Project Shikamana: Community Empowerment-Based Combination HIV Prevention Significantly Impacts HIV Incidence and Care Continuum Outcomes Among Female Sex Workers in Iringa, Tanzania

Abstract

Objective: To determine the impact of a community empowerment model of combination HIV prevention (Project Shikamana) among female sex workers (FSW) in Iringa, Tanzania. Methods: We conducted a 2-community randomized trial. Intervention elements included the following: (1) Community‐led drop‐in center and mobilization activities; (2) venue-based peer education, condom distribution, and HIV testing; (3) peer service navigation; (4) provider sensitivity trainings; and (5) SMS reminders. We used time-location sampling to enroll 496 FSW and conducted a survey and blood draws to screen for HIV and assess viral load at 0 and 18 months. We conducted an intent-to-treat analysis using logistic and Poisson regression and inverse probability weighting for primary outcomes. Results: The analysis included 171 HIV-positive and 216 HIV-negative FSW who completed baseline and 18-month study visits. Participants in the intervention were significantly less likely to become infected with HIV at 18-month follow-up (RR 0.38; P = 0.047), with an HIV incidence of 5.0% in the intervention vs. 10.4% control. Decreases in inconsistent condom use over time were significantly greater in the intervention (72.0%–43.6%) vs. control (68.8%–54.0%; RR 0.81, P = 0.042). At follow-up, we observed significant differences in behavioral HIV care continuum outcomes, and positive, but nonsignificant, increases in viral suppression (40.0%–50.6%) in the intervention vs. control (35.9%–47.4%). There was a strong association of between higher intervention exposure and HIV outcomes including viral suppression. Conclusions: Project Shikamana is the first trial of community empowerment-based combination prevention among FSW in Africa to show a significant reduction in HIV incidence warranting its broader implementation and evaluation.

Unmet Need for Family Planning and Experience of Unintended Pregnancy Among Female Sex Workers in Urban Cameroon: Results From a National Cross-Sectional Study

“…In Cameroon, most community-based facilities serving FSWs currently offer services fairly focused on HIV prevention, testing, and treatment support, with family planning often limited to counseling. 69 Although these services appear to be an effective way to deliver HIV testing to FSWs, 70 they may miss opportunities for contraceptive provision. Requiring women to access multiple service points to meet their sexual and reproductive health needs may further disincentivize contraceptive use and act as a structural barrier.…”

“…Elsewhere, it has been demonstrated that FSWled mobilization for HIV services through community drop-in centers has been associated with reductions in HIV incidence among FSWs in Tanzania. 70 Expanding this community empowerment model for integrated family planning, STI, and HIV service delivery may represent an effective strategy to reduce unintended pregnancies and be responsive to critical health care needs.…”

“I did not plan to have a baby. This is the outcome of our work”: a qualitative study exploring unintended pregnancy among female sex workers

“…Sex workers need more specifically targeted services. Experience from a community-based study among FSWs in Tanzania that included community-led drop-in centre and mobilization activities as well as venue-based peer education, condom distribution, and HIV testing, showed significant reduction in HIV incidence [ 77 ]. Expanding such community-based model which reaches out to FSWs in their areas of work, to further include family planning services can be an effective strategy to reduce unintended pregnancy among FSWs.…”

Mujeres Unidas: Addressing Substance Use, Violence, and HIV Risk through Asset-Based Community Development for Women in the Sex Trade

“…Women trading sex have taken collective action to reduce their risks of violence, abuse, HIV/STIs, and to increase their access to healthcare and other income [ 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 ]. For example, they have mobilized for human rights via a group, meeting, or marches, sharing concerns and helping each other.…”

“…For example, they have mobilized for human rights via a group, meeting, or marches, sharing concerns and helping each other. CM has reduced HIV/STI risk among women in the sex trade in India, the Caribbean, Brazil, and Africa [ 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 ]. Its dissemination in India has resulted in significant reductions in HIV prevalence at regional levels [ 22 ].…”