The HIV Cascade of Care and Service Utilisation at Sex Work Programmes Among Female Sex Workers in South Africa.
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ABSTRACT:
SUBMITTER: Jaffer M
PROVIDER: S-EPMC8897612 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:In South Africa, the rate of HIV in the sex worker (SW) population is exceedingly high, but critical gaps exist in our understanding of SWs and the factors that make them vulnerable to HIV. This study aimed to estimate HIV prevalence among female sex workers (FSWs) in Soweto, South Africa, and to describe their sexual behavior and other factors associated with HIV infection.A cross-sectional, respondent-driven sampling (RDS) recruitment methodology was used to enroll 508 FSWs based in Soweto. Data were collected using a survey instrument, followed by two HIV rapid tests. Raw and RDS adjusted data were analyzed using a chi-squared test of association and multivariate logistic regression to show factors associated with HIV infection.HIV prevalence among FSWs was 53.6% (95% CI 47.5-59.9). FSWs were almost exclusively based in taverns (85.6%) and hostels (52.0%). Less than a quarter (24.4%) were under 25 years of age. Non-partner violence was reported by 55.5%, 59.6% of whom were HIV-infected. Advancing age, incomplete secondary schooling, migrancy and multiple clients increased the likelihood of HIV acquisition: >30 years of age was associated with a 4.9 times (95% CI 2.6-9.3) increased likelihood of HIV; incomplete secondary schooling almost tripled the likelihood (AOR 2.8, 95% CI 1.6-5.0); being born outside of the Gauteng province increased the likelihood of HIV 2.3 times (95% CI 1.3-4.0); and having more than five clients per day almost doubled the likelihood (AOR 1.9, 95% CI 1.1-3.2).Our findings highlight the extreme vulnerability of FSWs to HIV. Advancing age, limited education and multiple clients were risk factors associated with HIV, strongly driven by a combination of structural, biological and behavioral determinants. Evidence suggests that interventions need to be carefully tailored to the varying profiles of SW populations across South Africa. Soweto could be considered a microcosm of South Africa in terms of the epidemic of violence and HIV experienced by the SW population, which is influenced by factors often beyond an individual level of control. While describing a hitherto largely undocumented population of FSWs, our findings confirm the urgent need to scale up innovative HIV prevention and treatment programs for this population.
| S-EPMC5628807 | biostudies-literature
Project description:Evidence suggests that economic factors play an important role in commercial sex work, in particular that condomless sex commands a price premium relative to condom-protected sex. This paper explores whether the use of a new HIV prevention product, with 100% efficacy but modeled after pre-exposure prophylaxis (PrEP), could change the price and quantity of condomless commercial sex supplied. We collected stated preference data from 122 HIV-negative female sex workers in urban South Africa, using a repeated choice experiment to simulate the impact of using PrEP on choices. Results suggest that the price premium for condomless sex would decrease by 73% with PrEP use and the quantity of condomless sex is predicted to increase by a factor of 2.27. Act price does not significantly affect choices without protection but strongly influences choices under full HIV protection. The utility offered by condoms reduces by around 15% under PrEP use. Because new HIV prevention products do not protect against other STIs or pregnancy, the unintended consequences of introducing HIV prevention products should be closely monitored, whereas users should not face stigma or blame for reacting rationally to exogenous changes to market conditions.
| S-EPMC6175015 | biostudies-literature
Project description:Between 20 and 40 % of female sex workers (FSWs) began sex work before age 18. Little is known concerning whether early initiation of sex work impacts later experiences in adulthood, including violence victimization. This paper examines the relationship between early initiation of sex work and violence victimization during adulthood. The sample included 816 FSWs in Mombasa, Kenya, recruited from HIV prevention drop-in centers who were 18 years or older and moderate-risk drinkers. Early initiation was defined as beginning sex work at 17 or younger. Logistic regression modeled recent violence as a function of early initiation, adjusting for drop-in center, age, education, HIV status, supporting others, and childhood abuse. Twenty percent of the sample reported early initiation of sex work. Although both early initiators and other FSWs reported commonly experiencing recent violence, early initiators were significantly more likely to experience recent physical and sexual violence and verbal abuse from paying partners. Early initiation was not associated with physical or sexual violence from non-paying partners. Many FSWs begin sex work before age 18. Effective interventions focused on preventing this are needed. In addition, interventions are needed to prevent violence against all FSWs, in particular, those who initiated sex work during childhood or adolescence.
