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Introduction Over half of female sex workers (FSW) in South Africa are living with HIV and clinical depression has been frequently documented among FSW. Data characterizing structural determinants of depression and the role of syndemic theory, synergistically interacting disease states, on viral suppression among FSW in South Africa are limited. Methods Between July 2018-March 2020, non-pregnant, cisgender women (≥ 18 years), reporting sex work as their primary income source, and diagnosed with HIV for ≥ 6 months were enrolled into the Siyaphambili trial in eThekwini, South Africa. Using baseline data, robust Poisson regression models were used to assess correlates of depression and associations between depression and syndemic factors on viral suppression. Results Of 1,384 participants, 459 (33%) screened positive for depression, defined as a score of ≥ 10 on the PHQ-9. Physical and sexual violence, drug use, alcohol use, anticipated stigma and internalized stigma were univariately associated with depression (all p’s Conclusion Substance use, violence, and stigma were all associated with depression. Depression and syndemic factors (substance use + violence) were related to unsuppressed viral load; we did not observe higher unsuppressed viral load amongst those experiencing both depression and syndemic factors. Our findings point to the need to understand the unmet mental health needs of FSW living with HIV. Trial registration Clinical Trial Number: NCT03500172.

INTRODUCTION: Key populations, including men who have sex with men, transgender people, sex workers, people who inject drugs and incarcerated populations, experience high burdens of HIV and urgently need effective interventions. Yet the evidence-base for implementation research (IR) with key populations remains weak and poses specific challenges to epidemiologic inference. We apply the Consolidated Framework for Implementation Research to consider specific challenges and recommendations for IR with key populations. DISCUSSION: Individuals within key populations exist within inner and outer settings-including organizational structures, legal (e.g. criminalization) and funding environments--which influence the design, adoption and fidelity of interventions, and the potential sustainability of intervention scale-up. Underlying vulnerabilities and external stressors experienced at the individual-level (e.g. homelessness, violence) further impact participation and retention in IR. Thus, researchers should account for representation in the research process, beginning with community engagement in IR design and consideration of enumeration/sampling methods for key populations who lack probabilistic sampling frames. Interventions for key populations require substantial adaptation and complexity (e.g. individually tailored, multi-component) to ensure appropriateness, however there is tension between the need for complexity and challenges to internal validity (fidelity) and external validity (generalizable scale-up). Finally, integrating contextual, sampling and implementation elements into analytic approaches is critical for effectiveness evaluation. CONCLUSIONS: Translation of efficacious findings at the individual-level to effectiveness at the population-level requires recognition of risk heterogeneity. Recognizing the nuances of working with key populations is essential to ensure that individuals are represented by design and therefore gains in population health can be achieved.

Background Health-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. Methods We used baseline data (2018-2020) 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-based 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. Findings Of 1363 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. Interpretation These 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. Funding National Institutes of Health (R01NR016650) RESEARCH IN CONTEXT Evidence before this study We searched PubMed on April 9, 2021 for studies published in English that examined the health-related quality of life of female sex workers (FSW) living with HIV. We used the search terms (“quality of life”) AND (“sex workers”) AND (“HIV”). Our search resulted in a total of 14 studies. We excluded 6 studies as their study sample did not include female sex workers; and another 2 studies as they were mathematical modeling or cost-effectiveness analyses which did not include original data. Of the remaining 6 studies, 5 were among FSW in general, regardless of their HIV status; we only identified one study that specifically examined the quality of life in FSW living with HIV: among 98 HIV-positive women who were former commercial sex workers in Nepal, the authors examined the degree to which indicators of physical, mental, and social domains explained variation in overall perceived life satisfaction. Of the 5 studies among FSW in general, 3 were qualitative studies, one was a quantitative individual-level study, and one was a systematic review and meta-analysis. The meta-analysis of eight studies (China, India, Korea, Philippines, Puerto Rico, Armenia, and the United States) published before July 2013 found that increased psychological health conditions were associated with increased HIV risk behavior. By searching citations of the above systematic review, we identified another more recent meta-analysis which examined the prevalence and risk factors of mental health conditions among FSW in low and middle income countries. This meta-analysis included 56 unique studies published up to April 2020, demonstrating prevalent mental health conditions among FSW in low- and middle-income settings, with increased burden of mental health conditions associated with experiences of violence, harmful alcohol and drug use, inconsistent condom use, and HIV incidence. In summary, although mental health conditions of FSW have been broadly explored in the literature, there remains a dearth of research which evaluated health-related quality of life of FSW living with HIV. Added value of this study We directly evaluated the HRQoL of FSW living with HIV in South Africa. We used data on a sample of FSW who were diagnosed with HIV and enrolled into a randomized trial via a local sex worker program in Durban. Our comprehensive baseline questionnaire allowed us to examine a range of factors (sociodemographic characteristics, clinical features and treatment of HIV, drug use and other social and structural factors) and their relationship with HRQoL among FSW living with HIV. The average HRQoL score was 0.857 for FSW living with HIV. We identified older age, lack of ART use, drug use, and experience of violence as being associated with a lower HRQoL score among FSW living with HIV. We did not find an independent association between CD4 count or viral load with HRQoL score after adjusting for current ART use and other covariates. In addition, we derived overall and subgroup-specific estimates of HRQoL scores, representing health utilities, which can be used to calculate quality-adjusted life-years in cost utility analysis for economic evaluations of interventions targeting FSW living with HIV in South Africa. Implications of all the available evidence The findings here reinforce the importance of comprehensive programs to optimize treatment outcomes among sex workers living with HIV. While ART is central given its association with improved quality of life for people living with HIV, a human-centered approach focused on addressing social and structural vulnerabilities including addiction services, violence, and stigma, represent critical components of optimizing quality of life among female sex workers living with HIV in South Africa.

