Abstract
IntroductionIn Bangalore, new HIV infections of female sex workers and men who have sex with men continue to occur, despite high condom use. Pre-exposure prophylaxis (PrEP) has high anti-HIV efficacy for men who have sex with men. PrEP demonstration projects are underway amongst Indian female sex workers. We estimated the impact and efficiency of prioritizing PrEP to female sex workers and/or men who have sex with men in Bangalore.MethodsA mathematical model of HIV transmission and treatment for female sex workers, clients, men who have sex with men and low-risk groups was parameterized and fitted to Bangalore data. The proportion of transmission attributable (population attributable fraction) to commercial sex and sex between men was calculated. PrEP impact (infections averted, life-years gained) and efficiency (life-years gained/infections averted per 100 person-years on PrEP) were estimated for different levels of PrEP adherence, coverage and prioritization strategies (female sex workers, high-risk men who have sex with men, both female sex workers and high-risk men who have sex with men, or female sex workers with lower condom use), under current conditions and in a scenario with lower baseline condom use amongst key populations.ResultsPopulation attributable fractions for commercial sex and sex between men have declined over time, and they are predicted to account for 19% of all new infections between 2016 and 2025. PrEP could prevent a substantial proportion of infections amongst female sex workers and men who have sex with men in this setting (23%/27% over 5/10 years, with 60% coverage and 50% adherence), which could avert 2.9%/4.3% of infections over 5/10 years in the whole Bangalore population. Impact and efficiency in the whole population was greater if female sex workers were prioritized. Efficiency increased, but impact decreased, if only female sex workers with lower condom use were given PrEP. Greater impact and efficiency was predicted for the scenario with lower condom use.ConclusionsPrEP could be beneficial for female sex workers and men who have sex with men in Bangalore, and give some benefits in the general population, especially in similar settings with lower condom use levels.
Highlights
In Bangalore, new HIV infections of female sex workers and men who have sex with men continue to occur, despite high condom use
Population attributable fractions Between 1986 and 1995, a median 68% of new HIV infections (95% credible interval (CrI) 55 to 84%) were estimated to be attributable to commercial sex, and 27% (13 to 54%) to sex between men, together accounting for 85% (72 to 95%) of new infections (Supplementary Figure 5a). These population attributable fraction (PAF) declined over time, as condom use amongst key populations and HIV prevalence in the rest of the population increased; we predicted that between 2016 and 2025, 19% (12 to 20%) of new infections would be attributable to commercial sex or men who have sex with men (MSM)
We found that Pre-exposure prophylaxis (PrEP) prioritized to female sex workers (FSWs) or high-risk’’ MSM (HR-MSM) in Bangalore could substantially reduce HIV incidence amongst the prioritized group, preventing 22 to 25% of infections over (a) 16,000 (b) 12
Summary
In Bangalore, new HIV infections of female sex workers and men who have sex with men continue to occur, despite high condom use. We estimated the impact and efficiency of prioritizing PrEP to female sex workers and/or men who have sex with men in Bangalore. Efficiency increased, but impact decreased, if only female sex workers with lower condom use were given PrEP. Conclusions: PrEP could be beneficial for female sex workers and men who have sex with men in Bangalore, and give some benefits in the general population, especially in similar settings with lower condom use levels. In Bangalore, as elsewhere in southern India, the highest HIV levels are found amongst female sex workers (FSWs; 8.0% prevalence 2009), FSWs’ commercial clients (2.4%, 2007), and men who have sex with men (MSM; 16.5%, 2009) [1Á4]. FSWs report much lower condom use with non-commercial partners [9]
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