integrating sw programming and research to reach 90 90 90 frances m cowan uz-ucsf annual research...
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Integrating SW programming and research to reach 90 90 90
Frances M CowanUz-ucSF Annual Research Day
17th April 2015
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• Global epidemiology of female sex work (FSW)
• Effective combination HIV / STI prevention care
programmes
• Novel biomedical approaches are being evaluated
• Sex work programme and research in Zimbabwe
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• Global epidemiology of female sex work
• Effective combination HIV / STI prevention care
programmes
• Novel biomedical approaches are being evaluated
• Sex work programme and research in Zimbabwe
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Systematic review of size estimation of FSW populations globally
Region FSW prevalence (range)
Sub Saharan Africa Capital cities Other Urban areas Transactional sex – DHS
0.7% - 4.3%0.4% - 4.3%0.6% - 9.1%
Asia 0.2% - 2.6%Ex Russian Federation 0.1% - 1.5%Eastern Europe 0.4% - 1.4%Western Europe 0.1% - 1.4%Latin America & Caribbean 0.2% - 7.4%
Vandepitte et al STI 2006
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Meta-analysis of the increased burden of HIV experienced by FSWs
Region(n countries)
N ofFSWs
% FSWs with HIV*
% HIV+ve in generalpopulation
PooledOR (95% CI)
Asia (14) 64,224 5.2 % 0.18 29.2(22.2–38.4)
EasternEurope (4)
3,037 10.9% 0.20% n/a
LA & C(11)
10,237 6.1% 0.38% 12.0(7.3–19.7)
ME and N Africa (5)
959 1.7% 0.43% n/a
SS Africa (16)
21,421 36.9% 7.42% 12.4(8.9–17.2)
World Bank 2012* pooled estimate
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HIV Burden among FSWs – how does this influence epidemics more generally?
• FSWs bear a disproportionate burden of HIV worldwide - 13.5 times more likely to be HIV +ve than general population (Baral et al Lancet 2013)
• Modes of Transmission studies suggest small proportion of new infections attributable to sex work in generalized epidemics (Gouws et al STI 2012)
Modes of transmission in Zimbabwe
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Modes of transmission studies likely underestimate the population attributable fraction of FSW over the longer term within generalised epidemics
Mishra et al PlosOne 2014; Boilly et al 2014 JAIDS
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Looking upstream to prevent HIV transmission: caninterventions with sex workers alter the course of HIV
epidemics in Africa as they did in Asia?
Steen et al AIDS 2014
XXX
x
Reference100% condom use – low activity (# clients) sex work100% condom use – high activity sex work100% condom use – high and medium activity100% condom use – high, medium and low activity
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• Global epidemiology of female sex work
• Effective combination HIV / STI prevention care
programmes
• Novel biomedical approaches are being evaluated
• Sex work programme and research in Zimbabwe
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Environment
Public policy
Community
Peers
Prevention framework
Individual
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Behavioural
Structural, social justice and human
rights
Biomedical – ART and non
ART
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Established Interventions
• Condoms and lubricant• STI treatment • Contraception• Harm reduction for SW-who inject drugs• Peer education• Violence reduction• Community empowerment
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Community empowerment
• Community empowerment is an approach, set within a broader health and human rights framework, which shapes and creates synergy across intervention components (biomedical, behavioural, structural)
• Cannot be reduced to a specific activity (e.g., a drop-in-center or other “mobilization” activities)
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Implementation
• Community empowerment often starts with the promotion of internal social cohesion and ensuring a safe space to gather
• Mobilization of collective power and action to address the social and structural context of HIV risk
• Sex worker participation in processes to influence access to material resources
Need to undertake this in the context of wider stakeholder engagement
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Effectiveness• Nested systematic review and meta-analysis (n=30,325 from 22
studies) from low- and middle-income countriesOutcome Pooled Odds Ratio 95% CI
HIV 0.68 0.52, 0.89Gonorrhea 0.61 0.46, 0.82Chlamydia 0.74 0.57, 0.98High-titre syphilis 0.53 0.41, 0.69Consistent condom use with: All clients 3.27 2.32, 4.62 New clients 3.03 1.89, 4.86 Regular clients 2.90 2.22, 3.78
Kerrigan et al Lancet 2015
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WHO guidance 2014The comprehensive packageEssential health sector Interventions1. Comprehensive condom and lube program2. Harm reduction for substance use3. Behavioural interventions4. HIV testing and counselling5. HIV treatment and care6. Sexual and Reproductive Health programs7. Prevention / management of co-morbiditiesEssential strategies for an enabling environment8. Supportive legislation, policy and financial
commitment9. Addressing stigma and discrimination10.Community empowerment11.Addressing violence against SWs
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Young women who sell sex• Under researched• Substantial minority report starting
sex work <18 years• < 18 = sexually exploited• Increased risk of HIV & STIs• Poor negotiation skills
– Less consistent condom use– Increased risk of gender-based violence
• Increased risk of poor mental health– Increased suicide attempts– Increased substance use
• Increased biological susceptibility• Able to attract more clients• Maintain longer working hours
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• Global epidemiology of female sex work
• Effective combination HIV / STI prevention care
programmes
• Novel biomedical approaches are being evaluated
• Sex work programme and research in Zimbabwe
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Newer Interventions
