Antenatal care presentation and engagement in the context of sex work: exploring barriers to care for sex worker mothers in South Africa

Impact and cost-effectiveness of the national scale-up of HIV pre-exposure prophylaxis among female sex workers in South Africa: a modelling analysis

INTRODUCTION

In 2016, South Africa (SA) initiated a national programme to scale-up pre-exposure prophylaxis (PrEP) among female sex workers (FSWs), with ∼20,000 PrEP initiations among FSWs (∼14% of FSW) by 2020. We evaluated the impact and cost-effectiveness of this programme, including future scale-up scenarios and the potential detrimental impact of the COVID-19 pandemic.

METHODS

A compartmental HIV transmission model for SA was adapted to include PrEP. Using estimates on self-reported PrEP adherence from a national study of FSW (67.7%) and the Treatment and Prevention for FSWs (TAPS) PrEP demonstration study in SA (80.8%), we down-adjusted TAPS estimates for the proportion of FSWs with detectable drug levels (adjusted range: 38.0-70.4%). The model stratified FSW by low (undetectable drug; 0% efficacy) and high adherence (detectable drug; 79.9%; 95% CI: 67.2-87.6% efficacy). FSWs can transition between adherence levels, with lower loss-to-follow-up among highly adherent FSWs (aHR: 0.58; 95% CI: 0.40-0.85; TAPS data). The model was calibrated to monthly data on the national scale-up of PrEP among FSWs over 2016-2020, including reductions in PrEP initiations during 2020. The model projected the impact of the current programme (2016-2020) and the future impact (2021-2040) at current coverage or if initiation and/or retention are doubled. Using published cost data, we assessed the cost-effectiveness (healthcare provider perspective; 3% discount rate; time horizon 2016-2040) of the current PrEP provision.

RESULTS

Calibrated to national data, model projections suggest that 2.1% of HIV-negative FSWs were currently on PrEP in 2020, with PrEP preventing 0.45% (95% credibility interval, 0.35-0.57%) of HIV infections among FSWs over 2016-2020 or 605 (444-840) infections overall. Reductions in PrEP initiations in 2020 possibly reduced infections averted by 18.57% (13.99-23.29). PrEP is cost-saving, with $1.42 (1.03-1.99) of ART costs saved per dollar spent on PrEP. Going forward, existing coverage of PrEP will avert 5,635 (3,572-9,036) infections by 2040. However, if PrEP initiation and retention doubles, then PrEP coverage increases to 9.9% (8.7-11.6%) and impact increases 4.3 times with 24,114 (15,308-38,107) infections averted by 2040.

CONCLUSIONS

Our findings advocate for the expansion of PrEP to FSWs throughout SA to maximize its impact. This should include strategies to optimize retention and should target women in contact with FSW services.

Maternal health and maternal health service utilization among female sex workers: A scoping review

BACKGROUND

High proportions of female sex workers (FSWs) become pregnant and have children. Many FSWs are at increased risk of maternal health complications due to factors such as poverty, violence, and healthcare barriers. Despite this, FSWs' maternal health and use of maternal health services (MHS) receive limited attention.

OBJECTIVES

The objectives of this scoping review are to (1) synthesize existing data on FSWs' maternal health and MHS utilization and (2) assess the state of peer-reviewed literature on FSWs' maternal health in regard to methodological approaches and reported outcomes.

ELIGIBILITY CRITERIA

Included articles were peer-reviewed, published in English, and reported empirical data on FSWs for outcomes related to antenatal care, pregnancy, and labor complications, postnatal and delivery care, and/or barriers to MHS.

SOURCES OF EVIDENCE

Article searches were conducted in PubMed, Web of Science, Global Health, Sociological Abstracts, Sociological Index, PsychInfo, and CINAHL.

CHARTING METHODS

Information extracted from eligible articles included publication year, study design, location, sample size, outcome measures, and findings. The "Three Delays" model was used to synthesize findings on barriers to MHS as relevant to phase I, II, or III delays.

RESULTS

Eighteen publications met the eligibility criteria. Studies were conducted in 11 countries and primarily reported quantitative data from cross-sectional surveys. The most frequently reported outcome was antenatal care utilization (n = 14), whereas few studies reported findings related to postnatal care and breastfeeding counseling (n = 2). Across publications, there was a substantial range in the proportion of FSWs who reported accessing different types of MHS.

CONCLUSION

Literature on FSWs' maternal health is limited and heterogenous. More research is needed that specifically focuses on measuring outcomes related to FSWs' maternal health and examines associated factors. Such work can inform future research directions and public health interventions for FSWs-a population of marginalized women whose maternal health has been overlooked in existing efforts.

Barriers and facilitators for access and utilization of reproductive and sexual health services among Female Sex Workers in urban and rural Maharashtra, India

Background

The public health interventions among Female Sex Workers (FSWs) have mainly addressed HIV/ STI prevention. The focus of the HIV prevention program on FSWs' Reproductive and Sexual Health (RSH) has been limited, thus, rendering them at a higher risk of unintended pregnancies, delayed pregnancy detection, and utilizing unsafe abortion methods.

