Sex Workers Should not Be Forgotten in Africa's COVID-19 Response

Psychosocial experience of the Covid-19 crisis among people who use or inject drugs in Algeria: A community-based qualitative study

The COVID-19 crisis had a global impact and many marginalised groups, such as people who use or inject drugs, are more vulnerable to the SARS-CoV-2 virus and its consequences due to their pre-existing health inequalities. Moreover, people who use/inject drugs are also criminalised in some countries such as Algeria. This analysis aimed to explore the psychosocial experience of the COVID-19 crisis among people who use/inject drugs in Algeria. Twenty-nine qualitative interviews were conducted in 2021 with a community-based approach. Results of the thematic content analysis showed the intersectional effects of the COVID-19 crisis among people who use or inject drugs through the experience of a double crisis: one related to COVID-19 and the second to their specific difficulties related to drug use. Addressing social inequalities in health of people who use or inject drugs, through better recognition of their rights and needs, is crucial to improving their health.

'Change creates change' - older female sex workers' experiences through the early COVID-19 pandemic

COVID-19 and associated policy responses created unique social, economic and health risks for sex workers. Through semi-structured interviews we explored pre- and early COVID-19 experiences and work practices of ten cisgender female sex workers 50 years of age and older in Queensland, Australia, analysing the findings using a risk environment framework. Throughout early 2020, participants navigated a complex risk environment, managing economic needs, health and safety, occupational stigma and policing. Australia's policy responses altered the risks and opportunities available to participants. Half the participants continued sex work and half stopped sex work with some accessing economic support and withdrawing superannuation savings. Those who continued sex work drew on life and work experience to reassess changing health, stigma, and policing risks, and adapted their work strategies by increasing client screening and modifying services. Participants relied on information from peer networks and organisations to guide work practices but remained wary of contact tracing, police and the media. Decriminalisation of sex work and the strengthening of sex worker organisation and government partnerships are important in embedding equity in responses to ongoing and new public health threats.

Surviving pandemic control measures: The experiences of female sex workers during COVID-19 in Nairobi, Kenya

At the beginning of the COVID-19 pandemic, the Kenya Ministry of Health instituted movement cessation measures and limits on face-to-face meetings. We explore the ways in which female sex workers (FSWs) in Nairobi were affected by the COVID-19 control measures and the ways they coped with the hardships. Forty-seven women were randomly sampled from the Maisha Fiti study, a longitudinal study of 1003 FSWs accessing sexual reproductive health services in Nairobi for an in-depth qualitative interview 4-5 months into the pandemic. We sought to understand the effects of COVID-19 on their lives. Data were transcribed, translated, and coded inductively. The COVID-19 measures disenfranchised FSWs reducing access to healthcare, decreasing income and increasing sexual, physical, and financial abuse by clients and law enforcement. Due to the customer-facing nature of their work, sex workers were hit hard by the COVID-19 restrictions. FSWs experienced poor mental health and strained interpersonal relationships. To cope they skipped meals, reduced alcohol use and smoking, started small businesses to supplement sex work or relocated to their rural homes. Interventions that ensure continuity of access to health services, prevent exploitation, and ensure the social and economic protection of FSWs during times of economic strain are required.

Impact of the COVID-19 Health Crisis on Key Populations at Higher Risk for, or Living With, HIV or Hepatitis C Virus and People Working With These Populations: Multicountry Community-Based Research Study Protocol (EPIC Program)

BACKGROUND

Information concerning the impact of the COVID-19 health crisis on populations most affected by HIV and hepatitis C virus (HCV; or key populations [KP]), and those working with these populations in community settings, is limited. Community-based organizations working in the field of HIV and viral hepatitis are well placed to identify and meet the new needs of KP owing to the health crisis.

OBJECTIVE

This study aims to describe the development and implementation of an exploratory and descriptive multicountry, community-based research program, EPIC (Enquêtes Pour évaluer l'Impact de la crise sanitaire covid en milieu Communautaire), within an international network of community-based organizations involved in the response to HIV and viral hepatitis. The EPIC program aimed to study the impact of the COVID-19 health crisis on KP or people living with HIV or HCV and people working with these populations at the community level (community health workers [CHWs]) and to identify the key innovations and adaptations in HIV and HCV services.

METHODS

A general protocol and study documents were developed and shared within the Coalition PLUS network. The protocol had a built-in flexibility that allowed participating organizations to adapt the study to local needs in terms of the target population and specific themes of interest. Data were collected using surveys or interviews.

RESULTS

From July 2020 to May 2022, a total of 79 organizations participated in the EPIC program. Across 32 countries, 118 studies were conducted: 66 quantitative (n=12,060 among KP or people living with HIV or people living with HCV and n=811 among CHWs) and 52 qualitative (n=766 among KP or people living with HIV or people living with HCV and n=136 among CHWs).

