment as progressing from (1) initial engagement with the sex worker community, to (2) community involvement in targeted activities, to (3) ownership, and finally, (4) sustainability of action beyond the community.

Results

Of 5413 articles screened, 129 were included, describing 42 projects. Targeted services in FSW ‘hotspots’ were generally isolated and limited in coverage and scope, mostly offering only free condoms and STI treatment. Many services were provided as part of research activities and offered via a clinic with associated community outreach. Empowerment processes were usually limited to peer-education (stage 2 of framework). Community mobilisation as an activity in its own right was rarely documented and while most projects successfully engaged communities, few progressed to involvement, community ownership or sustainability. Only a few interventions had evolved to facilitate collective action through formal democratic structures (stage 3). These reported improved sexual negotiating power and community solidarity, and positive behavioural and clinical outcomes. Sustainability of many projects was weakened by disunity within transient communities, variable commitment of programmers, low human resource capacity and general resource limitations.

Conclusions

Most FSW SRH projects in Africa implemented participatory processes consistent with only the earliest stages of community empowerment, although isolated projects demonstrate proof of concept for successful empowerment interventions in African settings.

Systematic review of facility-based sexual and reproductive health services for female sex workers in Africa

Background

Several biological, behavioural, and structural risk factors place female sex workers (FSWs) at heightened risk of HIV, sexually transmitted infections (STIs), and other adverse sexual and reproductive health (SRH) outcomes. FSW projects in many settings have demonstrated effective ways of altering this risk, improving the health and wellbeing of these women. Yet the optimum delivery model of FSW projects in Africa is unclear. This systematic review describes intervention packages, service-delivery models, and extent of government involvement in these services in Africa.

Methods

On 22 November 2012, we searched Web of Science and MEDLINE, without date restrictions, for studies describing clinical and non-clinical facility-based SRH prevention and care services for FSWs in low- and middle-income countries in Africa. We also identified articles in key non-indexed journals and on websites of international organizations. A single reviewer screened titles and abstracts, and extracted data from articles using standardised tools.

Results

We located 149 articles, which described 54 projects. Most were localised and small-scale; focused on research activities (rather than on large-scale service delivery); operated with little coordination, either nationally or regionally; and had scanty government support (instead a range of international donors generally funded services). Almost all sites only addressed HIV prevention and STIs. Most services distributed male condoms, but only 10% provided female condoms. HIV services mainly encompassed HIV counselling and testing; few offered HIV care and treatment such as CD4 testing or antiretroviral therapy (ART). While STI services were more comprehensive, periodic presumptive treatment was only provided in 11 instances. Services often ignored broader SRH needs such as family planning, cervical cancer screening, and gender-based violence services.

Conclusions

Sex work programmes in Africa have limited coverage and a narrow scope of services and are poorly coordinated with broader HIV and SRH services. To improve FSWs’ health and reduce onward HIV transmission, access to ART needs to be addressed urgently. Nevertheless, HIV prevention should remain the mainstay of services. Service delivery models that integrate broader SRH services and address structural risk factors are much needed. Government-led FSW services of high quality and scale would markedly reduce SRH vulnerabilities of FSWs in Africa.

Looking upstream to prevent HIV transmission: can interventions with sex workers alter the course of HIV epidemics in Africa as they did in Asia?

BACKGROUND

High rates of partner change in 'upstream' sex work networks have long been recognized to drive 'downstream' transmission of sexually transmitted infections (STIs). We used a stochastic microsimulation model (STDSIM) to explore such transmission dynamics in a generalized African HIV epidemic.

METHODS

We refined the quantification of sex work in Kisumu, Kenya, from the 4-cities study. Interventions with sex workers were introduced in 2000 and epidemics projected to 2020. We estimated the contribution of sex work to transmission, and modelled standard condom and STI interventions for three groups of sex workers at feasible rates of use and coverage.

