The HIV Cascade of Care and Service Utilisation at Sex Work Programmes Among Female Sex Workers in South Africa

Abstract

Female sex workers (FSWs) in South Africa experience a uniquely high prevalence of HIV. We describe the HIV cascade of care (CoC) in FSWs in South Africa, and explored service utilisation at sex work programmes. A cross-sectional, study enrolled FSWs across 12 sites in South Africa. Participants were recruited using chain-referral method. Inclusion criteria: ≥ 18 years, cis-gender female, sold/transacted in sex, HIV positive. 1862 HIV positive FSWs were enrolled. 92% were known positive, 87% were on antiretroviral treatment (ART). Of those on ART, 74% were virally suppressed. Younger FSWs were significantly less likely to be on ART or virally suppressed. Female sex workers using HIV services from specialised programs were 1.4 times more likely to be virally suppressed than non-program users. The pre-COVID-19 pandemic HIV CoC amongst FSWs in South Africa shows striking improvement from previous estimates, and approaches achievement of 90:90:90 goals.

HIV incidence estimation among female sex workers in South Africa: a multiple methods analysis of cross-sectional survey data

“…Given that female sex workers, by definition, have multiple sexual partners (and engage in various high-risk sexual activities), 5 sustained high incidence has implications for transmission beyond the study population, with our findings providing empirical support for modelling estimates that 41·9% of new infections are attributable to clients of sex workers who bridge to the general population. 11 Furthermore, our findings, supported by additional analyses of our sample, 7 emphasise the need for extensive efforts to improve viral suppression in female sex workers in supporting South Africa to achieve the UN 95–95–95 targets, including in this population. The high risk of HIV for sex workers and potential for onward transmission lend further credence to sex work continuing to be epidemiologically significant to the HIV pandemic and suggests the importance of interventions targeting client populations.…”

“… 23 However, serological assays, such as variants on the LAg Avidity EIA, are highly prone to false recent results among individuals who are virally supressed, 22 and a large FRR leads to imprecise and thus uninformative incidence estimates. 24 Since many respondents who were HIV positive in this study were virally suppressed (1143 [64·4%] of 1774 participants had viral load ≤1000 copies per mL), mainly due to treatment (1453 [86·8%] of 1673 participants self-reported antiretroviral therapy use in an analysis of data from the same survey, which focused on the HIV cascade 7 ), we adopted the widely used mitigation of including a viral load criterion in the definition of recent infection: cases with a viral load below a set threshold (ie, 1000 copies per mL) were defined as non-recent, independent of serological result. 25 This mitigation reduced the FRR and, although often neglected, the applicable MDRI.…”

“…4 , 5 A national study of female sex workers reported a prevalence of 62%. 6 , 7 These data were collected before the COVID-19 pandemic, which is likely to have negatively affected provision of HIV services.…”

Antiretroviral Treatment Sharing among Female sex Workers Living with HIV in eThekwini (Durban), South Africa: Drivers and Implications for Treatment Success

“…1,2 HIV prevalence among FSW in South Africa ranks among the highest in the world at estimated 62%. 1,[3][4][5] Research indicates recent improvements in continuum of care indicators, particularly HIV testing and ART coverage, among South African FSW in settings where sex worker-friendly programming is available. 3,4,6 However, VS has been slower to progress, and only 56% of FSW living with HIV are virally suppressed (HIV RNA VL <1000 copies/mL).…”

Differentiating the incidence and burden of HIV by age among women who sell sex: a systematic review and meta‐analysis

“…The high incidence of HIV among YWSS in this review/meta‐analysis along with lower levels of access to care and viral suppression in other studies also suggests opportunities for onward transmission to clients and other partners, as the risk of onward HIV transmission is greatest for newly acquired infections [5, 29, 59, 60]. Younger female sex workers are less likely to know they were HIV positive, to report any Antiretroviral therapy (ART) exposure and to be virally suppressed compared to older female sex workers [54, 61]. Thus, minimizing the duration of time of undiagnosed and untreated HIV infection among YWSS is critical to meeting the global HIV agenda of HIV elimination.…”