Background Female sex workers (FSWs) are disproportionately affected by HIV even in the most generalized HIV epidemics. Although structural HIV risks have been understood to affect condom negotiation among FSWs globally, there remain limited data on the relationship between structural determinants of HIV risk, including violence and socioeconomic status, and condom use among FSWs across sub-Saharan Africa. Here, we describe the prevalence of structural determinants and their associations with condom use among FSWs in Senegal. Methods In 2015, 758 FSWs >18 years of age were recruited using respondent driven sampling in Senegal. Data on individual, community, network, and structural-level risks were collected through an interviewer-administered questionnaire. Poisson regression with robust variance estimation was used to model the associations of consistent condom use (CCU) and selected structural determinants. Results The respondent driven sampling-adjusted prevalence of CCU in the last 10 sexual acts was 76.8% [95% confidence interval (CI): 70.8 to 82.8]. Structural determinants that were significantly associated with lower CCU were as follows: physical violence [adjusted prevalence ratio (aPR): 0.71; 95% CI: 0.52 to 0.98]; working primarily in a hotel or guest house (aPR: 0.85; 95% CI: 0.73 to 0.99); and difficultly accessing condoms (aPR: 0.72; 95% CI: 0.52 to 0.96). High income from sex work (aPR: 1.23; 95% CI: 1.04 to 1.46) was significantly associated with higher CCU. Conclusions Taken together, these data highlight the role of structural risk determinants on condom use among FSWs in Senegal. Moreover, these results highlight the need for structural interventions, including safe working spaces and violence mitigation programs, to support condom negotiation and access. Combined with condom distribution programs, structural interventions could ultimately increase condom use among FSWs in Senegal.

Adolescent girls and young women (AGYW) remain underserved and at risk for HIV acquisition in Ethiopia. However, there is significant risk heterogeneity among AGYW with limited consensus on optimal strategies of identifying vulnerable AGYW. This study assessed the utility of venue-based sampling approaches to identify AGYW at increased risk for HIV infection. Venue mapping and time-location-sampling (TLS) methods were used to recruit AGYW from three sub-cities of Addis Ababa, February–June 2018. Interviewer-administered surveys captured socio-demographic and behavioral characteristics. Measures of AGYW vulnerability were assessed geographically and described by venue type. A total of 2468 unique venues were identified, of which 802 (32%) were systematically selected for validation and 371 (46%) were eligible including many sites that would traditionally not be included as venues in need of HIV prevention services. Overall, 800 AGYW were enrolled across 81 sampled venues. AGYW reached were largely out-of-school (n = 599, 75%) with high proportions of AGYW reporting transactional sex (n = 101, 12.6%), food insecurity (n = 165, 20.7%) and migration (n = 565, 70.6%). Taken together, these data suggest the utility of TLS methods in reaching vulnerable, out-of-school AGYW in Addis Ababa, Ethiopia. Electronic supplementary material The online version of this article (10.1007/s10461-019-02537-1) contains supplementary material, which is available to authorized users.

