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Beattie TS, Adhiambo W, Kabuti R, Beksinska A, Ngurukiri P, Babu H, Kung’u M, Nyamweya C, Mahero A, Irungu E, Muthoga P, Seeley J, Kimani J, Weiss HA, Kaul R. The epidemiology of HIV infection among female sex workers in Nairobi, Kenya: A structural determinants and life-course perspective. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0001529. [PMID: 38190358 PMCID: PMC10773933 DOI: 10.1371/journal.pgph.0001529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 10/26/2023] [Indexed: 01/10/2024]
Abstract
High HIV prevalence among female sex workers (FSWs) is heavily influenced by structural determinants (e.g. criminalisation of sex work; violence) and significant life events (e.g. orphanhood, teenage pregnancy). This study aims to understand the epidemiology of HIV among FSWs in Nairobi, Kenya using a structural determinants and life-course perspective. Baseline cross-sectional survey data were collected June-December 2019 for the Maisha Fiti study with 1003 FSWs (aged 18-45 years). Odds ratios and 95% confidence intervals were estimated using multivariable logistic regression with a hierarchical modelling approach. HIV prevalence was 28.0%, and increased with age (<25 years 5.7%, 25-34 years 19.0%, ≥35 years 40.6%). In adjusted analyses, HIV seroprevalence was associated with childhood and adolescence including violence from militia or soldiers (AOR = 1.60; 95%CI:1.00-2.53), young age at sexual debut (≤15 years old vs. ≥18 years AOR = 0.57; 95%CI:0.39-0.84) and teenage pregnancy (AOR = 1.37; 95%CI:1.00-1.88). For adulthood the factors included lower SES score (lowest vs. highest tertile AOR = 0.63; 95%CI:0.40-0.98); reduced housing insecurity (AOR = 0.52; 95%CI:0.54-0.79); lower alcohol/drug use score (AOR = 0.44; 95%CI:0.31-0.61); and a longer duration of selling sex (0-5 years vs. ≥11 years AOR = 2.35; 95%CI:1.44-3.82). Among HIV-negative FSWs, prevalence of HIV risk factors was high (recent hunger 32.3%; internalised 67.7% and experienced 66.0% sex work stigma; recent police arrest 30.1%; recent physical or sexual violence 65.6%, condomless last sex intimate partner 71.1%; harmful alcohol or substance use 49.1%). Only 24.6% of HIV-negative FSWs reported taking PrEP. Taken together, adverse events in childhood and adolescence were associated with increased odds of living with HIV, and were more strongly associated with HIV serostatus than adulthood structural or behavioural risk factors. HIV-negative FSWs remain at high risk of HIV acquisition. This study highlights the importance of addressing adverse events throughout the life course to reduce HIV risk, and the need to continue multi-level HIV prevention and treatment efforts.
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Affiliation(s)
- Tara S. Beattie
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Wendy Adhiambo
- Partners for Health and Development in Africa, Nairobi, Kenya
| | - Rhoda Kabuti
- Partners for Health and Development in Africa, Nairobi, Kenya
| | - Alicja Beksinska
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Hellen Babu
- Partners for Health and Development in Africa, Nairobi, Kenya
| | - Mary Kung’u
- Partners for Health and Development in Africa, Nairobi, Kenya
| | | | - Anne Mahero
- Partners for Health and Development in Africa, Nairobi, Kenya
| | | | - Erastus Irungu
- Partners for Health and Development in Africa, Nairobi, Kenya
| | - Peter Muthoga
- Partners for Health and Development in Africa, Nairobi, Kenya
| | - Janet Seeley
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Joshua Kimani
- Partners for Health and Development in Africa, Nairobi, Kenya
- UNITID, University of Nairobi, Nairobi, Kenya
| | - Helen A. Weiss
- Department of Infectious Disease Epidemiology and International Health, MRC International Statistics and Epidemiology Group, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Rupert Kaul
- Department of Immunology, University of Toronto, Ontario, Canada
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Simmelink AM, Gichuki CM, Ampt FH, Manguro G, Lim MSC, Agius P, Hellard M, Jaoko W, Stoové MA, L'Engle K, Temmerman M, Gichangi P, Luchters S. Assessment of the lifetime prevalence and incidence of induced abortion and correlates among female sex workers in Mombasa, Kenya: a secondary cohort analysis. BMJ Open 2022; 12:e053218. [PMID: 36207033 PMCID: PMC9557798 DOI: 10.1136/bmjopen-2021-053218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Prevalence of lifetime-induced abortion in female sex workers (FSWs) in Kenya was previously estimated between 43% and 86%. Our analysis aimed at assessing lifetime prevalence and correlates, and incidence and predictors of induced abortions among FSWs in Kenya. METHODS This is a secondary prospective cohort analysis using data collected as part of the WHISPER or SHOUT cluster-randomised trial in Mombasa, assessing effectiveness of an SMS-intervention to reduce incidence of unintended pregnancy. Eligible participants were current FSWs, 16-34 years and not pregnant or planning pregnancy. Baseline data on self-reported