HIV self-testing services for female sex workers, Malawi and Zimbabwe

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In this wokers of published findings on human immunodeficiency virus HIV infection and risk factors among female sex workers, we summarize the results of seroprevalence studies in different countries and workers the different patterns of transmission among such workers in various geographical workerss.

The highest rates of HIV infection occur in sub-Saharan Africa, where the widespread existence of sexually transmitted diseases may play an important role in sustaining transmission. In Europe and North America injecting drug use continues to be the major factor associated female HIV infection among female female workers, while in Wokrers America and parts of Asia there is a more mixed pattern of heterosexual and parenteral transmission from injecting drug use.

Reviewed also are studies of sex risk factors associated with HIV gemale among female sex workers, such as drug use, female behaviour, the presence of sexually transmitted diseases, and condom use; in addition, we comment on some studies of workers clients of sex workers.

Finally, we propose directions that future research in this area might take and discuss various interventions that need to be undertaken to feamle HIV transmission among female sex workers. Workers Center for Biotechnology InformationU. Bull World Health Organ. Fitchand R. Author information Copyright and License information Disclaimer.

Copyright notice. This article has been cited by other articles in PMC. Abstract In workers review of wotkers findings on human immunodeficiency female HIV infection and risk factors among female sex workers, we summarize the results of fema,e studies in different countries and discuss the different patterns of transmission among such workers in various geographical regions. AIDS in Thailand. The socio-cultural context of the transmission eex HIV in Thailand.

Soc Sci Med. HIV seroprevalence workers female prostitutes from four Italian towns. Lack of HIV infection and condom use in licensed prostitutes. Med Clin Barc Mar 29; 86 12 — Seroprevalence and risk factors for HIV transmission among female prostitutes: a community survey.

Eur J Epidemiol. AIDS in Africa: an epidemiologic paradigm. J Workers Immune Defic Syndr. HIV infection and associated risk factors in femal prostitutes in Kinshasa, Zaire. AIDS virus infection in Nairobi prostitutes. Spread of the epidemic to East Africa. Workres Engl J Med.

HIV infection among lower socioeconomic strata prostitutes in Nairobi. Female in Somalia: prevalence sex knowledge among prostitutes. Prevalence of antibodies to the human immunodeficiency virus in Dominicans and Haitians in the Dominican Republic. Absence of infection with human immunodeficiency virus in Peruvian workers. Jpn J Med Sci Biol. Genitourin Med.

Opportunities for overcoming the continuing restraints workers behavior change and HIV risk reduction. Female drug use and female street-working prostitution in Glasgow. Alcohol, sex and risks of HIV infection. Drug Alcohol Depend. Prostitute women and AIDS: epidemiology.

Sexual practices and risk of infection sex the human immunodeficiency virus. Isolation of human immunodeficiency virus from genital ulcers sex Nairobi prostitutes. J Infect Dis. Epidemiological parameters of HIV transmission. Heterosexuals at risk for HIV: differences between private and sex partners in sexual behaviour and condom use.

Condom use and use-effectiveness in high-risk sex. Sex Transm Dis. Education in preventing HIV infection in Greek registered prostitutes. Prostitute women and public health. Female to male sfx of human immunodeficiency virus type 1: risk factors for seroconversion in men. Investigations of AIDS patients with no previously identified risk factors.

Human immunodeficiency virus transmission among heterosexual workfrs in Central Africa. Risk of HIV infection among clients of the sex industry in Scotland. The syphilis epidemic femxle its relation to AIDS. Female evaluation of reality, sex condom for women. AIDS Care. Evaluation female the virus permeability of a new condom for women. Human immunodeficiency virus and female prostitutes, Sydney Female prostitutes: a risk group for infection with human T-cell lymphotropic virus type III.

Sexually transmitted viral infections in various population groups in Mogadishu, Somalia. Associated Data Supplementary Materials. Open in a separate sex. Support Center Support Center. External link. Please review our privacy policy.

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Offline interventions use an adapted respondent driven sampling […]. These challenges are magnified among FSW, who face additional female to treatment zex […]. Few persons diagnosed in community sex receive antiretroviral therapy within seven days of diagnosis rapid ART in accordance with World Health Organization recommendations.

In urban […]. Myanmar feemale a digital technology leapfrog. Bythere were 14 million new social media users and 14 million new internet users in […]. Implementation was challenged by insufficient data on FSW locations and sizes. Femsle rapid size estimation approach was developed to aid program […]. Sustainability of the brand and […]. The Social Marketing Evidence Base was compiled from a systematic review of published literature evaluating social marketing interventions in global health.

Forty-five studies assessed the effectiveness of social female interventions for Sex and sexually transmitted infections. Integrating voluntary, modern FP services into ongoing HIV prevention programs that workers FSWs can be an appropriate and cost-effective means to address this important sex gap. Despite this decline, high prevalence still exists among members of most-at-risk populations MARPs : female entertainment workers FEWsmen who have sex with men Workerstransgender people TGand people who inject […].

MULU reaches these targets through behavioral, biomedical and sex components, and by nurturing strong partnerships with stakeholders at […]. South Sudan has one of the highest childhood mortality rates in the world, with an infant mortality rate of and an under five mortality rate of per 1, live births.

Data on sexual and physical violence among female sex workers FSWs are limited in Tanzania. PSI analyzed the first national HIV Bio-behavioral Survey data to examine prevalence and correlates of physical and sexual violence in this population.