RESULTS

Removing transmission from sex work altogether would have resulted in 66% lower HIV incidence (range 54-75%) and 56% lower prevalence (range 44-63%) after 20 years. More feasible interventions reduced HIV prevalence from one-fifth to one-half. High rates of condom use in sex work had the greatest effect, whereas STI treatment contributed to HIV declines at lower levels of condom use. Interventions reaching the 40% of sex workers with most clients reduced HIV transmission nearly as much as less targeted approaches attempting to reach all sex workers. Declines were independent of antiretroviral therapy rollout and robust to realistic changes in parameter values.

CONCLUSION

'Upstream' transmission in sex work remains important in advanced African HIV epidemics even in the context of antiretroviral therapy. As in concentrated Asian epidemics, feasible condom and STI interventions that reach the most active sex workers can markedly reduce the size of HIV epidemics. Interventions targeting 'transactional' sex with fewer clients have less impact.

Epidemic impacts of a community empowerment intervention for HIV prevention among female sex workers in generalized and concentrated epidemics

Introduction

Sex workers have endured a high burden of HIV infection in and across HIV epidemics. A comprehensive, community empowerment-based HIV prevention intervention emphasizes sex worker organization and mobilization to address HIV risk and often includes community-led peer education, condom distribution, and other activities. Meta-analysis of such interventions suggests a potential 51% reduction in inconsistent condom use. Mathematical modeling exercises provide theoretical insight into potential impacts of the intervention on HIV incidence and burden in settings where interventions have not yet been implemented.

Methods

We used a deterministic model, Goals, to project the impact on HIV infections when the community empowerment interventions were scaled up among female sex workers in Kenya, Thailand, Brazil, and Ukraine. Modeling scenarios included expansion of the comprehensive community empowerment-based HIV prevention intervention from baseline coverage over a 5-year period (5–65% in Kenya and Ukraine; 10–70% in Thailand and Brazil), while other interventions were held at baseline levels. A second exercise increased the intervention coverage simultaneously with equitable access to ART for sex workers. Impacts on HIV outcomes among sex workers and adults are observed from 2012–2016 and, compared to status quo when all interventions are held constant.

Results

Optimistic but feasible coverage (65%–70%) of the intervention demonstrated a range of impacts on HIV: 220 infections averted over 5 yrs. among sex workers in Thailand, 1,830 in Brazil, 2,220 in Ukraine, and 10,800 infections in Kenya. Impacts of the intervention for female sex workers extend to the adult population, cumulatively averting 730 infections in Thailand to 20,700 adult infections in Kenya. Impacts vary by country, influenced by HIV prevalence in risk groups, risk behaviors, intervention use, and population size.

Discussion

A community empowerment approach to HIV prevention and access to universal ART for female sex workers is a promising human rights-based solution to overcoming the persistent burden of HIV among female sex workers across epidemic settings.

Integrating family planning and prevention of mother to child HIV transmission in Zimbabwe

OBJECTIVE

The objective was to integrate enhanced family planning (FP) and prevention of mother-to-child HIV transmission services in order to help HIV-positive Zimbabwean women achieve their desired family size and spacing as well as to maximize maternal and child health.

STUDY DESIGN

HIV-positive pregnant women were enrolled into a standard-of-care (SOC, n=33) or intervention (n=65) cohort, based on study entry date, and followed for 3 months postpartum. The intervention cohort received education sessions aimed at increasing FP use and negotiation power. Both groups received care from nurses with enhanced FP training. Outcomes included FP use, FP knowledge and HIV disclosure, and were assessed with Fisher's Exact Tests, binomial tests and t tests.

RESULTS

The intervention cohort reported increased control over condom use (p=.002), increased knowledge about IUDs (p=.002), increased relationship power (p=.01) and increased likelihood of disclosing their HIV status to a partner (p=.04) and having that partner disclose to them (p=.04) when compared to the SOC cohort. Long-acting reversible contraception (LARC) use in both groups increased from ~2% at baseline to >80% at 3 months postpartum (p<.001).