CONCLUSIONS

The results of the EPIC program will provide data to describe the impact of the health crisis on KP and CHWs and identify their emerging needs. Documentation of innovative solutions that were put into place in this context may help improve the provision of services after COVID-19 and for future health crises.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/45204.

Struggling, Forgotten, and Under Pressure: A Scoping Review of Experiences of Sex Workers During the COVID-19 Pandemic

The COVID-19 pandemic profoundly affected physical, mental, and economic well-being across the globe and has disproportionately affected certain vulnerable groups. This paper provides a scoping review of literature on the impact of the COVID-19 pandemic on sex workers, published between December 2019 and December 2022. Six databases were systematically searched, identifying 1009 citations; 63 studies were included in the review. Thematic analysis revealed eight main themes: financial issues; exposure to harm; alternate ways of working; COVID-19 knowledge, protective behaviors, fear, and risk; well-being, mental health, and coping; access to support; access to health care; and the impact of COVID-19 on research with sex workers. COVID-associated restrictions led to reduced work and income, leaving many sex workers struggling to cover basic needs; additionally, government protections excluded those working in the informal economy. Fearing the loss of their already reduced number of clients, many felt compelled to compromise both prices and protective measures. Although some engaged in online sex work, this raised concerns about visibility and was impossible for those without technological access or skills. Many feared COVID-19, but felt pressure to continue working, often with clients who refused to wear masks or share exposure history. Other negative impacts on well-being related to the pandemic included reduced access to financial support or health care. Marginalized populations (and especially those in professions which require close contact like sex workers) need further support and capacity-building within the community to recover from the impact of COVID-19.

The COVID-19 pandemic and male sex workers who have sex with men: associations between age and race and advertising for work in 2019-2021

Despite government-mandated restrictions on business and social activities worldwide, some sex workers continued to see clients in person throughout the COVID-19 pandemic. To better understand this behaviour, we compiled publicly available data from Internet advertisements posted on a popular website before and during the pandemic by male sex workers providing services to men. We first collected data in March 2019 from 172 advertisements - the complete number available at that time - posted by male sex workers advertising services in the Atlanta region. We then assessed whether these same sex workers continued to advertise their availability at three subsequent points during the COVID-19 pandemic: April 2020, January 2021 and February 2021. We also determined whether age and race were associated with advertising presence at each time point. While advertising rates declined among sex workers in all race categories (Black, White and 'other'), results from our mixed effects logistic regression model show that the odds of older male sex workers continuing to advertise were greater than the odds for their younger counterparts. Further, the predicted probability of continued advertising was highest for White male sex workers. Our findings provide additional insights into male sex work during a global pandemic.

A scoping review of the impacts of COVID-19 physical distancing measures on vulnerable population groups

Most governments have enacted physical or social distancing measures to control COVID-19 transmission. Yet little is known about the socio-economic trade-offs of these measures, especially for vulnerable populations, who are exposed to increased risks and are susceptible to adverse health outcomes. To examine the impacts of physical distancing measures on the most vulnerable in society, this scoping review screened 39,816 records and synthesised results from 265 studies worldwide documenting the negative impacts of physical distancing on older people, children/students, low-income populations, migrant workers, people in prison, people with disabilities, sex workers, victims of domestic violence, refugees, ethnic minorities, and people from sexual and gender minorities. We show that prolonged loneliness, mental distress, unemployment, income loss, food insecurity, widened inequality and disruption of access to social support and health services were unintended consequences of physical distancing that impacted these vulnerable groups and highlight that physical distancing measures exacerbated the vulnerabilities of different vulnerable populations.

Association between interrupted access to sex work community services during the COVID-19 pandemic and changes in sex workers' occupational conditions: findings from a community-based cohort study in Vancouver, Canada

OBJECTIVES

Globally, criminalisation has shaped sex workers' structural exclusion from occupational protections, and this exclusion has been exacerbated during the COVID-19 pandemic. While community organisations aim to bridge this gap through providing health and safety resources for sex workers, many were forced to scale back services when Canadian provinces declared a state of emergency at the pandemic onset. As little empirical research has examined the impacts of sex work community services interruptions amid COVID-19, our objectives were to (1) examine the correlates of interrupted access to community services and (2) model the independent association between interrupted access to community services and changes in working conditions (ie, self-reported increases in workplace violence or fear of violence), among sex workers during the COVID-19 pandemic.

DESIGN, SETTING AND PARTICIPANTS

As part of an ongoing community-based cohort of sex workers in Vancouver, Canada (An Evaluation of Sex Workers Health Access, 2010-present), 183 participants completed COVID-19 questionnaires between April 2020 and April 2021.

ANALYSIS

Cross-sectional analysis used bivariate and multivariable logistic regression with explanatory and confounder modelling approaches.

