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Mokinu RA, Yonge SA, Lafort Y, Sandfort TGM, Mantell JE, Gichangi PB. Sexual practices, their influencers, and utilization of HIV services among female sex workers in Mombasa County, Kenya. Pan Afr Med J 2024; 47:209. [PMID: 39247770 PMCID: PMC11380618 DOI: 10.11604/pamj.2024.47.209.41775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 01/13/2024] [Indexed: 09/10/2024] Open
Abstract
Introduction female sex workers (FSWs) are vulnerable to acquiring HIV and other sexually transmitted infections due to unprotected sex. Understanding and addressing the gaps in safer sex among FSWs can help to reduce HIV acquisition and transmission. This study described sexual practices, their correlates and use of HIV services among FSWs in Mombasa County, Kenya. Methods participants were recruited for a baseline survey by a time-location cluster randomized design at predetermined intervals from five bars and five clubs in Mombasa County until a sample size of 160 was reached. Descriptive statistics and inferential analysis using R were conducted, and p<0.05 was regarded as statistically significant. Results nearly all (99%) of the participants were unmarried, and 11% had tertiary education. Ninety-eight percent (98%) reported vaginal intercourse, 51% reported using alcohol/drugs before sex, and 28% practiced unprotected intercourse. About 64% had tested for HIV within three months, 14% believed that it is safe to reuse condoms, and 10% that it is safe to engage in unprotected sex. In bi-variate analysis, FSWs were more likely to engage in unprotected intercourse if they reported more frequent sex, more frequent sex with regular clients, poor HIV knowledge, alcohol/drug use, and violence. In multivariate analysis, risky sexual practices were associated with frequency of sexual intercourse, alcohol/drug use, and poor HIV knowledge. Conclusion female sex workers engage in unprotected sex while under the influence of substances, belief in re-using condoms and have high frequency of sexual intercourse. Inadequate knowledge of HIV and substance use significantly correlated with unprotected sex. Interventions to address these modifiable factors are needed to mitigate the risk of HIV among FSWs.
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Affiliation(s)
- Robert Abuga Mokinu
- County Government of Mombasa, Mombasa, Kenya
- Department of Environment and Health Sciences, School of Applied and Health Sciences, Technical University of Mombasa, Mombasa, Kenya
| | - Shadrack Ayieko Yonge
- Department of Environment and Health Sciences, School of Applied and Health Sciences, Technical University of Mombasa, Mombasa, Kenya
| | - Yves Lafort
- Department of Uro-gynaecology, Ghent University, Ghent, Belgium
| | - Theodorus Gustavus Maria Sandfort
- Department of Psychiatry, HIV Center for Clinical and Behavioral Studies at the New York State Psychiatric Institute, New York, USA
- Columbia University Irving Medical Center, New York, USA
| | - Joanne Ellen Mantell
- Department of Psychiatry, HIV Center for Clinical and Behavioral Studies at the New York State Psychiatric Institute, New York, USA
- Columbia University Irving Medical Center, New York, USA
| | - Peter Bundi Gichangi
- Technical University of Mombasa, Mombasa, Kenya
- Department of Public Health and Primary Care, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
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Macleod CI, Reynolds JH, Delate R. Violence Against Women Who Sell Sex in Eastern and Southern Africa: A Scoping Review. TRAUMA, VIOLENCE & ABUSE 2024; 25:691-703. [PMID: 36964683 PMCID: PMC10666481 DOI: 10.1177/15248380231160847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Women who sell sex (WSS) are vulnerable to violence. We present a scoping review of the last decade of research on the prevalence and incidence of, factors associated with, and services regarding violence against WSS in Eastern and Southern African (ESA). A systematic search of various databases resulted in 20 papers being reviewed. Inclusion criteria, applied by the first two authors, were as follows: empirical papers, key research problem is violence against WSS, and conducted in ESA countries. The lifetime prevalence of violence revealed in the studies ranged from 21% to 82%. A pattern of generalized violence against WSS from paying clients, male partners, strangers, family members, friends/acquaintances, and the authorities emerged. Factors associated with violence included the context within which the sex work occurs, alcohol use, type of sex exchange interactions, and personal factors (low education, low income, marriage, youth, high client volume, time in sex work, forced sexual debut, and internalized sex work stigma). WSS seldom access services after violence. Evaluations of two programs, a woman-focused HIV intervention, and the Diagonal Interventions to Fast-Forward Reproductive Health project, showed improvements in gender-based violence services. Findings suggest that targeted programmes should be paired with improving general health services and focus on promoting collective agency among WSS.