lifetime abortion, correlates and predictors were collected between September 2016 and May 2017. Abortion incidence was measured at 6-month and 12-month follow-up. A multivariable logistic regression model was used to assess correlates of lifetime abortion and discrete-time survival analysis was used to assess predictors of abortions during follow-up. RESULTS Among 866 eligible participants, lifetime abortion prevalence was 11.9%, while lifetime unintended pregnancy prevalence was 51.2%. Correlates of lifetime abortions were currently not using a highly effective contraceptive (adjusted OR (AOR)=1.76 (95% CI=1.11 to 2.79), p=0.017) and having ever-experienced intimate partner violence (IPV) (AOR=2.61 (95% CI=1.35 to 5.06), p=0.005). Incidence of unintended pregnancy and induced abortion were 15.5 and 3.9 per 100 women-years, respectively. No statistically significant associations were found between hazard of abortion and age, sex work duration, partner status, contraceptive use and IPV experience. CONCLUSION Although experience of unintended pregnancy remains high, lifetime prevalence of abortion may have decreased among FSW in Kenya. Addressing IPV could further decrease induced abortions in this population. TRIAL REGISTRATION NUMBER ACTRN12616000852459.
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Affiliation(s)
| | - Caroline M Gichuki
- Department of Population Health, The Aga Khan University, Nairobi, Nairobi, Kenya
- International Centre for Reproductive Health Kenya, Mombasa, Kenya
| | - Frances H Ampt
- Burnet Institute, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Clayton, Victoria, Australia
| | - Griffins Manguro
- International Centre for Reproductive Health Kenya, Mombasa, Kenya
| | - Megan S C Lim
- Burnet Institute, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Clayton, Victoria, Australia
| | - Paul Agius
- Burnet Institute, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Clayton, Victoria, Australia
| | - Margaret Hellard
- Burnet Institute, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Clayton, Victoria, Australia
- Department of Infectious Diseases, The Alfred Hospital, Melbourne, Victoria, Australia
- Doherty Institute and School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Walter Jaoko
- Department of Medical Microbiology and Immunology, University of Nairobi, Nairobi, Nairobi, Kenya
| | - Mark A Stoové
- Burnet Institute, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Clayton, Victoria, Australia
- School of Psychology and Public Health, La Trobe University, Melbourne, Victoria, Australia
| | - Kelly L'Engle
- School of Nursing and Health Professions, University of San Francisco, San Francisco, California, USA
| | - Marleen Temmerman
- International Centre for Reproductive Health Kenya, Mombasa, Kenya
- Department of Obstetrics and Gynaecology, The Aga Khan University Hospital Nairobi, Nairobi, Kenya
- Department of Public Health and Primary Care, Ghent University, Gent, Belgium
| | - Peter Gichangi
- International Centre for Reproductive Health Kenya, Mombasa, Kenya
- Department of Public Health and Primary Care, Ghent University, Gent, Belgium
- Technical University of Mombasa, Mombasa, Kenya
| | - Stanley Luchters
- Burnet Institute, Melbourne, Victoria, Australia
- Department of Public Health and Primary Care, Ghent University, Gent, Belgium
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR), Harare, Zimbabwe
- Liverpool School of Tropical Medicine (LSTM), Liverpool, UK
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Kamau M, Musau A, Were D, Waruguru G, Kabue M, Mutegi J, Plotkin M, Reed J. Unmet Need for Contraception Among Female Sex Workers Initiating Oral Pre-Exposure Prophylaxis for HIV Prevention During Kenya's National Scale-Up: Results From a Programmatic Surveillance Study. Front Glob Womens Health 2022; 2:747784. [PMID: 35265940 PMCID: PMC8899534 DOI: 10.3389/fgwh.2021.747784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 12/30/2021] [Indexed: 11/24/2022] Open
Abstract
Background Female sex workers (FSWs) experience a higher risk for both HIV acquisition and unwanted pregnancies compared to women in the general population. Pre-exposure prophylaxis (PrEP) for HIV prevention offers protection against HIV infection but has no contraceptive effect. We examined the determinants of unmet need for contraception among FSWs who initiated PrEP to inform programs and policies to optimize contraceptive services and avert unwanted pregnancy among this high-risk group. Materials and Methods A cross-sectional analysis was conducted on routine, de-identified client data from a large-scale PrEP service delivery project, from February 2017 to December 2019. Data were collected from FSWs during clinic visits using Ministry of Health approved tools. Records for all 17,456 FSWs initiated on PrEP from 79 health facilities in 10 counties across three geographic clusters with high and medium HIV incidence were examined for eligibility for the analysis. Unmet need for non-barrier contraception was defined as not being pregnant, not currently using the non-barrier