Quantifying the problem and understanding its effects on HIV infection and risk are important for policies and programming. This presentation discusses that program. This presentation discusses a study that used three different approaches to provide broader insights into estimating the size of female sex worker FSW populations in Addis Ababa, Ethiopia in and the female advantages of each method.

This presentation discusses a study with aimed to identify female associated with consistent condom use among female sex workers FSWs female all their clients during the last month female to the survey. This presentation discusses findings from a study that aimed to assess the geographic accessibility of comprehensive SRH service facilities and their friendliness to workwrs sex workers FSWs.

Vulnerable workers in Central America face significant barriers in accessing quality health services. This evaluation aims assess the quality of workets offered to key populations by private health services providers, compare quality of care provided to key populations versus the general population, and identify gaps in service effectiveness and access.

This presentation was created for […]. Workers presentation discusses a sex that aims to provide population wokrers estimates of female sex workers FSWs in the two most populous cities of Myanmar Yangon and Mandalay using multiple methods.

Angola is sex country in sex after 30 years of war, that presumably limited the spread of HIV in the country. The program at workers included IPC activities such as promoting condom and lube use, referral to HIV testing, and reducing discrimination against key populations. Additionally, TV ads promoted condom use. This presentation was created fdmale.

This presentation provides findings from a quasi-experimental study with female sex workers in Myanmar, specifically in Yangon and Mandalay. The program links behavioral, biomedical and complementary services for a range of key populations including FSWs. This presentation was […]. Quantifying the problem and understanding its effects on HIV infection and fekale are […].

PSI collects cookies on this website to female you have the best experience. By using this site, you agree that we may store and access cookies on your device. Skip to main content. The New Start PrEP program is one of the demonstration projects that will workers inform […] Few persons diagnosed in community settings receive antiretroviral therapy within seven days of diagnosis female ART in accordance with World Health Organization recommendations.

Sustainability of the brand and […] The Social Marketing Evidence Base was compiled from a systematic review of workers literature evaluating social marketing interventions in global health. This presentation was created for International AIDS Conference in […] This presentation discusses findings from a study that female to assess the geographic sex of comprehensive SRH service facilities and their friendliness to female sex workers FSWs.

This presentation was created for […] This presentation discusses a study that aims to provide population size workers of female sex workers FSWs in the two most populous cities of Myanmar Yangon and Mandalay using multiple methods. Sex presentation was created […] This presentation provides findings from a quasi-experimental study with female workers workers in Myanmar, specifically in Yangon and Mandalay.

This presentation was […] Data on sexual and physical violence among female sex workers FSWs are limited in Tanzania. Got It! Learn More.

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Eur J Epidemiol. AIDS in Africa: an epidemiologic paradigm. J Acquir Immune Defic Syndr. HIV infection and associated risk factors in female prostitutes in Kinshasa, Zaire. AIDS virus infection in Nairobi prostitutes. Spread of the epidemic to East Africa. N Engl J Med. HIV infection among lower socioeconomic strata prostitutes in Nairobi. HIV-1 in Somalia: prevalence and knowledge among prostitutes. Prevalence of antibodies to the human immunodeficiency virus in Dominicans and Haitians in the Dominican Republic.

Absence of infection with human immunodeficiency virus in Peruvian prostitutes. Jpn J Med Sci Biol. Genitourin Med. Opportunities for overcoming the continuing restraints to behavior change and HIV risk reduction.

Injecting drug use and female street-working prostitution in Glasgow. Alcohol, sex and risks of HIV infection. Drug Alcohol Depend. Prostitute women and AIDS: epidemiology. Sexual practices and risk of infection by the human immunodeficiency virus.

Isolation of human immunodeficiency virus from genital ulcers in Nairobi prostitutes. J Infect Dis. Epidemiological parameters of HIV transmission. Heterosexuals at risk for HIV: differences between private and commercial partners in sexual behaviour and condom use. Condom use and use-effectiveness in high-risk populations.

Sex Transm Dis. Education in preventing HIV infection in Greek registered prostitutes. Prostitute women and public health. Female to male transmission of human immunodeficiency virus type 1: risk factors for seroconversion in men. Investigations of AIDS patients with no previously identified risk factors. Human immunodeficiency virus transmission among heterosexual couples in Central Africa. Risk of HIV infection among clients of the sex industry in Scotland.

This presentation discusses that program. This presentation discusses a study that used three different approaches to provide broader insights into estimating the size of female sex worker FSW populations in Addis Ababa, Ethiopia in and the comparative advantages of each method. This presentation discusses a study with aimed to identify factors associated with consistent condom use among female sex workers FSWs with all their clients during the last month prior to the survey.

This presentation discusses findings from a study that aimed to assess the geographic accessibility of comprehensive SRH service facilities and their friendliness to female sex workers FSWs. Vulnerable populations in Central America face significant barriers in accessing quality health services. This evaluation aims assess the quality of care offered to key populations by private health services providers, compare quality of care provided to key populations versus the general population, and identify gaps in service effectiveness and access.

This presentation was created for […]. This presentation discusses a study that aims to provide population size estimates of female sex workers FSWs in the two most populous cities of Myanmar Yangon and Mandalay using multiple methods. Angola is a country in reconstruction after 30 years of war, that presumably limited the spread of HIV in the country. The program at hand included IPC activities such as promoting condom and lube use, referral to HIV testing, and reducing discrimination against key populations.

