Estimating the contribution of key populations towards HIV transmission in South Africa

IntroductionIn generalized epidemic settings, there is insufficient understanding of how the unmet HIV prevention and treatment needs of key populations (KPs), such as female sex workers (FSWs) and men who have sex with men (MSM), contribute to HIV transmission. In such settings, it is typically assumed that HIV transmission is driven by the general population. We estimated the contribution of commercial sex, sex between men, and other heterosexual partnerships to HIV transmission in South Africa (SA).MethodsWe developed the “Key‐Pop Model”; a dynamic transmission model of HIV among FSWs, their clients, MSM, and the broader population in SA. The model was parameterized and calibrated using demographic, behavioural and epidemiological data from national household surveys and KP surveys. We estimated the contribution of commercial sex, sex between men and sex among heterosexual partnerships of different sub‐groups to HIV transmission over 2010 to 2019. We also estimated the efficiency (HIV infections averted per person‐year of intervention) and prevented fraction (% IA) over 10‐years from scaling‐up ART (to 81% coverage) in different sub‐populations from 2020.ResultsSex between FSWs and their paying clients, and between clients with their non‐paying partners contributed 6.9% (95% credibility interval 4.5% to 9.3%) and 41.9% (35.1% to 53.2%) of new HIV infections in SA over 2010 to 2019 respectively. Sex between low‐risk groups contributed 59.7% (47.6% to 68.5%), sex between men contributed 5.3% (2.3% to 14.1%) and sex between MSM and their female partners contributed 3.7% (1.6% to 9.8%). Going forward, the largest population‐level impact on HIV transmission can be achieved from scaling up ART to clients of FSWs (% IA = 18.2% (14.0% to 24.4%) or low‐risk individuals (% IA = 20.6% (14.7 to 27.5) over 2020 to 2030), with ART scale‐up among KPs being most efficient.ConclusionsClients of FSWs play a fundamental role in HIV transmission in SA. Addressing the HIV prevention and treatment needs of KPs in generalized HIV epidemics is central to a comprehensive HIV response.     

Female Sex Workers’ Experiences Selling Sex during Pregnancy and Post‐Delivery in South Africa

Nearly 75 percent of female sex workers (FSWs) in Port Elizabeth, South Africa are mothers, many of whom engage in sex work during pregnancy or after delivery. We conducted in‐depth interviews with 22 postpartum and 8 pregnant FSWs in Port Elizabeth. Interview guides were used to probe women's experiences, challenges, and concerns about selling sex during pregnancy and post‐delivery in a high‐HIV‐prevalence context. Interviews were transcribed, translated, and coded using thematic analysis. FSWs experienced and feared violence by clients during pregnancy, highlighting the need for safe work environments. Further, FSWs expressed concerns about HIV acquisition and vertical transmission during the perinatal period. Physical challenges related to pregnancy affected women's ability to work. Returning to work post‐delivery presented barriers to initiating and practicing exclusive breastfeeding. As a result, many FSWs practiced mixed feeding. Interventions, tailored to respond to FSW's challenges and experiences, may offer improved health outcomes in this context.     

Health‐related quality of life of female sex workers living with HIV in South Africa: a cross‐sectional study

IntroductionHealth‐related quality of life (HRQoL) is an important HIV outcome beyond viral suppression. However, there are limited data characterizing HRQoL of key populations, including female sex workers (FSW) living with HIV.MethodsWe used baseline data (22 June 2018–23 March 2020) of FSW who were diagnosed with HIV and enrolled into a randomized trial in Durban, South Africa. HRQoL information was collected by a generic preference‐accompanied tool with five domains (EQ‐5D), and summarized into a single score (range 0–1), which represents health utility. We employed multivariable beta regression models to identify determinants of HRQoL and to estimate subgroup‐specific HRQoL score. Using external estimates of life expectancy and population size, we estimated the number of quality adjusted life years reduced among FSW living with HIV in South Africa associated with violence and drug use.ResultsOf 1,363 individuals (mean age: 32.4 years; mean HRQoL score: 0.857) in our analysis, 62.6% used drugs, 61.3% experienced physical or sexual violence and 64.6% self‐reported taking antiretroviral treatment (ART). The following were associated with a reduction in the average marginal HRQoL score: older age (per decade: 0.018 [95% confidence interval (CI): 0.008, 0.027]), drug use (0.022 [0.007, 0.036]), experience of violence (0.024 [0.010, 0.038]) and moderate (vs. no) level of internalized stigma (0.023 [0.004, 0.041]). Current ART use was associated with a 0.015‐point (–0.001, 0.031) increase in the HRQoL score. The estimated mean (95% CI) HRQoL scores ranged from 0.838 (0.816, 0.860) for FSW who used drugs, experienced violence and were not on ART; to 0.899 (0.883, 0.916) for FSW who did not use drugs nor experience violence and were on ART. Our results can be translated into a reduction in 37,184 and 39,722 quality adjusted life years related to drug use and experience of violence, respectively, in South Africa.ConclusionsThese results demonstrate the association of ART with higher HRQoL among FSW and the need to further address structural risks, including drug use, violence and stigma. Population‐specific estimates of HRQoL score can be further used to calculate quality‐adjusted life years in economic evaluations of individual and structural interventions addressing the needs of FSW living with HIV.Clinical Trial Registration{"type":"clinical-trial","attrs":{"text":"NCT03500172","term_id":"NCT03500172"}}NCT03500172 (April 17, 2018).     

Characterizing the Patterns of HIV Disclosure to Clients Among South African Female Sex Workers in Port Elizabeth

Female sex workers (FSW) in South Africa are disproportionately affected by HIV, yet little is known about their HIV-status disclosure with clients. Among 410 FSW participating in a cross-sectional study, 213 were HIV positive and aware of their status prior to enrollment. Among FSW aware of their HIV-status, 35% (74/213) reported disclosing their HIV-status to paying clients, whereas 75% (118/158) of those with regular, non-paying partners disclosed to them. In a multivariable analysis, disclosure to clients was associated with more years of education, disclosure to non-paying partners, and meeting clients at established sex work venues, whereas a history of sexual violence was associated with less disclosure. There was also evidence of mutual disclosure with clients, however disclosure was not associated with condom use with clients or being on antiretrovirals. Safer working environments may improve FSW HIV disclosure practices, however disclosure must also be linked with protective behaviors in this population.