PrEPare_Morocco a successful community-based PrEP delivery demonstration program for men who have sex with men and female sex workers in Morocco.

Pre-exposure prophylaxis (PrEP) is an effective HIV prevention tool, recommended for persons at substantial risk for HIV, such as female sex workers (FSW) and men who have sex with men (MSM). We present Morocco's and the Middle East/North Africa's first PrEP demonstration project. Our pilot aimed to assess the feasibility and acceptability of a community-based PrEP program for FSW and MSM in Morocco's highest HIV prevalence cities: Agadir, Marrakech, and Casablanca. From May to December 2017, 373 eligible participants engaged in a 5-9 month program with daily oral TDF/FTC and clinic visits. Of these, 320 initiated PrEP, with 119 retained until the study's end. We report an 86% PrEP uptake, 37% overall retention, and 78% retention after 3 months. No seroconversions occurred during follow-up. These results underscore PrEP's need and acceptability among MSM and FSW and demonstrate the effectiveness of a community-based PrEP program in Morocco. These findings informed Morocco's current PrEP program and hold potential for the wider region with similar challenges.

Prevalence and correlates of hazardous alcohol drinking and drug use among female sex workers and men who have sex with men in Mozambique.

BACKGROUND: Hazardous drinking and drug consumption are associated with an increased risk of HIV due to the complex interplay of factors influencing decision-making capability, stigma and social marginalization. In this study, we explore the patterns of hazardous alcohol and drug use and correlates of risk factors among female sex workers (FSW) and men who as sex with men (MSM) in Mozambique. METHODS: We conducted a secondary data analysis of bio-behavioral surveys (BBS) among FSW and MSM using a respondent-driven sampling methodology conducted in five main urban areas of Mozambique from 2019 to 20. The survey included a standardized questionnaire, where hazardous drinking was assessed (using AUDIT-C scores ≥ 4 for men, ≥ 3 for women) and drug use in the last year (FSW). Chi-squared test was used to analyze the association between socio-demographic and behavioral variables, and multivariate logistic regression measured the impact of the associated factors. RESULTS: The prevalence of hazardous alcohol drinking was 47.1% (95% CI:44.8-49.5) for FSW and 46.5 (95% CI: 44.0-49.0) for MSM. Current drug use was reported in 13.3% of FSW. FSW engaging in hazardous alcohol drinking reported more sexual partners in the last month than those no reporting hazardous alcohol use (55.3% vs. 47,1%, p < 0.001), higher rates of self-reported STIs in the last year (62,5% vs. 48,2%, p < 0.001), physical (53.5% vs. 46.7%, p < 0.0001) and sexual violence (54.7% vs. 44.2%, p < 0.001), and HIV prevalence (55.2% vs. 44.2 p < 0.001). Among MSM with hazardous alcohol drinking, there was a higher prevalence of self-reported STIs (52.8% vs. 45.4%, p < 0.001), experiences of sexual violence (18.0% vs. 8.3%, p < 0.001), and HIV prevalence (53.0% vs. 46.3%, p < 0.001). In addition, FSW who reported illicit drug use were more likely to self-reported HIV own risk (14.2% vs. 9.7%), early start sexual activity (15.4% vs. 5.3%), self-reported STIs (17.9% vs. 10.2%), and experiences of both physical (17.4% vs. 7.0%) and sexual violence (18.6% vs. 8.9%). CONCLUSION: There is an immediate need for the introduction and integration of comprehensive substance use harm mitigation and mental health interventions into HIV prevention programs, particularly those targeting key populations in Mozambique.

Pharmaco-virological algorithm to target risk of drug resistance among a population of HIV-infected key populations in Togo.

No data about antiretroviral (ARV) treatment coverage and virological response are available among key populations (female sex workers [FSW] and Men having Sex with Men [MSM]) in Togo. This study aimed to both describe Human Immunodeficiency Virus (HIV) immunovirological status and evaluate the pertinence of an original algorithm combining pharmacology (PK) and viral load (VL) to identify subjects at risk of ARV drug resistance. A cross-sectional multicentric study was conducted in 2017 in Togo. Our PK-virological algorithm (PK-VA) defines subjects at risk of resistance when exhibiting both detectable plasma drug concentrations and VL > 200 c/mL. Among the 123 FSW and 136 MSM included, 50% and 66% were receiving ARV, with 69% and 80% of them successfully-treated, respectively. Genotypes showed drug-resistance mutation in 58% and 63% of nonvirologically controlled (VL > 200 c/mL) ARV-treated FSW and MSM, respectively. PK-VA would have enabled to save 75% and 72% of genotypic tests, for FSW and MSM, respectively. We reported first data about HIV care cascade among key populations in Togo, highlighting they are tested for HIV but linkage to care remains a concern. Furthermore, 70%-80% of ARV-treated participants experienced virological success. In limited resources settings, where genotyping tests are beyond reach, PK-VA might be an easiest solution to sort out patients needing ARV adaptation due to resistance.

