HIV prevention and care-seeking behaviour among female sex workers in four cities in India, Kenya, Mozambique and South Africa

The preventable burden of mortality from unsafe abortion among female sex workers: a Community Knowledge Approach survey among peer networks in eight countries

Previous studies have found high levels of unintended pregnancy among female sex workers (FSW), but less attention has been paid to their abortion practices and outcomes. This study is the first to investigate abortion-related mortality among FSW across eight countries: Angola, Brazil, Democratic Republic of Congo (DRC), India, Indonesia, Kenya, Nigeria, and South Africa. The Community Knowledge Approach (CKA) was used to survey a convenience sample of FSW (n = 1280). Participants reported on the deaths of peer FSW in their social networks during group meetings convened by non-governmental organisations (n = 165 groups, conducted across 24 cities in 2019). Details on any peer FSW deaths in the preceding five years were recorded. The circumstances of abortion-related deaths are reported here. Of the 1320 maternal deaths reported, 750 (56.8%) were due to unsafe abortion. The number of abortion-related deaths reported was highest in DRC (304 deaths reported by 270 participants), Kenya (188 deaths reported by 175 participants), and Nigeria (216 deaths reported by 312 participants). Among the abortion-related deaths, mean gestational age was 4.6 months and 75% occurred outside hospital. Unsafe abortion methods varied by country, but consumption of traditional or unknown medicines was most common (37.9% and 29.9%, respectively). The 750 abortion-related deaths led to 1207 children being left motherless. The CKA successfully recorded a stigmatised practice among a marginalised population, identifying very high levels of abortion-related mortality. Urgent action is now needed to deliver comprehensive sexual and reproductive healthcare to this vulnerable population, including contraption, safe abortion, and post-abortion care.

Healthcare seeking behavior among patients visiting public primary and secondary healthcare facilities in an urban Indian district: A cross-sectional quantitative analysis

In this work, we examined healthcare seeking behavior (HSB) of patients visiting public healthcare facilities in an urban context. We conducted a cross-sectional survey across twenty-two primary and secondary public healthcare facilities in the South-west Delhi district in India. The quantitative survey was designed to ascertain from patients at these facilities their HSB-i.e., on what basis patients decide the type of healthcare facility to visit, or which type of medical practitioner to consult. Based on responses from four hundred and forty-nine participants, we observed that factors such as wait time, prior experience with care providers, distance from the facility, and also socioeconomic and demographic factors such as annual income, educational qualification, and gender significantly influenced preferences of patients in choosing healthcare facilities. We used binomial and multinomial logistic regression to determine associations between HSB and socioeconomic and demographic attributes of patients at a 0.05 level of significance. Our statistical analyses revealed that patients in the lower income group preferred to seek treatment from public healthcare facilities (OR = 3.51, 95% CI = (1.65, 7.46)) irrespective of the perceived severity of their illness, while patients in the higher income group favored directly consulting specialized doctors (OR = 2.71, 95% CI = (1.34, 5.51)). Other factors such as having more than two children increased the probability of seeking care from public facilities. This work contributes to the literature by: (a) providing quantitative evidence regarding overall patient HSB, especially at primary and secondary public healthcare facilities, regardless of their presenting illness, (b) eliciting information regarding the pathways followed by patients visiting these facilities while seeking care, and (c) providing operational information regarding the surveyed facilities to facilitate characterizing their utilization. This work can inform policy designed to improve the utilization and quality of care at public primary and secondary healthcare facilities in India.