| S-EPMC5126017 | biostudies-literature
Project description:BackgroundHIV drug resistance (HIVDR) poses a threat to future antiretroviral therapy success. Monitoring HIVDR patterns is of particular importance in populations such as sex workers (SWs), where documented HIV prevalence is between 34-89%, and in countries with limited therapeutic options. Currently in South Africa, there is a dearth in evidence and no ongoing surveillance of HIVDR amongst sex work populations. This study aims to describe the prevalence of HIVDR amongst a sample of female sex workers (FSWs) from Soweto, South Africa.MethodologyA cross-sectional, respondent driven sampling (RDS) recruitment methodology was used to enrol FSWs based in Soweto. Participants were tested for HIV and undertook a survey that included HIV knowledge and treatment status. Whole blood specimens were collected from HIV positive FSWs to measure for CD4 counts, viral load (VL) and perform HIVDR genotyping. Frequencies were determined for categorical variables and medians and interquartile ranges (IQR) for the continuous.ResultsOf the 508 enrolled participants, 55% (n = 280) were HIV positive and of median age 32 (IQR: 20-51) years. Among the HIV positive, 51.8% (132/269) were defined as virologically suppressed (VL < 400 copies/ml). Of the 119 individuals with unsuppressed viral loads who were successfully genotyped for resistance testing 37.8% (45/119) had detectable drug resistance. In this group, HIVDR mutations were found amongst 73.7% (14/19) of individuals on treatment, 27.4% (26/95) of individuals who were treatment naïve, and 100% (5/5) of defaulters. One phylogenetic cluster was found amongst treatment naïve FSWs. The K103N mutation was detected most commonly in 68.9% (31/45) individuals with HIVDR mutations, with 20/26 (76.9%) of treatment naïve FSW with detectable resistance having this mutation. The M184V mutation was found in both FSWs on treatment (12/14, 85.7%) and those defaulting (1/5, 20.0%).DiscussionMore than one third (45/119) of the genotyped sample had HIVDR, with resistance to the NNRTI class being the most common. Almost half of HIV positive FSWs had unsuppressed viral loads, increasing the likelihood for onward transmission of HIV. Disturbingly, more than 1:4 treatment naïve women with unsuppressed viral loads had HIVDR suggesting that possible sexual transmission of drug resistance is occurring in this high-risk population. Given the high burden of HIVDR in a population with a high background prevalence of HIV, it is imperative that routine monitoring of HIVDR be implemented. Understanding transmission dynamics of HIVDR in FSW and its impact on treatment success should be urgently elucidated.
| S-EPMC5731765 | biostudies-literature
Project description:Little qualitative research is available on the role of frontline health service providers (FHSPs) in the implementation of clinical trials, particularly in developing countries. This paper presents findings from a qualitative study about the perspectives of FHSPs on future HIV vaccine trials involving female sex workers (FSWs) and men who have sex with men (MSM) in three districts of Karnataka, India. In particular, we explore FHSPs' knowledge of and views on clinical trials in general, and examine their potential willingness to play a role if such trials were introduced or implemented in the region.A field team of four researchers from Karnataka-two of whom self-identified with FSW or MSM communities ("community researchers") and two with backgrounds in social work-conducted in-depth interviews with FHSPs. Including community researchers in the study helped to build rapport with FSW and MSM participants and facilitate in-depth discussions. A coding scheme for transcribed and translated data was developed using a framework analysis approach. Data was then analysed thematically using a combination of a priori and emergent codes.Over half of FHSPs demonstrated limited knowledge or understanding of clinical trials. Despite reported skepticism around the testing of HIV vaccines in developing countries and concerns around potential side effects, most FHSPs strongly advocated for the implementation of HIV vaccine clinical trials in Karnataka. Further, most FHSPs expressed their willingness to be involved in future HIV vaccine clinical trials in varying capacities.Given that FHSPs are often directly involved in the promotion of health and well-being of FSWs and MSM, they are well-positioned to play leadership, ethical, and communicative roles in future HIV vaccine trials. However, our findings reveal a lack of awareness of clinical trials among FHSP participants, suggesting an important area for capacity building and staff development before viable and ethical clinical trials can be set up in the region.