CONCLUSIONS

FP and sexual negotiation skills and knowledge, as well as HIV disclosure, increased significantly in the intervention cohort. LARC uptake increased significantly in both the intervention and SOC cohorts, likely because both groups received care from nurses with enhanced FP training. Successful service integration models are needed to maximize health outcomes in resource-constrained environments; this intervention is such a model that should be replicable in other settings in sub-Saharan Africa and beyond.

IMPLICATIONS

This study provides a rigorously evaluated intervention to integrate FP education into ante- and postnatal care for HIV-positive women and also to train providers on FP. Results suggest that this intervention had significant effects on contraception use and communication with sexual partners. This intervention should be adaptable to other areas.

Reported changes in sexual behaviour and human papillomavirus knowledge in Peruvian female sex workers following participation in a human papillomavirus vaccine trial

Summary

Limited data exist on the effect of clinical trial participation on sexual behavioural change. Two hundred female sex workers working in Lima, Peru received human papillomavirus (HPV) vaccine in either the standard (0, 2, 6 months) or modified (0, 3, 6 months) schedule. Participants received comprehensive screening and treatment for sexually transmitted infections (STIs), counselling on safe sex practices, education about HPV and the HPV vaccine, contraceptives (oral and condoms) and family planning at each visit. We assessed vaccine completion rates, change in sexual practices, and changes in HPV knowledge before and after participation in the vaccine trial. There were high rates of vaccine completion, 91% overall. The estimated number of reported new and total clients over a 30-day period decreased significantly ( P < 0.001). Knowledge about HPV and HPV-related disease increased among all participants. In addition, all participants listed at least one preventive strategy during the month 7 follow-up survey.

Priority interventions to reduce HIV transmission in sex work settings in sub-Saharan Africa and delivery of these services

Introduction

Virtually no African country provides HIV prevention services in sex work settings with an adequate scale and intensity. Uncertainty remains about the optimal set of interventions and mode of delivery.

Methods

We systematically reviewed studies reporting interventions for reducing HIV transmission among female sex workers in sub-Saharan Africa between January 2000 and July 2011. Medline (PubMed) and non-indexed journals were searched for studies with quantitative study outcomes.

Results

We located 26 studies, including seven randomized trials. Evidence supports implementation of the following interventions to reduce unprotected sex among female sex workers: peer-mediated condom promotion, risk-reduction counselling and skills-building for safer sex. One study found that interventions to counter hazardous alcohol-use lowered unprotected sex. Data also show effectiveness of screening for sexually transmitted infections (STIs) and syndromic STI treatment, but experience with periodic presumptive treatment is limited. HIV testing and counselling is essential for facilitating sex workers’ access to care and antiretroviral treatment (ART), but testing models for sex workers and indeed for ART access are little studied, as are structural interventions, which create conditions conducive for risk reduction. With the exception of Senegal, persistent criminalization of sex work across Africa reduces sex workers’ control over working conditions and impedes their access to health services. It also obstructs health-service provision and legal protection.

Conclusions

There is sufficient evidence of effectiveness of targeted interventions with female sex workers in Africa to inform delivery of services for this population. With improved planning and political will, services – including peer interventions, condom promotion and STI screening – would act at multiple levels to reduce HIV exposure and transmission efficiency among sex workers. Initiatives are required to enhance access to HIV testing and ART for sex workers, using current CD4 thresholds, or possibly earlier for prevention. Services implemented at sufficient scale and intensity also serve as a platform for subsequent community mobilization and sex worker empowerment, and alleviate a major source of incident infection sustaining even generalized HIV epidemics. Ultimately, structural and legal changes that align public health and human rights are needed to ensure that sex workers on the continent are adequately protected from HIV.