Mobility and HIV vulnerabilities among female sex workers in Guinea-Bissau: findings from an integrated bio-behavioral survey.

BACKGROUND: Mobility is an important risk determinant for HIV given the potential for intermittent access to HIV services. Mobility may be particularly relevant among female sex workers, (FSW) who have been shown to be at high risk for HIV in settings around the world. Data regarding the role mobility plays in exacerbating HIV risks among FSW across Sub-Saharan Africa remains limited, and data on FSW in Guinea-Bissau is sparse. METHODS: FSW in four regions of Guinea-Bissau were recruited with a respondent-driven sampling (RDS) method and participated in an integrated bio-behavioral survey between September 27, 2017 and January 26, 2018. Associations between reported general mobility, mobility to or residence in Bissau, and social and HIV vulnerabilities among FSW in Guinea-Bissau were assessed using multivariable logistic regression models. Population proportions were weighted for RDS sampling, while logistic regression models were not. RESULTS: Survey respondents included 323 individuals in Bissau, 45 in Bissorã, 140 in Bafatá, and 59 in Gabu. Statistical analyses demonstrated that mobility to more than one destination was significantly associated with recent sex without a condom (ie, sex without a condom within the last three sex acts) with both clients (aOR: 2.47 (95% CI: 1.08, 5.64)) and non-paying partners (aOR: 5.39 (95% CI: 2.61, 11.15)) compared to non-mobility. However, mobility to one or more locations was also associated with higher odds of receiving HIV prevention information, and mobility to more than one location was associated with participating in programming with HIV-related organizations. CONCLUSIONS: These results suggest that while some prevention services including HIV prevention information reach mobile FSW in Guinea-Bissau more than their non-mobile counterparts, the higher rates of condomless sex among mobile FSW suggest that HIV prevention needs may remain unmet for mobile FSW in Guinea-Bissau. Additionally, the results suggest a nuanced relationship between mobility, place of residence, and HIV and social vulnerabilities and prevention indicators.

Does the perception of HIV risk among Female sex workers affect HIV prevention behavior? application of the Health Belief Model (HBM).

BACKGROUND: High prevalence of Human Immune virus/Acquired immunodeficiency syndrome (HIV/AIDS) in Female Sex Workers (FSWs) is identified as a bottleneck in fighting against HIV/AIDS. To this end, the international community planned a strategy of 'Ending inequality' and 'Ending the AIDS epidemic' by 2030. This could not be achieved without due attention to FSWs. Thus, this study attempted to assess HIV prevention behavior and associated factors among FSWs in Dima district of Gambella region, Ethiopia by using the Health Belief Model. METHODS: A community-based cross-sectional study was conducted from March to May 2019 among 449 FSWs selected using the snowball sampling technique. Socio-demographic features, knowledge about HIV, attitude toward HIV prevention methods, and Health Belief Model (HBM) constructs (perceived susceptibility to and severity of HIV, perceived barriers, and benefits of performing the recommended HIV prevention methods, self-efficacy, and cues to practice HIV prevention methods) were collected using face to face interview. Data were entered into Epi-data 3.1 and analyzed using SPSS version 23. Bivariable and multivariable binary logistic regression analysis was done to identify the association between dependent and independent variables. P-value < 5% with 95 CI was used as a cutoff point to decide statistical significance of independent variables. RESULTS: In this study, 449 FSWs participated making a response rate of 98.90%. Of these, 64.8% had high HIV prevention behavior. Age (AOR = 1.911, 95% CI: 1.100, 3.320), knowledge of HIV (AOR = 1.632, 95% CI: 1.083, 2.458), attitude towards HIV prevention methods (AOR = 2.335, 95% CI: 1.547, 3.523), perceived barriers (AOR = .627, 95% CI: .423, .930), and self-efficacy (AOR = 1.667, 95% CI: 1.107, 2.511) were significantly associated with high HIV prevention behavior. CONCLUSION: The study identified that about two third of FSWs practiced the recommended HIV prevention methods. Age of respondents, knowledge of HIV, favorable attitude towards the recommended HIV prevention methods, high self-efficacy, and low perceived barrier were associated with high HIV prevention behavior. Therefore, focusing on these factors would be instrumental for improving effectiveness of the ongoing HIV prevention efforts and attaining the 'Sustainable Development Goals of 'Ending inequality' and 'Ending the AIDS epidemic' by 2030.