In South Africa, 60% of female sex workers are estimated to be living with human immunodeficiency virus (HIV). Many of these women face structural and individual-level barriers to initiating, accessing, and adhering to antiretroviral therapy (ART). While data are limited, it is estimated that less than 40% of sex workers living with HIV achieve viral suppression, leading to suboptimal clinical outcomes and sustained risks of onward sexual and vertical HIV transmission. Siyaphambili, a NINR/NIH-funded study, focuses on studying optimal implementation strategies for meeting HIV treatment needs among cisgender female sex workers living with HIV who are not virally suppressed. Here, we present the study protocol of this sequential multiple assignment randomized trial. In total, 800 viremic female sex workers will be enrolled into an 18-month adaptive implementation study to 1) compare the effectiveness and durability of a nurse-led decentralized ART treatment program versus an individualized case management approach, in isolation or in combination to achieve viral suppression and 2) estimate incremental cost-effectiveness of interventions and combinations of interventions. The primary outcome is a combined intention-to-treat outcome of retention in ART care and viral suppression at 18 months with secondary implementation outcomes. Siyaphambili aims to inform the implementation of and scale-up of HIV treatment services for female sex workers by determining the minimal package of services needed to achieve viral suppression and by characterizing individuals in need of more intensive HIV treatment approaches.

Globally, sex workers of all genders and identities continue to face disproportionately high burdens of HIV, demonstrating the need for programmes better tailoring services to their unmet needs. The reasons for this high burden are complex, intersecting across behavioural, social, and structural realities experienced by sex workers. Here, we build on systematic reviews of HIV among sex workers and case studies rooted in sex workers’ lived experience to describe: (1) the global HIV burden among sex workers; (2) the factors and determinants that influence the HIV burden; (3) intervention coverage and gaps to reduce HIV-related inequities faced by sex workers, over the past decade.Sex workers living with HIV have not benefited enough from significant increases in HIV treatment among the general population. Engagement in this HIV treatment cascade is hindered by structural factors including stigma, migration, policing, criminalisation, and violence, as well as substance use, which present increasingly concurrent risks with HIV among sex workers.Emerging biomedical HIV prevention innovations exist to support the health and human rights of sex workers and reduce onward transmission risk, but persistent data gaps remain, and should be addressed via community-driven implementation research. Epidemiologic research engaging sex workers who are cismen and transgender persons is similarly crucial. Community empowerment approaches have reduced the odds of HIV infection, highlighting the case for greater investments in structural interventions. These investments, combined with filling data gaps and national action towards sex work decriminalisation alongside legal protections, are critical to achieving reductions in sex workers’ HIV burden.

Background Adolescent girls and young women (AGYW) aged 15-24 years have among the highest risk for HIV and other sexually transmitted infections (STI) across sub-Saharan Africa. A latent class analysis (LCA) was conducted to identify intersecting social- and structural-level determinants of HIV/STI acquisition among AGYW in Ethiopia. Methods AGYW were recruited from venues using time-location sampling, completing an interviewer-administered behavioral survey and biological testing for HIV, syphilis, and chlamydia. LCA was used to identify distinct groups, defined by social- and structural-level determinants of HIV/STI risk, among AGYW. Prevalence ratios (PR) and 95% confidence intervals (CI) compared differences in HIV/STI prevalence by group. Results A total of 1,501 AGYW were enrolled across Addis Ababa (March-May 2018) and Gambella (June-July 2019). We identified three patterns of vulnerability defined by schooling status, migration history, food insecurity, orphan status, social support, and employment. We labeled these groups as "highly vulnerable" (representing ~21% of the population), "stable, out-of-school, migrated" (~42%), and "stable, in-school, never migrated" (~37%). STI prevalence was nearly two-fold higher among AGYW in the "highly vulnerable" group compared to AGYW in the "stable, in-school, never migrated" group (PR 1.93; 95% CI 1.33, 2.80). Conclusions Characterizing patterns of vulnerability among AGYW that reflect higher-level social and structural factors can help facilitate early identification of AGYW at the highest risk of HIV/STI acquisition, thus differentiating groups of AGYW who may most benefit from targeted HIV prevention interventions during adolescence and early adulthood.

