HIV risk perception and behavior among sex workers in three major urban centers of Mozambique

Access to HIV-prevention in female sex workers in Ukraine between 2009 and 2017: Coverage, barriers and facilitators

The provision of comprehensive prevention services is vital for reducing the high burden of HIV amongst Ukrainian female sex workers (FSWs). To identify barriers and facilitators that influence access to HIV prevention amongst this population between 2009 and 2017, we developed a literature-informed conceptual framework and conducted a document analysis to identify the components of the Ukrainian prevention package (PP). Using the Integrated Bio Behavioural Surveillance Surveys, we then conducted descriptive analyses to explore PP coverage from 2009 to 2017 and the influence of factors, identified by our conceptual framework. After increasing over four years, a drop in PP coverage was observed from 2013 onwards. Being a client of a non-governmental organisation, street and highway solicitation, non-condom use, and knowledge of HIV may influence access to HIV prevention in the Ukrainian context. Future interventions should consider barriers and facilitators to HIV prevention and the multiple structural levels on which they operate.

High Mobility and STIs/HIV among Women Informal Cross Border Traders in Southern Mozambique: Exploring Knowledge, Risk Perception, and Sexual Behaviors

High circular mobility creates vulnerability and elevates risk for sexually transmitted infections (STIs) including Human Immunodeficiency Virus (HIV). We aim to explore knowledge, perceptions of risk, and sexual behaviors in relation to STIs/HIV, in Mozambican women involved in an informal cross border trade (ICBT) and residing in South Mozambique. A cross-sectional quantitative study, in 200 women cross border traders (WICBT), affiliated to the Mukhero Association, using a structured, face-to-face questionnaire, was conducted. Descriptive statistics and Pearson’s Chi-square test were used. The median age of participants was 37.0 years (interquartile range (IQR): 31.0–43.0), 100% were literate, travelled on average six times a month. WICBT with a high education level were more likely to have awareness of Gonorrhea, Syphilis, and Candidiasis; to self-perceive being at risk of getting HIV, Syphilis, and Human Papilloma Virus (HPV); and to test for HIV and Syphilis. Those with a low education level were more likely to have misconceptions about HIV and ever have sex in exchange for money/goods/services. Married participants were more likely to know how to prevent HIV. Participants with a high income were more likely to know about HPV; to self-perceive being at risk of getting Syphilis; to point sex workers as being at higher risk of getting HPV; and to ever test for HIV. WICBT with a low income were more likely to have sex in exchange for money/goods/services. Low and inconsistent knowledge and misconceptions of STIs/HIV, high sexual risky behavior, low perception of risk of getting STIs/HIV among this neglected and key population suggests their increased vulnerability to the STIs/HIV.

Multi-level experiences and determinants of alcohol misuse and illicit drug use among occupational groups at high-risk of HIV in sub-Saharan Africa: A thematic synthesis of qualitative findings

Occupational groups at high-risk of HIV in sub-Saharan Africa (SSA) may be at increased risk of substance use because of occupation-related factors. We synthesised qualitative data on determinants and context of alcohol misuse and illicit drug use in these groups. We systematically searched five databases for qualitative studies reporting on alcohol misuse or illicit drug use in fisherfolk, uniformed personnel, miners, truckers, motorcycle taxi riders, and sex workers in SSA. Qualitative data and interpretations were extracted and synthesised using a systematic iterative process to capture themes and overarching concepts. We searched for papers published prior to January 2018. We identified 5692 papers, and included 21 papers in our review, published from 1993 to 2017. Most studies were conducted among fisherfolk (n = 4) or sex workers (n = 12). Ten papers reported on alcohol use alone, three on illicit drug use alone and eight on both. Substance use was commonly examined in the context of work and risky behaviour, key drivers identified included transactional sex, availability of disposable income, poverty, gender inequalities and work/living environments. Substance use was linked to risky behaviour and reduced perceived susceptibility to HIV. Our review underscores the importance of multilevel, integrated HIV prevention and harm reduction interventions in these settings.

Determinants of access to HIV testing and counselling services among female sex workers in sub-Saharan Africa: a systematic review

BACKGROUND

HIV testing and counselling (HTC) is an essential component for HIV prevention and a critical entry point into the HIV continuum of care and treatment. Despite the importance of HTC for HIV control, access to HTC services among female sex workers (FSWs) in sub-Saharan Africa (SSA) remains suboptimal and little is known about factors influencing FSWs' access to HTC. Guided by the client-centred conceptual framework, we conducted a systematic review to understand the facilitators and barriers influencing FSWs in SSA to access HTC services.