Health vulnerabilities in female sex workers in Brazil, 2016

Female sex workers (FSW) suffer stigma and discrimination that negatively impact their physical and mental health and affect access to health care services. This paper aims to describe selected health indicators among FSW in 12 Brazilian cities in 2016. Brazilian cross-sectional Biological Behavioral Surveillance Survey was conducted in 2016 among 4328 FSW recruited by respondent-driven sampling. The sample weighing was inversely proportional to participant's network sizes and the seeds were excluded from the analysis. Health indicators were estimated with 95% confidence interval and included indicators of health status, symptoms of depression, antenatal care, pap smear coverage, signs and symptoms of sexually transmitted infection, contraception and regular condom use, number of births and children alive per women, human immunodeficiency virus and syphilis testing, usual source of care, and perception of discrimination. Most participants self-rated their health as very good/good (65.8%) and 27.7% were positively screened for major depressive disorder episode on Patient Health Questionnaire-2. Antenatal coverage was 85.8% and 62.3% of FSW had access to pap smear exam in the past 3 years. A total of 67.0% of FSW were using some contraceptive method at the time of the study. Male condom was the most common method (37.1%), followed by oral pill (28.9%). A total of 22.5% FSW had never been tested for HIV and the main reasons were "not feeling at risk" (40.4%) and "being afraid or ashamed" (34.0%). The vast majority of FSW used Brazilian National Health System as their usual source of health care (90.2%). Approximately one-fifth of the participants felt discriminated against or were treated worse for being FSW (21.4%) and only 24.3% disclose their sex work status in health services. The vulnerability of FSW is expressed in all health indicators. Indicators of health status, antenatal care, pap smear coverage, and contraception were worse than in the Brazilian population, and point out to the importance of increase FSW's access to health care services. Also, stigma and discrimination emerged as an important barrier to FSW's health care in all dimensions and need to be struggled.

"I expected little, although I learned a lot": perceived benefits of participating in HIV risk reduction sessions among women engaged in sex work in Uganda

BACKGROUND

The global HIV burden remains a public health concern. Women engaged in sex work (WESW) are at higher risk of acquiring HIV compared to the general adult population. Uganda reports high rates of HIV prevalence among WESW. While WESW in Uganda have long been the subject of surveillance studies, they have not been targeted by theory-informed HIV prevention intervention approaches. In this study, we explored the perceived benefits of an evidence-based HIV risk reduction intervention that was implemented as part of a combination intervention tested in a clinical trial in Uganda.

METHODS

As part of a larger randomized clinical trial, we conducted semi-structured in-depth interviews with 20 WESW selected using a stratified purposive sampling. All interviews were conducted in Luganda, language spoken in the study area, and audio-recorded. They were transcribed verbatim and translated to English. Thematic analysis was used to analyze the data.

RESULTS

WESW's narratives focused on: (1) condom use; (2) alcohol/drug consumption; (3) PrEP use; (4) "handling" customers; and (5) "massaging" customers. WESW agreed that male condom was one of the important learning points for them and planned to continue using them while female condoms were received with mixed reactions. Many women appreciated receiving information about the risks of consuming alcohol and drugs, and discussed how they reduced/ eliminated their consumption. PrEP information was appreciated though identified by fewer WESW. Handling a client was discussed as a helpful strategy for safer sex through improved ability to convince customers to use condoms or avoiding sex. Massaging was also beneficial to avoid penetrative sex, but similar to female condom, massaging also yielded mixed perceptions.

CONCLUSION

WESW found the intervention beneficial and described ways in which it improved their ability to engage in safer sex and stay healthy. The fact that WESW identified other strategies beyond condom use as helpful underlines the importance of adopting a comprehensive approach to behavioral interventions targeting HIV prevention even when combined with other interventions. Additionally, WESW's narratives suggest that incorporating the tenets of social cognitive theory and harm reduction approaches in HIV prevention among this population can result in risk behavior change.

Effect of community-based interventions targeting female sex workers along the HIV care cascade in sub-Saharan Africa: a systematic review and meta-analysis

BACKGROUND

Female sex workers are extremely vulnerable and highly susceptible to being infected with human immunodeficiency virus. As a result, community-based targeted interventions have been recommended as one of the models of care to improve access to HIV services and continued engagement in care. We conducted a systematic review to (1) assess the effect of FSW-targeted community interventions on the improvement of HIV services access along the treatment cascade and (2) describe community-based interventions that positively affect continuation in HIV care across the HIV treatment cascade for FSWs in sub-Saharan Africa.

METHODS

We defined the 5 steps that make up the HIV care cascade and categorized them as outcomes, namely, HIV testing and diagnosis, linkage to care, receipt of ART, and achievement of viral suppression. We conducted a systematic search of randomized controlled trials, cohort, and cross-sectional studies done in sub-Saharan African countries and published from 2004 to 2020. The period was selected based on the time span within which ART was scaled up through widespread roll-out of comprehensive HIV programs in sub-Saharan Africa. We reviewed studies with data on the implementation of community interventions for any of the HIV care cascade stage. The data were analyzed using random effects meta-analysis where possible, and for the rest of the studies, data were synthesized using summary statistics.