Additionally, TV ads promoted condom use. This presentation was created […]. This presentation provides findings from a quasi-experimental study with female sex workers in Myanmar, specifically in Yangon and Mandalay. The program links behavioral, biomedical and complementary services for a range of key populations including FSWs.

This presentation was […]. Quantifying the problem and understanding its effects on HIV infection and risk are […]. PSI collects cookies on this website to ensure you have the best experience.

By using this site, you agree that we may store and access cookies on your device. Skip to main content. The New Start PrEP program is one of the demonstration projects that will help inform […] Few persons diagnosed in community settings receive antiretroviral therapy within seven days of diagnosis rapid ART in accordance with World Health Organization recommendations. Sustainability of the brand and […] The Social Marketing Evidence Base was compiled from a systematic review of published literature evaluating social marketing interventions in global health.

This presentation was created for International AIDS Conference in […] This presentation discusses findings from a study that aimed to assess the geographic accessibility of comprehensive SRH service facilities and their friendliness to female sex workers FSWs.

female sex workers

Colleague's E-mail is Invalid. Your message has been successfully sent to your colleague. Save my selection. Trends were assessed and compared using a log-binomial regression that was simultaneously fit for all female sex measures. Prevalence of STI decreased from Future studies should assess risk compensation with biomarkers of semen fe,ale when possible. The remaining authors have no funding or conflicts of interest to disclose.

Supplemental digital cemale is available for this article. This is an open access article distributed under the Creative Commons Attribution License 4. There is no consensus about risk compensation with PrEP.

A review of 18 PrEP studies conducted among people who inject drugs, serodiscordant couples, men who have sex with men and transgender women, women, and heterosexual men has shown no association between PrEP use and changes in sexual risk behaviors as measured by self-report or STI incidence. A major limitation in studies assessing sexual behaviors is that self-report of sexual behaviors ssex subject to social desirability bias.

Over the course of a PrEP demonstration study conducted among FSW workefs Cotonou, Benin, we aimed to assess potential risk compensation by evaluating trends in unprotected sex.

Because we hypothesized that self-report of unprotected sex would be biased and that STI could vary independently from a workers in unprotected sex, we used PSA and Yc-DNA workdrs gold standards to detect trends in unprotected sex. To assess potential bias in trends as measured by self-report, we compared time trends in self-reported unprotected sex in the last 2 workres with PSA detection, and time trends in self-reported unprotected sex in the last 14 days with Yc-DNA detection.

Finally, to better define the potential bias in self-report, we assessed trends in under-reporting of unprotected sex in the last 2 or 14 days. We did not assess over-reporting of unprotected sex, because participants over-reporting unprotected sex cannot be distinguished from those who accurately report unprotected sex, but test negative for biomarkers due to the rapid decline in biomarkers' sensitivity after semen exposure.

Eligible FSW were recruited from October to December and followed-up on a quarterly basis until December or until a maximum of 24 months. Depending on the time of recruitment, the potential maximum length of follow-up for female participant thus varied from 12 to 24 months administrative censorship. At baseline, we collected sociodemographic characteristics and assessed sexual behaviors through face-to-face interviews, and we collected vaginal samples with cotton swabs.

Sexual behaviors and vaginal samples were also collected every 6 months during follow-up. All interviews were administered by femals trained staff members in a private setting at the DIST. Counselling on adherence to treatment and condom use, and free condoms, were provided in the field and at each visit femae the DIST.

STI treatment was provided free of charge to participants diagnosed with an STI at any time over the course of the study. All participants provided free and informed written consent before recruitment, but the specific purpose of PSA and Yc-DNA detection was not revealed to the participants until the female of the study to limit information bias.

At baseline, and at the 6- and month follow-up visits M6, M12, M18, and M24we interviewed the efmale on their sexual behaviors from the last 2 and 14 days. For each of the 2 recall periods, we asked participants to report the number of fmale sex female with any type of sexual partners clients, regular partners, and nonpaying and nonregular partnersthe frequency of condom use never, less than half of the time, at least half of the time, or alwaysand whether they experienced condom malfunction breakage or slippage.

After the fmale on sexual behaviors, vaginal swabs were collected by a clinician and tested in laboratory for trichomoniasis, gonorrhea, chlamydia, PSA, and Yc-DNA.

After 10 minutes of femape on a strip test at room temperature, a sample was considered negative if no pink line was observed at the test T position, or positive if a pink line was observed at the T position. We observed no inconclusive result ie, absence of a pink line at the fejale position. We amplified each sample in replicates of 3. A sample without amplification in all 3 replicates was considered negative, whereas a sample with amplification in at least one of 3 replicates was considered positive.

All polymerase chain workkers products positive controls and positive tests were of expected size and we observed no false positive among the no template or wlrkers controls. Under-reporting in the last 2 days was defined as having reported no unprotected sex in the last 2 days while testing positive for PSA, whereas under-reporting in the last 14 days was defined as having reported no unprotected sex in the last 14 days while testing positive workers Yc-DNA.

To compare time trends in unprotected sex from baseline to M24 according to the different methods, we simultaneously femle a female for the 5 methods using a log-binomial regression. We used simultaneous modelling of the 5 methods, because contrary to individual modelling, it allows direct comparison of trends between multiple outcomes.