METHODS

A systematic search was conducted in MEDLINE, POPLINE and Web of Science databases for literature published between January 2000 and July 2017. References of relevant articles were also searched. We included primary studies of any design, conducted in SSA and published in the English language. Studies conducted in multi-sites inclusive of SSA were included only if data from sites in SSA were separately analysed and reported. Similarly, studies that included other subpopulations were only eligible if a separate analysis was done for FSWs. This review excluded papers published as systematic reviews, editorial comments and mathematical modelling. The protocol for this review is registered in the Prospective Register of Systematic Reviews (PROSPERO), registration number CRD42017062203.

RESULTS

This review shows that factors related to approachability, acceptability, availability, affordability and appropriateness of the services are crucial in influencing access to HTC services among FSWs in SSA. These factors were mediated by individual attributes such as HIV risk perceptions, awareness of the availability of HTC, and perceptions of the importance and quality of HTC services. The decision to utilise HTC was predominantly hampered by discriminatory social norms such as HIV stigma and criminalisation of sex work.

CONCLUSIONS

FSWs' access to HTC is facilitated by multiple factors, including individual awareness of the availability of HTC services, and perceived quality of HTC especially with regard to assured confidentiality. Concerns about HIV stigma and fear about discrimination due to community intolerance of sex work acted as major barriers for FSWs to seek HTC services from the facilities offering health services to the general population.

Risk perception and the influence on uptake and use of biomedical prevention interventions for HIV in sub-Saharan Africa: A systematic literature review

BACKGROUND

Risk perception has been found to be a crucial factor explaining inconsistent or non-use of HIV prevention interventions. Considerations of risk need to expand beyond risk of infection to also include the personal, social, emotional, and economic risks associated with prevention intervention use.

OBJECTIVES

This systematic review of qualitative peer-reviewed literature from sub-Saharan Africa examines perceptions of risk associated with HIV infection and HIV prevention intervention use.

DATA SOURCES

We searched Medline, Embase, PsychInfo, Africa Wide Info, CINAHL, and Global Health for publications and screened them for relevance.

STUDY ELIGIBILITY CRITERIA

Peer-reviewed qualitative studies published since 2003 were eligible for inclusion if they examined risk perception or uncertainty in the context of a medically regulated intervention. Only studies focusing on adults were included.

STUDY APPRAISAL AND SYNTHESIS METHODS

Included publications were quality assessed using the Hawker method and coded thematically.

RESULTS

10318 unique papers were identified, of which 29 are included. Among the themes identified, a particularly salient one was the potential of HIV prevention interventions to threaten the stability of a relationship and impact on how and when people may-or may not-choose to use prevention interventions.

LIMITATIONS

This literature review excludes grey-literature, which may have distinct valuable insights. We also excluded quantitative studies that may have challenged or triangulated our findings.

CONCLUSIONS AND IMPLICATIONS

When considering the risk of HIV acquisition, it is insufficient to examine biological risk in isolation from the personal, relational and economic costs associated with intervention use. This loss of emotional, physical, or material support may be perceived as more consequential than the prevention of a potential infection.

High Burden of HIV Infection and Risk Behaviors Among Female Sex Workers in Three Main Urban Areas of Mozambique

This is the first integrated biological and behavioral survey among female sex workers (FSW) in Mozambique. Using respondent-driven sampling, 400, 411 and 429 FSW were enrolled respectively in Maputo, Beira and Nampula in 2011-2012. Estimates were produced using RDSAT 7.1. HIV prevalence was 31.2, 23.6, and 17.8 % in each location respectively. Among HIV-positive FSW, 48.1, 79.8 and 89.6 % in each city, were unaware of their serostatus. Condom use at last sex with a client was 85.8, 73.4 and 62.8 % among FSW, respectively. HIV was associated with current age, age of first sex for money, low educational level, and having had a genital ulcer in the last 6 months. Results suggest the urgent need to increase behavioral and structural interventions in this key population.