RESULTS

The significant impact of the community interventions was observed on HIV testing, HIV diagnosis, and ART use. However, for HIV testing and ART use, the improvement was not sustained for the entire period of implementation. There were minimal interventions that had impact on HIV diagnosis, with only one community service delivery model showing significance. Generally, the interventions that had reasonable impact are those that implemented targeted and comprehensive package of HIV services provided at one location, and with unique strategies specific to each cascade stage.

CONCLUSIONS

The evidence brought forward from this review shows that the effect of community-based interventions varies across the different stages of HIV care cascade. A broad package of interventions including a combination of behavioral, biomedical, and structural, designed with specific strategies, unique to each cascade stage appears to be more effective, although information on long-term treatment outcomes and the extent to which FSWs remain engaged in care is sparse. There is need to conduct a further research to deepen the assessment of the effectiveness of community-based interventions on HIV care cascade for FSWs. This will enhance identification of evidence-based optimal interventions that will guide effective allocation of scarce resources for strategies that would have a significant impact on HIV service delivery.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020157623.

Venue-Based HIV Testing at Sex Work Hotspots to Reach Adolescent Girls and Young Women Living With HIV: A Cross-sectional Study in Mombasa, Kenya

BACKGROUND

We estimated the potential number of newly diagnosed HIV infections among adolescent girls and young women (AGYW) using a venue-based approach to HIV testing at sex work hotspots.

METHODS

We used hotspot enumeration and cross-sectional biobehavioral survey data from the 2015 Transition Study of AGYW aged 14-24 years who frequented hotspots in Mombasa, Kenya. We described the HIV cascade among young females who sell sex (YFSS) (N = 408) versus those young females who do not sell sex (YFNS) (N = 891) and triangulated the potential (100% test acceptance and accuracy) and feasible (accounting for test acceptance and sensitivity) number of AGYW that could be newly diagnosed through hotspot-based HIV rapid testing in Mombasa. We identified the profile of AGYW with an HIV in the past year using generalized linear mixed regression models.

RESULTS

N = 37/365 (10.1%) YFSS and N = 30/828 (3.6%) YFNS were living with HIV, of whom 27.0% (N = 10/37) and 30.0% (N = 9/30) were diagnosed and aware (P = 0.79). Rapid test acceptance was 89.3%, and sensitivity was 80.4%. There were an estimated 15,635 (range: 12,172-19,097) AGYW at hotspots. The potential and feasible number of new diagnosis was 627 (310-1081), and 450 (223-776), respectively. Thus, hotspot-based testing could feasibly reduce the undiagnosed fraction from 71.6% to 20.2%. The profile of AGYW who recently tested was similar among YFSS and YFNS. YFSS were 2-fold more likely to report a recent HIV test after adjusting for other determinants [odds ratio (95% confidence interval): 2.2 (1.5 to 3.1)].

CONCLUSION

Reaching AGYW through hotspot-based HIV testing could fill gaps left by traditional, clinic-based HIV testing services.

HIV prevalence, sexual risk behaviours and HIV testing among female sex workers in three cities in Sri Lanka: Findings from respondent-driven sampling surveys

Sri Lanka has a low-level HIV epidemic. This study aims to provide evidence on HIV, syphilis and hepatitis B (HBV) prevalence, sexual risk behaviours and utilisation of HIV prevention interventions among female sex workers (FSW) in the cities Colombo, Galle, and Kandy. Using respondent-driven sampling (RDS), we recruited a total of 458 FSW in Colombo, 360 in Galle and 362 in Kandy from November 2017 to March 2018. Participants provided biological specimens for testing for infections and completed a behavioural questionnaire. We found no HIV nor HBV infections in Galle and Kandy, and low HIV (0.4%) and HBV surface antigen (0.6%) prevalence in Colombo. FSW in Colombo had higher positivity on Treponema pallidum-particle agglutination test (8.4%) compared to Galle (2.0%) and Kandy (2.5%). About two thirds of FSW heard of HIV in each of the cities. Around 90% of FSW used condom at last sex with a client in both Colombo and Galle, but considerably less in Kandy (57.1%). However, lower proportion of FSW used condoms every time during sex with clients in the past 30 day: 22.9% of FSW in Colombo, 26.6% in Kandy and 68.4% in Galle. Across cities, 17.5%-39.5% of FSW reported being tested for HIV in the past 12 months or knowing HIV positive status. The commonest reasons for never testing for HIV was not knowing where to test (54.2% in Colombo, 41.8% in Galle, 48.1% in Kandy) followed by inconvenient testing location (23.7% in Colombo and 31.1% in Kandy). HIV has not yet been firmly established among FSW in three cities in Sri Lanka, but the vulnerability towards HIV and STIs is substantial. HIV interventions should be intensified by expanding community-based HIV testing approaches, increasingawareness of HIV risks and addressing socio-structural vulnerabilities of FSW to HIV.

