PrEP and the syndemic of substance use, violence, and HIV among female and male sex workers: a qualitative study in Kisumu, Kenya

Abstract

Introduction Female and male sex workers experience heightened vulnerability to HIV and other health harms that are compounded by substance use, physical and sexual violence, and limited access to health services. In Kisumu, Kenya, where sex work is widespread and substance use is a growing public health concern, offering pre‐exposure prophylaxis (Pr EP ) for HIV prevention could help curtail the HIV epidemic. Our study examines “syndemics,” or mutually reinforcing epidemics of substance use, violence and HIV , in relation to Pr EP acceptability and feasibility among female and male sex workers in Kenya, one of the first African countries to approve Pr EP for HIV prevention. Methods From 2016 to 2017, sex workers in Kisumu reporting recent alcohol or drug use and experiences of violence participated in qualitative interviews on HIV risk and perspectives on health service needs, including Pr EP programming. Content analysis identified themes relating to Pr EP knowledge, acceptability, access challenges and delivery preferences. Results Among 45 female and 28 male sex workers, median age was 28 and 25 respectively. All participants reported past‐month alcohol use and 91% of women and 82% of men reported past‐month drug use. Violence was pervasive, with most women and men reporting past‐year physical (96% women, 86% men) and sexual (93% women, 79% men) violence. Concerning Pr EP , interviews revealed: (1) low Pr EP knowledge, especially among women; (2) high Pr EP acceptability and perceived need, particularly within syndemic contexts of substance use and violence; and (3) preferences for accessible, non‐stigmatizing Pr EP delivery initiatives designed with input from sex workers. Conclusions Through a syndemic lens, substance use and violence interact to increase HIV vulnerability and perceived need for Pr EP among female and male sex workers in Kisumu. Although interest in Pr EP was high, most sex workers in our sample, particularly women, were not benefiting from it. Syndemic substance use and violence experienced by sex workers posed important barriers to Pr EP access for sex workers. Increasing Pr EP access for sex workers will require addressing substance use and violence through integrated programming.

Intimate partner and client‐perpetrated violence are associated with reduced HIV pre‐exposure prophylaxis (PrEP) uptake, depression and generalized anxiety in a cross‐sectional study of female sex workers from Nairobi, Kenya

“…There is high HIV incidence and prevalence among FSW in sub-Saharan Africa [2], and PrEP is a highly effective HIV prevention tool [9,10]. However, the uptake of PrEP within these communities has been suboptimal [34]. Given the prior linkage of violence with both HIV acquisition and adverse mental health outcomes, the aim of our study was to explore the associations between specific types of IPV and client-perpetrated violence, mental health outcomes, and the uptake of effective HIV prevention services (PrEP) among FSW from Nairobi, Kenya.…”

HIV pre‐exposure prophylaxis for female sex workers: ensuring women’s family planning needs are not left behind

“…Building on these synergies between family planning and PrEP may reduce the administrative burden to both service providers and clients and promotes more cost‐effective service provision . Shared social, economic and structural factors underlying vulnerability to both unintended pregnancy and HIV acquisition, such as violence, substance use and financial insecurity, may also affect uptake of PrEP and family planning . Programmes which address these factors may support uptake and adherence to PrEP, contraception and condoms alike .…”

“…Current programmes providing PrEP to FSWs are predominantly implemented through FSW‐focused services, which include drop‐in centres and clinics led by community‐based organizations . Acceptability studies indicate that these focused services are often the preferred way for FSWs to access healthcare due to staff friendliness, lower cost, shorter waiting times, privacy, proximity to places of work and greater quality of care . There are several advantages of building upon this model for integrated PrEP and family planning delivery.…”

“…There are several advantages of building upon this model for integrated PrEP and family planning delivery. FSW‐focused services commonly utilize peer‐based prevention and community mobilization programmes and may provide opportunities to address syndemic vulnerabilities as well as informational, structural and social barriers to the use of PrEP and contraception, including condoms . Community mobilization approaches promoting social cohesion, leadership and empowerment have been empirically associated with reductions in HIV and STI acquisition and increased treatment adherence .…”

“…Intersectional stigmas remain major barriers to PrEP uptake among key populations in many settings . Interventions aimed at mitigating PrEP‐related stigmas in the community, as well as during PrEP provision and family planning services, through careful marketing and peer‐led, confidential and non‐judgemental services may potentiate PrEP uptake and retention and integration with reproductive health services .…”