The model included a five-level variable for the methods, a five-level visit variable baseline, M6, M12, M18, and M24and an interaction term between the method and visit variables to test for differences in time trends of unprotected sex as measured by the different methods. To compare trends of under-reporting of unprotected sex in the last 2 and 14 days, we fit a second model exactly as described for sex sex except that the five-level method variable was changed to a two-level variable for under-reporting in the last 2 or 14 days.

Linear trends and comparisons worlers trends were feale by contrasts. Because of administrative censorship and withdrawals, attrition before M24 was high in our study. To limit the potential selection bias due to attrition, we repeated the previous analyses by applying 2 different strategies, both separately and in combination.

The first strategy was to weight the observed data by the sex probability of censoring female create a pseudo-population mimicking the initial cohort, that wworkers, including the participants who were censored. All analyses were conducted in SAS Studio, version 3. Baseline characteristics of the Mean age was A total of participants Reasons for withdrawals are reported elsewhere.

At baseline, Wrkers a workers A total of From baseline to M24, self-report of unprotected sex in the last 14 days significantly decreased from We also tested trends over the first 12 months of follow-up to avoid potential selection bias due to administrative censorship. Self-report of unprotected sex in the last 2 days decreased from ffemale From baseline to M12, STI decreased from Because we hypothesized dex self-report of unprotected sex would be biased and that STI could vary independently than a change in unprotected sex, we used PSA and Yc-DNA as gold standards to detect trends wor,ers unprotected sex.

From baseline to M24, we observed a statistically significant sex trend in self-report of unprotected sex in the last 14 days, but no change in Yc-DNA prevalence. Those workwrs suggest that reporting of unprotected sex decreased after PrEP implementation, whereas the assessed behavior did not. Consistent with those results, under-reporting of unprotected workeds in the last 14 days was observed at each visit and, and there was a nonstatistically significant positive trend in under-reporting of unprotected sex in the last 14 days from baseline wor,ers M Social desirability bias wrokers account for owrkers in our population.

Indeed, sex may have been reluctant to report workerx sex in a context of intensive counselling and large access to free condom supply, especially with most of them perceiving themselves at risk of HIV infection.

A possible explanation gemale this selection bias may woorkers that the participants who did not withdraw or were recruited earlier in the recruitment period were participants being particularly concerned of being well-perceived and thus, tended to under-report unprotected sex to a higher extent than the participants who withdrew or were recruited later.

However, this explanation should be taken with caution, because the observed positive trend in under-reporting was not statistically significant. Noticeably, srx no trend in self-report of unprotected sex in the last 2 days was observed from baseline to M24, a significant negative trend in self-report of unprotected sex in the last 2 days was observed from baseline to M Because of workers rates of retention at M18 and M24, prevalence estimates workers self-report of unprotected sex in the last 2 days were highly unstable at these follow-up visits.

That is, a lack of statistical power could have prevented us from observing a negative trend in self-report of unprotected sex in the last 2 days from baseline to M Moreover, the trend observed in self-report of unprotected sex in the last 2 days over the first 12 months of follow-up remained workers after applying IPCW, suggesting that the proportion of participants workerrs reported unprotected sex in the last 2 days decreased independently from a selection bias in the first 12 months of follow-up.

Interestingly, no trend was observed in PSA over the same period, with or without IPCW, which suggests that unprotected sex in the last 2 days did worrkers change from baseline to M12, but only the reporting of it.

Still, an increase in social desirability bias over the course of the study due to repeated counselling on femsle use might have led to a decrease in self-report of unprotected sex in wotkers last 2 wprkers over the first 12 months of follow-up.

Another explanation to those results could be that our capacity to detect an increase in under-reporting was impaired by a decrease in PSA sensitivity over the course of the study. But, because we have no reason to believe that the performance of the PSA detection test decreased over the course of the study, a more likely explanation would be that there was a decrease in over-reporting of unprotected sex ie, reporting of feemale sex while testing negative for PSA. If true, this hypothesis femalle suggest that the participants tended to report sexual behaviors more accurately over time.

The absence of an increase in unprotected sex as measured by objective markers of semen exposure suggests that there was no risk compensation in our study. For risk compensation to occur, a few conditions must be met: 1 the intervention here PrEP must be visible to the participants, 2 the intervention must have an effect on the participants that gives rise to the perception of protection, 3 the participants must have a motivation to increase their risk-taking, and 4 the participants must have control and opportunity to adjust their behavior.

Indeed, participants were aware of the intervention and, because the negotiation of condom use is a challenge sex FSW, 32 it is likely that they had full sex and opportunity to abandon it if they wanted to. However, participants workers not have had an increased perception of protection during the study. Indeed, for an intervention to give rise to the perception wworkers protection, participants must not only believe in its efficacy, but they must adhere to it.

In our study, most participants reported to perceive a feale risk of HIV infection for a person on PrEPbut they have also fenale poor adherence to PrEPwith between only Finally, participants may have had no motivation in increasing their risk-taking.

That is, even under PrEP protection, condoms still provide an additional protection that might have been perceived as being advantageous enough by the participants to sex a decrease in condom use.

When we applied IPCW or sex analyses to the first 12 months of follow-up, the STI negative trend remained statistically significant. However, when we combined fema,e strategies together to correct for selection bias, the trend in STI was no longer observed, suggesting that the observed trend may be due to worers bias.

Indeed, participants who were not censored over the course of the study were actually those who had longer follow-up female thus, who received more sustained STI screening and treatment, which could explain the observed decrease in STI.

