Burden and characteristics of HIV infection among female sex workers in Kampala, Uganda - a respondent-driven sampling survey

Examining HIV Knowledge and Sexually Risky Behaviors among Female Sex Workers in Kampala, Uganda

HIV incidence remains alarmingly high among female sex workers (FSWs) in Uganda, necessitating targeted interventions. This study aimed to identify individual and provider-level barriers and facilitators to primary HIV prevention among FSWs in an urban setting. Focus groups involving FSWs and healthcare providers (HCPs) were conducted to inform the development of tailored prevention interventions. Results revealed that all participants had mobile phones, recent sexual activity, and a history of HIV testing, with high rates of sexually transmitted infections and varying HIV test results. FSWs displayed a well-informed awareness of HIV transmission risks, emphasizing the threat for those not testing positive. They unanimously recognized the crucial role of HIV testing in informing, mitigating risks, promoting ART use, and endorsing consistent condom usage. Despite heightened awareness, HCPs noted potential underestimation of vulnerability. Various challenges, including inadequate condom usage, substance abuse, and client dynamics, underscored the complexity of safeguarding against HIV transmission among FSWs. Widespread alcohol and drug use, including marijuana, kuber, and khat, served as coping mechanisms and social facilitators. Some FSWs successfully reduced alcohol intake, highlighting challenges in addressing substance use. FSWs preferred group discussions in health education programs, emphasizing peer interactions and the effectiveness of visual aids in HIV prevention education. This study provides comprehensive insights to guide the development of targeted interventions addressing the multi-faceted challenges FSWs face in HIV prevention.

Sexual pleasure and HIV-related worry in female sex workers on oral pre-exposure prophylaxis in south-western Uganda

BACKGROUND

Female sex workers (FSWs) contribute disproportionately to HIV transmission in Uganda, and pre-exposure prophylaxis (PrEP) is effective in preventing HIV among cisgender women. Psychological factors are important for PrEP uptake, but few studies have examined psychosocial changes due to PrEP use in Uganda.

METHODS

In 2021, we recruited 524 FSWs in three Trans-African Highway towns and four fishing communities in south-western Uganda. We conducted structured interviews among women who were attending routine PrEP follow-up visits in six health units. Bivariable and multivariable modified regression using a robust covariance matrix estimator were used to identify factors associated with experiencing increased sexual pleasure and less worry about HIV because of PrEP.

RESULTS

Overall, 80.9% participants reported that sex was more pleasurable because of taking PrEP. There were statistical trends for sex being more pleasurable when taking PrEP or when having condomless sex with casual paying partners (aPR=1.19, 95% CI=1.07-1.32, P =0.001). Almost three-quarters of the participants (76.3%) were less worried about getting HIV because of PrEP. Condomless sex with casual paying partners (aPR=1.17, 95% CI=1.05-1.31, P =0.032, P =0.003) and being On PrEP for the past 1-2years (aPR=1.18, 95% CI=1.00-1.38, P =0.032) was significantly associated with HIV-related worry (aPR=1.17, 95% CI=1.05-1.31, P =0.032, P =0.003) Conclusions : We found a positive impact of PrEP in Ugandan FSWs on two key psychosocial dimensions: (1) more pleasurable sex; and (2) less worry about acquiring HIV. Interventions aiming to increase PrEP uptake may find it useful to focus on psychosocial dimensions.

HIV treatment cascade among female sex workers in Ethiopia: Assessment against the UNAIDS 90-90-90 targets

BACKGROUND

HIV treatment cascades for HIV-positive female sex workers (FSWs) have been challenged by the overlapping stigma and discrimination associated with both their sex work and HIV status. This study aims to assess the proportion of HIV-positive FSWs who access care and treatment in Ethiopia.

METHOD

A cross-sectional study with a respondent-driven sampling technique was used to enroll 6,085 female sex workers from January to June 2020. Interviews were conducted to assess the FSWs' HIV status awareness and access to ART. A blood sample was drawn to determine the current HIV status and viral load level. Logistic regression was run to identify factors associated with FSWs' HIV status awareness.

RESULTS

Of the total 1140 HIV-positive FSWs, 50.38% knew they were HIV positive; 92.88% of those who knew their status were on ART, and 91.68% of those on ART had attained viral suppression of less than 1000 copies per milliliter. The adjusted odds of knowing HIV status was 3.20 (95% CI; 2.00, 5.13) among those aged 35 years and older, 1.81 (95% CI; 1.05, 3.12) among widowed, and 1.73 (95% CI; 1.28, 2.32) in those who did not perceive the risk of HIV acquisition.

CONCLUSION

Only about half of HIV-positive FSWs knew they were HIV positive. More than 90% of those who knew their status were put on ART and achieved viral suppression. The weakest point in achieving HIV control among FSWs is the identification of those living with HIV.

Estimating prevalence and modelling correlates of HIV test positivity among female sex workers, men who have sex with men, people who inject drugs, transgender people and prison inmates in Sierra Leone, 2021

Key populations (KPs) are particularly vulnerable to HIV infection and efforts to prevent HIV infections among KPs have been less successful, largely due to existing laws and legislation that classify the groups as illegal. Understanding the HIV infection pathway and the burden of HIV infection among Female Sex Workers (FSWs), Transgender people (TG), Men who have sex with Men (MSM), People who Inject Drugs (PWID), and Prison Inmates (PIs) is critical to combatting the HIV epidemic globally. This study aims to estimate HIV prevalence and model the risk factors of HIV positivity rate among the aforementioned KPs in Sierra Leone. This study used Time Location Sampling, Respondent Driven Sampling (RDS), and Conventional cluster Sampling designs to generate a representative sample of FSWs, MSM, TG, PI, and PWID. HIV prevalence and the corresponding 95% confidence intervals among each KP were estimated by adjusting for sampling weight using the logit-transformed confidence intervals. To determine correlates of HIV test positivity among KPs, a multivariable modified Poisson regression model that adjusts for RDS survey weights was used and sensitivity analysis was conducted using a multivariable logistic regression model with cluster robust standard errors. The prevalence of HIV among FSWs in the six regional headquarter towns was estimated to be 11.8% (95% CI: 7.9-17.1); MSM was 3.4% [95% CI: 1.9-5.8]; TGs was 4.2% (95% CI: 2.9-6.1); PWIDs was 4.2% (95% CI: 2.7-6.4) and PI was 3.7% (95% CI: 1.4-9.6). The correlates of HIV test positivity among KPs and PIs include HIV-related knowledge, marital status, district, income, age and sex of KP, level of education, alcohol intake, injecting drugs, and use of lubricants. HIV prevalence is relatively high among FSWs, MSMs, PWID, and TGs as compared to the previous estimate of the general population. There is a need to scale up and strengthen evidence-based HIV prevention interventions such Pre-Exposure Prophylaxis and needle and syringe exchange programmes targeting KPs, including prison inmates. Government must scale up both non-clinical and clinical routine HIV and STI testing and counseling services at the correctional center and drop-in centers for KPs screening/testing, and ensure that services are responsive to the needs of KP.

Nutritional status and its associated factors among commercial female sex workers in Hawassa city, south Ethiopia

Background

Commercial female sex workers (CFSWs) regularly or occasionally trade sex for money. Sex work is widespread, mainly in urban areas of Ethiopia. The study on the nutritional status of CFSWs is unavailable in Ethiopia, and data are also scanty at the global level. This study aims to assess nutritional status and associated factors among CFSWs in Hawassa city, Ethiopia.

Methods

This cross-sectional study used facility-based mixed data collection methods (qualitative and quantitative). The study was conducted in three key population clinics in Hawassa city. A total of 297 CFSWs were randomly selected for the 'quantitative survey,' and twelve (n = 12) purposively selected participants were involved in the 'qualitative study.' Body mass index/BMI (Kg/m2) was used in assessing the nutritional status of CFSWs. Statistical software packages were used for analyzing both quantitative and qualitative data. Significant variables (P<0.05) in bivariate analysis (Chi-square test) were incorporated in the multivariable analyses. Multinomial logistic regression (MNLR) was employed where dependable variable like 'normal BMI' (18.5-24.9 kg/m2) was set as a reference category and simultaneously compared with 'underweight' (<18.5 BMI) and 'overweight/obesity' (≥ 25 BMI) categories. Thus, two models, namely the underweight model (model-1: Underweight versus normal BMI) and the overweight/obesity model (model-2: overweight/obesity versus normal), were generated.

Results

The prevalence of underweight and overweight/obesity among CFSWs in Hawassa city were respectively 14.1% and 16.8%. Living alone (Adjusted odds ratio/AOR = 0.18), chewed Khat regularly (AOR = 0.23), used drugs regularly (AOR = 10.57), used drugs in exchange of sex (AOR = 4.97), and HIV positive status (AOR = 21.64) were significantly (P < 0.05) associated with underweight (model-1). In the overweight/obesity model-2, having jobs other than sex work (AOR = 0.11), higher daily mean income (AOR = 3.02), being hotel/home-based CFSWs (AOR = 12.35), and presence of any chronic illness (AOR = 5.15) were significant (P < 0.05) predictors of overweight/obesity. From the 'qualitative part' of this study, it was also revealed that 'lack of food and money' was the main influencing factor among CFSWs to enter into the sex business.

Conclusions

Commercial female sex workers in this study faced a double burden of malnutrition. Multiple factors influenced their nutritional status. Substance abuse and HIV-positivity are the most significant predictors of being underweight and having higher income, being hotel/home-based CFSWs, and suffering from any chronic illness are associated with overweight/obesity. Government and other partners should be essential in providing comprehensive programs focusing on sexual, reproductive health, and nutrition education. Steps should be taken to improve their socioeconomic status and strengthen those good initiatives at key population clinics and other health facilities.

Limited awareness of HIV Status hinders uptake of treatment among female sex workers and sexually exploited adolescents in Wau and Yambio, South Sudan

BACKGROUND

Several factors determine uptake of HIV testing services (HTS) by female sex workers (FSW), including their knowledge of HIV and their awareness of services supporting people who are HIV-positive. HTS provided entry into the UNAIDS 90-90-90 cascade of care. We conducted a cross-sectional biobehavioural survey (BBS) to determine HIV prevalence and progress towards UNAIDS 90-90-90 cascade targets among this population in South Sudan.

METHODS

Respondent-driven sampling (RDS) was used to recruit women and sexually exploited girls aged 13-18 years who exchanged sex for goods or money in the past 6 months and resided in the town for at least 1 month. Consenting participants were interviewed and tested for HIV and, if positive, they were also tested for their viral load (VL). Data were weighted in RDS Analyst and analyzed with Stata 13.

RESULTS

A total of 1,284 participants were recruited. The overall HIV cascade coverages were 64.8% aware of their HIV-positive status; 91.0% of those aware of their positive status were on ART; and VL suppression among those on ART was 93.0%.