RESULTS

18.6% of participants (n=34) reported interrupted access to community services (closure/reduction in drop-in hours, reduced access to spaces offering sex worker supports and/or reduced access/contact with outreach services). In multivariable analysis, sex workers who had difficulty maintaining social supports during COVID-19 (adjusted OR, AOR 2.29, 95% CI 0.95 to 5.56) and who experienced recent non-fatal overdose (AOR 2.71, 95% CI 0.82 to 8.98) faced marginally increased odds of service interruptions. In multivariable confounder analysis, interrupted access to community services during COVID-19 was independently associated with changes in working conditions (ie, self-reported increases in workplace violence or fear of violence; AOR 4.00, 95% CI 1.01 to 15.90).

CONCLUSIONS

Findings highlight concerning implications of community service interruptions for sex workers' labour conditions. Sustainable funding to community organisations is urgently needed to uphold sex workers' occupational safety amid COVID-19 and beyond.

"Right now we are scared of each other, we fear everyone, the whole world has COVID": The impact of COVID-19 on young female sex workers in Kampala, Uganda, during national lockdowns in 2020-2021

In 2020-2021 the COVID-19 pandemic led to multiple and diverse global public health response strategies globally and in Uganda to slow the spread of the virus by promoting wearing face coverings in public, frequent hand washing, physical distancing, restricting travel, and imposing home lockdowns. We conducted 146 interviews over four rounds of phone-follow up calls over 15 months with 125 young female sex workers coinciding in time with four different government-imposed lockdown periods in Kampala, Uganda, to assess the impact of these measures on young sex workers, their families and their communities as well as to gauge their resilience. Our findings revealed how COVID-19 fears and public health restrictions over time pushed an already marginalized population to the brink and how that pressure drove some participants into a new way of life.

Self-care from the perspective by female sex workers to prevent and face the SARS-CoV-2 pandemic

Abstract The objective was to identify the meanings attributed to self-care and its relationship with the actions taken by female sex workers in preventing and coping with COVID-19. Qualitative study supported by the Self-Care Nursing theory. An in-depth interview was carried out with 30 female sex workers from the Alto Sertão Produtivo Baiano. The IRAMUTEQ software was used to analyze the speeches, with the Descending Hierarchical Classification dendrogram. Four classes were observed, revealing the meanings attributed to self-care: the idea that self-care promotes quality of life and well-being; money as a facilitating instrument for self-care actions, both in preventing COVID-19 and in coping with difficulties; in addition to the notion that self-care contributes to the care of those around them. It is concluded that the female sex workers demonstrated to understand the concept of self-care in association with the notion of precaution, while prevention is carried out through the recommendations made by competent bodies. Furthermore, a self-care deficit was noticed due to the conditions present in the sexual service and the difficulties imposed by the pandemic.

Self-care from the perspective by female sex workers to prevent and face the SARS-CoV-2 pandemic

The objective was to identify the meanings attributed to self-care and its relationship with the actions taken by female sex workers in preventing and coping with COVID-19. Qualitative study supported by the Self-Care Nursing theory. An in-depth interview was carried out with 30 female sex workers from the Alto Sertão Produtivo Baiano. The IRAMUTEQ software was used to analyze the speeches, with the Descending Hierarchical Classification dendrogram. Four classes were observed, revealing the meanings attributed to self-care: the idea that self-care promotes quality of life and well-being; money as a facilitating instrument for self-care actions, both in preventing COVID-19 and in coping with difficulties; in addition to the notion that self-care contributes to the care of those around them. It is concluded that the female sex workers demonstrated to understand the concept of self-care in association with the notion of precaution, while prevention is carried out through the recommendations made by competent bodies. Furthermore, a self-care deficit was noticed due to the conditions present in the sexual service and the difficulties imposed by the pandemic.

"What will we do if we get infected?": An interview-based study of the COVID-19 pandemic and its effects on the health and safety of sex workers in the United States

Emerging evidence suggests that sex workers face unique and profound risks arising from the COVID-19 pandemic. To illuminate the pandemic's effects on sex worker health and safety and identify intervention opportunities, from May-August 2020 in-depth interviews were conducted with a purposive sample of 15 sex workers, four service providers and two individuals who were both. Sampled sex workers included eight people of color, eight cisgender women, five cisgender men, three non-binary people, and one transgender woman. Using Conservation of Resources Theory to define impacts on sex worker resources and resulting health and safety implications, a deductive thematic analysis was conducted. Seven resources were threatened due to the pandemic: work opportunity, sex work venues, social support, health services, money, food, and housing. The loss of these resources was exacerbated by stigma - notably sex work criminalization - and significantly undermined health and safety by increasing food and housing instability, increasing risks of violence, and diminishing safer sex negotiation. Six resources were activated in response: social support, digital skills, health knowledge, non-sex work employment, money, and resilience. While social support had numerous benefits, investing digital skills and non-sex work employment were generally of limited impact. The pandemic's negative health and safety effects were most profound at the intersections of race, gender, class, and migration status. These findings suggest sex workers need urgent and ongoing support, with investments in social support and sex work decriminalization likely to have the greatest effects on health and safety relative to and beyond the COVID-19 pandemic.

