Comparing the impact of increasing condom use or HIV pre-exposure prophylaxis (PrEP) use among female sex workers

Cost-effectiveness of HIV pre-exposure prophylaxis among female sex workers in Iran

The Iranian government does not fund pre-exposure prophylaxis (PrEP), and it is not used in Iran due to uncertainties in its cost-effectiveness. In this study, we examined the cost-effectiveness of PrEP among female sex workers (FSWs) in Iran. The cost-effectiveness analysis compared only PrEP, a combination of PrEP with harm reduction (HR) with only HR scenario among FSWs over a 10-year time horizon. The perspective of the healthcare provider was used in the analysis. The primary outcome was disability-adjusted life year (DALY) averted. Analyses included health and cost outcomes, as well as the incremental cost-effectiveness ratio (ICER), which was reported as the cost per DALY averted. Only PrEP was not cost-effective at a willingness to pay threshold of 4669.6 USD per DALY averted in Iran. In contrast, PrEP and HR strategies were cost-effective at the same willingness to pay threshold. The ICER was 868.47 USD per DALY averted for PrEP and HR compared to HR alone. Compared to HR, combining PrEP with HR is a cost-effective intervention among Iranian FSWs for reducing the clinical and economic burden associated with HIV over a 10-year time horizon. Iran should add PrEP to current HR programs for FSWs.

HIV prevention and treatment cascades among female sex workers in Ghana: gaps and priorities that should be addressed by the national programme

BACKGROUND

There is currently limited knowledge about HIV prevention and treatment cascades among female sex workers (FSW) in Ghana. This study sought to use the 2020 bio-behavioural survey (BBS) among FSWs to identify gaps and priorities in HIV treatment and prevention cascades to help achieve the 95-95-95 fast track targets.

METHOD

The study used a cross-sectional design with Time Location Sampling (TLS) technique in all regions of Ghana. All eligible FSW at the selected venues and stipulated time frame were interviewed and tested for HIV onsite using the national testing algorithm. For condom use and HIV testing cascades, each step of the cascade was calculated as a percentage of all FSW. Analysis of treatment cascade was restricted to HIV positive participants and was presented using both conditional (% eligible PLHIV) and unconditional (% all PLHIV) approaches. Viral suppression level was defined as < 1000 copies/ml.

RESULTS

A total of 6,773 participants took part in the behavioral interviews while 6,217 took part in the biological component which involves HIV testing. In all, 33% and 80% of all FSW do not consistently use condoms with their paying clients and non-paying partners respectively. The findings further show that 26.6% of FSW have never tested for HIV, and contrary to the HIV testing policy of every six months for FSW, 70.0% did not test for HIV 6 months preceding the survey and 40.7% of all FSW did not test for HIV 12 months preceding the survey. The conditional treatment cascade was 32%-71%-57% while the unconditional cascade was 32%-23%-49%. The study further shows 68% of the HIV positive FSW were not aware of their HIV positive status, 77% were not on treatment, while nearly 51% were not virally suppressed regardless of treatment status.

CONCLUSION

The results show that both the prevention and treatment cascades are suboptimal. Key gaps identified include low: HIV testing, viral load suppression, condom use with both paying clients and non-paying partners. There is therefore the need to scale prevention and treatment interventions particularly HIV testing, treatment initiation, consistent condoms use with both paying clients and non-paying partners to help achieve the 95-95-95 fast track targets.

Efficacy estimates of oral pre-exposure prophylaxis for HIV prevention in cisgender women with partial adherence

Pre-exposure prophylaxis (PrEP) with tenofovir (TFV) disoproxil fumarate and emtricitabine administered orally daily is effective in preventing human immunodeficiency virus (HIV) acquisition in both men and women with sufficient adherence; however, the adherence-efficacy relationship in cisgender women has not been well established. We calculated the adherence-efficacy curve for cisgender women by using HIV incidence and plasma TFV concentration data from three trials (FEM-PrEP, VOICE and Partners PrEP). We imputed TFV diphosphate (TFV-DP) concentrations, a measure of long-term adherence, from TFV quantification by using data from the HIV Prevention Trials Network 082 study, which measured both TFV-DP and TFV concentrations. Two, four and seven pills per week reduced HIV incidence by 59.3% (95% credible interval (CrI) 29.9-95.8%), 83.8% (95% CI 51.7-99.8%) and 95.9% (95% CI 72.6-100%), respectively. Our adherence-efficacy curve can be validated and updated by HIV prevention studies that directly measure TFV-DP concentrations. The curve suggests that high adherence confers high protection in cisgender women. However, the lower efficacy with partial adherence highlights the need for new PrEP products and interventions to increase adherence.