| S-EPMC4627793 | biostudies-other
Project description:IntroductionHealth-related quality of life (HRQoL) is an important HIV outcome beyond viral suppression. However, there are limited data characterizing HRQoL of key populations, including female sex workers (FSW) living with HIV.MethodsWe used baseline data (22 June 2018-23 March 2020) of FSW who were diagnosed with HIV and enrolled into a randomized trial in Durban, South Africa. HRQoL information was collected by a generic preference-accompanied tool with five domains (EQ-5D), and summarized into a single score (range 0-1), which represents health utility. We employed multivariable beta regression models to identify determinants of HRQoL and to estimate subgroup-specific HRQoL score. Using external estimates of life expectancy and population size, we estimated the number of quality adjusted life years reduced among FSW living with HIV in South Africa associated with violence and drug use.ResultsOf 1,363 individuals (mean age: 32.4 years; mean HRQoL score: 0.857) in our analysis, 62.6% used drugs, 61.3% experienced physical or sexual violence and 64.6% self-reported taking antiretroviral treatment (ART). The following were associated with a reduction in the average marginal HRQoL score: older age (per decade: 0.018 [95% confidence interval (CI): 0.008, 0.027]), drug use (0.022 [0.007, 0.036]), experience of violence (0.024 [0.010, 0.038]) and moderate (vs. no) level of internalized stigma (0.023 [0.004, 0.041]). Current ART use was associated with a 0.015-point (-0.001, 0.031) increase in the HRQoL score. The estimated mean (95% CI) HRQoL scores ranged from 0.838 (0.816, 0.860) for FSW who used drugs, experienced violence and were not on ART; to 0.899 (0.883, 0.916) for FSW who did not use drugs nor experience violence and were on ART. Our results can be translated into a reduction in 37,184 and 39,722 quality adjusted life years related to drug use and experience of violence, respectively, in South Africa.ConclusionsThese results demonstrate the association of ART with higher HRQoL among FSW and the need to further address structural risks, including drug use, violence and stigma. Population-specific estimates of HRQoL score can be further used to calculate quality-adjusted life years in economic evaluations of individual and structural interventions addressing the needs of FSW living with HIV.Clinical trial registrationNCT03500172 (April 17, 2018).
| S-EPMC8874880 | biostudies-literature
Project description:BackgroundSex workers in South Africa are exposed to high levels of violence, yet little is known about their mental health needs. This study aims to understanding the prevalence of depression and post-traumatic stress disorder (PTSD) and their risk factors amongst female sex worker (FSWs) in Soweto, South Africa.MethodsA cross-sectional, respondent-driven sampling (RDS) survey enrolled 508 FSWs. Raw and RDS adjusted data were analyzed using a chi-squared test of association and multinomial regression for risk factors associated with depression and PTSD.FindingsSymptoms of severe depression were prevalent amongst 68.7%, PTSD was 39.6%, and 32.7% suffered from comorbid PTSD and depression. Experiencing ≥3 kinds of violence increased the likelihood of comorbidity (RRR4.11, 95% CI 1.52-11.12,p = 0.005). Internalised stigma increased the likelihood of one mental health condition (RRR1.25, 95% CI 1.10-1.42,p = 0.001), higher self-esteem was associated with independent (RRR1.14, 95% CI 1.05-1.25,p = 0.002) and comorbid conditions (RRR1.17, 95% CI 1.07-1.27,p = 0.001).ConclusionOur findings highlight the sizable burden of treatable mental health conditions among FSWs in Soweto. This was driven by multiple exposures to violence, sex work related discrimination and overall moderate levels of self-esteem masking defence mechanisms. This suggests the urgent need to design and integrate services geared to the mental health needs for this population.
| S-EPMC6033380 | biostudies-literature
Project description:IntroductionFemale sex workers (FSWs) are a known high-risk group that are at increased risk of HIV transmission due to exposure to multiple sexual partners and inability to negotiate safe sex attributed to challenging economic circumstances. Previous systematic reviews have examined the effectiveness of HIV interventions prioritising FSWs and have shown that targeted interventions improve access to HIV prevention and treatment services. Interventions that increase FSWs' uptake of services are well documented; however, evidence on specific interventions aimed at improving FSWs' continuity in HIV care along the treatment cascade is lacking. This systematic review aims to document the performance of community-based interventions along the HIV treatment cascade.Methods and analysisWe will use a sensitive search strategy for electronic bibliographic databases, bibliographies of included articles and grey literature sources. In addition, the Joint United Nations Programme on HIV/AIDS and the WHO websites, peer-reviewed conference papers and grey literature sources will be searched for additional reports of sex work programmes. We will include randomised controlled trials, cross-sectional surveys and cohort interventions where community-based HIV services were provided to FSWs and measure the performance of the HIV intervention on one or more cascade stages. We will conduct a systematic review of studies published from 2004 to present within the sub-Saharan Africa region. We will report quantitative study outcomes of HIV testing and diagnosis, linkage to care, initiation on antiretroviral therapy and viral suppression. We will analyse the data using the random-effects meta-analysis method, and funnel plots will be used to assess the publication bias.Ethics and disseminationThis systematic review will not require ethical approval; we will publish data from manuscripts. The results of this study will be disseminated in peer-reviewed journals and conference presentations.Prospero registration numberCRD42020157623.