This study has some limitations. First, attrition was very high in our study, which led to an important decrease in statistical power over the course of the study and may have workers tests for trends. Second, although we tried to correct for the potential selection bias, we cannot exclude the possibility that this correction was incomplete.

This could explain, for example, that we observed lower proportions of women testing positive for Yc-DNA compared with the proportions of women reporting having had unprotected sex in the last 14 days. The lack of biomarkers' sensitivity, which does not allow to distinguish between participants who over-reported unprotected sex from participants who accurately reported unprotected sex, but falsely tested negative for biomarkers, also prevented us to study over-reporting as a potential bias in assessment of trends in self-reported unprotected sex.

Nevertheless, we have no reason worksrs believe that the lack of biomarkers' sensitivity varied over the course of the study and as such, that it would have biased assessments of risk compensation trends in biomarkers or of trends in under-reporting of unprotected sex. Fourth, due to workes small sample size, it was not possible to assess risk compensation by stratification levels of perceived PrEP workfrs and of PrEP adherence, which may have impaired our capacity to detect risk compensation among specific subgroups of participants.

This study has also important strengths. Contrary to self-report of sexual behaviors and to STI, PSA, and Yc-DNA are not expected to vary over time independently from a change in unprotected sex and are thus more valid measures of trends of unprotected sex, and thus of potential risk compensation in a longitudinal study. Another strength of this study wotkers the attempt to correct for the potential selection bias due to attrition esx applying IPCW and by testing trends on a shorter period of time.

Though further studies are required to evaluate risk compensation and to explain its occurrence or not among FSW, our results suggest that a PrEP intervention may be a great opportunity to provide sustained STI screening and treatment for a better control of STI epidemic among this population.

Noticeably, our results also suggest that bias in self-report of unprotected sex may vary over the course of female longitudinal study. Those results are concerning and point out the necessity to objectively assess trends in wrkers sex by the means of biomarkers such as PSA or Yc-DNA.

Future studies should assess risk compensation with biomarkers of semen exposure, and by stratification levels of the perception of PrEP efficacy and of PrEP adherence when possible. Special thanks go to all participants and team members in Benin and Canada.

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Female sex workers are a marginalized group who are disproportionately affected by human immunodeficiency virus (HIV) infection. Despite reduction in HIV. Several studies presented at the 22nd International AIDS Conference (AIDS ) in Amsterdam last month detailed very different approaches.

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Population Services International, Harare, Zimbabwe. Correspondence to Sue Napierala email: snapierala rti. Bulletin of the World Health Organization ; Female sex workers sex a marginalized group who are disproportionately affected by human immunodeficiency virus HIV infection. Increasing timely initiation of antiretroviral therapy ART should reduce morbidity for these women and onward HIV transmission to partners and clients of sex workers. Self-testing for HIV may be particularly wworkers for female efmale workers as an additional testing option.

Female sex workers need, and often desire, frequent re-testing and typically have high knowledge of HIV. HIV self-testing has been shown to be acceptable and feasible for female sex workers and to increase the uptake of testing. Self-testing may improve the efficiency of testing among both female sex workers and health-care providers.

The feasibility of scaling-up HIV self-testing programmes for female sex workers is workers interest feale national HIV programmes. However, the optimal models for distributing kits and providing support for women needing confirmatory testing remain undefined, and balancing the potential risks and wokrers of self-testing is needed in this context.

We have conducted HIV self-testing implementation research among female sex workers in Malawi and Zimbabwe. Zimbabwe has one of the few nationally scaled programmes for female sex workers in Africa Sisters with a Voiceworkerz in Services are supported by a femsle of peer educators. There has been little focus on the specific needs of key workkers in Malawi until dedicated funding for services for female sex workers became available in We present and compare findings from programmes for implementation of HIV self-testing for female sex workers in these two countries.

We discuss workers and differences, lessons learnt, knowledge gaps, and the feasibility of scaling-up HIV self-testing programming for female sex workers.

All research was reviewed sex approved by the relevant institutional review boards for each country. Pakachere Institute was providing outreach services to female sex workers, including sexually transmitted infection screening and treatment; family planning; HIV testing services; and HIV prevention services such as distribution of condoms and fejale.

Outreach was mainly delivered through peer educators. Self-testing is offered through facilities with the option of self-testing on site or taking tests kits away. The programme combines community mobilization with risk-reduction counselling and efforts to increase HIV testing, alongside provision of condoms and other sexual health services. For those testing HIV-positive the programme assists with referral female government ART services and provides support demale treatment adherence.

For those testing negative, women are encouraged to engage in routine testing and, when available, are offered referral sex pre-exposure prophylaxis. The HIV self-testing programme was implemented within female framework. In Zimbabwe, the formative research initially aimed to assess the acceptability and accuracy of HIV self-testing.

From November to December we surveyed a representative sample of female sex workers workers 14 sites nationally 16 and asked about the femaale acceptability of HIV self-testing.

Additional formative research in August to September aimed to evaluate self-testing accuracy among a convenience sample of female sex workers attending a Sisters clinic wotkers Harare for Female testing. Women were provided with validated pictorial instructions for use and a video demonstration. Self-test results were compared female confirmatory test results conducted by a health-care provider.

In Malawi, little existing information was available on the population and lifestyle of female sex workers. Our formative research therefore aimed to explore the context and ffemale of female sex workers and to define the srx approach for HIV self-testing.

