Abstract

IntroductionFemale sex workers (FSWs) experience overlapping burdens of HIV, sexually transmitted infections and unintended pregnancy. Pre‐exposure prophylaxis (PrEP) is highly efficacious for HIV prevention. It represents a promising strategy to reduce HIV acquisition risks among FSWs specifically given complex social and structural factors that challenge consistent condom use. However, the potential impact on unintended pregnancy has garnered little attention. We discuss the potential concerns and opportunities for PrEP to positively or negatively impact the sexual and reproductive health and rights (SRHR) of FSWs.DiscussionFSWs have high unmet need for effective contraception and unintended pregnancy is common in low‐ and middle‐income countries. Unintended pregnancy can have enduring health and social effects for FSWs, including consequences of unsafe abortion and financial impacts affecting subsequent risk‐taking. It is possible that PrEP could negatively impact condom and other contraceptive use among FSWs due to condom substitution, normalization, external pressures or PrEP provision by single‐focus services. There are limited empirical data available to assess the impact of PrEP on pregnancy rates in real‐life settings. However, pregnancy rates are relatively high in PrEP trials and modelling suggests a potential two‐fold increase in condomless sex among FSWs on PrEP, which, given low use of non‐barrier contraceptive methods, would increase rates of unintended pregnancy. Opportunities for integrating family planning with PrEP and HIV services may circumvent these concerns and support improved SRHR. Synergies between PrEP and family planning could promote uptake and maintenance for both interventions. Integrating family planning into FSW‐focused community‐based HIV services is likely to be the most effective model for improving access to non‐barrier contraception among FSWs. However, barriers to integration, such as provider skills and training and funding mechanisms, need to be addressed.ConclusionsAs PrEP is scaled up among FSWs, there is growing impetus to consider integrating family planning services with PrEP delivery in order to better meet the diverse SRHR needs of FSWs and to prevent unintended consequences. Programme monitoring combined with research can close data gaps and mobilize adequate resources to deliver comprehensive SRHR services respectful of all women’s rights.

Highlights

  • Female sex workers (FSWs) experience overlapping burdens of HIV, sexually transmitted infections and unintended pregnancy

  • Female sex workers (FSWs) in low- and middle-income countries experience overlapping burdens of high HIV prevalence alongside high rates of sexually transmitted infections (STIs) and unintended pregnancy [1,2]. Despite these coexisting reproductive health needs, in many settings family planning is poorly integrated into sexual and reproductive health and rights (SRHR) services for FSWs, which often maintain a narrow focus on HIV and STI prevention and treatment [3,4,5]

  • There is currently a lack of policy guidance to support implementers to integrate family planning into their programmes, with most national Pre-exposure prophylaxis (PrEP) policies and guidelines making fleeting references to including contraceptive counselling within a combination package of prevention services [104,105,106]. Means to overcome these barriers without relying on referrals to other services include task-shifting contraceptive administration to lower-cadre healthcare workers [107,108] and collaborations between family planning and HIV services to hold recurrent “family planning days” at FSW-friendly community services which are attended by trained personnel for long-acting reversible contraceptives (LARCs) administration

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Summary

| INTRODUCTION

Female sex workers (FSWs) in low- and middle-income countries experience overlapping burdens of high HIV prevalence alongside high rates of sexually transmitted infections (STIs) and unintended pregnancy [1,2]. Despite these coexisting reproductive health needs, in many settings family planning is poorly integrated into sexual and reproductive health and rights (SRHR) services for FSWs, which often maintain a narrow focus on HIV and STI prevention and treatment [3,4,5]. Drawing from our experience in working with national PrEP implementation programmes, the purpose of this commentary is to elaborate on the context in which PrEP is being implemented with FSWs and the potential concerns and opportunities for PrEP to impact unintended pregnancy and other aspects of SRHR

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Findings
COMPETING INTEREST
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