Prevalence of human immunodeficiency virus among female sex workers and associated risk factors in Rwanda, 2019

Background Female sex workers (FSWs) are more likely to be infected by Human immunodeficiency virus (HIV) than the general population. In Sub-Saharan countries, 18% of new HIV infections is attributed to FSWs. Study objective To determine HIV prevalence and its determinants among FSWs in Rwanda. Methodology A cross-sectional biological and behavioral surveillance survey in hotspots was conducted among FSWs countrywide. HIV laboratory tests were performed. Proportions and 95% confidence interval (CI) were calculated. Multivariable logistic regression was performed to determine factors associated with HIV in FSWs. Results The survey enrolled 1,883 FSWs. Of 1,770 FSWs who consented for HIV testing, 607 were HIV positive, giving the prevalence of 34% (95%CI= 32.11-36.54). High HIV prevalence was associated with age of 25 years or more (aOR = 3.68; 95%, CI: 2.62­5.18) and more than 5 years of sexwork (aOR = 1.31; 95% CI: 1.05­1.63). HIV prevalence and having more than three dependents (aOR= 0.34; 95%CI=0.23-0.5) and completing secondary and beyond education (aOR=0.50; 95%CI=0.36-0.71) were inversely related. Conclusion HIV prevalence is still high among FSWs in Rwanda. Prevention strategies should target the old ones in five first years of sex work and the less educated.

Awareness of and willingness to use pre-exposure prophylaxis to prevent HIV infection among female sex workers in Anambra State, south-eastern Nigeria

Background: Pre-exposure prophylaxis (PrEP) is a highly effective preventive measures against HIV infection but its success is strongly based on adherence, which in turn depends on willingness to use. This study is aimed at assessing the level of awareness and willingness to use PrEP to prevent HIV infection among female sex workers (FSWs) in Anambra State, Nigeria, and to identify factors that influence willingness to use PrEP. Methodology: The study was a cross-sectional survey involving 265 brothel-based FSWs recruited through snowballing technique. A structured questionnaire was used to collect relevant information on demographic characteristics, awareness of HIV/AIDS and transmission route, attitudes/behavior related to HIV/AIDS, and awareness of and willingness to use PrEP. Univariate and bivariate analyses with Chi square test (with Odds ratio and 95% confidence interval) was used to determine association of socio-demographic and predictive factors with willingness to use PrEP. Statistical significance was considered when p value was less than 0.05. Results: Of 265 FSW respondents, only 81 (31.2%) have heard of PrEP, 10 (3.9%) indicated they have previously used PrEP while 91.0% indicated willingness to use PrEP. Univariate analysis showed that FSWs in Onitsha had a significantly higher odds (OR=28.6, 95% CI=1.718-476.82, p=0.0006) while those from Awka had a significantly lower odds (OR=0.184, 95% CI=0.0704-0.1812, p=0.0004) of willingness to use PrEP. Also, FSWs with monthly income less than 18,000 Naira had a lower odd of willingness to use PrEP (OR=0.3980, 95% CI=0.1593-0.9945, p=0.08). Bivariate analysis shows that FSWs who wish to have more knowledge of HIV/AIDS had higher odd of willingness to use PrEP than those who did not wish to have more knowledge (OR=4.235, 95% CI=1.577­11.374, p=0.0066). Similarly, FSWs who are worried of being discriminated against have a lower odd of willingness to use PrEP than those who are not worried of being discriminated against (OR=0.3921, 95% CI=0.1582-0.9718, p=0.0439). Conclusion: Our study showed low awareness but high willingness to use PrEP among FSWs in Anambra State,Nigeria. Cost, HIV/AIDS knowledge and fear of discrimination are significant predicting factors of willingness to use HIV PrEP and should be considered when formulating PrEP policy. Adequate enlightenment on PrEP should be emphasized among FSWs.