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Affiliation(s)
| | | | - Richard Delate
- United Nations Population Fund (UNFPA), Pretoria, South Africa
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Nyariki E, Wanjiru R, Shah P, Kungu M, Babu H, Weiss HA, Seeley J, Kimani J, Beattie TS. Managing motherhood - the experiences of female sex workers in Nairobi, Kenya. CULTURE, HEALTH & SEXUALITY 2023; 25:1230-1243. [PMID: 36519798 DOI: 10.1080/13691058.2022.2153926] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 11/28/2022] [Indexed: 06/17/2023]
Abstract
Women selling sex often face challenges in raising their children in the context of significant socio-economic difficulties and the social stigma inherent in sex work. This paper is based on a cross-sectional qualitative study that explored the dual roles of motherhood and sex work among female sex workers enrolled for ongoing HIV prevention and treatment services in the Sex Workers Outreach Programme (SWOP) clinics in Nairobi, Kenya. We examined women's experiences and coping in negotiating and managing the dual roles of motherhood and sex work. In-depth interviews were conducted with 39 women randomly selected from 1,000 women included in a baseline behavioural-biological survey conducted in October-November 2020 as part of the Maisha Fiti study. The analysis focused on themes related to motherhood and making a living: (i) entry into sex work; (ii) childcare arrangements; (iii) ensuring respectability for their children; and (iv) pursuit of safety and security. Findings from the study show women's entry into sex work was necessitated by poverty and a lack of reliable sources of livelihood to support their children. While performing their motherhood roles, the women demonstrate agency in navigating through their stigmatised conflicted sex work role to be able to provide for their children.
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Affiliation(s)
- Emily Nyariki
- Partners for Health and Development in Africa (PHDA), UNITID, University of Nairobi, Nairobi, Kenya
| | - Rhoda Wanjiru
- Partners for Health and Development in Africa (PHDA), UNITID, University of Nairobi, Nairobi, Kenya
| | - Pooja Shah
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Mary Kungu
- Partners for Health and Development in Africa (PHDA), UNITID, University of Nairobi, Nairobi, Kenya
| | - Hellen Babu
- Partners for Health and Development in Africa (PHDA), UNITID, University of Nairobi, Nairobi, Kenya
| | - Helen A Weiss
- MRC International Statistics & Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Janet Seeley
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Joshua Kimani
- Partners for Health and Development in Africa (PHDA), UNITID, University of Nairobi, Nairobi, Kenya
| | - Tara S Beattie
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
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Bhattacharjee P, Isac S, Musyoki H, Gichangi P, Ma H, Becker M, Hontelez J, Mishra S. Changes in context, typology and programme outcomes between early and recent periods of sex work among young female sex workers in Mombasa, Kenya: A cross-sectional study. PLoS One 2023; 18:e0288717. [PMID: 37490512 PMCID: PMC10368250 DOI: 10.1371/journal.pone.0288717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 07/04/2023] [Indexed: 07/27/2023] Open
Abstract
INTRODUCTION The sex work context and typology change continuously and influence HIV related risk and vulnerability for young female sex workers (YFSW). We sought to describe changes in the context and typology of sex work between the first (early) and past month (recent) of sex work among YFSW to inform HIV prevention programming for sex workers. METHODS We used data from a cross-sectional survey (April-November 2015), administered using physical location-based sampling to 408 cis-women, aged 14-24 years, who self-identified as sex workers, in Mombasa, Kenya. We collected self-reported data on the early and recent month of sex work. The analysis focused on changes in a) sex work context and typology (defined by setting where sex workers practice sex work) where YFSW operated, b) primary typology of sex work, and c) HIV programme outcomes among YFSW who changed primary typology, within the early and recent month of sex work. We analysed the data using a) SPSS27.0 and excel; b) bivariate analysis and χ2 test; and c) bivariate logistic regression models. RESULTS Overall, the median age of respondents was 20 years and median duration in sex work was 2 years. Higher proportion of respondents in the recent period managed their clients on their own (98.0% vs. 91.2%), had sex with >5 clients per week (39.3% vs.16.5%); were able to meet > 50% of living expenses through sex work income (46.8% vs. 18.8%); and experienced police violence in the past month (16.4% vs. 6.5%). YFSW reported multiple sex work typology in early and recent periods. Overall, 37.2% reported changing their primary typology. A higher proportion among those who used street/ bus stop typology, experienced police violence, or initiated sex work after 19 years of age in the early period reported a change. There was no difference in HIV programme outcomes among YFSW who changed typology vs. those who did not. CONCLUSIONS The sex work context changes even in a short duration of two years. Hence, understanding these changes in the early period of sex work can allow for development of tailored strategies that are responsive to the specific needs and vulnerabilities of YFSW.