| S-EPMC7592303 | biostudies-literature
Project description:IntroductionSex workers in South Africa experience high levels of trauma and mental health issues, but little is known about their drug and alcohol use. This study assessed the prevalence of substance use and its key risk factors amongst female sex workers (FSWs) at two sites in South Africa.MethodsTwo cross-sectional studies were conducted, in Soweto and Klerksdorp, South Africa. Using respondent-driven sampling (RDS) 508 FSWs in Soweto and 156 in Klerksdorp were enrolled. A study-specific survey was used to collect social and demographic information, substance use, mental ill-health, and HIV status. Raw and RDS-adjusted data were analyzed using Chi-squared tests of association. Weighted and unweighted Poisson regression models were used to assess key risk factors for alcohol and drug use at both univariate and multivariate levels.ResultsOf the 664 FSWs, 56.2% were binge drinkers and 29.4% reported using drugs within the last year. Living in a home with regular food (RR: 1.2597, 95% CI: 1.1009-1.4413) and being HIV positive (RR: 1.1678, 95% CI: 1.0227-1.3334) were associated with a higher risk of binge drinking. Having symptoms suggestive of post-traumatic stress disorder (RR: 1.1803, 95% CI: 1.0025-1.3895) and past year physical/sexual abuse from either intimate (RR: 1.3648, 95% CI: 1.1522-1.6167) or non-intimate partners (RR: 1.3910, 95% CI: 1.1793-1.6407) were associated with a higher risk of drug use.DiscussionIn conclusion, our findings demonstrate a high prevalence of alcohol and drug use among FSWs in Soweto and Klerksdorp with site-specific contextual dynamics driving substance use. Site differences highlight the importance of tailoring site-specific substance use harm mitigation for this key population.
| S-EPMC8782394 | biostudies-literature
Project description:BackgroundYoung people aged 10-24 years are a vulnerable group with poor health service access relative to other populations. Recent South African initiatives, the She Conquers campaign, the Integrated School Health Policy and the Adolescent & Youth Health Policy, include a focus on improving the breadth and quality of youth-friendly health service delivery. However, in some settings the provision and impact of scaled-up youth friendly health services has been limited indicating a gap between policy and implementation. In this study we reviewed existing sources of data on health service utilisation to answer the following question: 'What health conditions do young people present with and what services do they receive at public health clinics, mobile clinics and school health services?'MethodsWe conducted a retrospective register review in three purposively selected primary healthcare clinics (PHCC), one mobile clinic, and one school health team in Hlabisa and Mtubatuba sub-districts of uMkhanyakude District, KwaZulu-Natal, South Africa. The focus was service utilisation for any reason by 10-24 year olds. We also conducted descriptive analysis of pre-existing data on service utilisation by young people available from the District Health Information System for all 17 PHCC in the study sub-districts.ResultsThree quarters of 4121 recorded young person visits in the register review were by females, and 40% of all young person visits were by females aged 20-24 years. The most common presenting conditions were HIV-related, antenatal care, family planning, general non-specific complaints and respiratory problems (excluding TB). There were relatively few recorded consultations for other common conditions affecting young people such as mental health and nutritional problems. Antibiotics, antiretrovirals, contraceptives, vitamins/supplements, and analgesics were most commonly provided. Routine health registers recorded limited information, were often incomplete and/or inconsistent, and age was not routinely recorded.ConclusionsMeasuring morbidity and service provision are fundamental to informing policy and promoting responsive health systems. Efforts should be intensified to improve the quality and completeness of health registers, with attention to the documentation of important, and currently poorly documented, young people's health issues such as mental health and nutrition.
| S-EPMC6883644 | biostudies-literature