Background: An estimated 44–69% of female sex workers (FSW) in South Africa are living with HIV, among whom 39% are virally suppressed. Digital technologies—increasingly advanced and accessible to marginalized populations—present new opportunities to improve the HIV care continuum. The objective of this study was to explore potential facilitators and barriers to incorporating mobile phones and advanced technologies (e.g., biometric identification methods, mobile phone applications for social media and other uses, and chatbots) to deliver HIV-related interventions to cisgender FSW living with HIV in Durban, South Africa. Methods: Four semi-structured, focus group discussions (FGDs) were conducted with 22 cisgender FSWs in December 2018. Participants were recruited from the ongoing Siyaphambili trial using maximum variation sampling to optimize diversity in participant age and sex work venue. FGDs were audio recorded in isiZulu, and translated and transcribed into English. Transcripts were inductively coded using thematic analysis and sub-themes were iteratively refined to connect and evaluate the saliency of codes. Results: Phone ownership was motivated by a desire to remain safe and to connect with family, peers, and clients. When FSW did not have access to a mobile phone, they reported sharing phones with their peers, though sharing only occurred under specific conditions. Still, to integrate mobile phones into HIV care, FSW identified consistent access to mobile phones as a key barrier. Mobile phone turnover due to frequent selling of phones to meet other financial priorities, substance use, and theft were common. To integrate advanced technologies into HIV care, FSW identified convenience, security, and additional opportunities for social support as the main facilitators. For example, FSW described how biometric identification at clinics could eliminate the need to retain a clinic card. FSW also described how chatbots could easily set medication alarms or be available to assist in emergencies. Barriers for advanced technologies included maintaining privacy, potential threats to security, and cost. Conclusions: FSWs were receptive to digital technologies for HIV care and beyond, but they also described many barriers such as inconsistent phone ownership and threats to privacy. As phone ownership grows and HIV programs increasingly leverage digital tools, strong considerations are needed to ensure the most vulnerable are not systematically excluded.

ObjectivesWhile female sex workers (FSW) are nearly 14 times more likely to be living with HIV than non-FSW, less than 40% of FSW living with HIV are on antiretroviral therapy (ART). We sought to understand how the work environment influences ART access and adherence for FSW in preparation for the Siyaphambili trial.MethodsFSW living with HIV (n=24) and key informants (n=15) were recruited to participate in semistructured in-depth interviews using maximum variation and snowball sampling, respectively. FSW were recruited on key variants including type of sex work venue, primary work time and history of ART use. Data were collected between September and November 2017 in Durban, South Africa. Interviews were audio-recorded, transcribed and translated. Data were then coded applying grounded theory in Atlas.ti.ResultsFSW experienced occupational barriers to adherence including work-related migration, substance use and theft of ART on the job. Fear of wage loss due to HIV disclosure to clients and brothel managers prevented some FSW from accessing ART at their clinic and taking medications while working. FSW employed coping strategies to overcome barriers including sharing ART with colleagues, carrying small supplies of ART and visiting the clinic prior to appointments for ART refills. Further, some FSW received adherence support from colleagues who were also living with HIV.ConclusionsConsidering these occupational pressures on FSW and supporting positive coping strategies are important when designing and implementing HIV treatment programmes. Findings suggest strengthening social cohesion and supporting differentiated care efforts to improve HIV outcomes among FSW living with HIV.

Background The burden of an HIV epidemic in Kosovo lies among the key populations (KPs) of female sex workers (FSWs), men who have sex with men (MSM), and people who inject drugs (PWIDs). The available interventions for KPs are fragmented and lack sufficient and appropriate granularity of information needed to develop large-scale outreach programs. Objective The aim of this study was to estimate the size and distribution of these populations to create evidence for developing action plans for HIV prevention. Methods The programmatic mapping approach was used to collect systematic information from key informants, including geographic and virtual locations in 26 municipalities of Kosovo between February to April 2016. In level 1, information was gathered about KPs' numbers and locations through 1537 key informant interviews within each municipality. Level 2 involved validating these spots by conducting another 976 interviews with KPs congregating at those spots. Population size estimates were calculated for each spot, and finally a national-level estimate was developed, which was corrected for duplication and overlaps. Results Of the estimated 6814 MSM (range: 6445 to 7117), nearly 4940 operate through the internet owing to the large stigma and discrimination against same-sex relationships. Geo-based MSM (who operate through physical spots) congregate at a few spots with large spot sizes (13.3 MSM/spot). Three-fourths of the MSM are distributed in 5 major municipalities. Fridays and Saturdays are the peak days of operation; however, the number only increases by 5%. A significant number are involved in sex work, that is, provide sex to other men for money. PWIDs are largely geo-based; 4973 (range: 3932 to 6015) PWIDs of the total number of 5819 (range: 4777 to 6860) visit geographical spots, with an average spot size of 7.1. In smaller municipalities, they mostly inject in residential locations. The numbers stay stable during the entire week, and there are no peak days. Of the 5037 (range: 4213 to 5860) FSWs, 20% use cell phones, whereas 10% use websites to connect with clients. The number increases by 25% on weekends, especially in larger municipalities where sex work is mostly concentrated. Other than a few street-based spots, most spots are establishments run by pimps, which is reflective of the highly institutionalized, structured, and organized FSW network. Conclusions This study provides valuable information about the population size estimates as well as dynamics of each KP, which is the key to developing effective HIV prevention strategies. The information should be utilized to develop microplans and effectively provide HIV prevention services to various KPs.