Perspectives on HIV self-testing among key and affected populations in Kenya

Background: Kenya's Key and Affected Populations (KAP) ­ men who have sex with men (MSM), female sex workers, peoplewho inject drugs (PWID), and young women aged 18-24 ­ often experience stigma and discrimination in Kenyan health care settings due to their identity and/or behaviors, which can deter facility-based testing for HIV. Kenya has promoted self-testing as a means to reach these communities. Objectives: To identify KAP perspectives on self-testing and place our findings within Kenya's human rights and legal context. Methods: We conducted 4 focus group discussions (FGD) and 16 in-depth interviews (IDI). One FGD was conducted with each of the following communities: MSM, female sex workers, PWID, and young women aged 18-24. 1-4 IDI were conducted with each KAP community, and 1-3 IDI were conducted with health professionals working on HIV care in each study site. The semi-structured question guideline included one question soliciting opinions on self-testing. Results: KAP support self-testing in concept, however prevailing concerns among participants included access to pre- and posttest counseling services, as well as risk for harms (self-inflicted and otherwise) that might result from a positive result. Conclusion: Kenya should ensure that human rights are promoted and respected through implementing rights-based policies and practices for HIV self-testing, including pre- and post-test counseling.

"It is just a lot to deal with": A qualitative study exploring the sexual and reproductive health needs of a sample of female sex workers in six locations in Southern Africa

The sexual and reproductive health of female sex workers in Southern Africa is particularly important, given the high prevalence of HIV among this population. This paper presents the results of a rapid assessment study conducted prior to the implementation of the "SRHR-HIV Knows No Borders" project in six Southern African countries. Trained interviewers interviewed 20 sex workers across 10 high migration communities. Data were analysed thematically. Participants were well informed about and were able toaccess preventive methods for STIs and pregnancy, although reports of condom failures were common. While sex workers found SRH services easily accessible, many reported experiences of stigma and discrimination when accessing them. Physical and sexual violence were common occurrences among participants, both from their clients and the police. In addition to addressing stigma within the healthcare and broader community, interventions could provide opportunities for those looking to exit the industry by providing skills training and microfinance support. (Afr J Reprod Health 2022; 26[5]: 72-80).

Utilisation of HIV services by female sex workers in Zimbabwe during the COVID-19 pandemic: a descriptive phenomenological study

This study focuses on female sex workers as a key population group that suffers a degree of vulnerability according to the World Health Organisation (WHO). Key populations refer to people at heightened risk of contracting the human immunodeficiency virus (HIV) due to specific behaviours and social and legal environments which increase their vulnerability to the virus. Key populations are disproportionately affected by HIV, yet they have less access to HIV services compared to the general population. The coronavirus (COVID-19) lockdown and its restrictive measures have further widened the inequalities and gaps in accessing HIV services for this group. A descriptive phenomenological study was undertaken to explore female sex workers' experiences of utilisation of HIV services during COVID-19. The study setting was the Bulawayo Metropolitan Province, Zimbabwe. Data were collected through in-depth individual interviews with 10 female sex workers. Purposive sampling coupled with snowballing was utilised for recruiting participants. Data were analysed guided by the seven-step Colaizzi technique. Rigour was ensured through adhering to Lincoln and Guba's trustworthiness criteria. The study found that the COVID-19 pandemic adversely affected the livelihoods of sex workers and their utilisation of HIV services. There was limited access to HIV services due to an initial lack of travel authorisation letters and financial challenges experienced by study participants. In addition, the quality of care in health care facilities was further compromised by poor screening processes and reduced provider-client interactions. Maintaining access to HIV services for female sex workers during pandemics is critical for the country to attain HIV epidemic control.