High prevalence of non-communicable diseases among key populations enrolled at a large HIV prevention & treatment program in Kenya

INTRODUCTION

People Living with HIV (PLHIV) bear a disproportionate burden of non-communicable diseases (NCDs). Despite their significant toll across populations globally, the NCD burden among key populations (KP) in Kenya remains unknown. The burden of four NCD-categories (cardiovascular diseases, cancer, chronic respiratory diseases and diabetes) was evaluated among female sex workers (FSWs) and men who have sex with men (MSM) at the Sex Workers Outreach Program (SWOP) clinics in Nairobi Kenya.

METHODS

A retrospective medical chart review was conducted at the SWOP clinics among KP clients ≥15 years living with HIV enrolled between October 1, 2012 and September 30, 2015. The prevalence of the four NCD-categories were assessed at enrollment and during subsequent routine quarterly follow-up care visits as per the Ministry of Health guidelines. Prevalence at enrollment was determined and distributions of co-morbidities assessed using Chi-square and t-tests as appropriate during follow-up visits. Univariate and multivariate analysis were conducted to identify factors associated with NCD diagnoses.

RESULTS

Overall, 1,478 individuals' records were analyzed; 1,392 (94.2%) were from FSWs while 86 (5.8%) were from MSM over the three-year period. FSWs' median age was 35.3 years (interquartile range (IQR) 30.1-41.6) while MSM were younger at 26.8 years (IQR 23.2-32.1). At enrollment into the HIV care program, most KPs (86.6%) were at an early WHO clinical stage (stage I-II) and 1462 (98.9%) were on first-line anti-retroviral therapy (ART). A total of 271, 18.3% (95% CI: 16.4-20.4%), KPs living with HIV had an NCD diagnosis in their clinical chart records during the study period. Majority of these cases, 258 (95.2%) were noted among FSWs. Cardiovascular disease that included hypertension was present in 249/271, 91.8%, of KPs with a documented NCD. Using a proxy of two or more elevated blood pressure readings taken < 12 months apart, prevalence of hypertension rose from 1.0% (95% CI: 0.6-1.7) that was documented in the charts during the first year to 16.3% (95% CI: 14.4-18.3) in the third year. Chronic respiratory disease mainly asthma was present in 16/271, a prevalence of 1.1% (95% CI: 0.6-1.8) in the study population. Cancer in general was detected in 10/271, prevalence of 0.7% (95% CI: 0.3-1.2) over the same period. Interestingly, diabetes was not noted in the study group. Lastly, significant associations between NCD diagnosis with increasing age, body-mass index and CD4 + cell-counts were noted in univariate analysis. However, except for categories of ≥ BMI 30 kg/m2 and age ≥ 45, the associations were not sustained in adjusted risk estimates.

CONCLUSION

In Kenya, KP living with HIV and on ART have a high prevalence of NCD diagnoses. Multiple NCD risk factors were also noted against a backdrop of a changing HIV epidemic in the study population. This calls for scaling up focus on both HIV and NCD prevention and care in targeted populations at increased risk of HIV acquisition and transmission. Hence, KP programs could include integrated HIV-NCD screening and care in their guidelines.