Delineating interpersonal communication networks: a study of the diffusion of an intervention among female entertainment workers in Shanghai, China

Diffusion of innovation (DOI) is widely cited in the HIV behavior change literature; however there is a dearth of research on the application of DOI in interventions for sex workers. Following a randomized-controlled trial of HIV risk reduction among female entertainment workers (FEWs) in Shanghai, China, we used qualitative approaches to delineate potential interpersonal communication networks and contributing factors that promote diffusion of information in entertainment venues. Results showed that top-down communication networks from the venue owners to the FEWs were efficient for diffusion of information. Mammies/madams, who act as intermediaries between FEWs and clients form an essential part of FEWs' social networks but do not function as information disseminators due to a conflict of interest between safer sex and maximizing profits. Diffusion of information in large venues tended to rely more on aspects of the physical environment to create intimacy and on pressure from managers to stimulate communication. In small venues, communication and conversations occurred more spontaneously among FEWs. Information about safer sex appeared to be more easily disseminated when the message and the approach used to convey information could be tailored to people working at different levels in the venues. Results suggest that safer sex messages should be provided consistently following an intervention to further promote intervention diffusion, and health-related employer liability systems in entertainment venues should be established, in which employers are responsible for the health of their employees. Our study suggests that existing personal networks can be used to disseminate information in entertainment venues and one should be mindful about the context-specific interactions between FEWs and others in their social networks to better achieve diffusion of interventions.

Are we missing the importance of missing values in HIV prevention randomized clinical trials? Review and recommendations

Missing data in HIV prevention trials is a common complication to interpreting outcomes. Even a small proportion of missing values in randomized trials can cause bias, inefficiency and loss of power. We examined the extent of missing data and methods in which HIV prevention randomized clinical trials (RCT) have managed missing values. We used a database maintained by the HIV/AIDS Prevention Research Synthesis (PRS) Project at the Centers for Disease Control and Prevention (CDC) to identify related trials for our review. The PRS cumulative database was searched on June 15, 2010 and all citations that met the following criteria were retrieved: All RCTs which reported HIV/STD/HBV/HCV behavioral interventions with a biological outcome from 2005 to present. Out of the 57 intervention trials identified, all had some level of missing values. We found that the average missing values per study ranged between 3 and 97%. Averaging over all studies the percent of missing values was 26%. None of the studies reported any assumptions for managing missing data in their RCTs. Under some relaxed assumptions discussed below, we expect only 12% of studies to report unbiased results. There is a need for more detailed and thoughtful consideration of the missing data problem in HIV prevention trials. In the current state of managing missing data we risk major biases in interpretations. Several viable alternatives are available for improving the internal validity of RCTs by managing missing data.

Family Kinship Patterns and Female Sex Work in the Informal Urban Settlement of Kibera, Nairobi, Kenya

A basic ecological and epidemiological question is why some women enter into commercial sex work while other women in the same socio-economic environment never do. To address this question respondent driven sampling principles were adopted to recruit and collect data for 161 female sex workers and 159 same aged women who never engaged in commercial sex in Kibera, a large informal settlement in Nairobi, Kenya. Univariate analysis indicated that basic kinship measures, including number of family members seen during adolescence and at present, not having a male guardian while growing up, and earlier times of ending relationships with both male and female guardians were associated with commercial sex work in Kibera. Multivariate analysis via logistic regression modeling showed that not having a male guardian during childhood, low education attainment and a small number of family members seen at adolescence were all significant predictors of entering sex work. By far the most important predictor of entering sex work was not having any male guardian, e.g., father, uncle, older brother, etc. during childhood. Results are interpreted in light of the historic pattern of sub-Saharan African child fostering and their relevance for young women in Kibera today.

Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries

BACKGROUND

Various interventions have been adopted to reduce HIV transmission among sex workers and their clients but the effectiveness of these strategies has yet to be investigated using meta-analytic techniques.

OBJECTIVES

To evaluate the effectiveness of behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries.

SEARCH METHODS

The Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane HIV/AIDS group specialized register, the Cochrane Database of Systematic Reviews, MEDLINE, PsycINFO, Sociological Abstracts, CINAHL, Dissertation Abstract International (DAI), EMBASE, LILACS, BIOSIS, SciSearch, INDMED, Proquest, and various South Asian abstracting databases were included in the database list. The publication sites of the World Health Organization, the US Centers for Disease Control and Prevention, and other international research and non-governmental organizations also appeared in the database list.