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Affiliation(s)
- Parinita Bhattacharjee
- Institute for Global Public Health, University of Manitoba, Winnipeg, Canada
- Partners for Health and Development in Africa, Nairobi, Kenya
| | - Shajy Isac
- Institute for Global Public Health, University of Manitoba, Winnipeg, Canada
| | - Helgar Musyoki
- National AIDS and STI Control Programme, Ministry of Health, Nairobi, Kenya
| | - Peter Gichangi
- International Centre for Reproductive Health- Kenya, Mombasa, Kenya
| | - Huiting Ma
- St. Michael's Hospital, Unity Health Toronto, Toronto, Canada
| | - Marissa Becker
- Institute for Global Public Health, University of Manitoba, Winnipeg, Canada
| | - Jan Hontelez
- Department of Public Health, Erasmus MC, Rotterdam, Netherlands
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | - Sharmistha Mishra
- St. Michael's Hospital, Unity Health Toronto, Toronto, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, Canada
- Institute of Health Policy Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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Neufeld B, Cholette F, Sandstrom P, Musyoki H, Ma H, Kaosa S, Kioko J, Isac S, Bhattacharjee P, Cheuk E, Pickles M, Mwatelah R, Capiña R, Daniuk C, Mckinnon LR, Blanchard J, Mishra S, Becker M. HIV acquisition prior to entry into formal sex work: inference from next-generation viral sequencing. AIDS 2023; 37:987-992. [PMID: 36727844 PMCID: PMC10090304 DOI: 10.1097/qad.0000000000003484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 12/15/2022] [Accepted: 01/04/2023] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To infer the timing of HIV acquisition in relation to self-reported events in the sexual life course of adolescent girls and young women (AGYW) who self-identify as female sex workers (FSW) in Mombasa, Kenya. DESIGN Next-generation viral sequencing of samples of AGYW living with HIV in the Transitions study, a cross-sectional bio-behavioural survey of AGYW aged 14-24 years in Mombasa, Kenya. METHOD Dried blood spot specimens were collected from study participants ( n = 37, all FSW). A portion of the HIV pol gene was sequenced using an in-house next-generation sequencing assay for HIV drug resistance mutation genotyping. Estimated time since infection (ETI) was inferred using the HIV EVO web-based tool ( https://hiv.biozentrum.unibas.ch/ETI/ ), and data on self-reported events were obtained from the survey. RESULTS The median ETI among FSW was 3.4 (interquartile range = 1.7, 6.3) years, with a median ETI of 1.5 years prior to entry into formal sex work. We estimated that 74.1% (95% confidence interval = 53.7-88.9%) of participants living with HIV and who self-identified as FSW likely acquired HIV prior to self-identification as a sex worker. CONCLUSIONS Findings suggest a large fraction of prevalent HIV infection among AGYW engaged in sex work stems from acquisition prior to entry into formal sex work. Current HIV prevention programs tailored for sex workers may miss key opportunities for HIV prevention as they are designed to reach women after entry into formal sex work, signaling a need for tailored programs to reach high-risk AGYW earlier on in their sexual life course.
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Affiliation(s)
- Bronwyn Neufeld
- Institute for Global Public Health, Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba
| | - François Cholette
- National HIV and Retrovirology Laboratories, National Microbiology Laboratory at the JC Wilt Infectious Diseases Research Centre, Public Health Agency of Canada
- Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | - Paul Sandstrom
- National HIV and Retrovirology Laboratories, National Microbiology Laboratory at the JC Wilt Infectious Diseases Research Centre, Public Health Agency of Canada
- Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | - Helgar Musyoki
- National AIDS and STI Control Programme, Ministry of Health, Nairobi, Kenya
| | - Huiting Ma
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, Unity Health Toronto, Toronto, Canada
| | - Shem Kaosa
- Partners for Health and Development in Africa, Nairobi, Kenya
| | - Japheth Kioko
- Partners for Health and Development in Africa, Nairobi, Kenya
| | - Shajy Isac
- India Health Action Trust, New Delhi, India
| | - Parinita Bhattacharjee
- Institute for Global Public Health, Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba
- Partners for Health and Development in Africa, Nairobi, Kenya
| | - Eve Cheuk
- Institute for Global Public Health, Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba
| | - Michael Pickles
- Medical Research Council Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
| | - Ruth Mwatelah
- Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | - Rupert Capiña
- National HIV and Retrovirology Laboratories, National Microbiology Laboratory at the JC Wilt Infectious Diseases Research Centre, Public Health Agency of Canada
| | - Christina Daniuk
- National HIV and Retrovirology Laboratories, National Microbiology Laboratory at the JC Wilt Infectious Diseases Research Centre, Public Health Agency of Canada
| | - Lyle R. Mckinnon
- Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
- Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
| | - James Blanchard
- Institute for Global Public Health, Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba
| | - Sharmistha Mishra
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, Unity Health Toronto, Toronto, Canada
- Department of Medicine
- Institute of Medical Sciences
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Marissa Becker
- Institute for Global Public Health, Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba
- Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
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Lichtwarck HO, Kazaura MR, Moen K, Mmbaga EJ. Harmful Alcohol Use and Associated Socio-Structural Factors among Female Sex Workers Initiating HIV Pre-Exposure Prophylaxis in Dar es Salaam, Tanzania. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 20:698. [PMID: 36613018 PMCID: PMC9819768 DOI: 10.3390/ijerph20010698] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 12/21/2022] [Accepted: 12/28/2022] [Indexed: 06/17/2023]
Abstract
Harmful alcohol use is an important risk factor for premature mortality and morbidity and associated with increased HIV risk and lower uptake of and adherence to HIV interventions. This study aimed to assess the extent of harmful alcohol use and associated socio-structural vulnerability factors among female sex workers in Dar es Salaam, Tanzania, a key population in the HIV epidemic. Data from a study of female sex workers initiating pre-exposure prophylaxis (PrEP) recruited through respondent driven sampling were used. We assessed harmful alcohol use with the Alcohol Use Disorders Identification Test (AUDIT) defined as having an AUDIT score ≥ 16. Associations between harmful alcohol use and socio-structural factors were assessed using logistic regression with marginal standardization. Of the 470 women recruited, more than one third (37.3%) had a drinking pattern suggestive of harmful alcohol use. Such use was independently associated with sex work-related mobility (aPR: 1.36, 95% CI: 1.11-1.61), arrest/incarceration (aPR: 1.55, 95% CI: 1.27-1.84) and gender-based violence (aPR: 1.31, 95% CI: 1.06-1.56). The high prevalence of harmful alcohol use and the interconnectedness with socio-structural factors indicate a need for a holistic programmatic approach to health for female sex workers. Programming should not solely direct attention to individual behavior but also include strategies aiming to address socio-structural vulnerabilities.
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Affiliation(s)
- Hanne Ochieng Lichtwarck
- Department of Community Medicine and Global Health, Institute of Health and Society, Faculty of Medicine, University of Oslo, 0450 Oslo, Norway
| | - Method Rwelengera Kazaura
- Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, Dar es Salaam 11103, Tanzania
| | - Kåre Moen
- Department of Community Medicine and Global Health, Institute of Health and Society, Faculty of Medicine, University of Oslo, 0450 Oslo, Norway
| | - Elia John Mmbaga
- Department of Community Medicine and Global Health, Institute of Health and Society, Faculty of Medicine, University of Oslo, 0450 Oslo, Norway
- Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, Dar es Salaam 11103, Tanzania
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Bhattacharjee P, Musau A, Manguro G, Ongwen P, Mutegi J, Kioko J, Lazarus L, Isac S, Musyoki H, Hontelez J, Were D. HIV prevention programme with young women who sell sex in Mombasa, Kenya: learnings for scale-up. J Int AIDS Soc 2022; 25:e25969. [PMID: 36028893 PMCID: PMC9418418 DOI: 10.1002/jia2.25969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 07/06/2022] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION In 2018, the National AIDS and sexually transmitted infection (STI) Control Programme developed a national guidelines to facilitate the inclusion of young women who sell sex (YWSS) in the HIV prevention response in Kenya. Following that, a 1-year pilot intervention, where a package of structural, behavioural and biomedical services was provided to 1376 cisgender YWSS to address their HIV-related risk and vulnerability, was implemented. METHODS Through a mixed-methods, pre/post study design, we assessed the effectiveness of the pilot, and elucidated implementation lessons learnt. The three data sources used included: (1) monthly routine programme monitoring data collected between October 2019 and September 2020 to assess the reach and coverage; (2) two polling booth surveys, conducted before and after implementation, to determine the effectiveness; and (3) focus group discussions and key informant interviews conducted before and after intervention to assess the feasibility of the intervention. Descriptive analysis was performed to produce proportions and comparative statistics. RESULTS During the intervention, 1376 YWSS were registered in the programme, 28% were below 19 years of age and 88% of the registered YWSS were active in the last month of intervention. In the survey, respondents reported increases in HIV-related knowledge (61.7% vs. 90%, p <0.001), ever usage of pre-exposure prophylaxis (8.5% vs. 32.2%, p < 0.001); current usage of pre-exposure prophylaxis (5.3% vs. 21.1%, p<0.002); ever testing for HIV (87.2% vs. 95.6%, p <0.04) and any clinic visit (35.1 vs. 61.1, p <0.001). However, increase in harassment by family (11.7% vs. 23.3%, p<0.04) and discrimination at educational institutions (5.3% vs. 14.4%, p<0.04) was also reported. In qualitative assessment, respondents reported early signs of success, and identified missed opportunities and made recommendations for scale-up. CONCLUSIONS Our intervention successfully rolled out HIV prevention services for YWSS in Mombasa, Kenya, and demonstrated that programming for YWSS is feasible and can effectively be done through YWSS peer-led combination prevention approaches. However, while reported uptake of treatment and prevention services increased, there was also an increase in reported harassment and discrimination requiring further attention. Lessons learnt from the pilot intervention can inform replication and scale-up of such interventions in Kenya.