HIV in Mauritius is in a concentrated phase. Most HIV infection is among key populations (KPs) including female sex workers (FSW), people who inject drugs (PWID), men who have sex with men (MSM), and transgender sex workers (TGSW). The objective of this research was to use geographical mapping to determine the precise locations, typologies and population estimates of each KP in Mauritius. From May to July 2014 a programmatic mapping approach determined national estimates and information on the specific locations, “hotspots”, frequented by KPs in Mauritius. Data were collected through multiple levels of activity. Key informants provided information about hotspots where KPs congregated and were actively engaged in risky behaviours. Validation of hotspots was done by engaging KPs. A total of 17 248 KP members were estimated spread over 1 964 hotspots in Mauritius. The largest KP was PWID with an estimate of 7 598 (range: 4 091–6 223), followed by 6 223 (range: 5 090–7 456) FSWs, spread over 694 and 731 hotspots respectively. A total of 2 020 (range: 1 595–2 446) MSM and 294 geographic MSM hotspots, and 1 407 TGSWs (range: 1 165–1 649) distributed over 245 hotspots. This research provided Mauritius with validated KPs size estimations and provided the first national data on KP hotspots and operational dynamics. The use of these data will strengthen HIV prevention, intervention, and programme planning in the country through focusing efforts to systematically target high-risk areas.Keywords: Africa, HIV, key populations, size estimation, venue mapping

BACKGROUND The burden of an HIV epidemic in Kosovo lies among the key populations (KPs) of female sex workers (FSWs), men who have sex with men (MSM), and people who inject drugs (PWIDs). The available interventions for KPs are fragmented and lack sufficient and appropriate granularity of information needed to develop large-scale outreach programs. OBJECTIVE The aim of this study was to estimate the size and distribution of these populations to create evidence for developing action plans for HIV prevention. METHODS The programmatic mapping approach was used to collect systematic information from key informants, including geographic and virtual locations in 26 municipalities of Kosovo between February to April 2016. In level 1, information was gathered about KPs’ numbers and locations through 1537 key informant interviews within each municipality. Level 2 involved validating these spots by conducting another 976 interviews with KPs congregating at those spots. Population size estimates were calculated for each spot, and finally a national-level estimate was developed, which was corrected for duplication and overlaps. RESULTS Of the estimated 6814 MSM (range: 6445 to 7117), nearly 4940 operate through the internet owing to the large stigma and discrimination against same-sex relationships. Geo-based MSM (who operate through physical spots) congregate at a few spots with large spot sizes (13.3 MSM/spot). Three-fourths of the MSM are distributed in 5 major municipalities. Fridays and Saturdays are the peak days of operation; however, the number only increases by 5%. A significant number are involved in sex work, that is, provide sex to other men for money. PWIDs are largely geo-based; 4973 (range: 3932 to 6015) PWIDs of the total number of 5819 (range: 4777 to 6860) visit geographical spots, with an average spot size of 7.1. In smaller municipalities, they mostly inject in residential locations. The numbers stay stable during the entire week, and there are no peak days. Of the 5037 (range: 4213 to 5860) FSWs, 20% use cell phones, whereas 10% use websites to connect with clients. The number increases by 25% on weekends, especially in larger municipalities where sex work is mostly concentrated. Other than a few street-based spots, most spots are establishments run by pimps, which is reflective of the highly institutionalized, structured, and organized FSW network. CONCLUSIONS This study provides valuable information about the population size estimates as well as dynamics of each KP, which is the key to developing effective HIV prevention strategies. The information should be utilized to develop microplans and effectively provide HIV prevention services to various KPs.