HIV self-testing services for female sex workers, Malawi and Zimbabwe

Objective To present findings from implementation and scale-up of human immunodeficiency virus (HIV) self-testing programmes for female sex workers in Malawi and Zimbabwe, 2013­2018. Methods In Zimbabwe, we carried out formative research to assess the acceptability and accuracy of HIV self-testing. During implementation we evaluated sex workers' preferences for, and feasibility of, distribution of test kits before the programme was scaled-up. In Malawi, we conducted a rapid ethnographic assessment to explore the context and needs of female sex workers and resources available, leading to a workshop to define the distribution approach for test kits. Once distribution was implemented, we conducted a process evaluation and established a system for monitoring social harm. Findings In Zimbabwe, female sex workers were able to accurately self-test. The preference study helped to refine systems for national scale-up through existing services for female sex workers. The qualitative data helped to identify additional distribution strategies and mediate potential social harm to women. In Malawi, peer distribution of test kits was the preferred strategy. We identified some incidents of social harm among peer distributors and female sex workers, as well as supply-side barriers to implementation which hindered uptake of testing. Conclusion Involving female sex workers in planning and ongoing implementation of HIV self-testing is essential, along with strategies to mitigate potential harm. Optimal strategies for distribution and post-test support are context-specific and need to consider existing support for female sex workers and levels of trust and cohesion within their communities

Pregnancy planning among female sex workers in Uganda: evaluation of the psychometric properties of the London measure of unplanned pregnancy

The aim of the study was to evaluate the psychometric properties of the London Measure of Unplanned Pregnancy (LMUP) among female sex workers (FSWs) in Uganda. The LMUP was translated into Luganda and adapted for use with FSWs and underwent cognitive testing and two field tests. From the final Luganda LMUP, three other language versions were created (Acholi, Lugisu and Runyakole), and preliminary field test data were collected. Final data were collected from 819 FSWs attending the Most at Risk Population Initiative' clinics. The Luganda field testing showed that there were no missing data, the scale was well targeted, Cronbach's alpha was 0.82, weighted Kappa was 0.78, measurement was unidimensional, and all construct validity hypotheses were met. Likewise, with the Acholi, Lugisu, and Runyankole translations, field testing showed that there were no missing data, the scales were well targeted, Cronbach's alpha were>0.70, and measurement was unidimensional.We concluded that the Luganda LMUP is a valid and reliable tool for assessing pregnancy planning among FSWs in Uganda and that the Acholi, Lugisu, and Runyankole versions of the LMUP also had good initial psychometric properties

HIV and sexually transmitted co-infections among sex workers in the Southern African economic region

Background: The Southern African Development Community (SADC) economic block is the most affected region by HIV epidemic in Sub-Saharan Africa (SSA). Despite programmatic interventions, HIV infections remain unprecedentedly high among female sex workers (FSW) in the region. This review assesses the HIV burden and the drivers associated with FSW in the SADC region. Methods: We systematically extracted and analyzed HIV burden and other sexually transmitted infections (STIs) research data on FSW indexed in various journal platform and reports from governmental and nongovernmental organizations between 2003 and 2015. Meta-analysis technique was used to estimate the pooled prevalence of the HIV burden among FSW in the region. Results: Of the 192 peer-reviewed articles and reports addressing HIV burden, only 21 articles met eligibility criteria totaling 14998 FSW. The combined overall pool HIV prevalence was estimated at 42.0% (95% CI 0.41­0.43). The estimated pooled HIV prevalence ranged from 16% (95% CI 0.13­18) in Democratic Republic of Congo, 59% (95% CI 0.57­0.62) in South Africa and 71% (95% CI 0.65­0.76) in Malawi. The most common STIs reported were syphilis, Chlamydia, and gonorrhea with little emphasis on viruses. Structural factors such as stigma and discrimination, access to healthcare services and various socioeconomic and political barriers impeded treatment and prevention. Conclusion: The HIV prevalence among FSW was 5­30 times higher when compared to the overall female reproductive age population in the SADC region. This signifies and necessitates increase evidence based HIV/STIs research and programs among FSW in the SADC region