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Affiliation(s)
- Parinita Bhattacharjee
- Institute for Global Public HealthUniversity of ManitobaWinnipegCanada
- Partners for Health and Development in AfricaNairobiKenya
| | | | | | | | | | - Japheth Kioko
- Partners for Health and Development in AfricaNairobiKenya
| | - Lisa Lazarus
- Institute for Global Public HealthUniversity of ManitobaWinnipegCanada
| | - Shajy Isac
- Institute for Global Public HealthUniversity of ManitobaWinnipegCanada
| | - Helgar Musyoki
- National AIDS and STI Control ProgrammeMinistry of HealthNairobiKenya
| | - Jan Hontelez
- Department of Public HealthErasmus MCRotterdamNetherlands
- Heidelberg Institute of Global HealthHeidelberg UniversityHeidelbergGermany
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Knight J, Kaul R, Mishra S. Risk heterogeneity in compartmental HIV transmission models of ART as prevention in Sub-Saharan Africa: A scoping review. Epidemics 2022; 40:100608. [PMID: 35843152 DOI: 10.1016/j.epidem.2022.100608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 06/11/2022] [Accepted: 07/05/2022] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Transmission models provide complementary evidence to clinical trials about the potential population-level incidence reduction attributable to ART (ART prevention impact). Different modelling assumptions about risk heterogeneity may influence projected ART prevention impacts. We sought to review representations of risk heterogeneity in compartmental HIV transmission models applied to project ART prevention impacts in Sub-Saharan Africa. METHODS We systematically reviewed studies published before January 2020 that used non-linear compartmental models of sexual HIV transmission to simulate ART prevention impacts in Sub-Saharan Africa. We summarized data on model structure/assumptions (factors) related to risk and intervention heterogeneity, and explored multivariate ecological associations of ART prevention impacts with modelled factors. RESULTS Of 1384 search hits, 94 studies were included. 64 studies considered sexual activity stratification and 39 modelled at least one key population. 21 studies modelled faster/slower ART cascade transitions (HIV diagnosis, ART initiation, or cessation) by risk group, including 8 with faster and 4 with slower cascade transitions among key populations versus the wider population. In ecological analysis of 125 scenarios from 40 studies (subset without combination intervention), scenarios with risk heterogeneity that included turnover of higher risk groups were associated with smaller ART prevention benefits. Modelled differences in ART cascade across risk groups also influenced the projected ART benefits, including: ART prioritized to key populations was associated with larger ART prevention benefits. Of note, zero of these 125 scenarios considered lower ART coverage among key populations. CONCLUSION Among compartmental transmission models applied to project ART prevention impacts in Sub-Saharan Africa, representations of risk heterogeneity and projected impacts varied considerably. Inclusion/exclusion of risk heterogeneity with turnover, and intervention heterogeneity across risk groups could influence the projected impacts of ART scale-up. These findings highlight a need to capture risk heterogeneity with turnover and cascade heterogeneity when projecting ART prevention impacts.
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Affiliation(s)
- Jesse Knight
- Institute of Medical Science, University of Toronto, Toronto, Canada.
