Priority interventions to reduce HIV transmission in sex work settings in sub‐Saharan Africa and delivery of these services

Abstract

IntroductionVirtually no African country provides HIV prevention services in sex work settings with an adequate scale and intensity. Uncertainty remains about the optimal set of interventions and mode of delivery.MethodsWe systematically reviewed studies reporting interventions for reducing HIV transmission among female sex workers in sub-Saharan Africa between January 2000 and July 2011. Medline (PubMed) and non-indexed journals were searched for studies with quantitative study outcomes.ResultsWe located 26 studies, including seven randomized trials. Evidence supports implementation of the following interventions to reduce unprotected sex among female sex workers: peer-mediated condom promotion, risk-reduction counselling and skills-building for safer sex. One study found that interventions to counter hazardous alcohol-use lowered unprotected sex. Data also show effectiveness of screening for sexually transmitted infections (STIs) and syndromic STI treatment, but experience with periodic presumptive treatment is limited. HIV testing and counselling is essential for facilitating sex workers’ access to care and antiretroviral treatment (ART), but testing models for sex workers and indeed for ART access are little studied, as are structural interventions, which create conditions conducive for risk reduction. With the exception of Senegal, persistent criminalization of sex work across Africa reduces sex workers’ control over working conditions and impedes their access to health services. It also obstructs health-service provision and legal protection.ConclusionsThere is sufficient evidence of effectiveness of targeted interventions with female sex workers in Africa to inform delivery of services for this population. With improved planning and political will, services – including peer interventions, condom promotion and STI screening – would act at multiple levels to reduce HIV exposure and transmission efficiency among sex workers. Initiatives are required to enhance access to HIV testing and ART for sex workers, using current CD4 thresholds, or possibly earlier for prevention. Services implemented at sufficient scale and intensity also serve as a platform for subsequent community mobilization and sex worker empowerment, and alleviate a major source of incident infection sustaining even generalized HIV epidemics. Ultimately, structural and legal changes that align public health and human rights are needed to ensure that sex workers on the continent are adequately protected from HIV.

HIV Prevalence and Risk Behaviors Among Female Sex Workers in Botswana: Results from the 2012 HIV/STI Bio-Behavioral Study

“…Gonorrhea and chlamydia were less prevalent at slightly over 10 %, and the prevalence of syphilis was lower at 3.5 %. With high HIV prevalence, a population size mid estimate of over 4,000 in the three districts studied, and a mean of 7.6 sex partners in the week before the survey, FSWs in Botswana, like their counterparts in other sub-Saharan African countries, have clearly played an important role in advancing the epidemic [16]. The mean duration of sex work of 4.7 years in the study is close to the 5.5 years reported during a recent literature review as the average duration of female sex work in Africa [17], which means the sample had a long cumulative exposure to HIV risk.…”

Sexual transactions between long distance truck drivers and female sex workers in South Africa

“…[5,9,14–16] Therefore, it is no wonder that FSWs are 13.5 times more likely to be living with HIV than other women, and are designated as a key population in relation to the HIV epidemic. [1,5,17–20] Yet, the industry of sex work continues to thrive despite the high prevalence of HIV among FSWs, with the continued risk of transmission to their clients who include other vulnerable groups, such as LDTDs. [2,12]…”

Behavioural interventions promoting condom use among female sex workers in sub-Saharan Africa: a systematic review

“…Furthermore, a hand-search of references cited in all eligible studies and previous reviews was conducted to obtain additional articles (Chersich et al, 2013;Lutchters et al, 2008;Steen et al, 2000;E. Williams, Lamson, Efem, Weir, & Lamptey, 1992).…”

“…A previous review (Chersich, Luchters, & Ntaganira, 2013) examined studies in sub-Saharan Africa aimed at reducing HIV transmission amongst FSWs. It broadly examined studies evaluating HIV-prevention strategies for FSWs within the region, but did not focus on behavioural interventions assessing the effectiveness and process outcomes related to condom use.…”