Diverse genetic subtypes of HIV-1 among female sex workers in Ibadan, Nigeria

Genetic diversity is the hallmark of HIV-1 infection. It differs among geographical regions throughout the world. This study was undertaken to identify the predominant HIV-1 subtypes among infected female sex workers (FSWs) in Nigeria. Methods: Two hundred and fifty FSWs from brothels in Ibadan Nigeria were screened for HIV antibody using ELISA. All reactive samples were further tested by the Western Blot Techniques. Peripheral Blood Mononuclear Cells (PBMCs) were separated from the blood samples of each subject. Fragments of HIV Proviral DNA was amplified and genetic subtypes of HIV-1 was determined by direct sequencing of the env and gag genes of the viral genome followed by phylogenetic analysis . Results: The age of the FSWs ranged from 15 to 55 years old (Mean = 25.8years; SD =3.74). Majority were Nigerians while others (1.6 ) were from neighboring West Africa countries. Four ( 1.6 ) of the FSWs were active for less than one year as sex workers; and the mean length of sex work was 2.80 years ( Range = 1.0 - 15.0 years ). Sixty-four (25.6) of the 250 CSWs were positive for HIV-1 while 7 (2-8) had dual infections to HIV-1 / HIV-2. Among the 34 HIV-1 strains characterized by sequencing; 19 (55-9) were subtype G; 9 (26.5) CRF02_A/G; 3 (8.8) CRF06_cpx while 1 (2.9) each were identified as subtype C; CRF01_A/E and CRF09_cpx respectively. Nineteen (55.9) of the FSWs with subtype G had been active in the sex work for between one to five years. The youngest of the HIV -1 infected FSWs with sexual activity of less than a year had subtype G strain. There is a significant probability that infection with this subtype occurred with a short incubation period (p 0.05). Conclusion: This study showed a wide range of HIV- 1 subtypes among FSWs in Nigeria. The situation poses serious challenge for the design of HIV vaccine candidate for use in Nigeria

Alcohol Consumption and High Risk Sexual Behaviour among Female Sex Workers in Uganda

Alcohol consumption has been associated with high risk sexual behaviour among key populations such as female sex workers. We explored the drivers of alcohol consumption and its relationship to high risk sexual behaviour. Participants were drawn from a cohort of 1 027 women selected from 'hot spots' in the suburbs of Kampala city. We conducted 3 in-depth interviews with 40 female sex workers between 2010 and 2011. Data were analysed thematically; focusing on alcohol use within the context of sex work. Alcohol consumption was very high with only seven women reporting that they did not drink. Alcohol consumption was driven by the emotional and economic needs of the participants; but also promoted by clients who encouraged consumption. Many sex workers only started drinking alcohol when they joined sex work on the advice of more experienced peers; as a way to cope with the job. Alcohol was blamed for unsafe sex; acts of violence and poor decision making which increased sexual and physical violence. Alcohol was reported to affect medication adherence for HIV-positive women who forgot to take medicine. The findings suggest that the drivers of alcohol consumption are multifaceted in this group and require both individual and structural interventions. Alcohol reduction counselling can be supportive at the individual level and should be an integral part of HIV prevention programmes for female sex workers and others such as patrons in bars. The counselling should be addressed in a sensitive manner to bar owners and managers

Reproductive Health Problems and Health Seeking Behavior of Female Sex Workers in Sabon Gari Local Government Area; Zaria; Nigeria