| | - Rupert Kaul
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Sharmistha Mishra
- Institute of Medical Science, University of Toronto, Toronto, Canada; MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Canada; Division of Infectious Disease, Department of Medicine, University of Toronto, Toronto, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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9
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Kamau M, Musau A, Were D, Waruguru G, Kabue M, Mutegi J, Plotkin M, Reed J. Unmet Need for Contraception Among Female Sex Workers Initiating Oral Pre-Exposure Prophylaxis for HIV Prevention During Kenya's National Scale-Up: Results From a Programmatic Surveillance Study. Front Glob Womens Health 2022; 2:747784. [PMID: 35265940 PMCID: PMC8899534 DOI: 10.3389/fgwh.2021.747784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 12/30/2021] [Indexed: 11/24/2022] Open
Abstract
Background Female sex workers (FSWs) experience a higher risk for both HIV acquisition and unwanted pregnancies compared to women in the general population. Pre-exposure prophylaxis (PrEP) for HIV prevention offers protection against HIV infection but has no contraceptive effect. We examined the determinants of unmet need for contraception among FSWs who initiated PrEP to inform programs and policies to optimize contraceptive services and avert unwanted pregnancy among this high-risk group. Materials and Methods A cross-sectional analysis was conducted on routine, de-identified client data from a large-scale PrEP service delivery project, from February 2017 to December 2019. Data were collected from FSWs during clinic visits using Ministry of Health approved tools. Records for all 17,456 FSWs initiated on PrEP from 79 health facilities in 10 counties across three geographic clusters with high and medium HIV incidence were examined for eligibility for the analysis. Unmet need for non-barrier contraception was defined as not being pregnant, not currently using the non-barrier contraceptive method, and not trying to conceive or intending to have a child in the near future. Univariate and multivariable regression analyses were conducted with selected variables to examine associations. Results In the 79 sites, eligible records from 17,063 FSWs who initiated PrEP were included. Two-thirds were under 30 years, and the majority were not married and had received PrEP at drop-in centers. Overall, the unmet need for non-barrier contraception was 52.6%, higher for those under 20 years of age (60.9%) and those served in public and private health facilities (67.4 and 83.2%, respectively) rather than drop-in centers (50.6%). Women from the Nairobi and Coast cluster regions reported a higher unmet need for contraception compared to those from the Lake region. All these associations were significant (p < 0.05) at the multivariate level. Conclusions The high unmet need for non-barrier contraception among FSWs initiating PrEP highlights the need for integrated delivery of contraception services within PrEP programs. Identifying groups with a high unmet need could lead to higher success in an integrated program. Two recommended approaches include training healthcare providers to deliver clear contraception messaging during PrEP initiation and making a range of contraceptives accessible within PrEP services for high-risk groups. Furthermore, accelerated research on multipurpose prevention technologies is necessary to reduce the burden on individuals using multiple prevention products concurrently.
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Affiliation(s)
- Mercy Kamau
- Jhpiego, Nairobi, Kenya
- *Correspondence: Mercy Kamau
| | | | | | - Gladys Waruguru
- International Centre for Reproductive Health Kenya, Mombasa, Kenya
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Hensen B, Machingura F, Busza J, Birdthistle I, Chabata S, Chiyaka T, Floyd S, Jamali G, Mushati P, Hargreaves J, Cowan F. How Can We Support the Use of Oral PrEP Among Young Women who Sell Sex? A PrEP Cascade Analysis. J Acquir Immune Defic Syndr 2021; 88:45-56. [PMID: 34050101 PMCID: PMC8357043 DOI: 10.1097/qai.0000000000002733] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 04/19/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND We constructed self-reported pre-exposure prophylaxis (PrEP) cascades and explored factors associated with and barriers to PrEP use to inform efforts to support PrEP use among young women who sell sex. METHODS Using self-reported data from HIV-negative young women who sell sex enrolled into a cohort study using respondent-driven sampling in Zimbabwe, we constructed PrEP cascades assessing knowledge of, ever offered, ever used, and current PrEP use in 2017 and 2019. We used logistic regression to examine factors associated with PrEP use by 2019. Through qualitative interviews with 43 women enrolled in the cohort, we investigated barriers to PrEP use. RESULTS At enrollment, 50% of women had heard of PrEP, 12% had ever been offered PrEP, and 7% ever used PrEP. Over time, all cascade domains: 96% of women had heard of and 55% reported an active offer of PrEP. Among women retained in the study in 2019 (56%; n = 538), 34% ever took PrEP by 2019. PrEP use was associated with, at enrollment, reporting more clients in the past month (10+: 45% vs 1-3: 27% adjOR = 1.71 95% CI: 1.06 to 2.76), duration of selling sex (24% <2 years vs 38% 2-3 years; adjOR = 0.51 95% CI: 0.32 to 0.83), and having visited a female sex worker program in the past 12 months (55% vs 27%; adjOR = 2.92 95% CI: 1.91 to 4.46). Qualitative interviews revealed fear of disclosing sex work, HIV-related/ART-related stigma, and (opportunity) costs of accessing PrEP as barriers to use. CONCLUSION PrEP use was associated with factors known to increase HIV risk. Fear of stigma, disclosure, and supply-side barriers need to be addressed to increase women's ability to use PrEP.
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Affiliation(s)
- B. Hensen
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom;
| | - F. Machingura
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe;
| | - J. Busza
- Centre for Evaluation, London School of Hygiene and Tropical Medicine, London, United Kingdom;
| | - I. Birdthistle
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom; and
| | - S.T. Chabata
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe;
| | - T. Chiyaka
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe;
| | - S. Floyd
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom; and
| | - G. Jamali
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe;
| | - P. Mushati
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe;
| | - J. Hargreaves
- Centre for Evaluation, London School of Hygiene and Tropical Medicine, London, United Kingdom;
| | - F.M. Cowan
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe;
- Faculty of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom.