Female sex workers perspectives and concerns regarding HIV self-testing: an exploratory study in Tanzania

BACKGROUND

HIV testing is a gateway to HIV care and treatment for people diagnosed with HIV and can link those with negative results to HIV preventive services. Despite the importance of HIV testing services (HTS) in HIV control, uptake of HTS among female sex workers (FSWs) across sub-Saharan Africa (SSA) remains sub-optimal. Concerns about stigma associated with sex work and fear of loss of livelihood if HIV status becomes known, are some of the restrictions for FSWs to utilize HTS offered through health care facilities. Introduction of HIV self-testing (HIVST) may mitigate some of the barriers for the uptake of HTS. This study explored the acceptability of FSWs towards the introduction of HIVST in Tanzania.

METHODS

We conducted an exploratory study employing in-depth interviews (IDI) and participatory group discussions (PGD) with FSWs in selected regions of Tanzania. Study participants were recruited through snowball sampling. Data were thematically analysed by two analysts using NVivo software. The analysis was informed by the social-ecological model and focused on factors associated with the acceptability of HIVST.

RESULTS

We conducted 21 PGD sessions involving 227 FSWs. Twenty three IDIs were conducted to complement data collected through PGD. Our study has demonstrated that FSWs are enthusiastic toward HIVST. Convenience (time and cost saved), and belief that HIVST will increase privacy and confidentiality motivated participants' support for the self-testing approach. Participants did express concerns about their ability to interpret and trust the results of the test. Participants also expressed concern that HIVST could cause personal harm, including severe distress and self-harm for individuals with a reactive test. Very likely, concern about adverse effects of HIVST was linked to the study participants' lay perception that HIVST would be provided only through unassisted modality.

CONCLUSIONS

FSWs demonstrated high enthusiasm to use the HIVST once it becomes available. Expectations for increased confidentiality, autonomy, and reduced opportunity costs were among the leading factors that attracted FSWs to HIVST. The major obstacles to the acceptability of HIVST included fear of HIV reactive test and not trusting self-diagnoses. Our findings underscore the importance of providing adequate access to counselling and referral services in conjunction with HIVST.

The role of health and advocacy organisations in assisting female sex workers to gain access to health care in South Africa

BACKGROUND

Globally, female sex workers (FSWs) are considered a key population group due to the high HIV prevalence. Studies show that there are various factors in some contexts that render FSWs marginalised, which limits their access to sexual reproductive health (SRH) services. Access to SRH services are particularly challenging in countries where sex work is criminalised such as is the case in South Africa. Evidently, there are alternative ways in which FSWs in this context receive non-stigmatising SRH care through non-governmental organisations. The aim of this study was to understand the functioning of these non-governmental health care services as well as to document the experiences of FSWs utilising these services.

METHODS

Eleven focus group discussions were held with 91 FSWs. In addition, 21 in-depth individual interviews with researchers, stakeholders and FSWs were conducted. Interview guides were utilised for data collection. Informed consent was obtained from all participants. Data were analysed thematically.

RESULTS

The FSWs expressed challenges related to SRH care access at public health facilities. The majority felt that they could not consult for SRH-related services because of stigma. The non-governmental health and advocacy organisations providing SRH services to FSWs through their mobile facilities utilising the peer approach, have done so in a way that promotes trust between FSWs and mobile health care providers. FSWs have access to tailored services, prevention materials as well as health information. This has resulted in the normalising of HIV testing as well as SRH seeking behaviours.

CONCLUSION

This study has established that health and advocacy organisations have attempted to fill the gap in responding to SRH care needs of FSWs amidst intersecting vulnerabilities. FSWs' engagement with these organisations has encouraged their willingness to test for HIV. However, it is important to note that these organisations operate in urban areas, thus FSWs operating outside these areas are most likely exposed to compounding health risks and lack access to tailored services.

Delivering community-led integrated HIV and sexual and reproductive health services for sex workers: A mixed methods evaluation of the DIFFER study in Mysore, South India

Introduction

Women in developing countries continue to face barriers to accessing sexual and reproductive health (SRH) services, with marginalized women facing increased challenges to accessing care. The Diagonal Interventions to Fast-Forward Enhanced Reproductive Health (DIFFER) project implemented a package of interventions for female sex workers and women from the general population which integrated horizontal health services for the general population with existing vertical targeted interventions aimed at sex workers with an aim to improve SRH and HIV services. We present an outcome evaluation of the DIFFER project in terms of uptake rates for SRH services among sex workers in Mysore, India.