Beaten but not down! Exploring resilience among female sex workers (FSWs) in Nairobi, Kenya.

BACKGROUND: In Kenya sex work is illegal and those engaged in the trade are stigmatized and marginalized. We explored how female sex workers in Nairobi, Kenya, utilize different resources to navigate the negative consequences of the work they do. METHODS: Qualitative data were collected in October 2019 from 40 FSWs who were randomly sampled from 1003 women enrolled in the Maisha Fiti study, a 3-year longitudinal mixed-methods study exploring the relationship between HIV risk and violence and mental health. All interviews were audio-recorded, transcribed and translated. Data were thematically coded and analyzed using Nvivo 12. RESULTS: Participants' age range was 18-45 years. Before entry into sex work, all but one had at least one child. Providing for the children was expressed as the main reason the women joined sex work. All the women grew up in adverse circumstances such as poor financial backgrounds and some reported sexual and physical abuse as children. They also continued to experience adversity in their adulthood including intimate partner violence as well as violence at the workplace. All the participants were noted to have utilised the resources they have to build resilience and cope with these adversities while remaining hopeful for the future. Motherhood was mentioned by most as the reason they have remained resilient. Coming together in groups and engaging with HIV prevention and treatment services were noted as important factors too in building resilience. CONCLUSION: Despite the adverse experiences throughout the lives of FSWs, resilience was a key theme that emerged from this study. A holistic approach is needed in addressing the health needs of female sex workers. Encouraging FSWs to come together and advocating together for their needs is a key resource from which resilience and forbearance can grow. Upstream prevention through strengthening of education systems and supporting girls to stay in school and complete their secondary and/or tertiary education would help them gain training and skills, providing them with options for income generation during their adult lives.

The PEARL study: a prospective two-group pilot PrEP promotion intervention for cisgender female sex workers living in Baltimore, MD, U.S.

HIV remains elevated among female sex workers (FSW) globally, with a number of structural (e.g., poverty, access to care) factors driving these persistently high rates. Pre-exposure prophylaxis (PrEP), a user-controlled prevention method, is a promising means of empowering vulnerable populations to protect themselves and enhance agency. Yet there is a dearth of PrEP research and interventions targeting cisgender women in the United States, and even fewer aimed to reach FSW. We developed and implemented a multifaceted PrEP pilot intervention, the Promoting Empowerment And Risk Reduction (PEARL) study, to meet this gap. This paper describes the development process and nature of a community-informed intervention for tenofovir/emticitrabine (TDF/FTC) pre-exposure prophylaxis engagement among street-based cisgender FSW in Baltimore, Maryland, U.S. In the course of the study's implementation, structural, programmatic, and medical barriers have already posed significant barriers to full engagement. PEARL implemented a number of strategies in an effort to counter barriers and facilitate increased success of PrEP uptake and maintenance. The study will provide critical insights into the nature of intervention components that could help FSW to initiate PrEP and reduce PrEP care cascade gaps.

Understanding issues around use of oral pre exposure prophylaxis among female sex workers in India.

BACKGROUND: Empowering female sex workers (FSWs) through women controlled HIV prevention option has been in focus globally. FSWs are important target for oral pre exposure prophylaxis (PrEP). A multi-centric qualitative study was conducted to explore the FSWs' willingness to use oral PrEP in India. METHODS: Seventy three interviews and 02 focus group discussions were conducted at 3 high HIV prevalent states in India during 2013-14. Study explored issues around willingness to use oral PrEP. The study was approved by the respective institutional ethics committee of the study sites. Thematic analysis using grounded theory approach was used to analyze the data in N-VIVO version 8.0. RESULTS: Thematic analysis showed events of forced condom-less sex. FSWs believed that oral PrEP could provide independence, financial gains, and privacy and therefore hoped to use it as an alternative to male condom. However, any impact on physical/ aesthetic attributes and reproductive system were not acceptable and could become a barrier. Provider initiated oral PrEP was not preferred. Providers voiced safety monitoring concerns. Adherence emerged as a challenge because of: (1) alcohol use; (2) taking PrEP tablet each day being boring; (3) Stigma because Oral PrEP is ARV based. Alcohol use and dread of repetitive dose brings forth the need for long acting oral PrEP. CONCLUSION: Oral PrEP is acceptable among FSWs; it should be rolled out alongside strong messages on STI protection and PrEP as compliment to condoms. PrEP roll out requires educating communities about HIV treatment versus prevention. Long-acting oral PrEP could address both 'boredom' and alcoholism and sustain adherence.