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Musyoki H, Bhattacharjee P, Sabin K, Ngoksin E, Wheeler T, Dallabetta G. A decade and beyond: learnings from HIV programming with underserved and marginalized key populations in Kenya. J Int AIDS Soc 2021; 24 Suppl 3:e25729. [PMID: 34189847 PMCID: PMC8242977 DOI: 10.1002/jia2.25729] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 04/16/2021] [Accepted: 04/20/2021] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Key populations (KP) continue to account for high HIV incidence globally. Still, prioritization of KP in the national HIV prevention response remains insufficient, leading to their suboptimal access to HIV programmes. This commentary aims to share Kenya's challenges and successes in achieving 2020 global HIV targets and scaling up the KP programme in the last decade. DISCUSSION The KP programme in Kenya has scaled up in the last decade with the inclusion of female sex workers (FSW), men who have sex with men (MSM), people who inject drugs (PWID), transgender people and people in prisons as priority populations in the national HIV response. KP coverage based on official size estimates for FSW is 73%, for MSM is 82%, for PWID through needle syringe programme (NSP) is 71%, and through opioid substitution therapy (OST) is 26% and for transgender people is 5%. The service outcomes for KP have been relatively strong in prevention with high condom use at last paid sex for FSW (92%) and use of sterile equipment among PWID (88%), though condom use at last sex with a non-regular partner among MSM (78%) is still low. The KP programme has not met care continuum targets for all subpopulations with low case findings. The national KP programme led by the Ministry of Health has scaled up the programme through (a) strategic partnerships with KP-led and competent organizations, researchers and donors; (b) development of policy guidance and programme standards; (c) continuous sensitization and advocacy to garner support; (d) development of national reporting systems, among others. However, the programme is still struggling with uncertain size estimates; lack of updated bio-behavioural survey data; inadequate scale-up of interventions among transgender people and people in prison settings; gaps in reaching adolescent and young KP, and effectively addressing structural barriers like violence and stigma. CONCLUSIONS To reach the ambitious global HIV targets, sufficient coverage of KP with quality HIV programmes is critical. Despite scaling up the KP programme, Kenya has not yet achieved the 2020 global HIV targets and needs more efforts to scale-up quality programmes for KP who are underserved in the HIV response.
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Affiliation(s)
- Helgar Musyoki
- National AIDS and STI Control Programme (NASCOP)Ministry of HealthNairobiKenya
| | - Parinita Bhattacharjee
- Institute of Global Public HealthUniversity of ManitobaWinnipegMBCanada
- Partners for Health and Development in AfricaNairobiKenya
| | - Keith Sabin
- The Joint United Nations Programme on HIV/AIDS (UNAIDS)GenevaSwitzerland
| | - Ed Ngoksin
- Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM)GenevaSwitzerland
| | - Tisha Wheeler
- United States Agency for International Development (USAID)WashingtonDCUSA
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12
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Chabata ST, Hensen B, Chiyaka T, Mushati P, Musemburi S, Dirawo J, Busza J, Floyd S, Birdthistle I, Hargreaves JR, Cowan FM. The impact of the DREAMS partnership on HIV incidence among young women who sell sex in two Zimbabwean cities: results of a non-randomised study. BMJ Glob Health 2021; 6:bmjgh-2020-003892. [PMID: 33906844 PMCID: PMC8088246 DOI: 10.1136/bmjgh-2020-003892] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 03/06/2021] [Accepted: 03/16/2021] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Young women who sell sex (YWSS) in Zimbabwe remain at high risk of HIV infection. Effective HIV prevention strategies are needed. Through support to access a combination of evidence-based interventions, including oral pre-exposure prophylaxis (PrEP), the Determined, Resilient, Empowered, AIDS-free, Mentored and Safe (DREAMS) partnership aimed to reduce new HIV infections among adolescent girls and young women by 40% over 24 months. METHODS Non-randomised 'plausibility' evaluation, powered to detect a 40% HIV incidence difference between DREAMS and non-DREAMS sites. Two large cities with DREAMS funding were included, and four smaller non-DREAMS towns for comparison. In all sites, YWSS were enrolled to a cohort through peer-referral. Women were followed up for 24 months. HIV seroconversion was the primary outcome, with secondary outcomes identified through a theory of change. Outcomes were compared between YWSS recruited in DREAMS cities and non-DREAMS towns, adjusting for individual-level confounders and HIV prevalence at enrolment. RESULTS From April to July 2017, 2431 women were enrolled, 1859 of whom were HIV negative at enrolment; 1019 of these women (54.8%) were followed up from March to May 2019 and included in endline analysis. Access to clinical services increased, but access to socioeconomic interventions promoted by DREAMS was limited. A total of 79 YWSS HIV seroconverted, with HIV incidence among YWSS in DREAMS cities lower (3.1/100 person-years) than in non-DREAMS towns (5.3/100 person-years). In prespecified adjusted analysis, HIV incidence was lower in DREAMS cities but with weak statistical evidence (adjusted rate ratio (RR)=0.68; 95% CI 0.40 to 1.19; p=0.18). Women in DREAMS cities were more likely to report ever and ongoing PrEP use, consistent condom use, fewer sexual partners and less intimate partner violence. CONCLUSION It is plausible that DREAMS lowered HIV incidence among YWSS in two Zimbabwean cities, but our evaluation provides weak statistical evidence for impact and suggests any reduction in incidence was lower than the anticipated 40% decline. We identified changes to some important 'pathways to impact' variables, including condom use.