CONCLUSION

Being unaware of their HIV-positive status limits, the uptake of HIV treatment among FSW in South Sudan. This underscores the importance of optimized case-finding approaches to increase HTS among FSW and sexually exploited minors.

Enrollment and retention of female sex workers in HIV care in health facilities in Mbarara city

Background

Sex work is a global driver of the HIV epidemic, and the risk of acquiring HIV is 13 times higher for female sex workers (FSWs) compared to the general population. The enrollment and retention of FSWs in HIV care is a challenge and has been a major contributing factor to increased new HIV infections.

Methods

We conducted a qualitative study among 30 FSWs and 21 healthcare workers (HCWs) working in antiretroviral therapy (ART) clinics at the selected three primary health facilities in Mbarara City, Southwestern Uganda. The study participants were enrolled by both purposive and snowball sampling techniques. We obtained informed consent from all the participants, and data were collected using in-depth interviews and thematically analyzed.

Results

Three themes emerged as facilitators toward enrollment and retention of FSWs into HIV care, namely, (1) good health living, (2) receptive HCWs and availability of health services, and (3) community outreach services and peer support. The barriers are summarized into four major themes: (1) stigma, community discrimination, and beliefs; (2) social obstacles; (3) adverse effects of ART; and (4) inadequate services at the health facilities.

Conclusion

FSWs are challenged by unsupportive environments and communities where they live and work, which hinders their enrollment and retention in HIV care. Creating awareness of the utilization of HIV care services and extending such services to hotspot communities could enhance the response of HIV-positive FSWs to ART.

High HIV and syphilis prevalence among female sex workers and sexually exploited adolescents in Nimule town at the border of South Sudan and Uganda

HIV prevalence among the general population in South Sudan, the world's newest country, is estimated at 2.9% and in Nimule, a town at the border with Uganda, it is estimated at 7.5%. However, there is limited data describing the HIV epidemic among female sex workers and sexually exploited adolescents (FSW/SEA) in the country. This study was conducted using a respondent-driven sampling (RDS) among FSW/SEA aged ≥15 years in January-February 2017 who sold or exchanged sex in the last six months in Nimule. Consenting participants were administered a questionnaire and tested for HIV according to the national algorithm. Syphilis testing was conducted using SD BIOLINE Syphilis 3.0 and Rapid Plasma Reagin for confirmation. Data were analyzed in SAS and RDS-Analyst and weighted results are presented. The 409 FSW/SEA participants with a median age of 28 years (IQR 23-35) and a median age of 23 years (IQR 18-28) when they entered the world of sex work, were enrolled in the Eagle survey. Nearly all (99.2%) FSW/SEA lacked comprehensive knowledge of HIV though almost half (48.5%) talked to a peer educator or outreach worker about HIV in the last 30 days. More than half (55.3%) were previously tested for HIV. Only 46.4% used a condom during their last vaginal or anal sexual act with a client. One in five (19.8%) FSW/SEA experienced a condom breaking during vaginal or anal sex in the last six months HIV prevalence was 24.0% (95% CI: 19.4-28.5) and 9.2% (95% CI: 6.5-11.9) had active syphilis. The multivariable analysis revealed the association between HIV and active syphilis (aOR: 6.99, 95% CI: 2.23-21.89). HIV and syphilis prevalence were higher among FSW/SEA in Nimule than the general population in the country and Nimule. Specifically, the HIV prevalence was eight times higher than the general population. Our findings underscore the importance of providing HIV and syphilis testing for FSW/SEA in conjunction with comprehensive combination prevention, including comprehensive HIV information, promotion of condom use, and availing treatment services for both HIV and syphilis.

HIV, sexual violence, and termination of pregnancy among adolescent and adult female sex workers in Malawi: A respondent-driven sampling study

Female Sex Workers (FSWs) are a hard-to-reach and understudied population, especially those who begin selling sex at a young age. In one of the most economically disadvantaged regions in Malawi, a large population of women is engaged in sex work surrounding predominantly male work sites and transport routes. A cross-sectional study in February and April 2019 in Nsanje district used respondent driven sampling (RDS) to recruit women ≥13 years who had sexual intercourse (with someone other than their main partner) in exchange for money or goods in the last 30 days. A standardized questionnaire was filled in; HIV, syphilis, gonorrhea, and chlamydia tests were performed. CD4 count and viral load (VL) testing occurred for persons living with HIV (PLHIV). Among 363 study participants, one-quarter were adolescents 13-19 years (25.9%; n = 85). HIV prevalence was 52.6% [47.3-57.6] and increased with age: from 14.7% (13-19 years) to 87.9% (≥35 years). HIV status awareness was 95.2% [91.3-97.4], ART coverage was 98.8% [95.3-99.7], and VL suppression 83.2% [77.1-88.0], though adolescent FSWs were less likely to be virally suppressed than adults (62.8% vs. 84.4%). Overall syphilis prevalence was 29.7% [25.3-43.5], gonorrhea 9.5% [6.9-12.9], and chlamydia 12.5% [9.3-16.6]. 72.4% had at least one unwanted pregnancy, 17.9% had at least one abortion (40.1% of which were unsafe). Half of participants reported experiencing sexual violence (SV) (47.6% [42.5-52.7]) and more than one-tenth (14.2%) of all respondents experienced SV perpetrated by a police officer. Our findings show high levels of PLHIV-FSWs engaged in all stages of the HIV cascade of care. The prevalence of HIV, other STIs, unwanted pregnancy, unsafe abortion, and sexual violence remains extremely high. Peer-led approaches contributed to levels of ART coverage and HIV status awareness similar to those found in the general district population, despite the challenges and risks faced by FSWs.

Self-reported and pill count measures of adherence to oral HIV PrEP among female sex workers living in South-Western Uganda

Background

Female sex workers (FSWs) in Uganda are at high risk of HIV infection. Scaling up oral pre-exposure prophylaxis (PrEP) will reduce HIV incidence if high levels of adherence are maintained. This study evaluates PrEP adherence using clinic-based pill counts and self-reported measures, and factors associated with protective levels of adherence.

Methods

Participants were sex workers who had been taking PrEP for at least 5 months and were attending routine follow-up visits for PrEP care in fishing communities and along the Trans-African Highway. Participants who had a pill count showing at least 85% use since their last clinic visit and those who reported taking their PrEP every day in the last 5 months were categorised as having ‘protective adherence’. Spearman’s correlation and weighted kappa assessed the relationship between pill count and self-reported measures. Bivariate and multivariate logistic regression was used to determine factors associated with protective adherence as measured by pill count.

Results

We recruited 524 FSWs, with a median age of 29 years (IQR 23–35). Participants were recruited from fishing communities and Trans-African Highway towns (n = 297, 56.7%, and n = 227, 43.0%). Nearly three quarters (n = 372, 71.0%) of women were estimated to have protective adherence based on pill count (i.e., a pill count of >85%) and 50.4% by self-report in last 3 months. There was a strong positive association between self-reported measures and pill count measures (rest = 0.6453, 95% CI = 0.5924–0.6927) and a moderate agreement between self-reported measures and pill count measures, κ = 0.544 (95%CI = 0.4869–0.6011, p < 0.001).

Factors associated with protective adherence included being aged 35 years or older (aOR = 2.40, 95% CI = 1.17–4.86), living in a fishing community (aOR = 1.45, 95% CI = 0.62–3.38), and having an STI in last 3 months (aOR = 1.64, 95% CI = 1.07–2.49).

Conclusion

Our findings indicate that PrEP-experienced FSWs attending clinical follow-up visits reported high protective levels of oral pre-exposure prophylaxis, as measured by both pill count and self-reported measures, and a moderate agreement between pill count and self-reported measures.

Prevalence and predictors of HIV and sexually transmitted infections among vulnerable women engaged in sex work: Findings from the Kyaterekera Project in Southern Uganda

INTRODUCTION

Women engaged in sex work (WESW) have an elevated risk of the human immunodeficiency virus (HIV) and sexually transmitted infections (STI). Estimates are three times higher than the general population. Understanding the predictors of HIV and STI among WESW is crucial in developing more focused HIV and STI prevention interventions among this population. The study examined the prevalence and predictors of HIV and STI among WESW in the Southern part of Uganda.

METHODOLOGY

Baseline data from the Kyaterekera study involving 542 WESW (ages 18-55) recruited from 19 HIV hotspots in the greater Masaka region in Uganda was utilized. HIV and STI prevalence was estimated using blood and vaginal fluid samples bioassay. Hierarchical regression models were used to determine the predictors of HIV and STI among WESW.

RESULTS

Of the total sample, 41% (n = 220) were found to be HIV positive; and 10.5% (n = 57) tested positive for at least one of the three STI (Neisseria gonorrhoeae, Chlamydia trachomatis and Trichomonas vaginalis) regardless of their HIV status. Older age (b = 0.09, 95%CI = 0.06, 0.13, p≤0.001), lower levels of education (b = -0.79, 95%CI = -1.46, -0.11, p≤0.05), fewer numbers of children in the household (b = -0.18, 95%CI = -0.36, -0.01), p≤0.05), location (i.e., fishing village (b = 0.51, 95%CI = 0.16, 0.85, p≤0.01) or small town (b = -0.60, 95%CI = -0.92, -0.28, p≤0.001)), drug use (b = 0.58, 95%CI = 0.076, 1.08, p≤0.05) and financial self-efficacy (b = 0.05, 95%CI = -0.10, 0.00, p≤0.05), were associated with the risk of HIV infections among WESW. Domestic violence attitudes (b = -0.24, 95%CI = -0.42, -0.07, p≤0.01) and financial distress (b = -0.07, 95%CI = -0.14, -0.004, p≤0.05) were associated with the risk of STI infection among WESW.

CONCLUSION

Study findings show a high prevalence of HIV among WESW compared to the general women population. Individual and family level, behavioural and economic factors were associated with increased HIV and STI infection among WESW. Therefore, there is a need for WESW focused HIV and STI risk reduction and economic empowerment interventions to reduce these burdens.

HIV prevalence and associated factors among female sex workers in Ethiopia, east Africa: A cross-sectional study using a respondent-driven sampling technique

BACKGROUND

HIV acquisition among Female Sex Workers (FSWs) is 30 times higher than the acquisition rate among females in the respective general population. A higher HIV burden in FSWs challenges the prevention and control of the virus in other population groups. However, there is inadequate evidence on the burden of HIV among FSWs in Ethiopia. This study was conducted to assess the extent of HIV and associated factors among FSWs in the country.

METHODS

This was a cross-sectional study that involved a total of 6,085 FSWs. The participants were selected using a respondent-driven sampling technique (RDS). FSWs who lived at the study sites for at least a month before the study time were considered eligible for recruitment. The study was conducted from January 01 to June 30, 2020 in 16 cities across Ethiopia. A mixed-effect logistic regression model was applied to determine factors associated with HIV positivity.