Feasible, Efficient and Necessary, without Exception - Working with Sex Workers Interrupts HIV/STI Transmission and Brings Treatment to Many in Need

BACKGROUND AND OVERVIEW

High rates of partner change in sex work-whether in professional, 'transactional' or other context-disproportionately drive transmission of HIV and other sexually transmitted infections. Several countries in Asia have demonstrated that reducing transmission in sex work can reverse established epidemics among sex workers, their clients and the general population. Experience and emerging research from Africa reaffirms unprotected sex work to be a key driver of sexual transmission in different contexts and regardless of stage or classification of HIV epidemic. This validation of the epidemiology behind sexual transmission carries an urgent imperative to realign prevention resources and scale up effective targeted interventions in sex work settings, and, given declining HIV resources, to do so efficiently. Eighteen articles in this issue highlight the importance and feasibility of such interventions under four themes: 1) epidemiology, data needs and modelling of sex work in generalised epidemics; 2) implementation science addressing practical aspects of intervention scale-up; 3) community mobilisation and 4) the treatment cascade for sex workers living with HIV.

CONCLUSION

Decades of empirical evidence, extended by analyses in this collection, argue that protecting sex work is, without exception, feasible and necessary for controlling HIV/STI epidemics. In addition, the disproportionate burden of HIV borne by sex workers calls for facilitated access to ART, care and support. The imperative for Africa is rapid scale-up of targeted prevention and treatment, facilitated by policies and action to improve conditions where sex work takes place. The opportunity is a wealth of accumulated experience working with sex workers in diverse settings, which can be tapped to make up for lost time. Elsewhere, even in countries with strong interventions and services for sex workers, an emerging challenge is to find ways to sustain them in the face of declining global resources.

Risk perception of sexually transmitted infections and HIV in Nigerian commercial sex workers in Barcelona: a qualitative study

OBJECTIVE

This study aimed to determine in detail the risk perception of sexually transmitted infections (STIs) and HIV, and the contextual circumstances, in Nigerian commercial sex workers (CSWs) in Barcelona.

DESIGN

A qualitative study with a phenomenological approach.

SETTING

Raval area in Barcelona.

PARTICIPANTS

8 CSWs working in Barcelona.

METHODS

A phenomenological study was carried out with Nigerian CSWs in Barcelona. Sampling was theoretical, taking into account: different age ranges; women with and without a partner; women with and without children; and women participating or not in STI/HIV-prevention workshops. Information was obtained by means of eight semistructured individual interviews. An interpretative content analysis was conducted by four analysts.

RESULTS

Illegal immigrant status, educational level, financial situation and work, and cultural context had mixed effects on CSW knowledge of, exposure to, and prevention and treatment of STI and HIV. CSWs were aware of the higher risk of STI associated with their occupation. They identified condoms as the best preventive method and used them during intercourse with clients. They also implemented other preventive behaviours such as personal hygiene after intercourse. Control of sexual services provided, health education and healthcare services had a positive effect on decreasing exposure and better management of STI/HIV.

CONCLUSIONS

Nigerian CSWs are a vulnerable group because of their poor socioeconomic status. The perception of risk in this group and their preventive behaviours are based on personal determinants, beliefs and experiences from their home country and influences from the host country. Interventions aimed at CSWs must address knowledge gaps, risk behaviours and structural elements.

Awareness of HIV status, prevention knowledge and condom use among people living with HIV in Mozambique

Objective

To determine factors associated with HIV status unawareness and assess HIV prevention knowledge and condom use among people living with HIV/AIDS (PLHIV) in Mozambique.

Design

Cross-sectional household-based nationally representative AIDS Indicator Survey.

Methods

Analyses focused on HIV-infected adults and were weighted for the complex sampling design. We identified PLHIV who had never been tested for HIV or received their test results prior to this survey. Logistic regression was used to assess factors associated with HIV status unawareness.

Results

Of persons with positive HIV test results (N = 1182), 61% (95% confidence interval [CI] 57–65%) were unaware of their serostatus. Men had twice the odds of being unaware of their serostatus compared with women [adjusted odds ratio (aOR) 2.05, CI 1.40–2.98]. PLHIV in the poorest wealth quintile were most likely to be unaware of their serostatus (aOR 3.15, CI 1.09–9.12) compared to those in the middle wealth quintile. Most PLHIV (83%, CI 79–87%) reported not using a condom during their last sexual intercourse, and PLHIV who reported not using a condom during their last sexual intercourse were more likely to be unaware of their serostatus (aOR 2.32, CI 1.57–3.43) than those who used a condom.

Conclusions

Knowledge of HIV-positive status is associated with more frequent condom use in Mozambique. However, most HIV-infected persons are unaware of their serostatus, with men and persons in the poorest wealth quintile being more likely to be unaware. These findings support calls for expanded HIV testing, especially among groups less likely to be aware of their HIV status and key populations at higher risk for infection.