Methods

Ashodaya Samithi, a sex worker-led organization, implemented the DIFFER strategy through their community-based clinic and a Well Women Clinic (WWC), established at a partner private hospital that provided SRH services for women living with HIV. Mixed methods were used to evaluate the intervention that included a baseline (2012–13) and end of project (2015–16) cross sectional surveys (CSS), focus group discussions (FGDs), key informant interviews, and analysis of service statistics from 2013–2016.

Results

The CSS found that condom use, STI testing, and treatment were high before, and throughout the intervention; cervical cancer screening and treatment increased significantly, from 11.5% to 56% (aOR 9.85, p<0.001) and HIV testing in the last 3 months increased from 26.3% to 73.3% (aOR 7.25, p<0.001). The proportion of sex workers using any SRH service in the past year doubled from 25.7% to 51.4% (aOR 2.91, p<0.001). Service statistics showed similar trends. The FGDs and key informant interviews showed that women and stakeholders held high levels of satisfaction with the strategy, and affirmed potential for scale up.

Conclusion

The DIFFER strategy demonstrated that SRH service uptake can occur in conjuction with HIV services offered to sex workers. This model of integrated service delivery has been accepted by policy makers and needs further analysis for scaling up.

Characterizing the Influence of Structural Determinants of HIV Risk on Consistent Condom Use Among Female Sex Workers in Senegal

BACKGROUND

Female sex workers (FSWs) are disproportionately affected by HIV even in the most generalized HIV epidemics. Although structural HIV risks have been understood to affect condom negotiation among FSWs globally, there remain limited data on the relationship between structural determinants of HIV risk, including violence and socioeconomic status, and condom use among FSWs across sub-Saharan Africa. Here, we describe the prevalence of structural determinants and their associations with condom use among FSWs in Senegal.

METHODS

In 2015, 758 FSWs >18 years of age were recruited using respondent driven sampling in Senegal. Data on individual, community, network, and structural-level risks were collected through an interviewer-administered questionnaire. Poisson regression with robust variance estimation was used to model the associations of consistent condom use (CCU) and selected structural determinants.

RESULTS

The respondent driven sampling-adjusted prevalence of CCU in the last 10 sexual acts was 76.8% [95% confidence interval (CI): 70.8 to 82.8]. Structural determinants that were significantly associated with lower CCU were as follows: physical violence [adjusted prevalence ratio (aPR): 0.71; 95% CI: 0.52 to 0.98]; working primarily in a hotel or guest house (aPR: 0.85; 95% CI: 0.73 to 0.99); and difficultly accessing condoms (aPR: 0.72; 95% CI: 0.52 to 0.96). High income from sex work (aPR: 1.23; 95% CI: 1.04 to 1.46) was significantly associated with higher CCU.

CONCLUSIONS

Taken together, these data highlight the role of structural risk determinants on condom use among FSWs in Senegal. Moreover, these results highlight the need for structural interventions, including safe working spaces and violence mitigation programs, to support condom negotiation and access. Combined with condom distribution programs, structural interventions could ultimately increase condom use among FSWs in Senegal.

Sex work stigma and non-disclosure to health care providers: data from a large RDS study among FSW in Brazil

Background

Stigma in health services may be detrimental to health seeking attitudes and practices. This study investigates non-disclosure of sex work to health care providers among female sex workers (FSW) in Brazil and its association with the utilization of health care services.

Methods

This study used cross-sectional respondent-driven sampling, carried out in 12 Brazilian cities to identify HIV risk behaviors among FSW. We first assessed statistical associations of sociodemographic, human right violations, health service access and utilization, and discrimination variables with non-disclosure of FSW status to health care providers as outcome. Secondly, we investigated the association of non-disclosure of FSW status with selected preventive health care outcomes: HIV testing, PAP smear exam, and post-exposure prophylaxis (PEP). Adjusted odds ratio with 95% confidence intervals were calculated by multivariable logistic regressions.