FINDINGS

The pooled HIV prevalence among FSWs in this study was 18·7% (95% CI: 17·8, 19·7) with considerable variation across cities. The highest HIV prevalence was observed in Bahir Dar city, 28·2% (95% CI: 23·9, 33.0) and the lowest was seen in Shashemene city, 14.0% (95% CI: 10·2, 18·9). The odds of HIV positivity in FSWs was associated with being older than 35 years of age (AOR = 8·1; 95% CI: 6·1, 10·3), reactive for Treponema Pallidum (AOR = 2·6; 95% CI: 1·0, 3·4), being widowed (OR = 2·2; 95% CI: 1·6, 2·9), not able to read and write (OR = 2·0; 95% CI: 1·5, 2·4), incidence of condom breakage (OR = 1·5; 95% CI: 1·2, 1·7) and having a history of STIs (OR = 1·3; 95% CI: 1·1, 1·6).

INTERPRETATION

One in five FSWs was HIV positive. HIV prevalence was higher in the older age groups and in those who were positive for Treponema Pallidum (Syphilis). The findings indicated the importance of strengthening HIV prevention and control in FSWs to achieve the national goal to eliminate HIV by 2030.

FUNDING

The study was supported by The Ethiopian Ministry of Health through the Federal HIV/AIDS Prevention and Control Office.

Factors associated with adherence to HIV testing guidelines among HIV-negative female sex workers in Kampala, Uganda

Background

Frequent human immunodeficiency virus (HIV) testing is recommended among female sex workers. This study examined the extent to which HIV-negative female sex workers (FSWs) in Kampala adhere to the HIV testing guidelines, and identified associated factors.

Methods

This cross-sectional study used a simple random sampling method to select 12 sex work hotspots. Two hundred participants were allocated proportionally in each hotspot. Frequencies were used to describe categorical characteristics of FSWs, and a multivariable logistic regression model was used to determine the factors associated with adherence to the HIV testing guidelines.

Results

Eighty-eight percent of the 200 study participants reported their HIV testing status; of these, 56% had tested three or more times in the 12 months preceding the survey. Attaining a secondary education was associated with adherence to the HIV testing guidelines [odds ratio (OR) 1.86, 95% confidence interval (CI) 1.01-3.44; P=0.047]. Sexually transmitted infection testing in the preceding 3 months (OR 2.13, 95% CI 0.95-4.74; P=0.065) and accessing HIV testing at a drop-in centre (OR 5.90, 95% CI 0.71-49.1; P=0.101) were associated with higher odds of adherence to the HIV testing guidelines.

Conclusion

Adherence to the HIV testing guidelines was suboptimal, indicating the need to scale up interventions to improve access to HIV testing, including rigorous behaviour change communication.

At the intersection of sexual and reproductive health and HIV services: use of moderately effective family planning among female sex workers in Kampala, Uganda

Background

Female sex workers are vulnerable to HIV, sexually transmitted diseases, and unintended pregnancies; however, the literature on female sex workers (FSW) focuses primarily on HIV and is limited regarding these other health issues.

Methods

We conducted a respondent-driven sampling (RDS) survey during April-December 2012 to characterize the reproductive health of and access to contraceptives FSW in Kampala, Uganda. Eligibility criteria included age ≥ 15 years, residence in greater Kampala, and having sold sex to men in ≤ 6 months. Data were analyzed using RDS-Analyst. Survey logistic regression was used in SAS.

Results

We enrolled 1,497 FSW with a median age of 27 years. Almost all FSW had been pregnant at least once. An estimated 33.8% of FSW were currently not using any form of family planning (FP) to prevent pregnancy; 52.7% used at least moderately effective FP. Among those using FP methods, injectable contraception was the most common form of FP used (55.4%), followed by condoms (19.7%), oral contraception (18.1%), and implants (3.7%). HIV prevalence was 31.4%, syphilis prevalence was 6.2%, and 89.8% had at least one symptom of a sexually transmitted disease in the last six months. Using at least a moderately effective method of FP was associated with accessing sexually transmitted disease treatment in a stigma-free environment in the last six months (aOR: 1.6, 95% CI: 1.1–2.4), giving birth to 2–3 children (aOR: 2.5, 95% CI: 1.4–4.8) or 4–5 children (aOR: 2.9, 95% CI: 1.4–5.9). It is plausible that those living with HIV are also less likely than those without it to be using a moderately effective method of FP (aOR: 0.7, 95% CI: 0.5–1.0).

Conclusions

The provision of integrated HIV and sexual and reproductive health services in a non-stigmatizing environment has the potential to facilitate increased health service uptake by FSW and decrease missed opportunities for service provision.

Male partners of female sex workers: The intersectional risk environment of HIV/AIDS in a Kampala informal settlement

AIM

This study examined the context and drivers of HIV risk and vulnerability among male partners of female sex workers in Kampala, Uganda, using an "intersectional risk environment" framework.

METHODS

This research reports on findings from an ethnographic study (2016-2019) of men in one informal settlement in Kabalagala Parish in Kampala. This research included long-term participant observation in and around the study community. Thematic analysis was used to assess aspects of the risk environment and how it influences HIV/AIDS among male partners of female sex workers.

RESULTS

The informal settlement context where sex work takes place is conceptualized here as a "risk environment," or a social-physical space in which risk and harm are produced (Rhodes, 2002). Risk is situated within a broader social and political structure that constrains choices and facilitates HIV risk, particularly for young, low-income men facing matrices of domination on the basis of age, gender, residence, and income. These intersectionalities guide experiences of HIV vulnerability in the risk environment, including physical, social, economic, and policy risks. This includes physical risks (population density, bar density), social risks (sex work, bar groups), economic risks (informal and low wage work), and political risks (anti-poverty laws and legislation, urban policy).

CONCLUSION

These findings highlight how an intersectional risk environment is differentially experienced by young, low-income men to produce unequal HIV/AIDS outcomes. This research fills a gap in the literature on the context of HIV/AIDS among men, particularly high-risk men like male partners of female sex workers. Using this framework will improve understandings of HIV outcomes among male partners of female sex workers and will facilitate context-specific and adapted structural interventions for HIV/AIDS prevention and treatment.

Understanding how social support influences peer-delivered HIV prevention interventions among Ugandan female sex workers: a case study from HIV self-testing

BACKGROUND

Female sex workers (FSWs) have tightly connected peer networks and remain at high risk of HIV acquisition. Peer delivery of HIV prevention interventions, such as HIV self-testing (HIVST), is a recommended implementation strategy for increasing intervention uptake and continuation among FSWs. We analyzed qualitative data from a peer-delivered HIVST intervention among FSWs in urban Uganda to understand the ways social support within this peer network can motivate or discourage the uptake of peer-delivered HIVST.

METHODS

Between February and April 2017, we conducted in-depth interviews (IDIs) with FSWs (n = 30) and focus group discussions (FGDs) with FSW peer educators (PEs, n = 5) finishing participation in a four-month randomized implementation trial testing models of peer-delivered HIVST in Kampala. FSW participants were ≥ 18 years old, self-reported exchanging sex for money or goods (past month) and had not recently tested for HIV (past 3 months). FSW PEs either directly distributed HIVST kits to participants or provided coupons exchangeable for HIVST kits from specified healthcare facilities. In the IDIs and FGDs, we asked participants to share their experiences receiving or delivering peer-delivered HIVST, respectively. Using a hybrid deductive and inductive coding approach, we arranged findings along the dimensions of an established social support theory: informational, instrumental, and emotional support.

RESULTS

The median age of participants was 30 years (IQR: 27-33) and PEs was 33 years (IQR: 29-37). We found that social support within FSW peer networks both motivated and discouraged uptake of peer-delivered HIVST. For example, sharing positive HIVST experiences (informational support), directly delivering HIVST kits (instrumental support), and encouraging linkage to care (emotional support) motivated HIVST uptake among FSWs. Conversely, the spread of misinformation (informational support), limited HIVST kit availability fostering mistrust of PEs (instrumental support), and fear of social exclusion following HIV status disclosure (emotional support) discouraged HIVST uptake among FSWs.

CONCLUSIONS

In Uganda, social support (e.g., informational, instrumental, and emotional support) among FSW peers can work in ways that both motivate and discourage peer-delivered intervention uptake. Future FSW peer-delivered HIV prevention interventions should be designed around the dimensions of social support within FSW peer networks to maximize initial and repeat intervention delivery and uptake.

Transactional sex work and HIV among women in conflict-affected Northeastern Uganda: a population-based study

BACKGROUND

Armed conflict and the HIV pandemic are significant global health issues. Evidence of the association between armed conflict and HIV infection has been conflicting. Our objective was to examine the role of mediating risk factors, such as engagement in transactional sex work, to elucidate the relation between armed conflict and HIV infection.

METHODS

We used multistage sampling across three Northeastern Ugandan districts to randomly select 605 women aged 13 to 49 to answer cross-sectional surveys from January to May of 2016. We used multivariate logistic regression model with R 4.0.3 to examine if exposure to armed conflict has an indirect effect on reporting having an HIV-positive serostatus through engagement in transactional sex work. Age and district residence were included as covariates.

RESULTS

Exposure to armed conflict β = .16, SE = .04, p < .05, OR = 1.17, 95% [CI .08, .23] was significantly associated with reporting a HIV-positive serostatus. For each 1-unit increase in exposure to armed conflict (i.e., additional type of armed conflict exposure), there was a 17% increase in the odds of reporting a HIV-positive serostatus. Engagement in transactional sex work was not associated with reporting a HIV-positive serostatus β = .04, SE = .05, p = .37, 95% [CI - .051, .138]. We found district of residence, age, and interaction effects.

CONCLUSIONS

Although exposure to armed was associated with reporting an HIV-positive serostatus, this relationship was not mediated by engagement in transactional sex. Further research is needed on risk factors that mediate this relationship. The likelihood of reporting a HIV-positive serostatus increased with each additional type of exposure to armed conflict. Thus, screening for exposure to multiple traumatic stressors should occur in HIV prevention settings. Healthcare services that are trauma-informed and consider mental distress would likely improve HIV outcomes.

Factors associated with the uptake of long-acting reversible contraception among female sex workers in post-conflict Northern Uganda: a cross-sectional study

BACKGROUND

Long-acting reversible contraception (LARC) is the most effective and reliable contraception option for female sex workers (FSWs) who desire future fertility. Unlike the other reversible contraceptive methods, LARC use requires only periodic users' involvement at the time of application and re-application. However, only a few studies on LARC uptake among FSWs are available in Uganda. To fill this knowledge gap, we examined factors associated with the uptake of LARC among FSWs in post-conflict Northern Uganda.