Mental health of female sex workers in the COVID-19 pandemic: stressors and coping strategies

The objective was to analyze the coping strategies adopted by female sex workers in the face of stressors resulting from the COVID-19 pandemic. Qualitative study supported by Systems and Coping theories. An in-depth interview was carried out with 30 sex workers from the Alto Sertão Produtivo Baiano between September and October 2020. The narratives were submitted to the resources of hermeneutics-dialectic to organize the categories. Four categories make reference to the system's stressors: negative feelings of fear, anxiety and difficulties in sleeping with the uncertainties in the face of the pandemic; concern about personal and family support; irritability in the face of conflicts; anxieties and insecurities with working conditions. Five categories allude to coping: strategies focused on the problem (pandemic); reframing and regulation of emotions; spirituality and religiosity; support networks and social support; use of medications. Stressors arise as a result of sexual service experiences combined with the pandemic situation with reduced customers and income, leading to the development of negative feelings and emotions. However, coping strategies are diverse and they women made effort to deal with problems and to balance their mental health.

Mental health of female sex workers in the COVID-19 pandemic: stressors and coping strategies

Abstract The objective was to analyze the coping strategies adopted by female sex workers in the face of stressors resulting from the COVID-19 pandemic. Qualitative study supported by Systems and Coping theories. An in-depth interview was carried out with 30 sex workers from the Alto Sertão Produtivo Baiano between September and October 2020. The narratives were submitted to the resources of hermeneutics-dialectic to organize the categories. Four categories make reference to the system’s stressors: negative feelings of fear, anxiety and difficulties in sleeping with the uncertainties in the face of the pandemic; concern about personal and family support; irritability in the face of conflicts; anxieties and insecurities with working conditions. Five categories allude to coping: strategies focused on the problem (pandemic); reframing and regulation of emotions; spirituality and religiosity; support networks and social support; use of medications. Stressors arise as a result of sexual service experiences combined with the pandemic situation with reduced customers and income, leading to the development of negative feelings and emotions. However, coping strategies are diverse and they women made effort to deal with problems and to balance their mental health.

Factors associated with poor access to HIV and sexual and reproductive health services in Nigeria for women and girls living with HIV during the COVID-19 pandemic

Aim: To determine the proportion of women and girls living with HIV (WGLHIV) who had poor access to HIV, tuberculosis and sexual and reproductive health (SRH) services in Nigeria during the COVID-19 pandemic and associated factors.Methods: This was a cross-sectional study that recruited WGLHIV with six categories of vulnerability (sex work, transactional sex, injecting or using illegal drugs, people on the move, transgender women and people with a disability) through an online survey conducted in ten Nigerian states between june and October 2021. The associations between the limited access to HIV, tuberculosis and SRH services due to COVID-19, the categories of vulnerability and the financial and non-financial barriers to these services were determined using multivariable logistics regression analysis.Results: Over 6 in 10, almost 2 in 10, and almost 4 in 10 WGLHIV had limited access to HIV, tuberculosis and SRH services respectively during the COVID-19 pandemic. Transgender women had 3.59 (95% CI 2.19-5.91) higher odds, women who engaged in sex work had 4.51 (95% CI 2.28-8.42) higher odds, and women who inject or use illegal drugs had 2.39 (95% CI 1.47-32.90) higher odds of facing limited access to sexual and reproductive health services when it was needed. In addition, the direct consequences of the COVID-19 crisis, such as the closure of HIV services and SRH service points, exacerbated pre-existing barriers significantly. Having no money, having to pay additional unofficial fees and the lack of security on the road to the health facility were the barriers with the greatest impact on access to health services.Conclusions: The COVID-19 pandemic had a negative impact on the access of WGLHIV to essential health services. This impact was disproportionately higher for marginalised groups. WGLHIV need non-discriminatory and affordable access to essential health services during the pandemic.

Sex Workers' Everyday Security in the Netherlands and the Impact of COVID-19

Introduction

The COVID-19 pandemic has laid bare and exacerbates the existing insecurities of sex workers. This paper asks: What are sex workers' everyday experiences of (in)security? And: How has the COVID-19 pandemic influenced these?

Methods

We engage with these questions through collaborative research based on semi-structured interviews carried out in 2019 and 2020 with sex workers in The Hague, the Netherlands.

Results

Revealing a stark mismatch between the insecurities that sex workers' experience and the concerns enshrined in regulation, our analysis shows that sex workers' everyday insecurities involve diverse concerns regarding their occupational safety and health, highlighting that work insecurity is more multi-faceted than sexually transmitted infections (STIs). Widespread employment and income insecurities for sex workers are exacerbated for transwomen and male sex workers. Their legal liminality is enabled not only by the opaque legal status of sex work in the Netherlands, but also by the gendering of official regulation. The COVID-19 pandemic made visible how the sexual and gender norms that informally govern sex workers' working conditions intersect with hierarchies of citizenship, complicating access to COVID-19 support, particularly for migrant sex workers.