Background: The sexual and reproductive health needs of sex workers have been neglected both in research and public health interventions. Among the reasons for this are the condemnation; stigma and ambiguous legal status of sex work in Nigeria. This study was aimed at determining the reproductive health problems and health-seeking behavior of brothel-based female sex workers (FSW). Materials and Methods: This cross-sectional study was conducted among brothel-based FSW in Sabon-Gari Local Government in Zaria; Nigeria between 1 st January 2011 and 31 st June 2011. A total of 208 FSW were randomly selected and information was obtained with the use of the semi-structured questionnaire. Data entry was done with the help of structured codes in Microsoft Excel. Descriptive analysis was carried out using the statistical package (SSPS 16-University of Bristol). Results: Majority 90.7 of the respondents had experienced reproductive morbidity in the last 3 months. Frequently experienced symptoms were vaginal discharge (63.8); acute lower abdominal pain (57.5); menstrual irregularities (37) and genital ulcer (32.3). Genital tear occurred in only 25 (9.8) respondents. Furthermore; 178 (63.6) had a termination of unwanted pregnancies. Most (32.3) sought care for their reproductive health problems from chemist shops; followed by the private hospitals in 23.6

Rewriting the Narrative of the Epidemiology of HIV in Sub-Saharan Africa

The fight against HIV remains complicated with contracting donor resources and high burden of HIV among reproductive age adults still often limiting independent economic development. In the widespread HIV epidemics of sub-Saharan Africa (SSA); it is proposed that key populations with specific HIV acquisition and transmission risk factors; such as men who have sex with men (MSM); female sex workers (FSW); and people who use drugs (PUD); are less relevant because HIV transmission is sustained in the general population with average HIV acquisition and transmission risks. However; the understanding that key populations are less relevant in the epidemics of Africa is based on the surveillance system from which these populations are mostly excluded. Outside of SSA; the epidemics of HIV are generally concentrated in the same populations that are excluded from the primary HIV surveillance systems in SSA. The manuscripts included in this special issue present convincing data that FSW; MSM; and PUD carry disproportionate burdens of HIV wherever studied in SSA; are underrepresented in HIV programs and research; and require specific HIV prevention services. These manuscripts collectively suggest that the only effective path forward is one that transcends denial and stigma and focuses on systematically collecting data on all populations at risk for HIV. In addition; there is a need to move to a third generation of HIV surveillance as the current one inadvertently devalues HIV surveillance among key populations in the context of widespread HIV epidemics. Overall; the data reviewed here demonstrate that the dynamics of HIV in Africa are complex and achieving an AIDS-free generation necessitates acceptance of that complexity in all HIV surveillance; research; and prevention; treatment; and care programs

Demand for Programs for Key Populations in Africa from Countries Receiving International Donor Assistance

There has been increasing attention in recent years to the HIV prevention; treatment; and care needs of key populations in Africa; in particular men who have sex with men (MSM); injection drug users (IDU); and female sex workers (FSW). While several major donors have undertaken efforts to prioritize these groups; it remains unclear which African countries are actively seeking donor support for these programs. For this analysis; we reviewed publicly available proposal and budget documentation from the US PEPFAR for fiscal years 2007 through 2010 and Rounds 1 through 10 of the Global Fund to Fight AIDS; Tuberculosis and Malaria for 40 countries in sub-Saharan Africa. Of the 164 searchable documents retrieved; nearly two-thirds contained at least one program serving FSW (65; 107 proposals); less than one-third contained at least one program serving MSM (29; 47 proposals); and a minority proposed programming for IDU (13; 21 proposals). Demand for these programs was highly concentrated in a subset of countries. Epidemiological data for at least one key population was included in a majority of these proposals (63; 67 proposals); but in many cases these data were not linked to programs

A Decade of Research Involving Men who have Sex with Men in Sub-Saharan Africa: Current Knowledge and Future Directions

It has been just over 10 years since the first large behavioral survey of men who have sex with men (MSM) was implemented in Senegal in 2001. Since then; behavioral and/or HIV prevalence surveys have been conducted in over 14 other countries in sub- Saharan Africa. Current available evidence and review have established that HIV prevalence among MSM in these countries are significantly higher than corresponding general populations; that MSM engage in sexual risk behaviors that place them and sexual partners at higher risk; and that issues of discrimination and stigmatization inhibit HIV interventions for MSM. This paper summarizes the existing knowledge; describes limitations of this evidence; and proposes new and enhanced research approaches to fulfill needed gaps to inform national HIV responses for MSM populations