METHODS

We conducted a cross-sectional study among adult FSWs operating in the post-conflict Gulu district in Northern Uganda. We collected quantitative data among 280 FSWs of reproductive ages (18-49 years) who were neither pregnant nor using permanent contraception. We utilized a pretested semi-structured questionnaire to gather information from each participant through face-to-face interviews. We collected data on socio-demographic characteristics, sex work-related characteristics, obstetric history, HIV status, and LARC uptake. Data were then entered into EPI INFO 7, cleaned, and analyzed using multivariable Poisson regression in STATA 14.0 to obtained adjusted prevalence ratios (PR).

RESULTS

Among the study participants: the mean age (SD, range) was 26.5 (5.9, 18-45) years, 48.6% reported at least one unintended pregnancy during sex work, and 37.4% had at least one induced abortion. Meanwhile, only less than two in three (58.6%) participants were using LARC. At multivariable level, factors that remained independently associated with LARC uptake included: longer duration of sex work (adjusted PR = 1.44, 95% CI: 1.03-2.02), higher parity (adjusted PR = 1.13, 95% CI: 1.02-1.26), history of unintended pregnancies during sex work (adjusted PR = 1.24 CI: 1.01-1.51), and being a brothel/lodge-based FSWs (adjusted PR = 1.28, 95% CI: 1.01-1.63).

CONCLUSIONS

The above findings revealed a gap in the uptake of LARC among FSWs in post-conflict Northern Uganda influenced by duration of sex work, parity, unintended pregnancies during sex work, and place of sex work. Interventions to improve LARC uptake should target the newly recruited FSWs with low parity and the non-brothel/lodge-based FSWs.

HIV Prevalence and the HIV Treatment Cascade Among Female Sex Workers in Cross-Border Areas in East Africa

In cross-border areas of East Africa, sexual networks include partnerships across resident, migrant, and mobile populations, and risky behaviors can coincide with fragmented health services given the challenges of cross-border coordination. Among those most at risk are female sex workers (FSWs). We map HIV prevalence among FSWs in 14 cross-border areas, estimate associations between FSW characteristics and HIV and undiagnosed HIV, and estimate progress towards the UNAIDS 90-90-90 targets. The 2016-2017 East Africa Cross-Border Integrated Health Study recruited 4040 women; 786 were classified as FSWs. Overall HIV prevalence among FSWs was 10.8% (95% CI 8.2%, 13.3%), though area-specific estimates varied considerably. Among FSWs living with HIV, 46.1% (95% CI 33.2%, 59.0%) knew their status, 80.6% (95% CI 66.3%, 94.9%) of FSWs who knew their status were on ART, and 84.8% (95% CI 66.1%, 100.0%) of FSWs on ART were virally suppressed. Results indicate a need for expanded HIV testing.

Feasibility of oral HIV self-testing in female sex workers in Gaborone, Botswana

BACKGROUND

Oral HIV self-testing (HIVST) may be useful for increasing testing in persons at elevated risk of acquiring HIV.

METHODS

We conducted a pilot study to evaluate the feasibility (defined by uptake) of HIVST among FSW in Gaborone, Botswana. FSW age 18 years and above were recruited through a non-governmental organization serving FSW. FSW with unknown or negative HIV status at screening performed HIVST in the study clinic following brief training. FSW testing HIV-negative were each given two test kits to take home: one kit to perform unassisted HIVST and another to share with others. Feasibility (use) of HIVST (and sharing of test kits with others) was assessed in these women at a study visit four months later.

RESULTS

Two hundred FSW were screened. Their average age was 34 years (range 18-59), and 115 (58%) were HIV-positive. Eighty-five (42%) tested HIV-negative at entry and were eligible to take part in the HIVST pilot study. All 85 (100%) agreed to take home HIVST kits. Sixty-nine (81%) of these 85 participants had a follow-up visit, 56 (81%) of whom reported performing HIVST at a mean of three and half months after the initial visit. All 56 participants who performed HIVST reported negative HIVST results. Fifty (73%) of the 69 participants who took HIVST kits home shared them with others. Of the 50 women sharing HIVST kits, 25 (50%) shared with their non-client partners, 15 with a family member, 8 with friends, and 3 with a client. One participant did not test herself but shared both her test kits. Most participants 53/56 (95%) found oral HIVST very easy to use whilst 3/56 (5%) felt it was fairly easy.

CONCLUSION

Oral HIVST is feasible among FSW in Gaborone, Botswana. The majority of FSW used the HIVST kits themselves and also shared extra HIVST kits with other individuals.

"I felt very small and embarrassed by the health care provider when I requested to be tested for syphilis": barriers and facilitators of regular syphilis and HIV testing among female sex workers in Uganda

Background

Periodic testing of female sex workers (FSW) for sexually transmitted infections (STIs) is a core component of global and national responses to achieve population-level STI elimination. We conducted a qualitative study to explore barriers and facilitators of regular syphilis and HIV testing among FSW in Uganda.

Methods

Within a quasi-experimental study among 436 FSW to assess the effect of peer education and text message reminders on uptake of regular STI and HIV testing among FSW, we conducted 48 qualitative interviews in four cities in Uganda from August–December 2018. We purposively selected FSW who tested for syphilis and HIV every 3–6 months; 12 FSW were interviewed in each city. Sex worker interviews explored: 1) reasons for periodic syphilis and HIV testing; 2) barriers and facilitators of testing; 3) experiences of testing; and 4) challenges faced while seeking testing services. Data were analyzed using thematic content analysis.

Results

Thematic analysis revealed individual- and health system-level barriers and facilitators of testing. For syphilis, barriers were a) interpersonal stigma, low perceived severity of syphilis and testing misconceptions (individual); and b) judgmental provider attitudes, paucity of facilities offering syphilis testing, stockouts of test kits and high cost (health system). Facilitators were c) desire to remain healthy, get married and have children, knowing the benefits of early treatment, influence of male partners/clients and normative testing behaviors (individual); and d) sex worker clinics offering dual syphilis/HIV testing (health system). For HIV, barriers included: a) internalized stigma (individual); and b) unfavorable clinic hours, stigma, discrimination, and unfriendly provider (health system). Facilitators were a) motivations to stay healthy and attract clients, habitual testing, self-efficacy, doubts about accuracy of negative test results, and use of post-exposure prophylaxis (individual); and d) availability of testing facilities (health system). Syphilis and HIV had similar testing barriers and facilitators.

Conclusions

HIV programs are likely to be important entry points for syphilis testing among FSW. Multi-level interventions to address testing barriers should consider focusing on these service delivery points. Extending the dual syphilis and HIV testing approach to FSW may improve testing uptake for both infections at public health facilities and decrease population-level incidence.

Client-perpetrated gender-based violence among female sex workers in conflict-affected Northern Uganda: a cross-sectional study

STUDY OBJECTIVE

To determine the prevalence and associated factors of client-perpetrated gender-based violence among female sex workers in conflict-affected Northern Uganda.

DESIGN AND SETTINGS

We conducted a cross-sectional study among female sex workers in Gulu district in conflict-affected Northern Uganda.

PARTICIPANTS

The study participants included 300 female sex workers aged 18+ years. The participants were selected using simple random sampling from a database of female sex workers maintained at a national non-governmental organisation in Gulu.

OUTCOME MEASURE

The outcome measure was self-reported exposure to client-perpetrated gender-based violence.

METHODS

We used a pretested semistructured questionnaire to collect data on sociodemographic characteristics, sex work-related characteristics, alcohol use, illicit drug use, HIV status and self-reported exposure to client-perpetrated gender-based violence. Then, data were entered into Epi Info V.7 and analysed using Stata V.14.0.

RESULTS

Among participants, 61.0% reported client-perpetrated gender-based violence. Economic (58.7%) and emotional (52.0%) violence were the most common forms of client-perpetrated gender-based violence in this population. Independently, being: street-based (adjusted OR=9.66, 95% CI 2.78 to 33.5), mobile (adjusted OR=3.21, 95% CI 1.83 to 5.64), HIV-positive (adjusted OR=1.90, 95% CI 1.09 to 3.31) and a low-income earner (<USh200 000 monthly) (adjusted OR=2.26, 95% CI 1.18 to 4.30) were positively associated with exposure to client-perpetrated gender-based violence.

CONCLUSIONS

There is a high prevalence of client-perpetrated gender-based violence among female sex workers in conflict-affected Northern Uganda. Furthermore, female sex workers who were street-based, mobile, HIV-positive and low-income earners were more likely to experience client-perpetrated gender-based violence. The ministry of health and the development partners need to provide targeted public health interventions to prevent and manage the rampant gender-based violence among this underserved population.

Adherence to oral HIV pre-exposure prophylaxis among female sex workers in Kampala, Uganda

INTRODUCTION

In Kampala Uganda, female sex workers (FSWs) have high HIV prevalence (33%). Oral PrEP is a novel HIV prevention intervention that offers hope to decrease HIV incidence in key populations especially among FSWs. Studies have shown that with poor adherence, oral PrEP has no efficacy, and therefore adherence to PrEP is critical among FSWs to maximize HIV prevention. However, implementation data on adherence to PrEP among FSWs is limited so this study sought to assess adherence to PrEP. Specifically, we sought to 1) determine the level of adherence to PrEP among FSWs, and 2) determine factors associated with PrEP adherence.

METHODS

This cross-sectional study was conducted from November to December 2018; 126 FSWs using PrEP were interviewed using a questionnaire. Adherence was categorically defined as high adherence and low adherence. Logistic regression was done.

RESULTS

Using long-term contraception methods (OR 0.06, 95% CI: 0.04-0.77) and not using condoms with clients (OR 0.07, 95% CI: 0.01-0.42) were negatively associated with high PrEP adherence.

CONCLUSION

Barriers to PrEP adherence need to be addressed for successful PrEP implementation to improve adherence going forward. Service care providers should reinforce positive behaviors such as use of condoms devotedly during PrEP breaks.

HIV prevalence and associated risk factors among female sex workers in Dar es Salaam, Tanzania: tracking the epidemic

Since 2014, HIV care and treatment services among key populations including female sex workers (FSWs) have intensified in Tanzania. We sought to track the epidemic among FSWs in Dar es Salaam, Tanzania. We conducted a cross-sectional integrated bio-behavioral survey using respondent-driven sampling and a structured questionnaire. Blood was drawn for HIV testing. Modified Poisson regression was used to determine factors associated with HIV infection. We recruited 958 FSWs (median age 26 years) of whom 952 consented to HIV testing. The HIV prevalence was 15.3% (95%CI: 12.5-18.6). Factors associated with higher HIV prevalence included old age (25-34 years: aPR 2.38; 95%CI: 1.23, 4.60 and over 35 years: aPR = 6.08; 95%CI: 3.19, 11.58) and having experienced sexual violence in the past year (aPR = 1.94; 95%CI: 1.34, 2.82). Attaining higher education level was associated with lower HIV prevalence (aPR = 0.51; 95%CI: 0.36, 0.73 for primary school level and aPR = 0.20; 95%CI: 0.08, 0.46 for secondary school level and/or above). The HIV prevalence among FSWs in Dar es Salaam has decreased by half since 2013. Prevention strategies should target older FSWs, aim to educate young girls, and institute approaches to mitigate violence among FSWs.