Factors associated with condom breakage among female sex workers in the Western Region of Ghana.

Condoms have been extensively demonstrated as being effective in reducing Human Immunodeficiency Virus (HIV) infection rates among both men and women. With proper use and production, condom breakage is ideally minimal. However, breakage is reportedly a widespread problem among Female Sex Workers (FSWs), who are classified as a Key Population and warrant special transmission prevention efforts. Nationally, Ghana records an average rate of 5% of condom breakage. This study sought to identify the factors associated with condom breakage among FSWs in the western region of Ghana, a region with an extensive sex worker population and HIV incidence rate of 2.5%, higher than the national average. This study employed a cross-sectional survey among FSW populations in the Western region, Ghana. A sample of 416 participants were proportionately invited between brothel based and roamer communities to participate in the surveys. A total of 403 consented to participate indicating a response rate of 96.9%. Data were analysed for frequencies and prevalence of variables including condom breakage. At the bivariate level, associations with breakage were examined and statistically significant variables were analysed with simple and multiple logistic regression analysis. Of the 403 research participants who consented to participate, 17.4% had experienced breakage over the past week. Brothel-based FSWs were only half as likely to report condom breakage as non-brothel based FSWs (aOR = 0.526; 95% CI, 0.296 - 0.936). Notably, FSWs who consumed alcohol-containing drinks every day were only 65.2% as likely as those who consumed alcohol at least once a week or less than once a week or never to experience condom breakage (aOR = 0.348; 95% CI, 0.164 - 0.740). The study determined that the occurrence of condom breakage among FSWs in the western region was 17.4%. Factors significantly associated with condom breakage were being non-brothel based, frequency of alcohol consumption and parity. Condom use education programmes targeted at non-brothel based FSWs are necessary to reduce breakage and lower the risk of HIV transmission.

A Mixed Methods Analysis of the Venue-Related Social and Structural Context of Drug Use During Sex Among Male Clients of Female Sex Workers in Tijuana, Mexico.

Drug use during sex increases risks for HIV acquisition. Male clients of female sex workers (FSW) represent both a key population at risk for HIV as well as a transmission bridge population. In Tijuana, Mexico, drug use is prevalent and there is a need to understand male clients' drug use during sex with FSW. Characteristics of sex work venues may confer higher risks for drug use, risky sex, and HIV/STI. It is essential to understand the venue-related social and structural factors associated with drug use during sex in order to inform HIV prevention interventions with male clients in this region. We used a Mixed-Methods Sequential Explanatory Design to conduct an enriched examination of drug use during sex among male clients of FSW in Tijuana. Findings from logistic regression analysis showed that drug use during sex was significantly correlated with police harassment (AOR = 4.06, p < .001) and methamphetamine use (AOR = 33.77, p < .001). In-depth interview data provided rich meaning behind and context around the quantitative associations. Social and structural interventions to reduce police harassment, methamphetamine use, and promote condom availability are needed to reduce risks for HIV among male clients of FSW in Tijuana.

The PrEP Care Continuum Among Cisgender Women Who Sell Sex and/or Use Drugs Globally: A Systematic Review.

HIV prevalence among cisgender female sex workers (FSW) and/or women who use drugs (WWUD) is substantially higher compared to similarly aged women. Consistent with PRISMA guidelines, we conducted the first systematic review on the pre-exposure prophylaxis (PrEP) continuum among FSW and/or WWUD, searching PubMed, Embase, CINAHL, PsycInfo, and Sociological Abstracts. Eligibility criteria included: reporting a PrEP related result among FSW and/or WWUD aged 18 + ; peer-reviewed; and published in English between 2012 and 2018. Our search identified 1365 studies; 26 met eligibility requirements, across the following groups: FSW (n = 14), WWUD (n = 9) and FSW-WWUD (n = 3). Studies report on at least one PrEP outcome: awareness (n = 12), acceptability (n = 16), uptake (n = 4), and adherence (n = 8). Specific barriers span individual and structural levels and include challenges to daily adherence, cost, and stigma. Combining health services and long-acting PrEP formulas may facilitate better PrEP uptake and adherence. The limited number of studies indicates a need for more research.