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Affiliation(s)
- Sungai T Chabata
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe .,Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bernadette Hensen
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Tarisai Chiyaka
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe
| | - Phillis Mushati
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe
| | - Sithembile Musemburi
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe
| | - Jeffrey Dirawo
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe
| | - Joanna Busza
- Centre for Evaluation, London School of Hygiene & Tropical Medicine, London, UK
| | - Sian Floyd
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Isolde Birdthistle
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - James R Hargreaves
- Centre for Evaluation, London School of Hygiene & Tropical Medicine, London, UK
| | - Frances M Cowan
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe.,Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
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Tago A, McKinnon LR, Wanjiru T, Muriuki F, Munyao J, Gakii G, Akolo M, Kariri A, Reed N, Shaw SY, Gelmon LJ, Kimani J. Declines in HIV prevalence in female sex workers accessing an HIV treatment and prevention programme in Nairobi, Kenya over a 10-year period. AIDS 2021; 35:317-324. [PMID: 33165030 DOI: 10.1097/qad.0000000000002747] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Empirical time trends in HIV prevalence in female sex workers (FSWs) are helpful to understand the evolving HIV epidemic, and to monitor the scale-up, coverage, and impact of ongoing HIV prevention and treatment programmes. DESIGN Serial HIV prevalence study. METHODS We analyzed time trends in HIV prevalence in FSWs accessing services at seven Sex Worker Outreach Programme (SWOP) clinics in Nairobi from 2008 to 2017 (N = 33 560). The Mantel--Haenszel test for trend and independent samples Kruskal--Wallis test were used to analyze categorical and continuous variables, respectively. Multivariable binomial regression was used to estimate prevalence ratios/year, adjusting for several covariates. RESULTS HIV prevalence decreased over time in all age groups. This was particularly evident among FSWs less than 25 years of age; HIV was 17.5% in 2008-2009, decreasing to 12.2% in 2010-2011, 8.3% in 2012-2013, 7.3% in 2014-2015, and 4.8% in 2016-2017 (P < 0.0001). Over time, FSWs reported increased condom use, particularly with regular partners, more frequent prior HIV testing, and were less likely to report a history of vaginal discharge (P < 0.0001). In adjusted analyses compared with 2008, HIV prevalence decreased in 2011 (aPR 0.64; 95% CI: 0.46-0.90), 2012 (aPR 0.58; 95% CI: 0.41-0.81), 2013 (aPR 0.53; 95% CI: 0.38-0.73), 2014 (aPR 0.48; 95% CI: 0.34-0.67), 2015 (aPR 0.50; 95% CI: 0.35-0.70), 2016 (aPR 0.40; 95% CI: 0.28-0.57), and 2017 (aPR 0.33; 95% CI: 0.22-0.50). CONCLUSION HIV prevalence has decreased among FSW accessing SWOP in Nairobi, Kenya. This decline is consistent with the scale-up of HIV prevention and treatment efforts, both in FSWs and in the general population.
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Affiliation(s)
- Achieng Tago
- Max Rady College of Medicine, Rady Faculty of Health Sciences
| | - Lyle R McKinnon
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, Canada
- University of Nairobi Institute of Tropical and Infectious Diseases (UNITID), University of Nairobi, Nairobi, Kenya
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
| | - Tabitha Wanjiru
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, Canada
| | - Festus Muriuki
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, Canada
| | - Julius Munyao
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, Canada
| | - Gloria Gakii
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, Canada
| | - Maureen Akolo
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, Canada
| | - Anthony Kariri
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, Canada
| | - Neil Reed
- Max Rady College of Medicine, Rady Faculty of Health Sciences
| | - Souradet Y Shaw
- Centre for Global Public Health (CGPH), University of Manitoba
- Winnipeg Regional Health Authority (WRHA), Winnipeg, Canada
| | - Lawrence J Gelmon
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, Canada
- University of Nairobi Institute of Tropical and Infectious Diseases (UNITID), University of Nairobi, Nairobi, Kenya
| | - Joshua Kimani
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, Canada
- University of Nairobi Institute of Tropical and Infectious Diseases (UNITID), University of Nairobi, Nairobi, Kenya
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