Mobility study of young women who exchange sex for money or commodities using Google Maps and qualitative methods in Kampala, Uganda

OBJECTIVES

We aimed to assess mobility patterns and reasons for high mobility among young women engaged in sex work within a randomised controlled trial to gauge how mobility may hinder access to health services and enhance HIV risk in a highly vulnerable population.

SETTING

Participants were recruited from a clinic in Kampala, Uganda set up for women at high risk of HIV infection.

PARTICIPANTS

Adolescent girls and young women engaged in sex for money and/or commodities are at particular risk in countries with high HIV prevalence and high fertility rates. High mobility increases exposure to HIV risk. Women participants were eligible for the parent study if aged 15-24 years, HIV negative and engaged in sex work. For this substudy, 34 qualitative interviews were held with 14 sex workers (6 HIV positive, 8 HIV negative), 6 health worker/policy makers, 3 peer educators, 5 'queen mothers' and 6 male partners MEASURES: Participants used Google Maps to identify work venues at 12-month and 18-month study visits. We also conducted 34 interviews on mobility with: high-risk women, male partners, health workers and sex-worker managers. Topics included: distance, frequency and reasons for mobility. We used Python software to analyse mapping data.

RESULTS

Interviews found in depth narratives describing lack of education and employment opportunities, violence, lack of agency, social, sexual and familial support networks and poverty as a complex web of reasons for high mobility among young sex workers.

CONCLUSIONS

Young women at high risk are highly mobile. Reasons for mobility impact access and retention to health services and research activities. Strategies to improve retention in care should be cognisant and tailored to suit mobility patterns.

TRIAL REGISTRATION NUMBER

NCT03203200.

Text message reminders and peer education increase HIV and Syphilis testing among female sex workers: a pilot quasi-experimental study in Uganda

BACKGROUND

Globally, female sex workers (FSW) are disproportionately affected by HIV and other sexually transmitted infections (STIs). However, uptake of STI and HIV testing services among FSW in sub-Saharan Africa remains low. We aimed to assess the effect of FSW-led peer education and text message reminders on 3-monthly syphilis and HIV testing among FSW in Uganda.

METHODS

Between September 2019 and February 2020, we implemented weekly peer education sessions and bi-monthly SMS reminders for FSW in Mbarara (intervention city). Peer education sessions were implemented by 20 FSW, who received five days of basic training as peer educators. We held monthly meetings with peer educators throughout the six-month implementation period. FSW in Mbale (control city) continued to receive standard of care consisting of HIV testing outreach campaigns, and facility-based testing. Using a quasi-experimental design in one intervention city, and one control city, we conducted pre- and post- questionnaire-based surveys on recent syphilis and HIV testing behavior among FSW in July-October 2018, and March 2020. We compared proportions and prevalence ratios at baseline and follow-up using chi-square tests and negative binomial regression.

RESULTS

We conducted 436 interviews (200 before/236 after) with FSW. At baseline similar proportions reported taking an HIV test (57 % vs. 54 %; p = 0.72), and a syphilis serology test (35 % vs. 39 %; p = 0.67) in the intervention and control cities, respectively, in the prior three months. After the intervention, this proportion increased to 82 % (95 % confidence interval [CI] 74.0-88.2) for HIV, and 81 % (95 % CI: 73.0-87.0) for syphilis in the intervention city. Relative to baseline in the control city, the proportion testing for HIV was unchanged (52 %) but decreased for syphilis (26 %).

CONCLUSIONS

Bi-monthly text message reminders with weekly peer education sessions increased uptake of 3-monthly syphilis and HIV testing in a Ugandan female sex work population and could help increase sex worker engagement in HIV/STI services in line with World Health Organization recommendations.

Prevalence and Factors Associated With HIV and Sexually Transmitted Infections Among Female Sex Workers in Bamako, Mali

BACKGROUND

We aimed to (1) estimate the prevalence of HIV and other sexually transmitted infections (STIs) among female sex workers (FSWs) in Bamako, Mali, and (2) identify factors associated with STIs including HIV infection in this population.

METHODS

We analyzed baseline data from a prospective observational cohort study on cervical cancer screening, human papillomavirus, and HIV infections among FSWs 18 years or older recruited in Bamako. Multivariable log-binomial regression was used to estimate the adjusted prevalence ratios (APRs) with 95% confidence interval (95% CI) for HIV infection and STIs versus associated factors.

RESULTS

Among 353 women participating in the study, mean age was 26.8 (±7.6) years. HIV prevalence was 20.4%, whereas 35.1% of the FSWs had at least one STI. Factors significantly associated with HIV were older age (P < 0.0001, test for trend), duration of sex work ≥6 years (APR, 1.92; 95% CI, 1.22-3.02), uneducated status (APR, 2.24; 95% CI, 1.16-4.34), less than 10 clients in the last 7 days (APR, 1.55; 95% CI, 1.02-2.34), and gonococcal (APR, 1.85; 95% CI, 1.21-2.82) and chlamydial (APR, 2.58; 95% CI, 1.44-4.62) infections. Younger age (P = 0.018, test for trend), having ≥10 clients in the last week (APR, 1.47; 95% CI, 1.11-1.94), and HIV infection (APR, 2.00; 95% CI, 1.49-2.69) were significantly associated with STIs.

CONCLUSIONS

HIV and curable STI prevalence are high among FSWs in Bamako. There is thus a need to enhance the efficiency of interventions toward FSWs in Mali to reduce the burden of HIV and STIs among them and prevent HIV spread to the general population.

Use of propensity score matching to create counterfactual group to assess potential HIV prevention interventions

The design of HIV prevention trials in the context of effective HIV preventive methods is a challenge. Alternate designs, including using non-randomised 'observational control arms' have been proposed. We used HIV simulated vaccine efficacy trials (SiVETs) to show pitfalls that may arise from using such observational controls and suggest how to conduct the analysis in the face of the pitfalls. Two SiVETs were nested within previously established observational cohorts of fisherfolk (FF) and female sex workers (FSW) in Uganda. SiVET participants received a licensed Hepatitis B vaccine in a schedule (0, 1 and 6 months) similar to that for a possible HIV vaccine efficacy trial. All participants received HIV counselling and testing every quarter for one year to assess HIV incidence rate ratio (IRR) between SiVET and non-SiVET (observational data). Propensity scores, conditional on baseline characteristics were calculated for SiVET participation and matched between SiVET and non-SiVET in the period before and during the SiVET study. We compared IRR before and after propensity score matching (PSM). In total, 3989 participants were enrolled into observational cohorts prior to SiVET, (1575 FF prior to Jul 2012 and 2414 FSW prior to Aug 2014). SiVET enrolled 572 participants (Jul 2012 to Apr 2014 in FF and Aug 2014 to Apr 2017 in FSW), with 953 non-SiVET participants observed in the SiVET concurrent period and 2928 from the pre-SiVET period (before Jul 2012 in FF or before Apr 2014 in FSW). Imbalances in baseline characteristics were observed between SiVET and non-SiVET participants in both periods before PSM. Similarly, HIV incidence was lower in SiVET than non-SiVET; SiVET-concurrent period, IRR = 0.59, 95% CI 0.31-0.68, p = 0.033 and pre-SiVET period, IRR = 0.77, 95% CI 0.43-1.29, p = 0.161. After PSM, participants baseline characteristics were comparable and there were minimal differences in HIV incidence between SiVET and non-SiVET participants. The process of screening for eligibility for efficacy trial selects participants with baseline characteristics different from the source population, confounding any observed differences in HIV incidence. Propensity score matching can be a useful tool to adjust the imbalance in the measured participants' baseline characteristics creating a counterfactual group to estimate the effect of interventions on HIV incidence.

Women at high risk of HIV-infection in Kampala, Uganda, and their candidacy for PrEP

Pre-exposure prophylaxis (PrEP), antiretroviral medication for prevention of HIV-acquisition, is part of biomedical HIV prevention strategies recommended for people at risk of HIV-infection. A decision to take PrEP depends on an assessment of 'being at risk' either by an individual, or healthcare provider. In this paper, we draw on the concept of 'candidacy' to examine the different ways in which women attending a dedicated clinic in Kampala, Uganda, for women at risk of HIV infection (including sex workers), assessed their suitability for PrEP. We conducted in-depth interviews with 30 HIV negative women up to four different times, to gather information on the motives for taking PrEP, and their life history and daily life. All the women described the relevance of PrEP to mitigate their risk of HIV infection. However, there were challenges to adherence because of alcohol use, irregular working hours and a fear of being seen taking pills that others might assume to be HIV treatment. The ways in which the different women used PrEP and interpreted the place of PrEP in their lives were not solely based on their assessment of protecting themselves during sex work. They also used PrEP to guard against infection from their regular partners, and as a tool to allow them to make more money safely, by having sex without a condom with clients. While eligibility to access PrEP was predicated on the women's being in an 'at risk' population group, an incentive to use PrEP was to protect themselves from HIV acquisition from a long-term partner and preserve the 'trust' in their intimate relationship by having condom-less sex. Applying a candidacy lens we highlight the complexity in how women experience and present as being 'at risk' and query the criteria on which categories of risk and PrEP eligibility are determined.

Comparison of HIV Risk Behaviors Between Clinical Trials and Observational Cohorts in Uganda

Many key populations have high-risk behaviors for HIV infection making them suitable for HIV vaccine efficacy trials. However, these behaviors may change when participants enroll into a trial. We used HIV simulated vaccine efficacy trials (SiVETs) nested within observational cohorts of fisherfolks and female sex workers in Uganda to evaluate this difference. We screened observational cohort participants for enrolment into SiVETs, until 572 were enrolled. Those not enrolled (n = 953) continued participation in the observational cohorts. We determined risk behaviors at baseline and at 1 year, assigned a numeric score to each behavior and defined composite score as the sum of reported behaviors. We compared changes in scores over 12 months. Both observational cohorts and SiVETs saw a significant decrease in score but greatest in the SiVETs. Investigators recruiting for trials from these populations should consider the likely effect of reduction in risk behaviors on incident HIV infection and trial statistical power.

High burden of self-reported sexually transmitted infections among key populations in Mozambique: the urgent need for an integrated surveillance system

BACKGROUND

Key populations - men who have sex with men (MSM), female sex workers (FSW) and people who inject drugs (PWID) - are at high risk for sexually transmitted infections (STI) given their sexual risk behaviours along with social, legal and structural barriers to prevention, care and treatment services. The purpose of this secondary analysis is to assess the prevalence of self-reported STIs and to describe associated risk factors among participations of the first Biological Behavioural Surveillance (BBS) in Mozambique.