Community-based antiretroviral therapy (ART) delivery for female sex workers in Tanzania: intervention model and baseline findings.

To increase linkage to and retention in antiretroviral therapy (ART) care, we piloted a community-based, ART service delivery intervention for female sex workers (FSWs). At baseline, we recruited and collected data from 617 FSWs (intervention: 309; comparison: 308) who were HIV positive and not on ART. This paper presents (1) the description of the intervention model, and (2) key descriptive and bivariate-level findings of the baseline FSW cohort. The data showed more than half of FSWs had a non-paying sex partner, and less than one-third used a condom at last sex with paying and non-paying clients, which suggest potentially high levels of HIV transmission. In addition, there is a gap in HIV testing and treatment because one-third learned about their HIV-positive status only at study enrollment, and among FSWs who had known their status for more than a month, half had not registered in care. This substantiates the importance of timely HIV diagnosis and treatment. A community-based ART program may serve as an important strategy in closing the HIV care and treatment gap for FSWs.

Sexually transmitted infections in male heterosexual Dutch clients who visited German cross-border female sex workers; a 3 year retrospective study.

BACKGROUND: Some male heterosexual clients prefer to visit a cross-border Female Sex Worker (FSW) because of cheaper sex and unsafe sex practices, and may therefore be at risk for sexually transmitted infections (STI). The objective of this study was to assess whether having commercial cross-border sex is an independent risk factor for being diagnosed with a STI. METHODS: An observational retrospective study was performed using data of 8 Dutch STI clinics bordering Germany, between 2011 and 2013. All male heterosexual clients of FSWs were selected and data on country of FSW visit and occurrence of STI were used for multivariable regression analysis. RESULTS: The study population consisted of 2664 clients of FSW. Most clients visited the Netherlands (82.4%), followed by visits to another country (beyond cross-border) (9.9%) and cross-border visits (7.8%). Clients of FSW were less likely to be STI positive when they were younger than 25 years(OR = 0.6, 95%CI 0.4 to 0.8 25-44 years and OR = 0.5, 95%CI 0.4 to 0.7 older than 45 years), and more likely when they had 20 or more sex partners in the last 6 months (OR = 2.9, 95%CI 1.9 to 4.4), did not use a condom during last sexual contact (OR = 2.2, 95%CI 1.6 to 2.9) and made cross-border visits (OR = 1.7, 95%CI 1.1 to 2.6). CONCLUSIONS: As cross-border visits appears to be a novel independent risk factor for STI in clients of FSW, this group should therefore be advised on STI prevention.

Structural vulnerabilities and HIV risk among sexual minority female sex workers (SM-FSW) by identity and behavior in Baltimore, MD.

BACKGROUND: Research suggests sexual minority female sex workers (SM-FSW) face elevated structural vulnerability and HIV risk compared to their heterosexual counterparts. Structural vulnerabilities reflect societal level factors (e.g., sexism, homophobia, racism) that constrain an individual's agency, particularly related to health outcomes. This study examines the association between SM status by identity and behavior, structural vulnerability, and HIV risk among a sample of street-based FSW. METHODS: The current study utilizes baseline data from the SAPPHIRE study, a prospective cohort of cis gender and transgender FSW in Baltimore, MD, recruited through targeted time-location sampling from April 2016 to January 2017. The current analysis focuses on cisgender women. The baseline survey ascertained demographics, substance use, intimate partner violence (IPV), and sex work characteristics. Multivariable models were constructed using self-identity and behaviorally defined SM status as independent variables with vulnerability outcomes (e.g., injection drug use, injection speedball, binge drinking, homelessness, physical IPV, ever had a pimp, and being a minor at sex work entry (age < 18)) as dependent variables. RESULTS: Of the participants (n = 247), 25.5% (n = 63) self-identified as a SM by identity (e.g., gay or bisexual), and 8.5% (n = 21) reported SM behavior (e.g., same-gender sexual behavior) in the past 3 months. In multivariable logistic regression models, SM status by identity was associated with increased odds of injection drug use, binge drinking, homelessness, physical IPV, and being a minor at sex work entry. SM status by behavior was associated with increased odds of binge drinking, homelessness, ever having a pimp, and being a minor at sex work entry. CONCLUSION: The study indicates disproportionate structural vulnerability and heightened HIV risk among SM-FSW, as compared to their heterosexual counterparts, with differences in their profile by sexual identity and behavior. Findings suggest a need for nuanced interventions tailored to these populations.