Conclusions

Sex work regulation in the Netherlands leaves workers in a limbo-not without obligations and surveillance, yet, without the full guarantee of their labour rights.

Policy Implications

To effectively address sex workers' insecurities, a shift in regulation from its current biopolitical focus to a labour approach is necessary. Besides, public policy and civil society actors alike need to address the sex industry's harmful social regulation through hierarchies of gender, sexuality and race.

Barriers to and strategies to address COVID-19 testing hesitancy: a rapid scoping review

Background

Testing is a foundational component of any COVID-19 management strategy; however, emerging evidence suggests that barriers and hesitancy to COVID-19 testing may affect uptake or participation and often these are multiple and intersecting factors that may vary across population groups. To this end, Health Canada’s COVID-19 Testing and Screening Expert Advisory Panel commissioned this rapid review in January 2021 to explore the available evidence in this area. The aim of this rapid review was to identify barriers to COVID-19 testing and strategies used to mitigate these barriers.

Methods

Searches (completed January 8, 2021) were conducted in MEDLINE, Scopus, medRxiv/bioRxiv, Cochrane and online grey literature sources to identify publications that described barriers and strategies related to COVID-19 testing.

Results

From 1294 academic and 97 grey literature search results, 31 academic and 31 grey literature sources were included. Data were extracted from the relevant papers. The most cited barriers were cost of testing; low health literacy; low trust in the healthcare system; availability and accessibility of testing sites; and stigma and consequences of testing positive. Strategies to mitigate barriers to COVID-19 testing included: free testing; promoting awareness of importance to testing; presenting various testing options and types of testing centres (i.e., drive-thru, walk-up, home testing); providing transportation to testing centres; and offering support for self-isolation (e.g., salary support or housing).

Conclusion

Various barriers to COVID-19 testing and strategies for mitigating these barriers were identified. Further research to test the efficacy of these strategies is needed to better support testing for COVID-19 by addressing testing hesitancy as part of the broader COVID-19 public health response.

Sex Workers’ Work-Related Victimisation and Drug Use During the First Year of the COVID-19 Pandemic in Switzerland

Criminologists have monitored the coronavirus pandemic’s effects on crime and criminal justice since the pandemic’s outbreak. Nonetheless, vulnerable and difficult-to-reach populations have been understudied thus far. This study sheds light on the experiences of sex workers (SW) during the first year of the coronavirus in Switzerland, a country where prostitution is legal. Based upon 40 questionnaires with SW outdoors and indoors and 50 h of field observation, SW reported that the pandemic has had adverse financial and psychosocial effects on them. During the first year of COVID-19, seventeen SW were victims of at least one work-related offence, the most prevalent of which were theft and fraud. Nevertheless, most SW did not report the incidents to the police. Comparing the non-victims with victims, we found that victims, particularly those of multiple crimes, are younger, more often foreigners from extra-EU countries, in an illegal situation and needed to work face to face during the prostitution ban during the lockdown in Switzerland. However, despite these circumstances, most SW do not use illegal drugs, and only a few of them used more during the pandemic. Our research findings were similar to those reported in former studies, although we could infer that the violent victimisation of our sample is less and none of the SW indicated violence on the part of the police. Nevertheless, we have no point of comparison with former years and thus propose a periodic crime victim survey of SW, as well as further prevention measures in the prostitution area.

Behavioral Changes, Adaptation, and Supports among Indonesian Female Sex Workers Facing Dual Risk of COVID-19 and HIV in a Pandemic

The objective of this study is to explore the impacts of COVID-19 and changes taking place among the Indonesian female sex worker (FSW) community during the COVID-19 pandemic and the predictors of these changes. We conducted a cross-sectional online survey and selected the participants using a purposive snowball sampling technique. Incentives were provided to participants in the form of a 5 USD e-wallet balance. Variables of interest included adaptation to online sex work, adherence to COVID-19 prevention measures during sex work, number of clients, income reduction, social support, condom access, and condom use frequency. Sociodemographic data and COVID-19 fear index values were also collected. Final analysis included 951 FSWs, of whom 36.4% of had adapted to online sex work and 48.6% had practiced COVID-19 prevention measures. Major reductions in client frequency and income were reported by 67.8% and 71.1% of respondents, respectively. However, only 36.3% of FSWs reported they had ever received any form of social support from any parties, public or private. Meanwhile, 16.7% encountered difficulties in accessing condoms and 12.5% reported less frequent condom use during the pandemic. Easy access to condoms was the main factor influencing the frequency of condom use. As expected, staying in employment protected FSWs from major income loss, while education and younger age predicted adaptive behavioral changes, such as taking up online sex work. The COVID-19 pandemic has disrupted access to socioeconomic support systems and HIV prevention services among FSWs and has further exposed them to the dual jeopardy of HIV and COVID-19 infections.