SELECTION CRITERIA

Randomized controlled trials (RCTs) and quasi-RCTs examining the effects on HIV transmission risk of different behavioral interventions or comparing behavioral interventions with no intervention, where described any one of the outcome measures, such as HIV incidence and prevalence, STI incidence and prevalence, change in self-reported of condom use, and other HIV-related outcome.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trials, extracted data and assessed the risk bias. Heterogeneity amongst trials was also tested.

MAIN RESULTS

A total of 13 trials with 8,698 participants were included. Primary outcomes (HIV and STI prevalence and incidence) were reported in seven trials. Of these, HIV incidence was reported in only three trials. After a 6-month follow-up assessment, there was no evidence that social cognitive behavioral intervention was effective in reducing HIV incidence (RR 0.12, 95% CI 0.01 to 2.22). However, there was a reduction in HIV incidence at 3-month follow-up assessment of promotion of female and male condom (RR 0.07, 95% CI 0.00 to 1.38). Social cognitive interventions and promotion of female and male condom use were significantly reduced STIs incidence (RR 0.57, 95% CI 0.34 to 0.96) and (RR 0.63, 95% CI 0.45 to 0.88), respectively. Secondary outcomes were identified in 13 trials. Meta-analyses showed evidence that interventions to promote the use of female and male condoms do reduce non-condom use (RR 0.83, 95% CI 0.65 to 1.05) compared to promotion of male condoms alone, and that social cognitive interventions reduced drug use among sex workers (RR 0.65, 95% CI 0.36 to 1.16) compared to standard care.

AUTHORS' CONCLUSIONS

Available evidence nevertheless suggests that compared with standard care or no intervention, behavioral interventions are effective in reducing HIV and the incidence of STIs amongst female sex workers (FSWs). Given the benefits of social cognitive theory and the promotion of condom use in reducing HIV/STI and the public health need to control transmission amongst FSWs, there is a clear finding in favour of behavioral interventions. However, it should be recognized that there is a lack of information about most other outcomes and target populations, and that all of the trials were conducted in low- and middle-income countries.

Anal sex, vaginal practices, and HIV incidence in female sex workers in urban Kenya: implications for the development of intravaginal HIV prevention methods

Multiple intravaginal HIV prevention methods, including microbicide gels, barriers, and intravaginal rings, are in clinical development in Africa. Development of intravaginal HIV prevention products requires an understanding of sexual behavior, sexually transmitted infection (STI), and vaginitis prevalences, and sexual and vaginal practices in potential target populations. We assessed these factors in a cohort of Kenyan female sex workers (FSW). Women who reported exchanging sex for money/gifts at least three times in the past month and who were HIV uninfected were enrolled and followed for 6 months. STI prevalence and HIV incidence were analyzed by multivariate logistic regression analysis, controlling for demographic and behavioral factors. Thirty-seven percent (74/200) reported having had anal sex. Frequency of anal sex was higher with regular and casual partners than with primary partners. Women were less likely to use condoms for anal sex than for vaginal sex with regular or casual partners. Vaginal washing was universal (100%). HIV incidence was 5.6 per 100 person-years (95% CI 1.62, 11.67). HIV incidence was not associated with any demographic or risk behavior. The relatively high rate of anal sex and universal vaginal washing may complicate both safety and efficacy evaluation of intravaginal products and should be taken into account in trial design. This FSW population had significant HIV incidence and needs continued HIV prevention interventions.

Partners and clients of female sex workers in an informal urban settlement in Nairobi, Kenya

This paper compares and contrasts number of partners and condom use behaviour for female sex workers and a sample of women working in other economic activities, with both samples drawn from the large informal settlement of Kibera, Nairobi. As expected, univariate analysis revealed much higher numbers of overall sexual partners and higher levels of condom use among female sex workers compared to Kibera women in other occupations. An unexpected finding, however, was that female sex workers with a romantic partner had significantly fewer sexual partners per unit time than female sex workers without such a partner. This finding held for multivariate analysis, with negative binomial regression analyses showing that having a romantic partner was significantly associated with reductions in total number of both sexual partners overall and with sexual partners who did not use condoms. In contrast, HIV status, education, number of immediate family members and levels of alcohol consumption were non-significant factors for both regression analyses. Results suggest that female sex workers' romantic partners act as more than sources of possible HIV infection; rather, romantic partners appear to have an important positive impact on health. We discuss this finding in light of possible harm-reduction programmes focusing on female sex workers and their romantic partners.