METHODS

Responses from the first BBS surveys conducted in 2011-2014 were aggregated across survey-cities to produce pooled estimates for each population. Aggregate weighted estimates were computed to analyse self-reported STI prevalence. Unweighted pooled estimates were used in multivariable logistic regression to identify risk factors associated with self-reported STI.

RESULTS

The prevalence of self-reported STI was 11.9% (95% CI, 7.8-16.0), 33.6% (95% CI, 29.0-41.3), and 22.0% (95% CI, 17.0-27.0) among MSM, FSW and PWID, respectively. MSM who were circumcised, had HIV, reported drug use, reported receptive anal sex, and non-condom use with their last male partner had greater odds of STI self-report. STI-self report among FSW was associated with living in Beira, being married, employment aside from sex work, physical violence, sexual violence, drug use, access to comprehensive HIV prevention services, non-condom use with last client, and sexual relationship with a non-client romantic partner. Among PWID, risk factors for self-reported STI included living in Nampula/Nacala, access to HIV prevention services, and sex work.

CONCLUSION

The high-burden of STIs among survey participants requires integrated HIV and STI prevention, treatment, and harm reduction services that address overlapping risk behaviours, especially injection drug use and sex work. A robust public health response requires the creation of a national STI surveillance system for better screening and diagnostic procedures within these vulnerable populations.

Prevalence and characteristics of HIV infection among female sex workers in Lubumbashi, Democratic Republic of Congo

Introduction

female sex workers (FSWs) are considered a high-risk group for acquiring HIV infection due to their HIV prevalence estimated to be 10-20 times higher than in woman in the general population. This study aimed to determine the prevalence and risk factors of HIV among female sex workers (FSWs) in Lubumbashi.

Methods

a cross-sectional study was conducted among FSWs presenting for the first time at the sexually transmitted infections (STIs) clinic of Katuba, Lubumbashi, between April 2016 and December 2017. Information on the participants´ socio-demographic characteristics, sexual behaviors, and HIV serology results were collated and analyzed using a multiple logistic regression to identify factors associated to HIV infection among FSWs.

Results

information on 1555 sex workers was analysed in this study, the prevalence of HIV was 8.2%. The median age of the participants was 26 years (IQR: 21-34). Of the 127 HIV positive sex workers, 74% have been in the business for two years or less, 97% sell sex as their main income, 74% have more than 5 sexual intercourses per week, 95% reported using condom, 73% reported having history of STIs, 70% reported using alcohol before sex and 97% reported having three or more sexual partners per week. After adjusting for potentials cofounders, Age, Sex work as main income, years of selling sex, condom use, and alcohol use before sex were found to have a significant effect on HIV infection among sex workers.

Conclusion

these findings highlight the vulnerability of FSWs to HIV infection and the necessity of immediate interventions to strengthen HIV prevention through behavioral change strategies and making available Pre-exposure Prophylaxis (PrEP) for FSWs in Lubumbashi.

HIV and syphilis testing behaviors among heterosexual male and female sex workers in Uganda

Background

In Sub-Saharan Africa where HIV disproportionately affects women, heterosexual male sex workers (HMSW) and their female clients are at risk of acquiring or transmitting HIV and other STIs. However, few studies have described HIV and STI risk among HMSW. We aimed to assess and compare recent HIV and syphilis screening practices among HMSW and female sex workers (FSW) in Uganda.

Methods

Between August and December 2019, we conducted a cross-sectional study among 100 HMSW and 240 female sex workers (FSW). Participants were enrolled through snowball sampling, and an interviewer-administered questionnaire used to collect data on HIV and syphilis testing in the prior 12 and 6 months respectively. Integrated change model constructs were used to assess intentions, attitudes, social influences, norms and self-efficacy of 3-monthly Syphilis and 6-monthly HIV testing. Predictors of HIV and syphilis recent testing behaviors were estimated using negative binomial regression.

Results

We enrolled 340 sex workers of whom 100 (29%) were HMSW. The median age was 27 years [interquartile range (IQR) 25–30] for HMSW and 26 years [IQR], (23–29) for FSW. The median duration of sex work was 36 and 30 months for HMSW and FSW, respectively. HMSW were significantly less likely than FSW to have tested for HIV in the prior 12 months (50% vs. 86%; p = 0.001). For MSW, non-testing for HIV was associated with higher education [adjusted prevalence ratio (aPR) 1.66; 95% confidence interval (CI) 1.09–2.50], poor intention to seek HIV testing (aPR 1.64; 95% CI 1.35–2.04), perception that 6-monthly HIV testing was not normative (aPR 1.33; 95% CI 1.09–1.67) and low self-efficacy (aPR 1.41; 95% CI 1.12–1.79). Not testing for syphilis was associated with low intention to seek testing (aPR 3.13; 95% CI 2.13–4.55), low self-efficacy (aPR 2.56; 95% CI 1.35–4.76), negative testing attitudes (aPR 2.33; 95% CI 1.64–3.33), and perception that regular testing was not normative (aPR 1.59; 95% CI 1.14–2.22).

Conclusions

Non-testing for HIV and syphilis was common among HMSW relative to FSW. Future studies should evaluate strategies to increase testing uptake for this neglected sub-population of sex workers.

Acceptability of oral HIV self-testing among female sex workers in Gaborone, Botswana

Background

HIV prevalence among female sex workers (FSW) in sub-Saharan Africa is much higher than in the general population. HIV self-testing (HIVST) may be useful for increasing testing rates in FSW.

Methods

We conducted semi-structured in-depth interviews among FSW, nurses and lay counsellors providing services to FSWs in Botswana. We aimed to gain understanding of perceived acceptability, anticipated barriers, and preferred approaches to HIVST among FSW. Interviews were audio-recorded, transcribed and translated. Transcripts were reviewed and coded independently by two investigators; high inter-coder agreement was achieved (Kappa = 0.80).

Results

We interviewed five care providers whose average age was 40 years (SD = 2,64, range = 37–43); three nurses and two counsellors. Thirty FSW were interviewed, with mean age 34 years (range = 20–52). Most (27; 90%) FSW expressed great interest in using HIVST kits. Facilitators of HIVST were: awareness of own risky sexual behaviours, desire to stay healthy, and perceived autonomy over one’s healthcare decisions. Perceived advantages of HIVST included convenience, privacy, and perception of decreased stigma. Identified barriers to HIVST included lack of knowledge about the HIVST kit, fear of testing due to anticipated stigma, mistrust of the test’s accuracy, doubt of self-competency to perform HIVST, and concerns about not linking to care. Assisting someone to test was noted as good for providing emotional support, but there were concerns about confidentiality breaches. Providers expressed concerns over low literacy among FSWs which could affect comprehension of testing instructions, and competency to perform testing and interpret results. Participants’ recommendations for implementation of HIVST included: ensuring wide dissemination of information on HIVST, engaging peers in information-sharing and education, making test kits accessible in FSW-friendly centres, and having clear instructions for linkage to healthcare and support.

Conclusion

HIVST shows high acceptability among FSWs in Gaborone Botswana, with providers expressing some concerns. Implementation should be peer-driven with healthcare provider oversight.

Confidential, accessible point-of-care sexual health services to support the participation of key populations in biobehavioural surveys: Lessons for Papua New Guinea and other settings where reach of key populations is limited

To achieve the UNAIDS 90-90-90 targets at a national level, many countries must accelerate service coverage among key populations. To do this, key population programs have adopted methods similar to those used in respondent-driven sampling (RDS) to expand reach. A deeper understanding of factors from RDS surveys that enhance health service engagement can improve key population programs. To understand the in-depth lives of key populations, acceptance of expanded point-of-care biological testing and determine drivers of participation in RDS surveys, we conducted semi-structured interviews with 111 key population participants (12-65 years) were purposefully selected from six biobehavioral surveys (BBS) in three cities in Papua New Guinea. Key populations were female sex workers, men who have sex with men, and transgender women. Four reasons motivated individuals to participate in the BBS: peer referrals; private, confidential, and stigma-free study facilities; "one-stop shop" services that provided multiple tests and with same-day results, sexually transmitted infection treatment, and referrals; and the desire to know ones' health status. Biobehavioral surveys, and programs offering key population services can incorporate the approach we used to facilitate key population engagement in the HIV cascade.

PrEP rollout in Africa: status and opportunity

Following recommendations by the World Health Organization in 2015, and key clinical trials, countries in sub-Saharan Africa, the region with the highest burden of human immunodeficiency virus (HIV), developed policies that incorporate pre-exposure prophylaxis (PrEP) into national HIV-prevention strategies. By the end of 2019, more than one third of people receiving PrEP globally were in Africa. Crucial understandings gained from early rollout among at-risk populations, such as HIV-serodiscordant couples, adolescent girls and young women, female sex workers, and men who have sex with men, include the importance of strategies for maintaining persistent adherence to PrEP and novel approaches to making PrEP services accessible, simplified and efficient. This Perspective will discuss the current status of these programs and how to further widen their implementation.

Injection and sexual risk among people who use or inject drugs in Kampala, Uganda: An exploratory qualitative study

Background

Countries in Sub-Saharan Africa (SSA) have seen rapid increases in injection drug use since 2008. In Uganda, the Global Sate of Harm report and studies conducted by Makerere University Crane Surveys have estimated HIV prevalence among people who inject drugs (PWID) at approximately 17%. The objective of the research was to document injection and other drug-related risks among people who use drugs in Uganda to develop comprehensive HIV/HCV prevention interventions.

Methods

Between August and September 2018, we conducted qualitative interviews among male and female people who use drugs. Interview topics included the availability and accessibility of clean syringes, injection risks, overdose, sexual-risk behaviors, and the availability and accessibility of harm reduction and drug treatment services.

Results

Participants reported several injection-related risks including sharing and reusing syringes, pooling and mixing drugs in the same container, measuring drugs using syringes, getting prefilled injections from dealers, being injected by other people who inject drugs, and using contaminated water or blood to dilute drugs. Participants reported a scarcity of harm reduction services, although a few appear to have participated in the syringe exchange pilot conducted by the Uganda Harm Reduction Network (UHRN). Even fewer reported knowing organizations that helped people who use drugs abstain from or reduce their use. Medication assisted therapy (MAT) and naloxone to reverse overdoses are not currently available.

Conclusions

Comprehensive prevention and treatment services are needed in Uganda and should include expanded syringe exchange programs, social network HIV testing, HCV testing, provision of naloxone and MAT, and linkage to and retention in HIV care.