HIV Prevention among Female Sex Workers in Africa

Sex work occurs to meet the demand for sexual services and is a universal phenomenon. In Africa sex work takes many forms and is an important source of income for many women. Yet sex worker reproductive health needs remain largely unmet. The criminalisation of sex work; community and service provider stigma; violence; substance use and limited access to health services and prevention commodities contribute to the high HIV burden evident among female sex workers in Africa. Following UNAIDS' three pillar approach to HIV prevention and sex work we present an overview of current opportunities; barriers and suggestions to improve HIV prevention policy and programming for sex work in Africa. Universal access to a comprehensive package of HIV services is the first pillar. Reproductive health commodities; voluntary and anonymous HIV counselling and esting; treatment of sexually transmitted infections; HIV and opportunistic infections; harm reduction for substance use and psychosocial support services make up the recommended package of services. The second pillar is a sex worker-supportive environment. The inclusion of sex worker programmes within national HIV strategic planning; sex worker-led community mobilisation and the establishment of sex work community networks (comprised of sex workers; health service providers; law enforcers and other stakeholders) enable effective programme implementation and are recommended. The reduction of sex worker vulnerability and addressing structural issues form the final pillar. The decriminalisation of sex work; development of supportive policy; gender equality and economic development are key factors that need to be addressed to increase sex worker resilience. Evidence supports the public health benefit of human rights based approaches to HIV prevention; moralistic and restrictive policy and laws towards sex work are harmful and should be removed. The establishment of these pillars will increase sex worker safety and enhance the inclusiveness of the HIV response

Concurrent Sexual and Substance-Use Risk Behaviours Among Female Sex Workers in Kenya's Coast Province: Findings from a Behavioural Monitoring Survey

While many studies confirm the association between HIV; alcohol and injecting drug use by female sex workers (FSWs); little is known about their use of marijuana; khat and other substances and the association of these substances with HIV; risky sexual behaviour; and sexual violence. To better understand this association; data were analysed from a cross-sectional; behavioural survey of 297 FSWs in Mombasa; a well-known tourist destination and the second largest port in Africa and capital city of the Coast Province in Kenya. Among the FSWs; lifetime use of different substances was reported by 91 for alcohol; 71 for khat; 34 for marijuana; and 6 for heroin; cocaine; glue or petrol. The majority (79) used more than one substance; and multiple-substance use was reported by all respondents who ever used marijuana; heroin; cocaine; glue and petrol. The risk of HIV acquisition was perceived as medium to high by 41 of respondents; 75 of whom attributed this risk to multiple partners. Sexual violence was reported by 48 of respondents; and 30 indicated that this happened several times. Despite HIV prevention programmes targeting FSWs in Mombasa; most of them continue to engage in risky sexual behaviours. This suggests that harm reduction strategies for substance use should be coupled with efforts to promote consistent condom use and partner reduction

Enquête "connaissances, attitudes, pratiques" et séroprévalence VIH1 chez les prostituées et filles "libres" de Mbaimboum (Cameroun)

Cette étude confirme que le taux de séroprévalence pour l'infection à VIH1 est préoccupant dans cette région frontalière. La situation géographique exceptionnelle de ce village; et l'importance des transactions commerciales qui y sont effectuées en font un point de convergence pour des femmes se livrant à la prostitution. S'installe alors; une prostitution occasionnelle non contrôlée qui fait de ce village un foyer épidémique important et une source potentielle de dissémination. Ce modèle n'est pas unique et montre que l'épidémie gagne les zones rurales par l'intermédiaire des places marchandes ou il devient impératif d'apporter aux populations l'information et l'éducation nécessaires. Ainsi les prostituées et les filles libres sont des populations cibles qu'il conviendrait d'informer et d'éduquer rapidement et en priorité dans ces régions si l'on ne veut pas voir la situation exploser dans un avenir proche