contraceptive method, and not trying to conceive or intending to have a child in the near future. Univariate and multivariable regression analyses were conducted with selected variables to examine associations. Results In the 79 sites, eligible records from 17,063 FSWs who initiated PrEP were included. Two-thirds were under 30 years, and the majority were not married and had received PrEP at drop-in centers. Overall, the unmet need for non-barrier contraception was 52.6%, higher for those under 20 years of age (60.9%) and those served in public and private health facilities (67.4 and 83.2%, respectively) rather than drop-in centers (50.6%). Women from the Nairobi and Coast cluster regions reported a higher unmet need for contraception compared to those from the Lake region. All these associations were significant (p < 0.05) at the multivariate level. Conclusions The high unmet need for non-barrier contraception among FSWs initiating PrEP highlights the need for integrated delivery of contraception services within PrEP programs. Identifying groups with a high unmet need could lead to higher success in an integrated program. Two recommended approaches include training healthcare providers to deliver clear contraception messaging during PrEP initiation and making a range of contraceptives accessible within PrEP services for high-risk groups. Furthermore, accelerated research on multipurpose prevention technologies is necessary to reduce the burden on individuals using multiple prevention products concurrently.
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Affiliation(s)
- Mercy Kamau
- Jhpiego, Nairobi, Kenya
- *Correspondence: Mercy Kamau
| | | | | | - Gladys Waruguru
- International Centre for Reproductive Health Kenya, Mombasa, Kenya
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Musyoki H, Bhattacharjee P, Sabin K, Ngoksin E, Wheeler T, Dallabetta G. A decade and beyond: learnings from HIV programming with underserved and marginalized key populations in Kenya. J Int AIDS Soc 2021; 24 Suppl 3:e25729. [PMID: 34189847 PMCID: PMC8242977 DOI: 10.1002/jia2.25729] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 04/16/2021] [Accepted: 04/20/2021] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Key populations (KP) continue to account for high HIV incidence globally. Still, prioritization of KP in the national HIV prevention response remains insufficient, leading to their suboptimal access to HIV programmes. This commentary aims to share Kenya's challenges and successes in achieving 2020 global HIV targets and scaling up the KP programme in the last decade. DISCUSSION The KP programme in Kenya has scaled up in the last decade with the inclusion of female sex workers (FSW), men who have sex with men (MSM), people who inject drugs (PWID), transgender people and people in prisons as priority populations in the national HIV response. KP coverage based on official size estimates for FSW is 73%, for MSM is 82%, for PWID through needle syringe programme (NSP) is 71%, and through opioid substitution therapy (OST) is 26% and for transgender people is 5%. The service outcomes for KP have been relatively strong in prevention with high condom use at last paid sex for FSW (92%) and use of sterile equipment among PWID (88%), though condom use at last sex with a non-regular partner among MSM (78%) is still low. The KP programme has not met care continuum targets for all subpopulations with low case findings. The national KP programme led by the Ministry of Health has scaled up the programme through (a) strategic partnerships with KP-led and competent organizations, researchers and donors; (b) development of policy guidance and programme standards; (c) continuous sensitization and advocacy to garner support; (d) development of national reporting systems, among others. However, the programme is still struggling with uncertain size estimates; lack of updated bio-behavioural survey data; inadequate scale-up of interventions among transgender people and people in prison settings; gaps in reaching adolescent and young KP, and effectively addressing structural barriers like violence and stigma. CONCLUSIONS To reach the ambitious global HIV targets, sufficient coverage of KP with quality HIV programmes is critical. Despite scaling up the KP programme, Kenya has not yet achieved the 2020 global HIV targets and needs more efforts to scale-up quality programmes for KP who are underserved in the HIV response.
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Affiliation(s)
- Helgar Musyoki
- National AIDS and STI Control Programme (NASCOP)Ministry of HealthNairobiKenya
| | - Parinita Bhattacharjee
- Institute of Global Public HealthUniversity of ManitobaWinnipegMBCanada
- Partners for Health and Development in AfricaNairobiKenya
| | - Keith Sabin
- The Joint United Nations Programme on HIV/AIDS (UNAIDS)GenevaSwitzerland
| | - Ed Ngoksin
- Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM)GenevaSwitzerland
| | - Tisha Wheeler
- United States Agency for International Development (USAID)WashingtonDCUSA
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