How Can Programs Better Support Female Sex Workers to Avoid HIV Infection in Zimbabwe? A Prevention Cascade Analysis.

Elizabeth Fearon,Joanna Busza,James R Hargreaves,Sungai T Chabata,Sharon S Weir,Sue Napierala,Stefan Baral,Frances M Cowan,Andrew Phillips,Valentina Cambiano,Brian Rice,Bernadette Hensen,Phillis Mushati,Sibongile Mtetwa

doi:10.1097/qai.0000000000001980

Abstract

"HIV prevention cascades" have been proposed to support programs by identifying gaps in demand for, access to, and capability to adhere to HIV prevention tools, but there are few empirical examples to guide development. We apply a prevention cascade framework to examine prevention coverage and factors associated with condoms and/or PrEP adherence among female sex workers. Seven sites across Zimbabwe. Seven respondent-driven sampling surveys from the intervention sites of a pragmatic cluster-randomized trial in Zimbabwe in 2016 were analyzed, and 611/1439 women testing HIV-negative included. We operationalized key components of an HIV prevention cascade including demand, supply, and capability to adhere to 2 tools for HIV prevention: condoms and pre-exposure prophylaxis (PrEP). We used adjusted logistic regression to identify determinants of adherence to condoms and PrEP in turn, examining the effect of adherence to one tool on adherence to the other. There were 343/611, 54.7%, women reporting adherence to condoms and/or PrEP, leaving almost half uncovered. Although women were aware that condoms prevented HIV and reported good access to them, only 45·5% reported full adherence to condom use. For PrEP, a new technology, there were gaps along all 3 domains of demand, supply, and adherence. Alcohol use decreased adherence to PrEP and condoms. Younger and newer entrants to sex work were less likely to take PrEP every day. HIV prevention programming among female sex workers in Zimbabwe could consider increasing awareness of PrEP alongside supply, alcohol use interventions, and approaches to engaging younger women.

Highlights

UNAIDS has set ambitious goals for reducing global HIV incidence through its HIV Prevention 2020 framework[1]
Structural factors including poverty and economic shocks, criminalisation, and stigma interact to raise the risk of HIV acquisition among female sex workers (FSW) via causal pathways affecting their vulnerability to violence, ability to negotiate with clients, access, carry and use condoms, and receive services and sensitive healthcare[6,7,8,9,10]
We examined sociodemographic and sex work characteristics; frequency of alcohol consumption and binge drinking in the previous 12 months; whether FSW reported ‘good’ or ‘very good’ relations with other FSW, whether they discussed health with other FSW and were encouraged by them; recent experience of being stopped by the police; violence; and stigma related to being a sex worker

Summary

Introduction

UNAIDS has set ambitious goals for reducing global HIV incidence through its HIV Prevention 2020 framework[1]. Meeting these targets requires increasing coverage of populations at risk of HIV acquisition, including female sex workers (FSW). HIV prevalence is 13.5 times higher among FSW than among all women aged 15-49 years[5]. Structural factors including poverty and economic shocks, criminalisation, and stigma interact to raise the risk of HIV acquisition among FSW via causal pathways affecting their vulnerability to violence, ability to negotiate with clients, access, carry and use condoms, and receive services and sensitive healthcare[6,7,8,9,10]

Methods

Results

Conclusion