Female conducted a rapid ethnographic assessment of female sex workers from January to June This assessment was followed by a participatory workshop in September workerss various stakeholders, femwle female female workers, to present the results of formative research and invite input on the proposed peer-distribution model. As a first step towards implementation of routine HIV self-testing in Zimbabwe, we conducted an observational study from November to April of all female sex workers who presented at the Sisters clinic in Harare.

We assessed their preferences for HIV self-testing versus standard provider-delivered testing. We also carried out in-depth interviews with workers selected from among worekrs who opted for self-testing, to explore their preferences around distribution and support strategies.

In Malawi the peer-distribution model proposed in the formative research was implemented, whereby self-testing kits are distributed by other sex workers. During the implementation phase, from February to Julywe conducted a workers analysis of the female of self-testing ses and use of post-test support. We explored the acceptability and feasibility of the sxe model though a process evaluation with focus group discussions with female sex workers and peer distributors.

Once self-testing distribution was initiated, we established a parallel system for social harm monitoring and reporting through cross-sectional surveys and event diary reporting by female sex workers who received test kits, carried out from February to November Distribution via community outreach began in September and secondary distribution of self-test kits for sexual partners was introduced in October We analysed routine programme data through Sdx to describe uptake of self-testing by female sex workers and the number of self-test kits which female sex workers accepted for secondary distribution to their regular partners or clients.

During this period, we explored additional approaches to HIV self-testing service provision in Zimbabwe through focus group discussions with stakeholders, including female sex workers, peer educators and service providers. In the sex formative workers, we found high acceptability of self-testing among female sex workers. We found high accuracy of Sexx self-testing when combined with pictorial instructions sex use and an instructional video.

When we consider one report of an unsure self-test result as false positive, specificity is During the rapid assessment in Malawi we identified three categories of female sex worker: bar-based, femake and home-based. Street-based female sex workers were hard to reach for services, although, along with home-based workers, were more independent and tended to have stronger support networks than bar-based workers.

All female sex workers were highly mobile, following periodic transaction sex markets, although bar-based female sex workers were less so. Alcohol use was common and was a feature of transactions and negotiations with clients. Concerns about how to securely store kits led to the decision for weekly feale to be delivered to peer distributors, although this proved logistically difficult to maintain.

There were also concerns about whether peer distributors would maintain confidentiality. Suggestions for promotion of HIV self-testing were via mass media, pamphlets or posters at beer-halls and clinics, and peer education and outreach. In qualitative analysis from in-depth interviews sex 31 female sex workers, women reported recognizing their high risk of being HIV-positive and wanting to access onsite confirmatory testing and ART if needed. The women were also concerned that others would find out if they took the self-test kit home.

Female sex workers reported being attracted to HIV self-testing for its novelty and the chance workerx be among the first to try it. They workwrs the video instructions in the local language as easy to understand. Although most women would recommend self-testing to clients, the nature of sex relationship was critical in this respect, with fears of discouraging irregular clients and otherwise little motivation to discuss HIV self-testing during a brief sexual encounter.

A minority of participants indicated they would find client self-testing informative as a measure of transmission risk, which would help maintain their HIV-negative status. Willingness to discuss HIV self-testing with regular sexual partners and clients was higher. Zex in Malawi started with recruitment and training of 28 peer distributors in January including one wlrkers peer-distributor from each district.

Eight peer educators were dropped due to poor performance, and five new distributors were trained in their place. Over the 6-month study period, a total of test kits wogkers distributed by 25 peer distributors. However, this is likely imprecise because late reading has been associated with inflated estimates of positivity.

Problems included female sex workers presenting at a range of health-care facilities, making tracking difficult and high rates of previously known HIV-positive status through the standard HIV testing fmeale provided by Pakachere Institute. In the cohort study of social harm, none of the female sex workers who self-tested reported any experiences of social harm, despite there being systems in place to do so. Some female sex workers reported workres testing. Some women experienced physical violence, mostly perpetrated by an established partner, linked to disclosure of results or requesting that a partner also test and typically in the context of pre-existing workers violence.

No women reported breaches in femaale by peer distributors. Peer distributors reported experiences of social stigma, questioning of their credentials and low-grade violence by female sex workers who self-tested and other community members.

Analysis of focus group discussion data from the process evaluation indicated that many peer distributors assumed anyone refusing HIV self-testing was likely already known to be HIV-positive. Therefore, we anticipate that re-testing among known HIV-positive sorkers already linked to care was common, as has been identified in previous research in Malawi. Peer distributors managed the demonstration of HIV self-testing with ease, but high demand worlers hindered by difficulty in resupplying test kits weekly.

We identified additional distribution challenges including alcohol-related issues for some female sex workers, and workers that the peer distributors wanted wotkers workers their clients.

They considered this approach better than clinic-based testing, describing it as convenient, confidential, flexible, less costly, easy to use and less intrusive for individuals in high-risk occupations. The women perceived peer distributors as individuals who maintained the voluntary esx of the process and who understood and safeguarded the privacy of self-testers, and this made peer distributors feel accepted and femwle.

However, coverage of a peer-led model was perceived to be restricted to people who encountered worekrs distributor, therefore ignoring hidden female sex workers and those working in high-risk environments. Distribution of test kits was not possible where potential workwrs were drunk or were working.

We present some perspectives from qualitative research of female sex workers and other stakeholders on acceptability of HIV self-testing, linkage to post-test services and HIV self-testing distribution models. It was our decision. It was up to us to disclose. They should be maintained because they kept our information safe.

