Occupational barriers to HIV care in female sex workers living with HIV: structural or community solutions?

Determinants of Intention to Use HIV Pre-exposure Prophylaxis and Condom Use Among a Sample of Cisgender Female Sex Workers Working Mostly Outdoors in Madrid, Spain

There is scant knowledge regarding pre-exposure prophylaxis (PrEP) use among female sex workers (FSWs) in Europe. Spain recognized FSWs as a population at high risk of acquiring HIV and granted them subsidized access to PrEP when the medication first became nationally available in 2019. Nevertheless, FSWs represented just 0.2% of PrEP users in 2022. A total of 102 HIV-negative FSWs reached through field activities of local NGOs located in Madrid were interviewed between January and March 2022. Participants were selected through convenience sampling over a fixed recruitment period. FSWs completed a 73-item survey with questions about individual, occupational, social, and structural determinants. The objective of this study was to identify (1) the prevalence of intention to use oral PrEP and its determinants, and (2) the prevalence of inconsistent condom use, which is the risk factor that qualifies FSWs for subsidized PrEP in the national health system, and its determinants. Importantly, the study sample overrepresented street-based FSWs (71.6%). A quarter (25.5%) of the study participants used condoms inconsistently. PrEP awareness was low (9.8%), but intention to use PrEP was high (72.5%). Intention to use oral PrEP was significantly associated with feeling protected against HIV by taking PrEP and perceiving insufficient protection by condom use alone. Inconsistent condom use was significantly associated with frequent heroin/cocaine use, having clients who inject drugs, and willingness to take PrEP despite it not protecting 100% against HIV infection. FSWs, in this specific sample, are likely to benefit from targeted PrEP awareness campaigns and implementation projects that prioritize those who use drugs and are more likely to engage in condomless sex.

HIV and associated factors among female sex workers in Tajikistan: Analysis from a national bio-behavioral survey

Tajikistan, a country of approximately nine million people, has a relatively small but quickly growing HIV epidemic. No peer-reviewed study has assessed factors associated with HIV, or associated risk factors, among female sex workers (FSWs) in Tajikistan. The purpose of the current study is to elucidate the factors associated with HIV status and risk factors in the Tajikistani context and add to the scant literature on risk factors among FSWs in Tajikistan and Central Asia. We used cross-sectional data from an HIV bio-behavioral survey (BBS) conducted among FSWs in the Republic of Tajikistan (n = 2174) in 2017. Using Respondent Driven Sampling Analysis Tool software, we calculated the prevalence of HIV, diagnosed cases, linkage to antiretroviral therapy (ART), and the prevalence of syphilis for FSWs in Tajikistan. Prevalence data were adjusted for network size and any clustering effects in the network. Further, using univariate and multivariable logistic regression, we determined correlates of HIV-positive status. Results were as follows: Of all FSWs in Tajikistan, 2.6% (95% CI: 1.7-3.8%) are HIV positive, 2.3% (95% CI: 1.4-3.5%) are diagnosed and aware of their status, and 2.0% (95% CI: 1.2-3.1%) are on ART. About 5.7% (95% CI: 4.5-7.4%) of FSWs in Tajikistan have ever had syphilis, and 0.8% (95% CI: 0.4-1.3%) have active syphilis infections. The epidemic of injection drug use was found to be strongly synergistic with HIV infection as having had sex with a person who injects drugs was shown to be strongly associated with HIV-positive status (OR: 5.2; 95% CI: 2.6-10.2) in the multivariable model. While this study estimates that HIV prevalence among Tajikistani FSWs is relatively low, it is likely an underestimated due to selection and social desirability biases. To curb the small, but potentially volatile, HIV epidemic among FSWs, the government should consider targeted testing and linkage-to-care efforts for FSWs who inject drugs or who have people who inject drugs partners. Services should also be prioritized in Gorno-Badakhshan, which has a higher number of FSWs per capita relative to other regions. Additionally, the link between HIV and experiences of stigma, violence, and discrimination against FSWs should motivate advocates to protect Tajikistani FSWs from these experiences.