Resilience and pathways to wellness among HIV-positive patients in Ghana: a qualitative study.

Few African studies have focused on resilience factors related to engagement in HIV-related care among people living with HIV; instead, many studies have identified health risk factors and barriers within this population. Informed by the Disability-Stress-Coping Model of Adjustment, a qualitative study was conducted to develop a better understanding of psychosocial factors that can promote positive behaviours and subjective wellness for people living with HIV in Accra, Ghana. Thirty patients from the two largest HIV clinics in Accra participated in in-depth individual interviews. Using a thematic analysis approach, three individual-level factors related to resilience and subjective wellness were identified: (1) holding positive attitudes towards the pathway from HIV testing and diagnosis to healthy living with HIV; (2) placing appropriate (but not absolute) levels of trust in the clinical care environment; and (3) judicious disclosure of their HIV status to key individuals. Findings support a resilience framework that focuses on individual strengths and positive adaptations to HIV diagnosis in order to enhance understanding and promote the HIV care continuum for people living with HIV in this context. Development of resilience-focused approaches to public health intervention is particularly important in low-resource settings such as Ghana where research tends to focus on deficiencies and healthcare inadequacies for people living with HIV.

Community-Based Antiretroviral Therapy (ART) Delivery for Female Sex Workers in Tanzania: 6-Month ART Initiation and Adherence.

We conducted an implementation science study of a community-based ART distribution program for HIV-positive female sex workers (FSW) whereby clients received ART services through community-based mobile and home-based platforms. We compared 6-month treatment-related outcomes in the community-based ART arm (N = 256) to the standard facility-based ART delivery arm (N = 253). Those in the intervention arm were more likely to have initiated ART (100.0% vs. 71.5%; p = 0.04), be currently taking ART at the 6-month visit (100.0% vs. 95.0%; p < 0.01), and less likely to have stopped taking ART for more than 30 days continuously (0.9% vs. 5.7%; p = 0.008) or feel high levels of internalized stigma (26.6% vs. 39.9%; p = 0.001). In the adjusted regression model, internalized stigma (adjusted OR [aOR]: 0.5; 95% CI 0.28-0.83) and receiving community-based ART (aOR: 208.6; 95% CI 12.5-3479.0) were significantly associated with ART initiation. Community-based ART distribution model can improve linkage to and adherence to ART over standard facility-based ART programs for FSWs.

HIV prevalence among female sex workers in Guigang City, Guangxi, China: an 8-year consecutive cross-sectional study.

BACKGROUND: Female sex workers (FSW) are a population that are at high risk for HIV infection, and their HIV/AIDS knowledge levels and sexual behaviors are of concern. This study describes changes in HIV prevalence and factors associated among female sex workers in Guigang City, Guangxi, one of the highest HIV prevalence areas in China. METHODS: Data were derived from an annual cross-sectional venue-based survey, 2008 to 2015, in the form of sentinel surveillance. The participants were recruited using cluster sampling. FSW aged 16 years and above who completed a questionnaire and HIV testing. Both descriptive and multi-level analyses were used to explore factors associated with changes in HIV prevalence. RESULTS: Seven thousand four hundred ninety-six FSW were recruited in this study. HIV prevalence among FSW in Guigang City fell into two periods, one with an increasing trend (2008-2011) and one with a decline (2012-2015). Differences between these time periods included age, relationship status, HIV knowledge, consistent condom use, lifetime illicit drug use, history of sexually transmitted infection in the past year, HIV testing, receipt of a condom distribution and education program or HIV counseling and testing, and peer education services. CONCLUSIONS: Since 2012, a reduction in HIV prevalence among FSW in Guigang City has been observed. The decline of HIV prevalence was associated with coinciding changes in demographic characteristics of FSW, improvement of HIV knowledge and safer sexual behaviors, and a program that promotes condom use, HIV counseling & testing, and peer education.

Factors in the HIV risk environment associated with bacterial vaginosis among HIV-negative female sex workers who inject drugs in the Mexico-United States border region.

