Emergency Departments as Under-Utilized Venues to Provide HIV Prevention Services to Female Sex Workers in Nairobi, Kenya

Abstract

Background: Female sex workers (FSW) in sub-Saharan Africa are disproportionately affected by HIV and remain a key target population for efforts to reduce transmission. While HIV prevention tools such as PEP and PrEP are available through outpatient FSW clinics, these services are underused. Emergency medicine is a rapidly expanding field in Kenya and may provide a novel venue for initiating or optimizing HIV prevention services. This study examined the characteristics of FSW from Nairobi, Kenya who had utilized an Emergency Department (ED) during the past year to broaden our understanding of the patient factors related to usage. Methods: An anonymous questionnaire was administered to a convenience sample of 220 Nairobi FSW attending dedicated clinics from June to July 2019. Participants were categorized into those who attended an ED over the past year (acute care users) and clinic-only users (control). A modified version of the WHO Violence Against Women Instrument assessed gender-based violence. Multivariable negative binomial logistic regressions evaluated predictors of health care use among these populations. Results: Of the total 220 women (median [IQR] age 32 [27-39]), 101 and 116 were acute care and control populations, respectively. Acute care users had 12.7 +/- 8.5 healthcare visits over a 12-month period, and the control population had 9.1 +/- 7.0 (p<0.05). ED attendance did not improve PrEP usage, with 48.5%, and 51% of acute care and clinic users indicated appropriate PrEP use. Patient factors that correlated with health care utilization among acute care users included client sexual violence (OR 2.2 [1.64-2.94 ],p<0.01), PrEP use (OR 1.54 (1.25-1.91), <0.01), and client HIV status (OR 1.35 (1.02-1.69), p <0.01). Conclusions:Many FSW at high risk for HIV were not accessing HIV prevention tools despite attending a dedicated FSW clinic offering such services. FSW who had attended an ED over the past year had a higher prevalence of HIV risk factors, demonstrating that emergency departments may be important acute intervention venues to prevent HIV transmission in this population. These results can guide policy design, health care provider training and facility preparedness to support strategies aimed at improving HIV prevention strategies for FSW in Kenyan ED’s.

Leveraging emergency care to reach key populations for ‘the last mile’ in HIV programming: a waiting opportunity

“…Globally, MSM, transgender people, and PWID populations are at a high risk for injury in the forms of interpersonal violence, sex-based violence and victimization, homicide, nonsuicidal self-harm, and suicide [17,18]. A HIV screening program in Kenya targeting FSW found that those who had received emergency care in the past year had higher prevalence of HIV risk factors as well as client-perpetrated sexual violence [19]. Country wide representative data collected by the National AIDS and STIs Control Program in Kenya also showed high prevalence of violence experienced by FSW (48%), PWID (44%), and MSM (20%) [20].…”