• Post Exposure Prophylaxis services – Sexual assault, unintended exposures
• Pre Exposure Prophylaxis services – Oral (PrEP) – Topical (microbicides)
• FSW HIV care and treatment:– Antiretroviral treatment services– Prevention of vertical transmission
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• Global epidemiology of female sex work
• Effective combination HIV / STI prevention care
programmes
• Novel biomedical approaches are being evaluated
• Sex work programme and research in Zimbabwe
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Initially in five sites – providing two models of care - expanded in 2013 to 36 sites nationally
Developed in close consultation with SWs and other stakeholders following a situational analysis by NAC
‘Sisters with a Voice’
• Clinical services
• Health education
• Supported by 170 peer educators (50% paralegals)
• Participatory group meetings to support social cohesion and community empowerment
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End of 2014
• >24,000 women seen• > 60,000 visits• > 20,000 STIs treated• >7,500 HIV tests • >3,200 women diagnosed HIV positive and
referred for ART services
• >1.4 million (M), >96,000 (F) condoms distributed in 2014
01
000
200
03
000
400
05
000
rank
of (
_n)
by
site
01jul2009 01jul2010 01jul2011 01jul2012 01jul2013Date:
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Analysis of programmatic data• > 13,000 women between
2009 and March 2014
• 28% never tested at first visit (40% falling to 22%)
• At first visit, already knew HIV+ but not on ART 21% (22% falling to 21%)
• At first visit, knew HIV+ and on ART 15 % (11% rising to 21%)
Hargreaves et al submitted 2015
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Analysis of programmatic data
• 10 new infections per 100 person years of follow-up
(95% CI: 7-16%)
Hargreaves et al submitted 2015
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Future uses of programme data
• To support national size estimation studies • To look at trends in engagement with
prevention and care over time• Triangulating incidence and coverage
measures• Morbidity and mortality of sex workers• Mobility in and out of sex work• Internal and external migration
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Access to Health Care sub-optimal
“I was afraid that I would be arrested. …..”
“ It’s just the thought of being seen as a sex worker that gives me the shivers …”
“We are not treated well in hospitals. Sometimes if you are suffering from an STI, they will embarrass and
humiliate you so that other people will know.”
RDS survey in 3 sites in 2011 (n=870)
50-70% of SWs HIV +• 50% of HIV +ve knew their
status• 25-37% of HIV +ve SWs
were on ART• 12-22% of HIV –ve SWs had
HTC within 6 months
Cowan et al PLoS ONE 2013
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Cluster randomised trial of enhanced ART prevention and treatment – including PrEPGoal: to reduce the prevalence of all FSWs with a detectable HIV viral load, >1,000 copies/ml
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Conduct baseline survey using RDS in 14 outreach sitesRecruit ≈ 200 SWs per site (total n=2,800 )
Usual Care SitesHealth education, HTC Referral to government HIV care services as needed, Syndromic STI Contraception,CondomsCervical Ca screening,Legal advice
Random allocation of 7 matched sites to intervention arms
SAPPH-IRe Ix SitesUsual care plus:HIV negatives•Repeat HTC, Offer of PrEPHIV positives•PoC CD4; On site ARTIntensified community mobilisation with SMS adherence supportAdherence sisters program
After 18 months conduct endline survey using RDS in all 14 sites. Recruit ≈ 200 SWs per site (total n=2,800 )
Process E
valuationP
rogram data collection
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HIV prevalence among SWs at baseline at 14 trial sites
Overall HIV prevalence 57.5% (95% CI 42.8-79.2)
Age n % (min and max) *
18-24 233/655 36% (14-59%)
25-29 372/665 57% (38-76%)
30-39 649/948 67% (43-91%)
>40 345/440 79% (57-97%)Total 2722 100
* percents are RDS weighted and means of site values
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64.0%100% 43.3% 33.7%
Additional 15.8% with viral suppression but reporting not on ART
Cascade of care at the 14 SAPPH-IRe sites
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Cascade of care for HIV +ve sex workers a) <25 years b) > 25 years
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Size estimation and engagement in services among sex workers in Harare, Bulawayo and
Mashonaland Central
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Estimating the size of SW population in Zimbabwe
Size estimates are just that - ESTIMATES
• Useful for – Advocacy– Informing prevention, treatment
and care programmes– Programme evaluation– Surveillance
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Methods used for size estimation
• No perfect method• Method to use
– Local context – Existing information– Often use a combination of methods and take
median• Enumeration/Census• Multiplier• Capture recapture
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SistersProgramme
provides framework for
surveillance and evaluation of
prevention and care
interventions
• Sisters Programme– Service provision– Expanding to work with young
women +/- ART for prevention intervention
• Size estimation– Including methodological
issues• Migration• HIV measurement and
surveillance consortium
• Self testing• SAPPH-IRe trial
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Proper inclusion of sex workers and other key populations is essential to reach 90: 90: 90
The principles of good public health demand that
we strive to reach all affected populations with
core HIV services even when facing difficult cultural contexts, severe stigma and
discrimination, or challenging security
environments.Ambassador Birx May 2014
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AcknowledgementsJoanna BuszaValentina CambianoMilton ChemhuruSamson ChidiyaTarisai ChiyakaCalum DaveyJeffrey DirawoLiz FearonEmily GwavavaStephano Gudekeya
Nyasha MasukaJames HargreavesKarin HatzoldSue MavedzengeSibongile MtetwaBoniface MudengeOwen MugurungiSithembile MusemburiPhillis MushatiGetrude NcubeAndrew Phillips