Do not forget the children: a model‐based analysis on the potential impact of COVID‐19‐associated interruptions in paediatric HIV prevention and care

Introduction

The COVID‐19 pandemic has affected women and children globally, disrupting antiretroviral therapy (ART) services and exacerbating pre‐existing barriers to care for both pregnant women and paediatric populations.

Methods

We used the Spectrum modelling package and the CEPAC‐Pediatric model to project the impact of COVID‐19‐associated care disruptions on three key populations in the 21 Global Plan priority countries in sub‐Saharan Africa: (1) pregnant and breastfeeding women living with HIV and their children, (2) all children (aged 0–14 years) living with HIV (CLWH), regardless of their engagement in care and (3) CLWH who were engaged in care and on ART prior to the start of the pandemic. We projected clinical outcomes over the 12‐month period of 1 March 2020 to 1 March 2021.

Results

Compared to a scenario with no care disruption, in a 3‐month lockdown with complete service disruption, followed by 3 additional months of partial (50%) service disruption, a projected 755,400 women would have received PMTCT care (a 21% decrease), 187,800 new paediatric HIV infections would have occurred (a 77% increase) and 516,800 children would have received ART (a 35% decrease). For children on ART as of March 2020, we projected 507,200 would have experienced ART failure (an 80% increase). Additionally, a projected 88,400 AIDS‐related deaths would have occurred (a 27% increase) between March 2020 and March 2021, with 51,700 of those deaths occurring among children engaged in care as of March 2020 (a 54% increase).

Conclusions

While efforts will continue to curb morbidity and mortality stemming directly from COVID‐19 itself, it is critical that providers also consider the immediate and indirect harms of this pandemic, particularly among vulnerable populations. Well‐informed, timely action is critical to meet the health needs of pregnant women and children if the global community is to maintain momentum towards an AIDS‐free generation.

Socioeconomic Burdens of the COVID-19 Pandemic on LMIC Populations with Increased HIV Vulnerabilities

Purpose of Review

To review the impact of the COVID-19 pandemic and its public health response on key populations at risk of HIV infection, with a focus on sex workers.

Recent Findings

Since last year several groups have documented how the COVID-19 pandemic has impacted the livelihoods and health of sex workers. We focus on case studies from Kenya, Ukraine, and India and place these in the broader global context of sex worker communities, drawing on common themes that span geographies.

Summary

COVID-19-associated lockdowns have significantly disrupted sex work, leading to economic and health challenges for sex workers, ranging from HIV-related services to mental health and exposure to violence. Several adaptations have been undertaken by sex workers and frontline workers, including migration, a move to mobile services, and struggling to find economic supports. Strengthening community-based responses for future pandemics and other shocks is critical to safeguard the health of marginalized populations.

"It went through the roof": an observation study exploring the rise in PrEP uptake among Zimbabwean female sex workers in response to adaptations during Covid-19

Introduction

Sisters with a Voice (Sisters), a programme providing community‐led differentiated HIV prevention and treatment services, including condoms, HIV testing, pre‐exposure prophylaxis (PrEP) and antiretroviral therapy linkage for sex workers, reached over 26,000 female sex workers (FSW) across Zimbabwe in 2020. Zimbabwe's initial Covid “lockdown” in March 2020 and associated movement restrictions interrupted clinical service provision for 6 weeks, particularly in mobile clinics, triggering the adaptation of services for the Covid‐19 context and a scale up of differentiated service delivery (DSD) models. PrEP service delivery decentralized with shifts from clinical settings towards community/home‐based, peer‐led PrEP services to expand and maintain access. We hypothesize that peer‐led community‐based provision of PrEP services influenced both demand and supply‐side determinants of PrEP uptake. We observed the effect of these adaptations on PrEP uptake among FSW accessing services in Sisters in 2020.

Methods

New FSW PrEP initiations throughout 2020 were tracked by analysing routine Sisters programme data and comparing it with national PrEP initiation data for 2020. We mapped PrEP uptake among all negative FSW attending services in Sisters alongside Covid‐19 adaptations and shifts in the operating environment throughout 2020: prior to lockdown (January–March 2020), during severe restrictions (April–June 2020), subsequent easing (July–September 2020) and during drug stockouts that followed (October–December 2020).

Results and discussion

PrEP uptake in 2020 occurred at rates <25% (315 initiations or fewer) per month prior to the emergence of Covid‐19. In response to Covid‐19 restrictions, DSD models were scaled up in April 2020, including peer demand creation, community‐based delivery, multi‐month dispensing and the use of virtual platforms for appointment scheduling and post‐PrEP initiation support. Beginning May 2020, PrEP uptake increased monthly, peaking at an initiation rate of 51% (n = 1360) in September 2020. Unexpected rise in demand coincided with national commodity shortages between October and December 2020, resulting in restriction of new initiations with sites prioritizing refills.