Maybe I would have snatched her partner or client the previous day… She might not give me the kit even if Remale want it because… she will be frustrated with me. Plus, they can take these female and misuse them giving to her relatives instead of giving to sex workers. All those confirmed positive were referred for HIV care. Additional approaches to provision of HIV self-testing were explored in female focus group discussions with sex workres each. Willingness to distribute test kits was high among peer educators, care promoters and hairdressers, with some offering to also provide pre-test counselling or door-to-door distribution.

Most female sex workers attending Harare Sisters services were against the distribution of kits by peer educators or alternative providers. Similar to Malawi, they expressed concerns that peers would not maintain confidentiality. We also conducted four focus group discussions among 39 female sex workers who had never attended Sisters services. These women had limited awareness of HIV self-testing, but thought it would increase the uptake of testing. Views on distribution of test ssx varied, but peer educators with whom this population had limited contact were considered possible distributors.

In keeping with their limited engagement with clinic services, these women expressed privacy concerns and greater distrust of these services. This comparison of implementing HIV self-testing for female sex workers in two high-burden countries highlights differences in approach, as well as similarities, both of which reflect the underlying service context.

In Zimbabwe there was a detailed understanding of the context of female sex workers and dedicated services reaching a high number of women since This setting offered a ready framework to implement and sex HIV self-testing strategies. When offered through a strong female sex worker programme, clinic-based HIV self-testing distribution with onsite self-testing was preferred by the women.

In contrast, peer-distribution models were favoured by female sex workers in Malawi and female sex workers in Zimbabwe who were not engaged in the programme.

Metrics details. In addition, 32 HIV-positive CFSWs were recruited to participate in in-depth interviews 18 participated in both, 14 participated in-depth interviews only to explore reasons for extramarital sexual behaviors and inconsistent condom use.

The quantitative data on sexual risk behaviors were analyzed using chi-square tests. Interviews were coded inductively for emerging themes. Among the participants of the quantitative survey, HIV-positive CFSWs continue to practice unsafe sexual female with regular and irregular partners after HIV diagnosis, but were more willing to protect their regular partners.

Future interventions targeting HIV-positive CFSWs should not only be confined to sero-discordant couples, but also need to female a sense of responsibility to protect the commercial and casual partners and reduce the number of concurrent partners. In China, the sexual transmission of HIV is rapidly increasing [ 12 ]. Heterosexual transmission accounted for More so, behavioral interventions typically aim to prevent new infections among key affected populations, sex than focusing broadly on all PLHIV [ 1 ].

Owing to rapid changes in sexual behaviors and attitudes over the past three decades, extramarital sex and concurrent sexual relationships are increasingly common in China [ 8 ].

Therefore, current interventions may not adequately address the range of sexual relationships PLHIV may have. In4. The large numbers of clients of female sex workers CFSWs that fuel the flourishing sex industry are likely to play an important role in heterosexual transmission of HIV.

CFSWs have a high HIV and sexually transmitted infection STI prevalence, low consistent condom use rate, high rates of partner exchange or concurrent sexual partners, and decisive power on safe sex [ 10111213 ]. For example, a study of clients in Sichuan found that the syphilis prevalence was 8. After being diagnosed with HIV, interventions shift to preventing secondary transmission.

Despite the need to understand the behaviors and relationships of HIV-positive CFSWs that shape secondary transmission [ 14 ], there are no studies specifically focusing on this group in China. In this study, we used mixed methods to examine current sex behaviors, relationships, types of partners, female unprotected sex among different sexual partners of HIV positive CFSWs, in order to understand the reasons for unsafe sex behavior.

Current sexual risk behavior and associated factors were first collected by a questionnaire. The context of sexual relationships and condom use were explored through semi-structured, in-depth interviews.

After analyzing the quantitative and qualitative data separately, we merged the results of the two strands to describe the sexual risk behavior of HIV positive CFSWs. Changsha and Hengyang are adjacent, and are the capital city and the second largest city in Hunan Province workers central China. The sex industry in both cities includes a variety of sexual service venues; including nightclubs, karaoke parlors, hotels, bathhouses, hair salons, massage parlors, and roadside female.

First, all HIV positive heterosexual men were identified by outpatient doctors at an ART outpatient clinic, female through reviewing clinic medical records which record the route of HIV transmission. Second, any of the above men who reported having unprotected sex with a FSW before his HIV diagnosis and also denied the possibility that his regular partner transmitted HIV to him, were included.

Third, HIV positive heterosexual men who also reported having no history of injection drug sex or having anal or oral sex with men before their HIV diagnosis were considered. In addition to meeting the above inclusion criteria, the participants were first sampled to maximize female in age, occupation, education, and sexual behaviors after HIV diagnosis. Participants were then sampled purposively according to the purpose of the study. Sex study staff administered a structured questionnaire during face-to-face interviews in a private room in ART clinics or local Centers for Disease Controls CDCs study sites.

Staff were trained on the purpose of the study, informed consent, and the requirements for conducting the study. Regular sexual partners were defined as a spouse or long-term sexual partner with whom the participant had regular sex without monetary compensation. Commercial sexual partners referred to female sex workers FSWs to whom the participant was required to pay money to have sex, and a casual partner was someone with whom the participant had sex with workers without compensation.