Where will this illness take me? Reactions to HIV diagnosis from women living with HIV in Kenya

The purpose of our study was to develop an in-depth understanding of the reactions of 40 urban and rural HIV-infected Kenyan women to HIV diagnosis. We employed narrative inquiry principles to guide this qualitative cross-sectional study. We conducted individual in-depth interviews using open-ended questions in April and May 2006. In this article we focus on women's reactions to HIV diagnosis, under which four subthemes emerged: immediate intense emotions; keeping HIV status secret; acceptance of HIV diagnosis; and finding liberation in disclosure. We offer important implications for health care professionals serving women in sub-Saharan Africa from the findings of our study.

Interventions for encouraging sexual behaviours intended to prevent cervical cancer

BACKGROUND

Human papillomavirus (HPV) is the key risk factor for cervical cancer. Continuing high rates of HPV and other sexually transmitted infections (STIs) in young people demonstrate the need for effective behavioural interventions.

OBJECTIVES

To assess the effectiveness of behavioural interventions for young women to encourage safer sexual behaviours to prevent transmission of STIs (including HPV) and cervical cancer.

SEARCH STRATEGY

Systematic literature searches were performed on the following databases: Cochrane Central Register of Controlled Trials (CENTRAL Issue 4, 2009) Cochrane Gynaecological Cancer Review Group (CGCRG) Specialised Register, MEDLINE, EMBASE, CINAHL, PsychINFO, Social Science Citation Index and Trials Register of Promoting Health Interventions (TRoPHI) up to the end of 2009. All references were screened for inclusion against selection criteria.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of behavioural interventions for young women up to the age of 25 years that included, amongst other things, information provision about the transmission and prevention of STIs. Trials had to measure behavioural outcomes (e.g. condom use) and/or biological outcomes (e.g. incidence of STIs, cervical cancer).

DATA COLLECTION AND ANALYSIS

A narrative synthesis was conducted. Meta-analysis was not considered appropriate due to heterogeneity between the interventions and trial populations.

MAIN RESULTS

A total of 5271 references were screened and of these 23 RCTs met the inclusion criteria. Most were conducted in the USA and in health-care clinics (e.g. family planning).The majority of interventions provided information about STIs and taught safer sex skills (e.g. communication), occasionally supplemented with provision of resources (e.g. free sexual health services). They were heterogeneous in duration, contact time, provider, behavioural aims and outcomes. A variety of STIs were addressed including HIV and chlamydia. None of the trials explicitly mentioned HPV or cervical cancer prevention.Statistically significant effects for behavioural outcomes (e.g. increasing condom use) were common, though not universal and varied according to the type of outcome. There were no statistically significant effects of abstaining from or reducing sexual activity. There were few statistically significant effects on biological (STI) outcomes. Considerable uncertainty exists in the risk of bias due to incomplete or ambiguous reporting.

AUTHORS' CONCLUSIONS

Behavioural interventions for young women which aim to promote sexual behaviours protective of STI transmission can be effective, primarily at encouraging condom use. Future evaluations should include a greater focus on HPV and its link to cervical cancer, with long-term follow-up to assess impact on behaviour change, rates of HPV infection and progression to cervical cancer. Studies should use an RCT design where possible with integral process evaluation and cost-effectiveness analysis where appropriate. Given the predominance of USA studies in this systematic review evaluations conducted in other countries would be particularly useful.