Conclusions

Despite the impact of Covid‐19 on the Sisters Programme and FSW mobility, DSD adaptations led to a large increase in PrEP initiations compared to pre‐Covid levels demonstrating that a peer‐led, community‐based PrEP service delivery model is effective and can be adopted for long‐term use.

The syndemic burden of HIV/AIDS in Africa amidst the COVID-19 pandemic

INTRODUCTION

The human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) has long affected millions of individuals across the globe. Historically, the prevalence of this disease is particularly noted within the African continent. Before the coronavirus disease 2019 (COVID-19) pandemic, many African countries struggled to effectively manage the increasing burden associated with HIV/AIDS. There is now a need to reassess this in a COVID-19 pandemic context so that the impact of COVID-19 on HIV/AIDS healthcare within Africa can be adequately evaluated.

METHODS

Data collection was performed on the PubMed, Ovid MEDLINE and Embase bibliographical databases with a predefined search strategy. Searches were performed in blind duplicate and all articles considering COVID-19 and HIV/AIDS within African healthcare were considered.

RESULTS

The COVID-19 pandemic has severely exacerbated the many issues surrounding HIV/AIDS care within many African countries. These impacts are noticeable in medical, psychological, and socio-political contexts.

CONCLUSIONS

Before efforts are made to improve the provision of HIV/AIDS and COVID-19 care within Africa, it is important that this issue is brought to the attention of the scientific and clinical community so that the continent can receive the necessary support and aid.

Law, criminalisation and HIV in the world: have countries that criminalise achieved more or less successful pandemic response?

How do choices in criminal law and rights protections affect disease-fighting efforts? This long-standing question facing governments around the world is acute in the context of pandemics like HIV and COVID-19. The Global AIDS Strategy of the last 5 years sought to prevent mortality and HIV transmission in part through ensuring people living with HIV (PLHIV) knew their HIV status and could suppress the HIV virus through antiretroviral treatment. This article presents a cross-national ecological analysis of the relative success of national AIDS responses under this strategy, where laws were characterised by more or less criminalisation and with varying rights protections. In countries where same-sex sexual acts were criminalised, the portion of PLHIV who knew their HIV status was 11% lower and viral suppression levels 8% lower. Sex work criminalisation was associated with 10% lower knowledge of status and 6% lower viral suppression. Drug use criminalisation was associated with 14% lower levels of both. Criminalising all three of these areas was associated with approximately 18%-24% worse outcomes. Meanwhile, national laws on non-discrimination, independent human rights institutions and gender-based violence were associated with significantly higher knowledge of HIV status and higher viral suppression among PLHIV. Since most countries did not achieve 2020 HIV goals, this ecological evidence suggests that law reform may be an important tool in speeding momentum to halt the pandemic.

The Impact of the Coronavirus Disease (COVID-19) on the Health and Social Needs of Sex Workers in Singapore

We evaluated the impact of the coronavirus disease (COVID-19) on the sex work industry and assessed how it has impacted the health and social conditions of sex workers in Singapore. We conducted a sequential exploratory mixed methods study amidst the COVID-19 pandemic from April to October 2020, including in-depth interviews with 24 stakeholders from the sex work industry and surveyor-administered structured surveys with 171 sex workers. COVID-19 had a substantial impact on sex workers' income. The illegality of sex work, stigma, and the lack of work documentation were cited as exclusionary factors for access to alternative jobs or government relief. Sex workers had experienced an increase in food insecurity (57.3%), housing insecurity (32.8%), and sexual compromise (8.2%), as well as a decrease in access to medical services (16.4%). Being transgender female was positively associated with increased food insecurity (aPR = 1.23, 95% CI [1.08, 1.41]), housing insecurity (aPR = 1.28, 95% CI [1.03, 1.60]), and decreased access to medical services (aPR = 1.74, 95% CI [1.23, 2.46]); being a venue-based sex worker was positively associated with increased food insecurity (aPR = 1.46, 95% CI [1.00, 2.13]), and being a non-Singaporean citizen or permanent resident was positively associated with increased housing insecurity (aPR = 2.59, 95% CI [1.73, 3.85]). Our findings suggest that COVID-19 has led to a loss of income for sex workers, greater food and housing insecurity, increased sexual compromise, and reduced access to medical services for sex workers. A lack of access to government relief among sex workers exacerbated such conditions. Efforts to address such population health inequities should be implemented.

Commercial Sex Work During Novel Coronavirus (SARS-CoV-2) Era in the Niger Delta Region: Relationships Between Knowledge, Preventive Practice, and Transmission Potential

BACKGROUND

Sex workers, like others, are facing economic hardships and anxiety about their health and safety due to coronavirus disease-2019 (COVID-19), an infectious disease caused by a novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Universally, most sex work has largely reduced, moved online, or undertaken covertly because of lockdown measures and need for social distancing to break the transmission of SARS-CoV-2. However, the ability of sex workers to protect themselves against COVID-19 depends on their individual and interpersonal behaviors and work environment. In this study, we sought to determine the relationships between COVID-19 knowledge, awareness and prevention practice (KAP) among female commercial sex workers (FCSW) in the Niger Delta region of Nigeria to inform the development of prevention interventions for this vulnerable population.