Results

Among 4245 recruited FSW, a high percentage received free condoms (82%) but only 24.4% were counseled on STI. Most FSW used non-specialized public healthcare routinely (62.6%), but only 51.5% had a Pap smear exam in the last two years and less than 40% were tested for HIV in the last 12 months. Among FSW who engaged in risky behavior (49.6%), only 8.3% used PEP. Regarding human rights violations, approximately 15% were required to give part of their earnings to owners of workplace establishments, 38% started sex work under 18 years old and 6% were required to periodically present their HIV test results. 21.3% reported having faced discrimination in health services, and 24.3% always disclosed their FSW status. Multivariable logistic models indicated significant associations of non-disclosure on the four healthcare outcomes, with lower odds of using preventive health services among women who did not disclose their sex work status, even after controlling for age, educational level, NGO affiliation, and type of health care routinely used.

Conclusions

Our results indicate that sex work stigmatization within health services may be one of the main barriers to STI control and HIV response among FSW. It is essential to combat stigmatization and discrimination against FSW in health services to guarantee the appropriate uptake of preventive services available in the public health system in Brazil.

Feasibility, acceptability and potential sustainability of a 'diagonal' approach to health services for female sex workers in Mozambique

Background

Female sex workers (FSWs) in many settings have restricted access to sexual and reproductive health (SRH) services. We therefore conducted an implementation study to test a ‘diagonal’ intervention which combined strengthening of FSW-targeted services (vertical) with making public health facilities more FSW-friendly (horizontal). We piloted it over 18 months and then assessed its performance.

Methods

Applying a convergent parallel mixed-methods design, we triangulated the results of the analysis of process indicators, semi-structured interviews with policy makers and health managers, structured interviews with health care providers and group discussions with peer outreach workers. We then formulated integrated conclusions on the interventions’ feasibility, acceptability by providers, managers and policy makers, and potential sustainability.

Results

The intervention, as designed, was considered theoretically feasible by all informants, but in practice the expansion of some of the targeted services was hampered by insufficient financial resources, institutional capacity and buy-in from local government and private partners, and could not be fully actualised. In terms of acceptability, there was broad consensus on the need to ensure FSWs have access to SRH services, but not on how this might be achieved. Targeted clinical services were no longer endorsed by national government, which now prefers a strategy of making public services more friendly for key populations. Stakeholders judged that the piloted model was not fully sustainable, nor replicable elsewhere in the country, given its dependency on short-term project-based funding, lack of government endorsement for targeted clinical services, and viewing the provision of community activities as a responsibility of civil society.

Conclusions

In the current Mozambican context, a ‘diagonal’ approach to ensure adequate access to sexual and reproductive health care for female sex workers is not fully feasible, acceptable or sustainable, because of insufficient resources and lack of endorsement by national policy makers for the targeted, vertical component.

Effect of a 'diagonal' intervention on uptake of HIV and reproductive health services by female sex workers in three sub-Saharan African cities

OBJECTIVES

To enhance uptake of sexual and reproductive health (SRH) services by female sex workers (FSWs), we conducted an implementation study in which we piloted and tested context-specific 'diagonal' interventions, combining vertical, targeted interventions with horizontally improved access to the general health services, in three cities in sub-Saharan Africa.

METHODS

We collected indicators of SRH service uptake through face-to-face interviews with approximately 400 FSWs, pre- and post-intervention, in Durban, South Africa; Tete, Mozambique; and Mombasa, Kenya, recruited by respondent-driven sampling. Changes in uptake were tested for their statistical significance using multivariate logistic regression models.

RESULTS

In all cities, overall uptake of services increased. Having used all services for contraception, STI care, HIV testing, HIV care, cervical cancer screening and sexual violence, if needed, increased from 12.5% to 41.5% in Durban, 25.0% to 40.1% in Tete and 44.9% to 69.1% in Mombasa. Across cities, the effect was greatest in having been tested for HIV in the past six months which increased from 40.9% to 83.2% in Durban, 56.0% to 76.6% in Tete and 70.9% to 87.6% in Mombasa. In Tete and Mombasa, rise in SRH service use was almost entirely due to a greater uptake of targeted services. Only in Durban was there additionally an increase in the utilisation of general health services.

CONCLUSION

SRH service utilisation improved in the short-term in three different sub-Saharan African contexts, primarily through vertical, targeted components. The long-term effectiveness of diagonal approaches, in particular on the use of general, horizontal health services, needs further investigation.