What Proportion of Female Sex Workers Practise anal Intercourse and How Frequently? A Systematic Review and Meta-analysis

HIV is more efficiently acquired during receptive anal intercourse (AI) compared to vaginal intercourse (VI) and may contribute substantially to female sex workers' (FSW) high HIV burden. We aim to determine how common and frequent AI is among FSW globally. We searched PubMed, Embase and PsycINFO for studies reporting the proportion of FSW practising AI (prevalence) and/or the number of AI acts (frequency) worldwide from 01/1980 to 10/2018. We assessed the influence of participant and study characteristics on AI prevalence (e.g. continent, study year and interview method) through sub-group analysis. Of 15,830 identified studies, 131 were included. Nearly all (N = 128) reported AI prevalence and few frequency (N = 13), over various recall periods. Most studies used face-to-face interviews (N = 111). Pooled prevalences varied little by recall period (lifetime: 15.7% 95%CI 12.2-19.3%, N = 30, I2 = 99%; past month: 16.2% 95%CI 10.8-21.6%, N = 18, I2 = 99%). The pooled proportion of FSW reporting < 100% condom use tended to be non-significantly higher during AI compared to during VI (e.g. any unprotected VI: 19.1% 95%CI 1.7-36.4, N = 5 and any unprotected AI: 46.4% 95%CI 9.1-83.6, N = 5 in the past week). Across all study participants, between 2.4 and 15.9% (N = 6) of all intercourse acts (AI and VI) were anal. Neither AI prevalence nor frequency varied substantially by any participant or study characteristics. Although varied, AI among FSW is generally common, inconsistently protected with condoms and practiced sufficiently frequently to contribute substantially to HIV acquisition in this risk group. Interventions to address barriers to condom use are needed.

Comparison of retention in observational cohorts and nested simulated HIV vaccine efficacy trials in the key populations in Uganda

Background

Outcomes in observational studies may not best estimate those expected in the HIV vaccine efficacy trials. We compared retention in Simulated HIV Vaccine Efficacy Trials (SiVETs) and observational cohorts drawn from two key populations in Uganda.

Methods

Two SiVETs were nested within two observational cohorts, one in Fisherfolk (FF) and another one in Female Sex Workers (FSW). Adult participants in each observational cohort were screened for enrolment into SiVETs. Those screened-out or not screened continued participation in the observational (non-SiVET) cohorts. SiVET participants were administered a licensed hepatitis B vaccine in a schedule that mimicked an actual HIV vaccine efficacy trial. Both cohorts were followed for 12 months and retention was assessed through dropout, defined as lost to follow up, being uncontactable, refusal to continue or missing the last study clinic visit. Dropout rates were compared using Poisson models giving rate ratios and 95% confidence intervals (95%CI).

Results

Out of 1525 participants (565 FF and 960 FSW), 572 (38%) were enrolled into SiVETs (282-FF and 290-FSW), and 953 (62%) remained in the non-SiVET cohorts. Overall, 326 (101 SiVET, 225 non-SiVET) dropped out in 1260 Person Years of Observation (PYO), a dropout rate of 25.9 /100 PYO (95%CI: 23.2–28.8); fewer dropped out in the SiVET cohorts (18.4, 95% CI: 15.1–22.4) than in the non-SiVET cohorts (31.6, 95% CI: 27.8–36.1), rate ratio (RR) =0.58, 95% CI: 0.46–0.73. In all cohorts, the dropout was more marked in FSW than in FF population. Duration lived in community was associated with dropout in both SiVETs and religion in both non-SiVET cohorts.

Conclusion

The rate of dropout was lower in SiVET compared to non-SiVET cohort. Though the difference in dropout between SiVET and non-SiVET was generally similar, the actual dropout rates were higher in the FSW population. Conduct of SiVETs in these key populations could mean that designing HIV Vaccine Efficacy Trials will benefit from lower dropout rate shown in SiVET than non-SiVET observational cohort.

Alcohol Misuse and Illicit Drug Use Among Occupational Groups at High Risk of HIV in Sub-Saharan Africa: A Systematic Review

Key occupational groups in sub-Saharan Africa (SSA) are at increased risk of HIV, and may be at increased risk of substance use. In January 2018, we systematically searched for studies reporting prevalence of, and risk factors for alcohol misuse or illicit drug use and their association with HIV incidence or prevalence among fisherfolk, uniformed personnel, truckers, miners, motorcycle taxi riders and sex workers in SSA. Seventy-one studies published between 1983 and 2017 were included: 35 reported on alcohol misuse (19 using AUDIT, 5 using CAGE) and 44 on illicit drug use (eight reported both). Median prevalence of alcohol misuse based on AUDIT/CAGE was 32.8% (IQR 20.8-48.5%). Prevalence of illicit drug use ranged from 0.1% (95% CI: 0.0-0.2%) for injection drug use to 97.1% (95% CI: 85.1-99.9%) for khat (among uniformed personnel). Among papers examining associations between substance use and HIV incidence (n = 3) or prevalence (n = 14), nine papers (53%) reported a significant positive association (2 with incidence, 7 with prevalence). Harm reduction interventions in occupational settings are urgently required to prevent new HIV infections.

Use of reliable contraceptives and its correlates among women participating in Simulated HIV vaccine efficacy trials in key-populations in Uganda

To prevent pregnancy in trials, reliable contraceptive use is key. We investigated reliable contraceptive use at baseline and six months in key-populations in Uganda, during two Simulated HIV Vaccine Efficacy trials (SiVETs). SiVETs were nested within observational cohorts of Fisherfolk (2012–2014) and Female sex workers (2014–2017). Women in the observational cohorts were screened and enrolled into the SiVET. The trial administered a licensed Hepatitis B vaccine at 0, 1 and 6 months. Contraceptive use data were recorded at baseline and follow-up clinic visits. Reliable contraceptives (injectable Depot Medroxyprogesterone Acetate (DMPA), implant, pills, and intrauterine device (IUD)) were promoted and provided to women not using a reliable method at enrolment. Overall, 367 women were enrolled. At baseline 203 (55%) reported use of reliable contraceptive. Of the 164 women not using a reliable method at enrolment, 131 (80%) started using them during follow-up bringing the overall number to 334 (91%) at the end of follow-up. Young age (≤35 years) was an independent predictor of reliable contraceptive use at both time points while other factors varied. Promotion and provision of reliable contraceptives increased the proportion using them and could help reduce the risk of pregnancy in future HIV prevention trials.

Psychosocial correlates of regular syphilis and HIV screening practices among female sex workers in Uganda: a cross-sectional survey

BACKGROUND

Limited data are available regarding correlates of regular sexually transmitted infections (STIs) and HIV screening among female sex workers (FSW) in Sub-Saharan Africa. In this study, we aimed to assess the frequency of regular syphilis and HIV screening and the psychosocial correlates associated with screening among FSW in Uganda.

METHODS

This cross-sectional correlational study was conducted among 441 FSW, aged 17-49 years. We enrolled FSW through peer referrals and ascertained self-reported data on number of serological tests for HIV, syphilis and other STIs in the prior 12 months using an interviewer-administered questionnaire. In addition, we assessed attitudes, norms, social influences and self-efficacy towards 3-monthly Syphilis and 6-monthly HIV testing. We estimated the correlates of regular STI and HIV testing using negative binomial regression.

RESULTS

Of the respondents 420 (95.2%) reported to have ever taken an HIV test with 297 (67.4%) testing two or more times in the prior 12 months. Over half of the respondents (59%) reported ever taking a syphilis test with only 62 (14.1%) reporting testing three or more times in the prior 12 months. After adjusting for socio-demographics, attitude and norms, high perceived self-efficacy was associated with a 33% increase in the likelihood of repeated HIV testing [prevalence ratio (PR), 1.33, 95% confidence interval (CI) 1.15-1.53] while low perceived confidence was associated with a 25% decrease in the likelihood of repeated HIV testing (PR, 0.75, 95% CI 0.63-0.89). Similarly low attitudes and norms were associated with a decrease of 52.6% (PR, 0.47, 95% CI 0.37-0.61) and 47% (PR, 0.53, 95% CI 0.41-0.69) in the likelihood of repeated syphilis testing respectively.

CONCLUSION

Compared to HIV, uptake of repeated syphilis testing was very low. Correlates of HIV testing include; perceived self-efficacy amidst barriers and perceived confidence for HIV and low attitudes and accepting norms for syphilis. Health campaigns should emphasize overcoming barriers to HIV testing while promoting attitudes and norms including integration of serological syphilis testing and other STIs into HIV services.

Estimating the Size of Key Populations in Kampala, Uganda: 3-Source Capture-Recapture Study

Background

Key populations, including people who inject drugs (PWID), men who have sex with men (MSM), and female sex workers (FSW), are disproportionately affected by the HIV epidemic. Understanding the magnitude of, and informing the public health response to, the HIV epidemic among these populations requires accurate size estimates. However, low social visibility poses challenges to these efforts.

Objective

The objective of this study was to derive population size estimates of PWID, MSM, and FSW in Kampala using capture-recapture.

Methods

Between June and October 2017, unique objects were distributed to the PWID, MSM, and FSW populations in Kampala. PWID, MSM, and FSW were each sampled during 3 independent captures; unique objects were offered in captures 1 and 2. PWID, MSM, and FSW sampled during captures 2 and 3 were asked if they had received either or both of the distributed objects. All captures were completed 1 week apart. The numbers of PWID, MSM, and FSW receiving one or both objects were determined. Population size estimates were derived using the Lincoln-Petersen method for 2-source capture-recapture (PWID) and Bayesian nonparametric latent-class model for 3-source capture-recapture (MSM and FSW).

Results

We sampled 467 PWID in capture 1 and 450 in capture 2; a total of 54 PWID were captured in both. We sampled 542, 574, and 598 MSM in captures 1, 2, and 3, respectively. There were 70 recaptures between captures 1 and 2, 103 recaptures between captures 2 and 3, and 155 recaptures between captures 1 and 3. There were 57 MSM captured in all 3 captures. We sampled 962, 965, and 1417 FSW in captures 1, 2, and 3, respectively. There were 316 recaptures between captures 1 and 2, 214 recaptures between captures 2 and 3, and 235 recaptures between captures 1 and 3. There were 109 FSW captured in all 3 rounds. The estimated number of PWID was 3892 (3090-5126), the estimated number of MSM was 14,019 (95% credible interval (CI) 4995-40,949), and the estimated number of FSW was 8848 (95% CI 6337-17,470).

Conclusions

Our population size estimates for PWID, MSM, and FSW in Kampala provide critical population denominator data to inform HIV prevention and treatment programs. The 3-source capture-recapture is a feasible method to advance key population size estimation.