Validation of Brief Condom Use Attitudes Scales for Spanish-Speaking People Who Use Crack Cocaine in El Salvador

People who use crack cocaine (PWUCC) are a population severely impacted by a concentrated epidemic of HIV. Behavioral interventions to prevent and treat HIV among PWUCC have been implemented around the world including in low- and middle-income countries which have been disproportionately affected by HIV. However, few studies have validated and assessed psychometric properties of measures on PWUCC, especially in transnational populations. Our sample was comprised of 1324 PWUCC, Spanish mono-lingual speakers, residing in the metropolitan area of San Salvador, El Salvador. Exploratory factor analysis and subsequent confirmatory factor analysis using statistical softwares SPSS and Amos were conducted on three abbreviated and translated condom use attitude measures (i.e., Condom Use Attitudes Scale-Spanish Short Form, Condom Use Social Norm-Spanish Short Form [CUSN-SSF], Condom Use Self-Efficacy-Spanish Short Form). Convergent validity was examined by computing bivariate correlations between the scales and condom use and sexually transmitted disease diagnosis. Results indicated that a two-factor, 8-item correlated model for the CUAS-SSF scale had an excellent fit and adequate reliability (α = .76). The confirmatory factor analysis for the 5-item CUSN-SSF scale indicated a satisfactory fit with 3 of 6 fit indices indicating adequate fit. Analysis of the two-factor 5-item CUSE-SSF scale indicated satisfactory fit and adequate reliability (α = .84). There were significant correlations between all measures and with self-reported condom use. Results indicate that these brief measures are reliable and valid and can be utilized to assess the effectiveness of HIV risk reduction interventions among Spanish-speaking PWUCC.

Healthcare needs of people living with human immunodeficiency virus: A qualitative descriptive study

AIM

A better understanding about the health care and support needs is beneficial to maintain the linkage between People Living with Human Immunodeficiency Virus (PLWH) and healthcare services. This study aims to explore the healthcare needs of PLWH from their perspectives.

DESIGN

A qualitative descriptive study design was undertaken in July 2017 to June 2018.

METHODS

Fourteen participants were recruited by purposive sampling technique. Face-to-face in-depth interview and focus-group discussion (FGD) were conducted and analysed using content analysis.

RESULTS

Data revealed five themes, namely the needs to be free from stigma and discrimination, strengthen life spirit, have safe sexual practices, social support, and have accessible and affordable healthcare services.

CONCLUSION

People Living with Human Immunodeficiency Virus have their own perspectives on their healthcare needs. Therefore, nurses and other healthcare providers need to explore, understand, and respond to the needs, and incorporate them into comprehensive and holistic care.

Intimate Relationships and HIV Infection Risks Among Shan Female Sex Workers From Myanmar in Chiang Mai, Thailand: A Qualitative Study

This study aimed to investigate HIV risks among female sex workers (FSWs) who were from the Shan ethnic group, and how they relate to complex relationships with inconsistent condom use. The study was conducted using in-depth interviews with 17 Shan FSWs (aged 18-45 years old) in Chiang Mai. Intimate relationships between participants and regular clients/steady partners were found to facilitate inconsistent condom use. Participating Shan FSWs sustained intimacy with regular clients not only for economic ends but also for emotional support. Gender norms and male power dominated condom use decision making. Some participants lacked proper HIV preventive knowledge regarding condom breakage and HIV risks. Effective intervention and proper HIV preventive practices should address these intimate contexts. Capacity building among women would assist FSWs to make choices that protect them from HIV/STDs infections. Couples-based HIV interventions addressing emotional intimacy is an urgent need for HIV communication and service delivery in Thailand.

Prevalence and incidence of HIV among female sex workers and their clients: modelling the potential effects of intervention in Rwanda

BACKGROUND

Rwanda has identified several targeted HIV prevention strategies, such as promotion of condom use and provision of antiretroviral therapy (ART) and pre-exposure prophylaxis (PrEP) for female sex workers (FSWs). Given this country's limited resources, understanding how the HIV epidemic will be affected by these strategies is crucial.

METHODS

We developed a Markov model to estimate the effects of targeted strategies to FSWs on the HIV prevalence/incidence in Rwanda from 2017 to 2027. Our model consists of the six states: HIV-; HIV+ undiagnosed/diagnosed pre-ART; HIV+ diagnosed with/without ART; and death. We considered three populations: FSWs, sex clients and the general population. For the period 2017-2027, the HIV epidemic among each of these population was estimated using Rwanda's demographic, sexual risk behaviour and HIV-associated morbidity and mortality data.

RESULTS

Between 2017 and 2027, with no changes in the current condom and ART use, the overall number of people living with HIV is expected to increase from 344,971 to 402,451. HIV incidence will also decrease from 1.36 to 1.20 100 person-years. By 2027, a 30% improvement in consistent condom use among FSWs will result in absolute reduction of HIV prevalence among FSWs, sex clients and the general population by 7.86%, 5.97% and 0.17%, respectively. While recurring HIV testing and improving the ART coverage mildly reduced the prevalence/incidence among FSWs and sex clients, worsening the two (shown by our worst-case scenario) will result in an increase in the HIV prevalence/incidence among FSWs and sex clients. Introduction of PrEP to FSWs in 2019 will reduce the HIV incidence among FSWs by 1.28%.

