Abstract
IntroductionIn generalized epidemic settings, there is insufficient understanding of how the unmet HIV prevention and treatment needs of key populations (KPs), such as female sex workers (FSWs) and men who have sex with men (MSM), contribute to HIV transmission. In such settings, it is typically assumed that HIV transmission is driven by the general population. We estimated the contribution of commercial sex, sex between men, and other heterosexual partnerships to HIV transmission in South Africa (SA).MethodsWe developed the “Key‐Pop Model”; a dynamic transmission model of HIV among FSWs, their clients, MSM, and the broader population in SA. The model was parameterized and calibrated using demographic, behavioural and epidemiological data from national household surveys and KP surveys. We estimated the contribution of commercial sex, sex between men and sex among heterosexual partnerships of different sub‐groups to HIV transmission over 2010 to 2019. We also estimated the efficiency (HIV infections averted per person‐year of intervention) and prevented fraction (% IA) over 10‐years from scaling‐up ART (to 81% coverage) in different sub‐populations from 2020.ResultsSex between FSWs and their paying clients, and between clients with their non‐paying partners contributed 6.9% (95% credibility interval 4.5% to 9.3%) and 41.9% (35.1% to 53.2%) of new HIV infections in SA over 2010 to 2019 respectively. Sex between low‐risk groups contributed 59.7% (47.6% to 68.5%), sex between men contributed 5.3% (2.3% to 14.1%) and sex between MSM and their female partners contributed 3.7% (1.6% to 9.8%). Going forward, the largest population‐level impact on HIV transmission can be achieved from scaling up ART to clients of FSWs (% IA = 18.2% (14.0% to 24.4%) or low‐risk individuals (% IA = 20.6% (14.7 to 27.5) over 2020 to 2030), with ART scale‐up among KPs being most efficient.ConclusionsClients of FSWs play a fundamental role in HIV transmission in SA. Addressing the HIV prevention and treatment needs of KPs in generalized HIV epidemics is central to a comprehensive HIV response.
Highlights
In generalized epidemic settings, there is insufficient understanding of how the unmet HIV prevention and treatment needs of key populations (KPs), such as female sex workers (FSWs) and men who have sex with men (MSM), contribute to HIV transmission
Despite high HIV prevalence’s among key populations (KPs) such as female sex workers (FSW, 39.5% to 71.8% [1,2,3,4,5,6,7,8,9,10,11]) and men who have sex with men (MSM, 13.2% to 58.4% [11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27]) in South Africa (SA), the HIV response has traditionally focussed on the general population, based on the assumption that KPs play a small role in HIV transmission in generalized HIV epidemics
The Incidence Patterns Model (IPM) does not include partners of KPs. These limitations have been highlighted by other dynamic transmission modelling analyses that have shown that commercial sex [30,31,32,33,34,35], non-commercial sex of clients [30], or sex between men [30,35,36] can be important contributors to HIV transmission in sub-Saharan Africa (SSA)
Summary
Despite high HIV prevalence’s among key populations (KPs) such as female sex workers (FSW, 39.5% to 71.8% [1,2,3,4,5,6,7,8,9,10,11]) and men who have sex with men (MSM, 13.2% to 58.4% [11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27]) in South Africa (SA), the HIV response has traditionally focussed on the general population, based on the assumption that KPs play a small role in HIV transmission in generalized HIV epidemics This assertion has largely been based on the UNAIDS modes of transmission (MOT) model, a static model which represents risk in a single year, and generally estimates that
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