Reported oral and anal sex among adolescents and adults reporting heterosexual sex in sub-Saharan Africa: a systematic review

BACKGROUND

Oral and anal sexual behaviours are increasingly reported among adolescents and adults reporting heterosexual sex in peer-reviewed journals in high income countries, but less is known about these behaviours in low and middle-income countries, especially in sub-Saharan Africa. The aim of this systematic review is to describe the prevalence of, and motivations for, oral and anal sex among adolescents and adults reporting heterosexual sex in sub-Saharan Africa.

METHODS

A systematic review of published articles that reported oral and or anal sex in sub-Saharan Africa was conducted from seven databases up to and including 30th August 2018.

RESULTS

Of 13,592 articles, 103 met the inclusion criteria. The prevalence of reporting ever practising oral sex among adolescents, university students and a combined population of adolescents/adults ranged from 1.7-26.6%, 5.0-46.4% and 3.0-47.2% respectively. Similarly, prevalences of reported ever practising anal sex ranged from 6.4-12.4% among adolescents, 0.3-46.5% among university students and 4.3-37.8% amongst combined population of adolescents and adults. Higher prevalences of oral and anal sex were reported among populations at high-risk for sexually transmitted infections and HIV and university students and, in most studies, both behaviours were more commonly reported by males than females. Heterosexual oral and anal sexual acts were associated with some high-risk behaviours such as inconsistent condom use and multiple sexual partners.

CONCLUSION

Reported oral and anal sex between men and women are prevalent behaviours in sub-Saharan Africa. Health professionals and policy makers should be aware of these behaviours and their potential associated health risks.

Capture-Recapture Among Men Who Have Sex With Men and Among Female Sex Workers in 11 Towns in Uganda

BACKGROUND

Key populations at higher risk for HIV infection, including people who inject drugs, men who have sex with men (MSM), and female sex workers (FSWs), are disproportionately affected by the HIV/AIDS epidemic. Empirical estimates of their population sizes are necessary for HIV program planning and monitoring. Such estimates, however, are lacking for most of Uganda's urban centers.

OBJECTIVE

The aim of this study was to estimate the number of FSWs and MSM in select locations in Uganda.

METHODS

We utilized conventional 2-source capture-recapture (CRC) to estimate the population of FSWs in Mbale, Jinja, Wakiso, Mbarara, Gulu, Kabarole, Busia, Tororo, Masaka, and Kabale and the population of MSM in Mbale, Jinja, Wakiso, Mbarara, Gulu, Kabarole, and Mukono from June to August 2017. Hand mirrors and key chains were distributed to FSWs and MSM, respectively, by peers during capture 1. A week later, different FSWs and MSM distributors went to the same towns to collect data for the second capture. Population size estimates and 95% CIs were calculated using the CRC Simple Interactive Statistical Analysis.

RESULTS

We estimated the population of FSWs and MSM using 2 different recapture definitions: those who could present the object or identify the object from a set of photos. The most credible (closer to global estimates of MSM; 3%-5%) estimates came from those who presented the objects only. The FSW population in Mbale was estimated to be 693 (95% CI 474-912). For Jinja, Mukono, Busia, and Tororo, we estimated the number of FSWs to be 802 (95% CI 534-1069), 322 (95% CI 300-343), 961 (95% CI 592-1330), and 2872 (95% CI 0-6005), respectively. For Masaka, Mbarara, Kabale, and Wakiso, we estimated the FSWs population to be 512 (95% CI 384-639), 1904 (95% CI 1058-2749), 377 (95% CI 247-506), and 828 (95% CI 502-1152), respectively. For Kabarole and Gulu, we estimated the FSWs population to be 397 (95% CI 325-469) and 1425 (95% CI 893-1958), respectively. MSM estimates were 381 (95% CI 299-462) for Mbale, 1100 (95% CI 351-1849) for Jinja, 368 (95% CI 281-455) for Wakiso, 322 (95% CI 253-390) for Mbarara, 180 (95% CI 170-189) for Gulu, 335 (95% CI 258-412) for Kabarole, and 264 (95% CI 228-301) for Mukono.

CONCLUSIONS

The CRC activity was one of the first to be carried out in Uganda to obtain small town-level population sizes for FSWs and MSM. We found that it is feasible to use FSW and MSM peers for this activity, but proper training and standardized data collection tools are essential to minimize bias.

Simulated vaccine efficacy trials to estimate HIV incidence for actual vaccine clinical trials in key populations in Uganda

BACKGROUND

Fisherfolks (FF) and female sex workers (FSW) in Uganda could be suitable key populations for HIV vaccine efficacy trials because of the high HIV incidence and good retention in observational cohorts. However, the observed HIV incidence may differ in participants who enroll into a trial. We used simulated vaccine efficacy trials (SiVET) nested within observational cohorts in these populations to evaluate this difference.

METHODS

SiVETs were nested in two observational cohorts (Jul 2012-Apr 2014 in FF and Aug 2014-Apr 2017 in FSW). From Jan 2012 all observational cohort participants (aged 18-49 years) presenting for quarterly visits were screened for enrolment into SiVETs, until 572 were enrolled. Those not enrolled (screened-out or not screened) in SiVET continued participation in the observational cohorts. In addition to procedures in the observational cohorts (HIV testing & risk assessment), SiVET participants were given a licensed Hepatitis B vaccine mimicking a schedule of a possible HIV vaccine, and followed-up for 12 months.

FINDINGS

In total, 3989 participants were enrolled into observational cohorts (1575 FF prior to Jul 2012 and 2414 FSW prior to Aug 2014). Of these 3622 (90.8%) returned at least once, 672 (44.1%) were screened and 572 enrolled in the SiVETs. HIV incidence pre SIVETs was 4.5/100 person years-at-risk (pyar), 95%CI (3.8-5.5). HIV incidence in SiVET was 3.5/100 pyar, (2.2-5.6) and higher in those not enrolled in the SiVET, 5.9/100 pyar, (4.3-8.1). This difference was greatest among FF. In the 12 months post-SIVET period (FF, May 2014-Apr 2015 and FSW, May 2017-Apr 2018), the HIV incidence was 3.7/100 pyar, (2.5-5.8).

INTERPRETATION

HIV incidence was lower in SiVET participants compared to non-SiVET. This difference was different for the two populations. Researchers designing HIV efficacy trials using observational cohort data need to consider the potential for lower than expected HIV incidence following screening and enrolment.

Progress toward UNAIDS 90-90-90 targets: A respondent-driven survey among female sex workers in Kampala, Uganda

BACKGROUND

We investigated progress towards UNAIDS 90-90-90 targets among female sex workers in Kampala, Uganda, who bear a disproportionate burden of HIV.

METHODS

Between April and December 2012, 1,487 female sex workers, defined as women, 15-49 years, residing in greater Kampala, and selling sex for money in the last 6 months, were recruited using respondent-driven sampling. Venous blood was collected for HIV and viral load testing [viral load suppression (VLS) defined as <1,000 copies/mL]. We collected data using audio computer-assisted self-interviews and calculated weighted population-level estimates.

RESULTS

The median age was 27 years (interquartile range: 23 to 32). HIV seroprevalence was 31.4% (95% confidence interval [CI]: 29.0, 33.7%). Among all female sex workers who tested HIV-positive in the survey (population-level targets), 45.5% (95% CI: 40.1, 51.0) had knowledge of their serostatus (population-level target: 90%), 37.8% (95% CI: 32.2, 42.8) self-reported to be on ART (population-level target: 81%), and 35.2% (95% CI: 20.7, 30.4) were virally suppressed (population-level target: 73%).

CONCLUSIONS

HIV prevalence among Kampala female sex workers is high, whereas serostatus knowledge and VLS are far below UNAIDS targets. Kampala female sex workers are in need of intensified and targeted HIV prevention and control efforts.

Prevalence of Soft-Tissue Lesions among Women in Sex Work in the Red Light Area of Pune, India: A Cross-Sectional Survey

Aim and Objective

The women in sex work have no felt need for oral health and much of the stress has always been on sexually transmitted infections (STIs). There is a need for a baseline data for the oral lesions of these women to further assist in the policy formulations and training of personnel for the identification of the oral conditions which need treatment. The aim of the study was to evaluate the presence of oral lesions among female sex workers in the red light area of Pune, India.

Materials and Methods

The Community Periodontal Index and loss of attachment (LA) index was recorded along with the other soft-tissue lesions as per the WHO Oral Health Assessment from 1997. The calculated sample was 350. Systematic sampling technique was followed. The data collected were subjected to statistical analysis and analysis was done using SPSS package 16.0.

Results

A total of 110 (31.4%) women had leukoplakia, 6 women (1.7%) had ulceration, 41 (11.7%) women had candidiasis, and 1 woman (0.3%) had swollen gingiva. As the age increased, there was an increase in the number of pockets. The percentage of women above 60 years had higher LA.

Conclusion

The women in sex work are mainly spoken to about HIV and STIs. With almost all of these women requiring some or the other form of treatment, utilization of the available dental workforce with both government and public partnership could be the route.

Factors associated with HIV infection among female sex workers in Brazil

BACKGROUND

Female sex workers (FSWs) are one of the most-at-risk population groups for human immunodeficiency virus (HIV) infection. This paper aims at identifying the main predictors of HIV infection among FSW recruited in the 2nd Biological and Behavioral Surveillance Survey in 12 Brazilian cities in 2016.

METHOD

Data were collected on 4245 FSW recruited by respondent driven sampling (RDS). Weights were inversely proportional to participants' network sizes. To establish the correlates of HIV infection, we used logistic regression models taking into account the dependence of observations resultant from the recruitment chains. The analysis included socio-demographic sex work characteristics, sexual behavior, history of violence, alcohol and drug use, utilization of health services, and occurrence of other sexually transmitted infections (STIs).

RESULTS

HIV prevalence was estimated as 5.3% (4.4%-6.2%). The odds ratio (OR) of an HIV-positive recruiter choosing an HIV-positive participant was 3.9 times higher than that of an HIV-negative recruiter (P < .001). Regarding socio-demographic and sex work characteristics, low educational level, street as the main work venue, low price per sexual encounter, and longer exposure time as a sex worker were found to be associated with HIV infection, even after controlling for the homophily effect. The OR of being HIV infected among FSW who had been exposed to sexual violence at least once in a lifetime (OR = 1.5, P = .028) and the use of illicit drugs at least once a week were highly significant as well, particularly for frequent crack use (OR = 3.6, P < .001). Among the sexual behavior indicators, not using condoms in some circumstances were significantly associated with HIV infection (OR = 1.8, P = .016). Regarding the occurrence of other STI, the odds of being HIV infected was significantly higher among FSW with a reactive treponemal test for syphilis (OR = 4.6, P < .001).

CONCLUSIONS

The main factors associated with HIV infection identified in our study characterize a specific type of street-based sex work in Brazil and provided valuable information for developing interventions. However, there is a further need of addressing social and contextual factors, including illicit drug use, violence, exploitation, as well as stigma and discrimination, which can influence sexual behavior.