Estimating the number of female sex workers in Côte d'Ivoire: results and lessons learned.

OBJECTIVE: To report on the results of three size estimations of the populations of female sex workers (FSW) in five cities in Côte d'Ivoire and on operational lessons learned, which may be relevant for key population programmes in other parts of the world. METHODS: We applied three methods: mapping and census, capture-recapture and service multiplier. All were applied between 2008 and 2009 in Abidjan, San Pedro, Bouaké, Yamoussoukro and Abengourou. RESULTS: Abidjan was the city with the highest number of FSW by far, with estimations between 7880 (census) and 13 714 (service multiplier). The estimations in San Pedro, Bouaké and Yamoussoukro were very similar, with figures ranging from 1160 (Yamoussoukro, census) to 1916 (San Pedro, capture-recapture). Important operational lessons were learned, including strategies for mapping, the importance of involving peer sex workers for implementing the capture-recapture and the identification of the right question for the multiplier method. CONCLUSIONS: Successful application of three methods to estimate the population size of FSW in five cities in Côte d'Ivoire enabled us to make recommendations for size estimations of key population in low-income countries.

The Epidemiology of HIV and Prevention Needs of Men Who Have Sex with Men in Abidjan, Cote d'Ivoire.

To determine HIV prevalence and associated risk factors among men who have sex with men (MSM) in Abidjan, Côte d'Ivoire. We conducted a cross-sectional RDS survey of MSM in Abidjan from October 2011 to February 2012. Eligibility criteria included age ≥ 18 years and having had oral or anal sex with another man in the last 12 months. Weighted data analysis was conducted with RDSAT and SAS. We enrolled 603 participants, of whom 601 (99.7%) completed the questionnaire and 581 (96.7%) consented to HIV testing. HIV population prevalence was estimated as 18.0% (95% CI: 13.0-23.1); 86.4% (95% CI: 75.1-94.9) of HIV-positive MSM were unaware of their serostatus. In multivariable analysis, adjusting for age, education, and income, HIV infection was associated with unprotected sex at last sex with a woman, more than two male anal sex partners in last 12 months, inconsistent condom use during anal sex with a man, self-perceived risk of HIV, history of forced sex, history of physical abuse due to MSM status, and not receiving last HIV test result prior to study. HIV prevalence among MSM in Abidjan is more than four times as high as that of general population men. MSM engage in high-risk sexual behavior and most HIV-positive MSM are unaware of their serostatus. Greater access to HIV prevention, care, and treatment services targeted to MSM is necessary.

Retention and risk factors for loss to follow-up of female and male sex workers on antiretroviral treatment in Ivory Coast: a retrospective cohort analysis.

BACKGROUND: Antiretroviral therapy (ART) for HIV-infected sex workers is an important HIV prevention strategy. However, sex workers may have additional challenges for retention in ART care. The objectives of this study were to assess retention of sex workers on ART in a routine setting in Ivory Coast and identify risk factors for loss to follow-up (LTFU). METHODS: The design was a retrospective cohort study. An analysis of clinic files was conducted in 2 sites providing ART services to sex workers in Ivory Coast. Demographic, behavior, and clinical data of female and male sex workers on ART were abstracted onto a standardized anonymous data collection form. Data collection took place between May 11 and 28, 2010. RESULTS: A total of 376 female and 38 male sex workers were included in the analysis. The retention probability was 75% at 6 months, 68% at 12 months, 55% at 24 months, and 47% at 36 months. Attrition was mainly because of LTFU. Factors significantly associated with LTFU in bivariate analysis were lower schooling level, later calendar year of starting ART, and not receiving initial adherence counseling. Later year of starting ART and not receiving adherence counseling at ART initiation remained significantly associated with LTFU in a multivariate Cox regression model. CONCLUSIONS: To improve the retention of sex workers on ART, there is a need for more in-depth investigation of the role of pre-ART counseling and the increasing rates of LTFU with each calendar year.

Exploring risk behaviors and vulnerability for HIV among men who have sex with men in Abidjan, Cote d'Ivoire: poor knowledge, homophobia and sexual violence.

Men who have sex with men (MSM) are at high risk of HIV. Few data are available on MSM and HIV-related risk behaviors in West Africa. We aimed to describe risk behaviors and vulnerability among MSM in Abidjan, Cote d'Ivoire. We conducted a cross-sectional respondent-driven sampling survey with 601 MSM in 2011-2012. Sociodemographic and behavioural data as well as data related to emotional state and stigma were collected. Population estimates with 95% confidence intervals were produced. Survey weighted logistic regression was used to assess factors associated with inconsistent condom use in the prior 12 months. Most MSM were 24 years of age or younger (63.9%) and had attained at least primary education (84.4%). HIV risk behaviors such as low condom and water-based lubricant use, high numbers of male and female sex partners, and sex work were frequently reported as well as verbal, physical and sexual abuse. Inconsistent condom use during anal sex with a male partner in the prior 12 months was reported by 66.0% of the MSM and was positively associated with history of forced sex, alcohol consumption, having a regular partner and a casual partner, having bought sex, and self-perception of low HIV risk. MSM in Abidjan exhibit multiple and frequent HIV-related risk behaviors. To address those behaviours, a combination of individual but also structural interventions will be needed given the context of stigma, homophobia and violence.

