Abstract
IntroductionSex workers have endured a high burden of HIV infection in and across HIV epidemics. A comprehensive, community empowerment-based HIV prevention intervention emphasizes sex worker organization and mobilization to address HIV risk and often includes community-led peer education, condom distribution, and other activities. Meta-analysis of such interventions suggests a potential 51% reduction in inconsistent condom use. Mathematical modeling exercises provide theoretical insight into potential impacts of the intervention on HIV incidence and burden in settings where interventions have not yet been implemented.MethodsWe used a deterministic model, Goals, to project the impact on HIV infections when the community empowerment interventions were scaled up among female sex workers in Kenya, Thailand, Brazil, and Ukraine. Modeling scenarios included expansion of the comprehensive community empowerment-based HIV prevention intervention from baseline coverage over a 5-year period (5–65% in Kenya and Ukraine; 10–70% in Thailand and Brazil), while other interventions were held at baseline levels. A second exercise increased the intervention coverage simultaneously with equitable access to ART for sex workers. Impacts on HIV outcomes among sex workers and adults are observed from 2012–2016 and, compared to status quo when all interventions are held constant.ResultsOptimistic but feasible coverage (65%–70%) of the intervention demonstrated a range of impacts on HIV: 220 infections averted over 5 yrs. among sex workers in Thailand, 1,830 in Brazil, 2,220 in Ukraine, and 10,800 infections in Kenya. Impacts of the intervention for female sex workers extend to the adult population, cumulatively averting 730 infections in Thailand to 20,700 adult infections in Kenya. Impacts vary by country, influenced by HIV prevalence in risk groups, risk behaviors, intervention use, and population size.DiscussionA community empowerment approach to HIV prevention and access to universal ART for female sex workers is a promising human rights-based solution to overcoming the persistent burden of HIV among female sex workers across epidemic settings.
Highlights
Sex workers have endured a high burden of HIV infection in and across HIV epidemics
Optimistic but feasible coverage (65%–70%) of the intervention demonstrated a range of impacts on HIV: 220 infections averted over 5 yrs. among sex workers in Thailand, 1,830 in Brazil, 2,220 in Ukraine, and 10,800 infections in Kenya
Impacts of the intervention for female sex workers extend to the adult population, cumulatively averting 730 infections in Thailand to 20,700 adult infections in Kenya
Summary
Sex workers have endured a high burden of HIV infection in and across HIV epidemics. A comprehensive, community empowerment-based HIV prevention intervention emphasizes sex worker organization and mobilization to address HIV risk and often includes community-led peer education, condom distribution, and other activities. [3] Peer-driven condom promotion and risk reduction counseling demonstrated effectiveness, as did combinations of clinical and peer-based services.[3,4,5,6,7,8,9,10] STI screening and presumptive treatment allowed for identification of and treatment for infection, though high coverage of return visits for STI care and treatment was not well maintained in some settings.[5,11,12,13] Contrary to recent recommendations by the WHO, interventions that are currently considered priority for female sex workers –HIV counseling and testing, access to ART, and structural interventions - have rarely been evaluated or reported in the Sub-Saharan region. A recent review by Cherish and colleagues of HIV prevention interventions for female sex workers in Sub-Saharan countries, suggested there was evidence of behavioral interventions to effectively reduce unprotected sex. [3] Peer-driven condom promotion and risk reduction counseling demonstrated effectiveness, as did combinations of clinical and peer-based services.[3,4,5,6,7,8,9,10] STI screening and presumptive treatment allowed for identification of and treatment for infection, though high coverage of return visits for STI care and treatment was not well maintained in some settings.[5,11,12,13] Contrary to recent recommendations by the WHO, interventions that are currently considered priority for female sex workers –HIV counseling and testing, access to ART, and structural interventions - have rarely been evaluated or reported in the Sub-Saharan region. [3]
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