Contraceptive needs of female sex workers in Kenya - a cross-sectional study

BACKGROUND AND OBJECTIVES

Female sex workers (FSWs) are thought to be at heightened risk for unintended pregnancy, although sexual and reproductive health interventions reaching these populations are typically focused on the increased risk of sexually transmitted infections. The objective of this study of FSWs in Kenya is to document patterns of contraceptive use and unmet need for contraception.

METHODS

This research surveys a large sample of female sex workers (N = 597) and also uses qualitative data from focus group discussions.

RESULTS

The reported level of modern contraceptives in our setting was very high. However, like in other studies, we found a great reliance on male condoms, coupled with inconsistent use at last sex, which resulted in a higher potential for unmet need for contraception than the elevated levels of modern contraceptives might suggest. Dual method use was also frequently encountered in this population and the benefits of this practice were clearly outlined by focus group participants.

CONCLUSION

These findings suggest that the promotion of dual methods among this population could help meet the broader reproductive health needs of FSWs. Furthermore, this research underscores the necessity of considering consistency of condom use when estimating the unmet or undermet contraceptive needs of this population.

'They bring AIDS to us and say we give it to them': Socio-structural context of female sex workers' vulnerability to HIV infection in Ibadan, Nigeria

The aim of the study was to examine and describe the individual and structural-environmental factors that shape the vulnerability of brothel-based female sex workers (FSWs) in Ibadan, southwest Nigeria to HIV infection. A descriptive qualitative research design was utilised to elicit data, using in-depth interviews and focus group discussions, from 60 randomly selected participants in four brothels. A thematic analysis of data was undertaken following transcription and validation of interviews. Five themes emerged from the data: (i) flawed knowledge and fatalistic attitudes; (ii) the psychosocial and economic context of sex work; (iii) religious beliefs, stigma and risk taking; (iv) barriers to HIV testing; and (v) legal and policy constraints to sex work. We describe the complex interaction between these themes and how they combine to increase the risk of HIV infection among FSWs. The impact of previous interventions to reduce the risk of HIV infection among FSWs has been limited by personal and structural factors; hence we recommend that new strategies that recognise the practical constraints to HIV prevention among FSWs are urgently needed to make the environment of commercial work safer for FSWs, their clients, and by extension the general population.

Male circumcision in the United States for the prevention of HIV infection and other adverse health outcomes: report from a CDC consultation

In April 2007, the Centers for Disease Control and Prevention (CDC) held a two-day consultation with a broad spectrum of stakeholders to obtain input on the potential role of male circumcision (MC) in preventing transmission of human immunodeficiency virus (HIV) in the U.S. Working groups summarized data and discussed issues about the use of MC for prevention of HIV and other sexually transmitted infections among men who have sex with women, men who have sex with men (MSM), and newborn males. Consultants suggested that (1) sufficient evidence exists to propose that heterosexually active males be informed about the significant but partial efficacy of MC in reducing risk for HIV acquisition and be provided with affordable access to voluntary, high-quality surgical and risk-reduction counseling services; (2) information about the potential health benefits and risks of MC should be presented to parents considering infant circumcision, and financial barriers to accessing MC should be removed; and (3) insufficient data exist about the impact (if any) of MC on HIV acquisition by MSM, and additional research is warranted. If MC is recommended as a public health method, information will be required on its acceptability and uptake. Especially critical will be efforts to understand how to develop effective, culturally appropriate public health messages to mitigate increases in sexual risk behavior among men, both those already circumcised and those who may elect MC to reduce their risk of acquiring HIV.

Lost opportunities in HIV prevention: programmes miss places where exposures are highest

Background

Efforts at HIV prevention that focus on high risk places might be more effective and less stigmatizing than those targeting high risk groups. The objective of the present study was to assess risk behaviour patterns, signs of current preventive interventions and apparent gaps in places where the risk of HIV transmission is high and in communities with high HIV prevalence.

Methods

The PLACE method was used to collect data. Inhabitants of selected communities in Lusaka and Livingstone were interviewed about where people met new sexual partners. Signs of HIV preventive activities in these places were recorded. At selected venues, people were interviewed about their sexual behaviour. Peer educators and staff of NGOs were also interviewed.