Impact of a "Diagonal" Intervention on Uptake of Sexual and Reproductive Health Services by Female Sex Workers in Mozambique: A Mixed-Methods Implementation Study

Background

Female sex workers (FSWs) have high risks for adverse sexual and reproductive health (SRH) outcomes, yet low access to services. Within an implementation research project enhancing uptake of SRH services by FSWs, we piloted a “diagonal” intervention, which combined strengthening of FSW-targeted services (vertical) with making public health facilities more FSW-friendly (horizontal), and tested its effect.

Methods

The study applied a convergent parallel mixed-methods design to assess changes in access to SRH services. Results of structured interviews with FSWs pre-intervention (N = 311) and thereafter (N = 404) were compared with the findings of eight post-intervention focus group discussions (FGDs) with FSWs and two with FSW-peer educators (PEs).

Results

Marked and statistically significant rises occurred in consistent condom use with all partners (55.3–67.7%), ever use of female condoms (37.9–54.5%), being tested for HIV in the past 6 months (56.0–76.6%), using contraception (84.5–95.4%), ever screened for cervical cancer (0.0–16.9%) and having ≥10 contacts with a PE in the past year (0.5–24.45%). Increases mostly resulted from FSW-targeted outreach, with no rise detected in utilization of public health facilities. FGD participants reported that some facilities had become more FSW-friendly, but barriers such as stock-outs, being asked for bribes and disrespectful treatment persisted.

Conclusion

The combination of expanding FSW-targeted SRH services with improving access to the public health services resulted in an overall increased uptake of services, but almost exclusively because of the strengthened targeted (vertical) outreach services. Utilization of public SRH services had not yet increased and many barriers to access remained. Our diagonal approach was thus only successful in its vertical component. Improving access to the general health services remains nevertheless important and further research is needed how to reduce barriers. Ideally, the combination approach should be maintained and more successful approaches to increase utilization of public services should be explored.

Sexual and reproductive health services utilization by female sex workers is context-specific: results from a cross-sectional survey in India, Kenya, Mozambique and South Africa

BACKGROUND

Female sex workers (FSWs) are extremely vulnerable to adverse sexual and reproductive health (SRH) outcomes. To mitigate these risks, they require access to services covering not only HIV prevention but also contraception, cervical cancer screening and sexual violence. To develop context-specific intervention packages to improve uptake, we identified gaps in service utilization in four different cities.

METHODS

A cross-sectional survey was conducted, as part of the baseline assessment of an implementation research project. FWSs were recruited in Durban, South Africa (n = 400), Mombasa, Kenya (n = 400), Mysore, India (n = 458) and Tete, Mozambique (n = 308), using respondent-driven sampling (RDS) and starting with 8-16 'seeds' identified by the peer educators. FSWs responded to a standardised interviewer-administered questionnaire about the use of contraceptive methods and services for cervical cancer screening, sexual violence and unwanted pregnancies. RDS-adjusted proportions and surrounding 95% confidence intervals were estimated by non-parametric bootstrapping, and compared across cities using post-hoc pairwise comparison tests with Dunn-Šidák correction.

RESULTS

Current use of any modern contraception ranged from 86.2% in Tete to 98.4% in Mombasa (p = 0.001), while non-barrier contraception (hormonal, IUD or sterilisation) varied from 33.4% in Durban to 85.1% in Mysore (p < 0.001). Ever having used emergency contraception ranged from 2.4% in Mysore to 38.1% in Mombasa (p < 0.001), ever having been screened for cervical cancer from 0.0% in Tete to 29.0% in Durban (p < 0.001), and having gone to a health facility for a termination of an unwanted pregnancy from 15.0% in Durban to 93.7% in Mysore (p < 0.001). Having sought medical care after forced sex varied from 34.4% in Mombasa to 51.9% in Mysore (p = 0.860). Many of the differences between cities remained statistically significant after adjusting for variations in FSWs' sociodemographic characteristics.

CONCLUSION

The use of SRH commodities and services by FSWs is often low and is highly context-specific. Reasons for variation across cities need to be further explored. The differences are unlikely caused by differences in socio-demographic characteristics and more probably stem from differences in the availability and accessibility of SRH services. Intervention packages to improve use of contraceptives and SRH services should be tailored to the particular gaps in each city.