Abstract
Knowledge of HIV status is a necessary pre-condition for most HIV interventions, including treatment as well as biomedical and behavioral prevention interventions. We used data from a female sex worker (FSW) cohort in three Zambian transit towns to understand the effect that knowledge of HIV status has on FSWs' HIV risk-related sexual behaviors with clients. The cohort was formed from an HIV self-testing trial that followed participants for 4 months. Participants completed three rounds of data collection at baseline, 1 month, and 4 months where they reported their perceived knowledge of HIV status, number of clients on an average working night, and consistent condom use with clients. We measured the effect of knowledge of HIV status on participants' sexual behaviors by using linear regression models with individual fixed effects. The majority of the 965 participants tested for HIV at least once during the observation period (96%) and changed their knowledge of HIV status (79%). Knowledge of HIV status did not affect participants' number of clients, but it did affect their consistency of condom use. Compared with unknown HIV status, knowledge of HIV-negative status significantly increased participants' consistent condom use by 8.1% points [95% confidence interval (CI): 2.7–13.4, p = 0.003] and knowledge of HIV-positive status increased participants' consistent condom use by 6.1% points (95% CI: −0.1 to 12.9, p = 0.08); however, this latter effect was not statistically significant. FSWs in Zambia engaged in safer sex with clients when they learned their HIV status. The expansion of HIV testing programs may serve as a behavioral HIV prevention measure among FSWs.
Highlights
IntroductionDespite numerous studies in diverse populations, the effect of knowledge of HIV status on sexual behaviors associated with an increased risk of HIV transmission remains unclear.[1,2,3,4,5,6,7,8,9,10,11] The efficacy and effectiveness of a range of biomedical and behavioral HIV interventions on HIV transmission, are firmly established.[12,13,14,15,16,17,18,19,20,21,22,23] Knowledge of HIV status is a necessary pre-condition for most HIV interventions and HIV testing is a priority for HIV prevention interventions such as treatment as prevention (TasP)[14,15] and pre-exposure prophylaxis (PrEP).[18,19,24,25,26,27]Many governments and international organizations are currently investing heavily in the expansion of HIV testing services in high HIV prevalence settings,[28,29] including clinic-based testing,[28] home-based testing,[30,31] and, recently, HIV self-testing.[32,33,34] regular HIV testing is important for all individuals in high HIV prevalence settings, it is especially important for individuals engaging in behaviors that put them at particular risk of HIV infection, such as female sex workers (FSWs) and men who have sex with men.Previous studies among members of the general population in high HIV prevalence settings largely suggest that knowledge of HIV-negative status does not affect HIV risk-related sexual behaviors,[2,3,6,7,8,9,10] whereas knowledge of HIV-positive status decreases HIV risk-related sexual behaviors.[1,2,4,5,7,8,10] The assumption here is that individuals who learn they are not living with HIV do not change their sexual behavior because they do not perceive themselves at risk of infection, whereas those who learn they are living with HIV change their behavior to protect their sexual partners from becoming HIV infected
Knowledge of HIV status was unknown to the majority of participants (64%, 610/956), but by 1 month and 4 months knowledge of HIV status was HIV-negative for roughly half of participants (1 month: 51%, 450/879; 4 months: 51%, 453/882)
In the sub-group analyses that measured how different changes in knowledge of HIV status affected participants’ HIV risk-related sexual behaviors, we found no effect of knowledge of HIV status on participants’ number of clients on an average working night (Fig. 3) and some larger effects of knowledge of HIV status on participants’ consistent condom use with clients (Fig. 4)
Summary
Despite numerous studies in diverse populations, the effect of knowledge of HIV status on sexual behaviors associated with an increased risk of HIV transmission remains unclear.[1,2,3,4,5,6,7,8,9,10,11] The efficacy and effectiveness of a range of biomedical and behavioral HIV interventions on HIV transmission, are firmly established.[12,13,14,15,16,17,18,19,20,21,22,23] Knowledge of HIV status is a necessary pre-condition for most HIV interventions and HIV testing is a priority for HIV prevention interventions such as treatment as prevention (TasP)[14,15] and pre-exposure prophylaxis (PrEP).[18,19,24,25,26,27]Many governments and international organizations are currently investing heavily in the expansion of HIV testing services in high HIV prevalence settings,[28,29] including clinic-based testing,[28] home-based testing,[30,31] and, recently, HIV self-testing.[32,33,34] regular HIV testing is important for all individuals in high HIV prevalence settings, it is especially important for individuals engaging in behaviors that put them at particular risk of HIV infection, such as female sex workers (FSWs) and men who have sex with men.Previous studies among members of the general population in high HIV prevalence settings largely suggest that knowledge of HIV-negative status does not affect HIV risk-related sexual behaviors,[2,3,6,7,8,9,10] whereas knowledge of HIV-positive status decreases HIV risk-related sexual behaviors.[1,2,4,5,7,8,10] The assumption here is that individuals who learn they are not living with HIV do not change their sexual behavior because they do not perceive themselves at risk of infection, whereas those who learn they are living with HIV change their behavior to protect their sexual partners from becoming HIV infected. Despite numerous studies in diverse populations, the effect of knowledge of HIV status on sexual behaviors associated with an increased risk of HIV transmission remains unclear.[1,2,3,4,5,6,7,8,9,10,11] The efficacy and effectiveness of a range of biomedical and behavioral HIV interventions on HIV transmission, are firmly established.[12,13,14,15,16,17,18,19,20,21,22,23] Knowledge of HIV status is a necessary pre-condition for most HIV interventions and HIV testing is a priority for HIV prevention interventions such as treatment as prevention (TasP)[14,15] and pre-exposure prophylaxis (PrEP).[18,19,24,25,26,27].
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