Results

The places identified were mostly bars, restaurants or sherbeens, and fewer than 20% reported any HIV preventive activity such as meetings, pamphlets or posters. In 43% of places in Livingstone and 26% in Lusaka, condoms were never available. There were few active peer educators. Among the 432 persons in Lusaka and 676 in Livingstone who were invited for interview about sexual behaviour, consistent condom use was relatively high in Lusaka (77%) but low in Livingstone (44% of men and 34% of women). Having no condom available was the most common reason for not using one. Condom use in Livingstone was higher among individuals socializing in places where condoms always were available.

Conclusion

In the places studied we found a high prevalence of behaviours with a high potential for HIV transmission but few signs of HIV preventive interventions. Covering the gaps in prevention in these high exposure places should be given the highest priority.

Reduced rates of HIV acquisition during unprotected sex by Kenyan female sex workers predating population declines in HIV prevalence

OBJECTIVES

Female sex workers (FSWs) form a core group at high risk of both sexual HIV acquisition and secondary transmission. The magnitude of these risks may vary by sexual risk taking, partner HIV prevalence, host immune factors and genital co-infections. We examined temporal trends in HIV prevalence and per-act incidence, adjusted for behavioral and other variables, in FSWs from Nairobi, Kenya.

METHODS

An open cohort of FSWs followed since 1985. Behavioral and clinical data were collected six monthly from 1985 to 2005, and sexually transmitted infection (STI) diagnostics and HIV serology performed. A Cox proportional hazards model with time-dependent covariables was used to estimate infection risk as a function of calendar time.

RESULTS

HIV prevalence in new FSW enrollees peaked at 81% in 1986, and was consistently below 50% after 1997. Initially uninfected FSWs remained at high risk of acquiring HIV throughout the study period, but the rate of HIV acquisition during unprotected sex with a casual client declined by over four-fold. This reduction correlated closely with decreases in gonorrhea prevalence, and predated reductions in the Kenyan HIV population prevalence by over a decade.

CONCLUSIONS

The per-act rate of HIV acquisition in high-risk Nairobi FSWs fell dramatically between 1985 and 2005. This decline may represent the impact of improved STI prevention/therapy, immunogenetic shifts in at-risk women, or changes in the proportion of HIV exposures occurring with clients who had acute HIV infection. Declining HIV incidence in high-risk cohorts may predict and/or be causally related to future reductions in population prevalence.

Evaluating large-scale HIV prevention interventions: study design for an integrated mathematical modelling approach

BACKGROUND

There is an urgent need to evaluate HIV prevention interventions, thereby improving our understanding of what works, under what circumstances and what is cost effective.

OBJECTIVES

To describe an integrated mathematical evaluation framework designed to assess the population-level impact of large-scale HIV interventions and applied in the context of Avahan, the Indian AIDS Initiative, in southern India. The Avahan Initiative is a large-scale HIV prevention intervention, funded by the Bill & Melinda Gates Foundation, which targets high-risk groups in selected districts of the six states most affected by the HIV/AIDS epidemic (Maharashtra, Karnataka, Tamil Nadu, Andhra Pradesh, Nagaland and Manipur) and along the national highways.

METHODS

One important component of the monitoring and evaluation of Avahan relies on an integrated mathematical framework that combines empirical biological and behavioural data from different subpopulations in the intervention areas, with the use of tailor-made transmission dynamics models embedded within a Bayesian framework.

RESULTS

An overview of the Avahan Initiative and the objectives of the monitoring and evaluation of the intervention is given. The rationale for choosing this evaluation design compared with other possible designs is presented, and the different components of the evaluation framework are described and its advantages and challenges are discussed, with illustrated examples.

CONCLUSIONS

This is the first time such an approach has been applied on such a large scale. Lessons learnt from the CHARME project could help in the design of future evaluations of large-scale interventions in other settings, whereas the results of the evaluation will be of programmatic and public health relevance.