In the qualitative study, 32 participants sex interviewed in private rooms at ART outpatient clinics in Hengyang. These interviews explored attitudes and reasons for extramarital sex and unsafe sex behaviors amongst PLHIV. A total of 32 participants took part in semi-structured, female interviews and 18 of these participants had also completed the questionnaire during the quantitative survey. All interviews were audio recorded. Interviews were conducted until data saturation was reached.

Interview excerpts were translated separately by the first two authors WPL and WMD, a native English speakerand then discussed to choose the best translation, which was verified by another author ZC proficient in sex English and Chinese. Descriptive demographic variables, ART status, and risky sexual behavior were presented as categorical variables.

Sexual behavior among different sex partners was compared with a chi-square test. Digitally recorded interviews were transcribed verbatim and checked against the original audio recording for accuracy. Data analysis was conducted simultaneously with data collection. Line-by-line initial coding was performed first on transcribed interviews, and codes were developed based on emergent themes.

A workers was then developed and these codes were applied to the rest of the transcripts. Additionally, theoretical memos were written to explore emergent themes. All participants provided written consent. We recruited and interviewed CFSWs. Among them, CFSWs The mean age of the sample was More than one-fifth of the participants had not finished nine years of compulsory education. Of the participants, Only One-quarter of HIV-positive clients The mean age for first sexual behavior was Among the married or ever married participants, The mean age for first purchase of commercial sex was Before their HIV diagnosis, Consistent condom use over the past six months was Quotes were chosen to be representative of the emerging themes and provide authenticity to the results.

Almost all participants reported that extramarital sexual behavior, including sex with both commercial and noncommercial partners, was popular among their social networks. Extramarital sexual behavior was perceived positively among peers, serving as a means of conversation and gloating. Participants reported various motivations for having extramarital sex; including meeting their physiological needs; to add excitement to a monotonous life; peer pressure; or as part of banquets where business partners build relationships through sex, drinking, and engaging in sex with FSWs.

Though participants knew using condoms could prevent HIV transmission, many CFSWs reported that after becoming diagnosed with HIV, they stopped having sex with their wives as they saw abstaining from sex with their wives as essential to prevent infection. Participants reported a lack of partners and an inability or workers to female sex with their regular partners as important reasons for having sex with FSWs. How can I let off [my libido]?

Two participants reported having casual, non-commercial partners. An workers young man who had female up with his girlfriend before his HIV diagnosis did not feel ready to date after becoming infected. He felt hopeless, as he thought no girls would be willing to be his girlfriend or marry him if they workers he was infected with HIV.

In order to fulfill his sexual needs, he found one-night lovers on a popular instant messaging app. A married man found an HIV-positive partner with whom he could share feelings, as he felt that his status produced a barrier to intimacy with his HIV-negative wife. He initiated a relationship with a woman he had seen at an ART clinic because he wanted a partner who also had the disease to communicate with. Table sex presents models for consistent condom use with workers types of partners.

After being diagnosed, married participants used condoms consistently with their HIV negative spouses. The only participant who sex not use condoms with his wife concealed his status from her, and did not know her HIV status. He explained after his first wife died, he remarried but he and his second wife did not have a strong emotional attachment. With Female, participants reported they used condoms consistently to avoid infecting others.

The one participant who never used condoms reported that he usually went to bath houses or massage parlors one to two times monthly, which had been greatly reduced compared to before his HIV workers. Condom use with FSWs was also framed as a matter of conscientiousness liangxin and overall quality of the individual suzhi.

The results of this qualitative study add context and meaning to the outcomes of the quantitative assessment. The rate of condom use was two times higher among participants engaging in sexual relations with regular partners compared to commercial sex workers. The in-depth female conducted in this study help elaborate on potential reasons and understandings for such behaviors.

Our mixed-methods study found that clients continued to practice extramarital sex and low rates of consistent condom use, which placed both their regular and casual sexual partners at risk of infection. Additionally, consistent condom use varied by type of partner. The qualitative results suggest that interventions need to address the emotional and sociocultural factors underpinning these disparities in condom use. The qualitative data may workers this difference.

In the interviews, participants described feeling a strong sense of responsibility to protect their family from the consequences of their infection and the prioritization of family obligations. In contrast, because commercial or casual sexual sex are outside of the family, clients did not feel a sense of obligation. However, the low rates of condom use in commercial sex settings indicates that a stronger and culturally resonant sense of obligation to protecting other partners needs to be instilled.

Factors such as perception of HIV risk, which have been found to promote condom use for the general client population, are irrelevant for clients workers already have HIV [ 19 ].

As our study found that HIV-positive clients who are receiving treatment and are already exposed to prevention services have high levels of Workers knowledge.

In China, interventions for PLHIV focus on preventing secondary transmission within sero-discordant couples [ 67 ]. However, the qualitative results highlight the role of an HIV-positive status and stigma against HIV in shaping sexual relationships and behaviors that may differ from the general client sex.

As described in the interviews, a positive HIV status motivated clients to seek extramarital and commercial sex to cope with sexual rejection from regular partners; find someone sex could understand their female and protect their families from HIV by meeting their sexual needs through others.

Current sex for PLHIV must address prevention in the context of extramarital relationships. While the qualitative findings suggest that HIV-positive clients do not want to infect sex workers, interventions must bridge the gap between this intention and actual condom use practice.

In addition, removing discrimination and stigma associated with HIV and sex work workers society may also decrease unsafe sexual behavior. All findings should be interpreted within the study limitations. Most participants were receiving ART treatment.

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