CONCLUSIONS

Continued efforts toward improving condom and ART use will be critical for Rwanda to continue their HIV epidemic control. Implementing a targeted intervention strategy in PrEP for FSWs will reduce the HIV epidemic in this high-risk population.

The impact, cost and cost-effectiveness of oral pre-exposure prophylaxis in sub-Saharan Africa: a scoping review of modelling contributions and way forward

INTRODUCTION

Oral pre-exposure prophylaxis (PrEP) is a new form of HIV prevention being considered for inclusion in national prevention portfolios. Many mathematical modelling studies have been undertaken that speak to the impact, cost and cost-effectiveness of PrEP programmes. We assess the available evidence from mathematical modelling studies to inform programme planning and policy decision making for PrEP and further research directions.

METHODS

We conducted a scoping review of the published modelling literature. Articles published in English which modelled oral PrEP in sub-Saharan Africa, or non-specific settings with relevance to generalized HIV epidemic settings, were included. Data were extracted for the strategies of PrEP use modelled, and the impact, cost and cost-effectiveness of PrEP for each strategy. We define an algorithm to assess the quality and relevance of studies included, summarize the available evidence and identify the current gaps in modelling. Recommendations are generated for future modelling applications and data collection.

RESULTS AND DISCUSSION

We reviewed 1924 abstracts and included 44 studies spanning 2007 to 2017. Modelling has reported that PrEP can be a cost-effective addition to HIV prevention portfolios for some use cases, but also that it would not be cost-effective to fund PrEP before other prevention interventions are expanded. However, our assessment of the quality of the modelling indicates cost-effectiveness analyses failed to comply with standards of reporting for economic evaluations and the assessment of relevance highlighted that both key parameters and scenarios are now outdated. Current evidence gaps include modelling to inform service development using updated programmatic information and ex post modelling to evaluate and inform efficient deployment of resources in support of PrEP, especially among key populations, using direct evidence of cost, adherence and uptake patterns.

CONCLUSIONS

Updated modelling which more appropriately captures PrEP programme delivery, uses current intervention scenarios, and is parameterized with data from demonstration and implementation projects is needed in support of more conclusive findings and actionable recommendations for programmes and policy. Future analyses should address these issues, aligning with countries to support the needs of programme planners and decision makers for models to more directly inform programme planning and policy.

Consistent Condom Use by Married and Cohabiting Female Sex Workers in India: Investigating Relational Norms with Commercial Versus Intimate Partners

This study examines determinants of consistent condom use (CCU) among married and cohabiting female sex workers (FSW) in India. Although CCU with clients is normative in the study area, most FSW do not consistently use condoms with intimate partners. Multiple logistic regression models indicated that condom use with intimate partners was associated with relationship status, cohabitation, HIV knowledge, STI symptoms, and being offered more money for sex without a condom by clients. Additionally, more days of sex work in the last week, serving as a peer educator, and participating in community mobilization activities were associated with higher odds of CCU across all partner types. Although improving economic security may increase CCU with clients, mobilization to reduce stigma and promote disclosure of sex work to non-cohabiting partners may be necessary to increase CCU overall.

Implementation of pre-exposure prophylaxis for human immunodeficiency virus infection: progress and emerging issues in research and policy

BACKGROUND

In this article, we present recent evidence from studies focused on the implementation, effectiveness and cost-effectiveness of pre-exposure prophylaxis (PrEP) for HIV infection; discuss PrEP scale-up to date, including the observed levels of access and policy development; and elaborate on key emerging policy and research issues to consider for further scale-up, with a special focus on lower-middle income countries.

DISCUSSION

The 2015 WHO Early Release Guidelines for HIV Treatment and Prevention reflect both scientific evidence and new policy perspectives. Those guidelines present a timely challenge to health systems for the scaling up of not only treatment for every person living with HIV infection but also the offer of PrEP to those at substantial risk. Delivery and uptake of both universal antiretroviral therapy (ART) and PrEP will require nation-wide commitment and could reinvigorate health systems to develop more comprehensive "combination prevention" programmes and support wider testing linked to both treatments and other prevention options for populations at highest risk who are currently not accessing services. Various gaps in current health systems will need to be addressed to achieve strategic scale-up of PrEP, including developing prioritization strategies, strengthening drug regulations, determining cost and funding sources, training health providers, supporting user adherence and creating demand.

CONCLUSIONS

The initial steps in the scale-up of PrEP globally suggest feasibility, acceptability and likely impact. However, to prevent setbacks in less well-resourced settings, countries will need to anticipate and address challenges such as operational and health systems barriers, drug cost and regulatory policies, health providers' openness to prescribing PrEP to populations at substantial risk, demand and legal and human rights issues. Emerging problems will require creative solutions and will continue to illustrate the complexity of PrEP implementation.

Potential impact of pre-exposure prophylaxis for female sex workers and men who have sex with men in Bangalore, India: a mathematical modelling study

INTRODUCTION

In 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.

METHODS

A 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.

RESULTS

Population 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.

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.