HIV and STI prevalence among female sex workers in Côte d'Ivoire: why targeted prevention programs should be continued and strengthened.

OBJECTIVE: To assess condom use and prevalence of STIs and HIV among female sex workers (FSWs), as part of a comprehensive monitoring and evaluation plan of a nationwide sex worker prevention project in Côte d'Ivoire. DESIGN AND METHODS: Cross sectional surveys were conducted among FSWs attending five project clinics in Abidjan and San Pedro (2007), and in Yamoussoukro and Gagnoa (2009). A standardized questionnaire was administered in a face-to-face interview, which included questions on socio-demographic characteristics, sexual behaviour and condom use. After the interview, the participants were asked to provide samples for STI and HIV testing. RESULTS: A total of 1110 FSWs participated in the surveys. There were large differences in socio-demographic and behavioural characteristics between FSW coming for the first time as compared to FSW coming on a routine visit. The prevalence of N. gonorrhoeae or C.trachomatis was 9.1%, 11.8% among first vs. 6.9% routine attendees (p = 0.004). The overall HIV prevalence was 26.6%, it was lower among first time attendees (17.5% as compared to 33.9% for routine attendees, p<0.001). The HIV prevalence among first attendees was also lower than the proportion of HIV positive tests from routine testing and counselling services in the same clinics. CONCLUSIONS: The results show a relatively high STI and HIV prevalence among FSWs in different cities in Côte d'Ivoire. In the light of these results, prevention efforts should continue to focus on FSWs in the country.

High prevalence of HIV and sexually transmitted infections among male sex workers in Abidjan, Cote d'Ivoire: need for services tailored to their needs.

OBJECTIVES: To assess condom use and prevalence of sexually transmitted infections (STI) and HIV among male sex workers (MSW) in Abidjan, Côte d'Ivoire. METHODS: A cross-sectional survey was conducted between October 2007 and January 2008 among MSW attending a sex worker clinic in Abidjan. A short questionnaire was administered in a face-to-face interview, and the participants were asked to provide a urine sample for STI testing and to self-collect transudate of the gingival mucosa for anonymous HIV testing, using a rapid test. A rectal swab for STI testing was taken by a physician. Molecular amplification assays were performed for the detection of Chlamydia trachomatis, Neisseria gonorrhoeae and Trichomonas vaginalis. RESULTS: 96 MSW participated in the survey, their median age was 27 years and the median duration of sex work was 5 years. Consistent condom use with clients during the last working day was 86.0%, and consistent condom use with the regular partner during the last week was 81.6%. HIV infection was detected in 50.0% of the participants. The prevalence of N gonorrhoeae was 12.8%, chlamydia infection was present in 3.2% and T vaginalis in 2.1% of the study participants. CONCLUSIONS: HIV and STI rates found in this study confirm the high risk and vulnerability status of MSW in Côte d'Ivoire. There is a definite need for studies exploring risk and risk perceptions among MSW in more depth and for services tailored to their needs, including developing and validating simple algorithms for the diagnosis of STI in MSW and men who have sex with men.

Capture-recapture for estimating the size of the female sex worker population in three cities in Côte d'Ivoire and in Kisumu, western Kenya.

OBJECTIVE: To estimate the female sex worker population size in three cities in Côte d'Ivoire and in Kisumu, Kenya. METHODS: Capture-recapture was used, calculating size estimates by first 'tagging' a number of individuals and, through an independent recapture, calculating the proportion of overlap. The same procedures were used in all four cities. In the first phase, members of the target population were 'captured' and 'marked' by giving them a capture card. Six days later, in the same places and at the same time, a second sample was 'captured', which comprised a certain number of people who were captured in the first round. During the exercise, questions were asked to estimate the coverage of the sex worker clinics. RESULTS: Using capture-recapture, the estimated number of female sex workers was 1160 in Yamoussoukro (95% CI 1053-1287), 1202 in Bouaké (95% CI 1128-1279), 1916 in San Pedro (95% CI 1809-2030) and 1350 in Kisumu (95% CI 1261-1443). The proportion of female sex workers in Côte d'Ivoire who had visited the clinic ranged from 15% in Yamoussoukro to 30% in San Pedro and was 34% in Kisumu. CONCLUSIONS: Capture-recapture was successfully applied to estimate the population size of female sex workers. These estimations were urgently needed to help mobilize an increased response to HIV, to assess programme coverage and to estimate potential impact of the targeted intervention.