METHODS

Data used in this study were obtained from a cross-sectional survey of 604 FCSW operating in the Niger Delta region of Nigeria. We used descriptive and inferential statistics to assess their socio-demographic characteristics and COVID-19 KAP adopted against the novel coronavirus. Latent class analysis was used to systematically classify participants' attributes and behaviors into the most likely distinct clusters or risk groups.

RESULTS

The majority of the FCSW were singles (86.8%) of childbearing ages, 21-35 years (86.2%), with almost three quarters (73.2%) of them having sex with 3-4 clients per day during the COVID-19 pandemic. Overall, almost three quarters of the participants had both good knowledge and awareness about COVID-19 but less than half of them (41.1%) implemented good practice to prevent the spread of the disease. However, a highly significant and positive relationship was recorded between COVID-19 knowledge (r=0.90, p<0.0001) and awareness (r=0.65, p<0.0001), and preventive practice of FCSW, respectively. About 89.1% of the participants were not very familiar with the symptoms of COVID-19 (p<0.0001). Only 10.9% of the FCSW indicated that they wear facemask at all times, while 45.2% of them do not wear facemask during sexual intercourse with their clients (p<0.0001). Based on the FCSW attributes and behaviors, we identified three distinct clusters or risk groups (p<0.0001), namely, low-risk takers (Cluster 1), high-risk takers (Cluster 2) and very high-risk takers (Cluster 3) with latent class prevalence rates (γc) of 41.13% (95% CI: 37.26-45.10), 33.17% (95% CI: 29.53-37.02) and 25.71% (95% CI: 22.38-29.34), respectively.

CONCLUSION

Sex work has high transmission potentials for SARS-CoV-2 because of its operational nature, which does not permit social distancing, and thus, renders certain preventive measures practically ineffective. This is a major challenge in the fight against COVID-19 in this high-risk group and calls for the development of operational guidelines and targeted intervention strategies to help reduce the spread of COVID-19 in the Niger Delta region.

COVID-19 COPING-PREVENTION STRATEGIES FOR FEMALE SEXUAL WORKERS IN THE CONTEXT OF VARIOUS COUNTRIES

ABSTRACT Objective: to analyze the scientific evidence on COVID-19 coping and prevention strategies implemented to female sex workers in the context of several countries. Methods: this is an integrative literature review, with data collected in the PubMed, Scopus, Virtual Health Library and Google Scholar databases using the Boolean descriptors “COVID-19” and “sex workers” and “Delivery of Health Care”, with a time frame from 2019 to 2020. A priori, 215 publications were found. After selection, anchored in the inclusion criteria and in the answer to the guiding question, 19 articles were used, whose information was organized in a synoptic table, and the texts were analyzed using semantic content. Results: after content analysis of actions implemented or recommended in different countries, so that female sex workers can prevent contamination by Sars-CoV-2, four categories were highlighted: programmatic/governmental actions and responses from society; combating the stigmas involved in sex work; health education through technological/digital and media resources; adjustment of health services. Conclusion: gender, race and class inequalities, as well as social stigmas, have been maintained by states governed by patriarchy and, therefore, are the main barriers for female sex workers to adopt strategies to combat COVID-19. Even so, intersectoral actions have been implemented/recommended in several countries such as the adjustment of sexual health services, financial incentives to improve the services of signal operators and digital technologies to implement effective actions to promote health education and enable the distribution of inputs for individual protection and prevention.

COVID-19 Highlights the Need for Inclusive Responses to Public Health Emergencies in Africa

COVID-19 is a global public health emergency affecting many countries around the world. Although African governments and other stakeholders are making efforts to contain the pandemic, the outbreak continues to impact human rights and exacerbates inequalities and disparities that are already in existence. The concept of inclusive health focuses on good health and well-being for everyone, and this entails health services that are equitable, affordable, and efficacious. Creating equitable access to mainstream health and healthcare services and ensuring inclusive health responses remain a means of addressing health inequities and disparities. In this article, we argue on the need for inclusive responses to public health emergencies in Africa using COVID-19 as a case example. Africa's response to public health emergencies needs to recognize that for every marginalized/vulnerable group, it is important to strategize to address their particular needs in such a way to surmount any barrier to the right to health. For Africa's public health response to be more inclusive, we therefore need to be more strategic and proactive in reaching out to specific groups and to identify and address their needs. Strengthening the healthcare systems of African countries through increased political will, increased funding to health care, collaboration and cooperation among stakeholders, and effective leadership remains essential in ensuring inclusive responses to health emergencies.