Methods

A multistakeholder analysis was performed to study access and use of RSH services among FSWs in urban and rural India. Between January 2016 and June 2019, a qualitative grounded theory approach was used to explore the FSWs' perspectives and experiences about services pertaining to HIV prevention, Antenatal Care (ANC), child delivery, abortion, and pregnancy prevention. Using purposive and convenience sampling, 29 In-Depth Interviews (IDIs), 2 Focus Group Discussions (FGDs) and 22 Key Informant Interviews (KIIs) were conducted with consenting FSWs and indirect stakeholders, respectively. Verbatim translated data was entered in NVivo12 Software and analyzed inductively.

Results

The following themes emerged: (1) Condomless sex, unintended pregnancy, vertical transmission, (2) Signs/ indication used for pregnancy detection causing delay (3) Pregnancy prevention methods used, (4) Pregnancy prevention or AIDS prevention, (5) Legal formalities as a barrier to access RSH, (6) Differential facility preference.

Conclusion

Pregnancy prevention is a greater motivation for condom use than HIV prevention among FSWs. Therefore, there is an emerging need to reallocate public health resources and redesign policies to meet the RSH needs of FSWs, especially for the prevention of unintended pregnancies. FSW-focused Information Education Communication (IEC) strategies for RSH service utilization are essential to reduce the burden of unintended pregnancies. The National HIV Targeted Intervention (TI) program needs to include pregnancy testing services and information to non-barrier contraceptive methods. An ambient policy environment calls for examining the need for male involvement in pregnancy, family planning and abortion decisions.

Causes of mortality among female sex workers: Results of a multi-country study

BACKGROUND

The vast majority of studies on female sex workers (FSW) focus on causes of morbidity while data on causes of mortality are scarce. In low- and middle-income countries, where civil registry and vital statistics data are often incomplete and FSW may not be identified as such in official registries, identifying causes of mortality among FSW has proven challenging.

METHODS

As part of a larger investigation on the maternal health of FSW, the current study used the Community Knowledge Approach (CKA) to identify causes of mortality among FSW in LMIC across three global regions in 2019. The CKA, validated to identify maternal, neonatal, and jaundice-associated deaths among women living in a community, was employed to identify deaths of any cause among communities of FSW. Study participants, recruited by in-country partner non-governmental organizations (NGOs) working with local FSW, provided detailed information about FSW deaths in their communities.

FINDINGS

1280 FSW participated in 165 group meetings through which 2112 FSW deaths were identified. Of these reported deaths, 57·9% occurred in 2019 and 57·2% were among women aged 20-29. Causes of death included abortion (35·5%), other maternal causes (16·6%), suicide (13·6%), murder (12·5%), unclassified causes (11·6%), HIV/AIDS (7·9%), and accidents (3·2%). A total of 3659 children lost their mothers.

INTERPRETATION

Maternal death comprised the leading cause of FSW mortality in our sample. This methodology can be used by local governments and NGOs to identify unrecognized patterns and clusters of FSW deaths in near-real time and urgently steer targeted preventative strategies.

FUNDING

New Venture Fund.

Women Who Sell Sex in Eastern and Southern Africa: A Scoping Review of Non-Barrier Contraception, Pregnancy and Abortion

Objectives: There is a need to hone reproductive health (RH) services for women who sell sex (WSS). The aim of this review was to collate findings on non-barrier contraception, pregnancies, and abortion amongst WSS in Eastern and Southern African (ESA). Methods: A scoping review methodology was employed. Inclusion criteria were: 1) empirical papers from 2) ESA, 3) published since 2010, and 4) addressing WSS in relation to 5) the identified RH issues. Results: Reports of rates of non-barrier contraceptive usage varied from 15% to 76%, of unintended pregnancy from 24% to 91%, and of abortion from 11% to 48%. Cross-cutting factors were alcohol use, violence, health systems problems, and socio-economic issues. Pregnancy desire was associated with having a non-paying partner. Barriers to accessing, and delaying, antenatal care were reported as common. Targeted programmes were reported as promoting RH amongst WSS. Conclusion: Programmes should be contextually relevant, based on local patterns, individual, interpersonal and systemic barriers. Targeted approaches should be implemented in conjunction with improvement of public health services. Linked HIV and RH services, and community empowerment approaches are recommended.

Becoming a mother in the context of sex work: Women's experiences of bonding with their children

Many females engaged in sex work are mothers, often experiencing poverty, violence, marginalization, and psychological distress, factors also found to affect parental bonds. However, little is known about how this context impacts the bonding process. Given the ubiquity of sex work across geographical territories, understanding the relationship it has with mother-child bonding is an important international consideration in providing healthcare for sex working mothers and their children. Therefore, in this study we sought to explore women's experiences of bonding with their children in the context of sex work. We interviewed six women in the UK who were sex working during the first two years of their child's life about their bonding experiences and analyzed transcripts using Interpretative Phenomenological Analysis. We identified four themes were identified: (1) the complex process of bonding; (2) the role of powerlessness on bonding; (3) the powerful impact of receiving help, and (4) new perspectives of the body and sex work following motherhood. Findings contribute to the research literature on bonding by emphasizing the value of supportive care and the importance of social context, indicating specific factors to inform psychological support among sex working women.