Abstract
Female sex workers (FSWs) play a key role in HIV transmission in West Africa, while they have limited access to antiretroviral therapy (ART). In line with UNAIDS recommendations extending ART to all HIV-infected individuals, we conducted this demonstration project on immediate treatment as prevention (TasP) among FSWs in Cotonou, Benin. We report data on treatment response and its relation to adherence, as well as on ART-resistant genotypes. Complete follow-up varied between 12 and 24 months. At each three-monthly visit, a questionnaire was administered, clinical examinations were carried out and blood samples collected. Adherence to treatment was estimated by self-report. Viral RNA was genotyped at baseline and final visits for drug resistance. Generalized estimating equations for repeated measures with a log-binomial link were used to analyze time trends and the association between adherence and virological response to treatment. One-hundred-seven HIV-positive and ART-naive FSWs were enrolled; 59.8% remained in the cohort till study completion and 62.6% had a final visit. Viral load<1000 (below quantification limit [<50]) was attained in 73.1% (64.6%) of participants at month-6, 84.8% (71.2%) at month-12, and 80.9% (65.1%) at the final visit. The proportion of women with suppressed (below quantification limit) viral load increased with increasing self-reported adherence (p = 0.06 (0.003), tests for trend). The proportion of participants with CD4≤500 also decreased drastically throughout follow-up (p < .0001). Twelve participants exhibited ART-resistant genotypes at baseline, but only two at their final visit. Our findings indicate that TasP is widely accepted among FSWs in Cotonou and could be implemented with relative success. However, due to mobility in this population, follow-up was sub-optimal, suggesting that large geographical coverage of FSW-friendly clinics is needed for sustained treatment implementation. We also fell short of the UNAIDS objective of 90% viral suppression among treated patients, underlining the need for better adherence support programs.
Highlights
Western and central Africa is the second most affected region by the HIV epidemic with an estimated 5 million people living with HIV (PLHIV) at the end of 2018
One-hundred-seven HIV-positive and antiretroviral therapy (ART)-naive Female sex workers (FSWs) were enrolled; 59.8% remained in the cohort till study completion and 62.6% had a final visit
Our findings indicate that treatment as prevention (TasP) is widely accepted among FSWs in Cotonou and could be implemented with relative success
Summary
Western and central Africa is the second most affected region by the HIV epidemic with an estimated 5 million people living with HIV (PLHIV) at the end of 2018 (representing 13.2% of all HIV-infected people in the world). Several reports in the region suggest that FSWs contributed to between 32–84% of HIV prevalent cases among men [9,10,11] and to 18% in the general population of women (12), providing evidence that prioritizing this high-risk group with specific preventive interventions could reduce HIV incidence and prevalence in both prioritized groups and the general population at lower risk [12,13,14] Despite such contribution, ART coverage among FSWs remains low in the region [15, 16] For these reasons, we considered FSWs as a priority population for the implementation of new biomedical preventive interventions such as immediate HIV treatment as prevention (TasP) and pre-exposure prophylaxis (PrEP) [17,18,19]. The present paper reports the main findings of the TasP component of this demonstration project [20] including virological and immunological response to treatment, and resistance to antiretroviral drugs
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