BACKGROUND: Bacterial vaginosis (BV) is the most common cause of vaginitis among women worldwide and is associated with increased susceptibility to sexually transmitted infections (STIs), including HIV. We aimed to determine the impact of the HIV risk environment on BV among female sex workers who inject drugs (FSW-PWIDs) in Tijuana and Ciudad Juarez, Mexico. METHODS: We performed a cross-sectional analysis utilizing baseline data from a randomized controlled trial evaluating a behavioral HIV prevention intervention. Participants underwent testing for BV using the OSOM BVBlue® Rapid Test (Genzyme Diagnostics, San Diego, CA) and completed a survey eliciting information on the HIV risk environment, sexual risk behaviors, and substance use. We applied logistic regression to identify correlates of BV in the physical, social, economic, and political HIV risk environments stratified by study site (Ciudad Juarez vs. Tijuana). RESULTS: In total, 584 HIV-negative FSW-PWIDs (300 Ciudad Juarez; 284 Tijuana) were enrolled. The prevalence of BV was 39% (n = 228), which was higher in Ciudad Juarez (56.7%) compared to Tijuana (20.4%). In both cities, micro-level components of the physical HIV risk environment were associated with BV. In Ciudad Juarez, BV was associated with past experiences or threats of physical violence in response to proposed condom use (adjusted odds ratio [aOR] = 3.66, 95% confidence interval [CI]: 1.74-7.69, p = 0.001) and lifetime residence in Ciudad Juarez (aOR = 1.74, 95% CI: 1.05-2.87, p = 0.031). In Tijuana, BV was associated with the number of hours spent on the street daily in the past six months looking for, using, or dealing drugs, engaging in other income generating activities, or sleeping (aOR = 1.05, 95% CI: 1.001-1.097, p = 0.045). CONCLUSIONS: Our findings suggest that FSW-PWIDs' risk of BV may be shaped by the microphysical HIV risk environment. Addressing components of the physical risk environment, including interventions to reduce gender-based violence, may alleviate the burden of BV and subsequent susceptibility to HIV/STIs among FSW-PWIDs in the Mexico/US border region. TRIAL REGISTRATION: National Institute of Health (NIH) Clinical Trials Identifier NCT00840658 , and date of NIH trial registration February 7, 2009.

Behavioral and Psychosocial Correlates of HIV Testing Among Male Clients of Female Sex Workers in Tijuana, Mexico.

We use data collected from a sample of 400 male clients of female sex workers (FSW) to examine their HIV testing behavior. We present frequencies of HIV testing and used bivariate and multivariable analyses to assess its socio-demographic, behavioral, and psychosocial correlates. We found that the majority (55 %) of male clients of FSW in Tijuana, Mexico had never had an HIV test and the prevalence of HIV testing within the past year was low (9 %). In multivariable analyses, significant correlates of having ever tested for HIV were higher age, higher HIV knowledge score, lower sexual compulsiveness score, lower misogynistic attitudes score, having a condom break during sex with a FSW, and higher frequency of sex with a FSW while she was high. Our findings represent an important starting point for developing effective interventions to address the need to promote HIV testing among this population.

The association between substance use and sub-optimal HIV treatment engagement among HIV-infected female sex workers in Lilongwe, Malawi.

Female sex workers (FSW) have a high prevalence of substance use and HIV, but the impact of substance use on HIV treatment engagement is not well established. We evaluated the association between alcohol and marijuana use and sub-optimal HIV treatment engagement outcomes among HIV-infected FSW in Lilongwe, Malawi. We enroled FSW using venue-based recruitment into a cross-sectional evaluation assessing substance use and HIV treatment engagement. Seropositive FSW, identified through HIV rapid testing, received rapid CD4 count and viral load testing. We used Poisson regression with robust variance estimates to ascertain associations of alcohol and marijuana use with sub-optimal HIV treatment outcomes: (1) lack of ART use among previously diagnosed, ART-eligible FSW and (2) viral nonsuppression among FSW on ART. Of previously diagnosed, ART-eligible FSW (n = 96), 29% were not using ART. Patterns of hazardous drinking were identified in 30%, harmful drinking in 10%, and alcohol dependence in 12%. ART-eligible FSW with harmful drinking or alcohol dependency were 1.9 (95% CI: 1.0, 3.8) times as likely to not use ART compared to FSW without harmful or dependent drinking. Among those on ART, 14% were virally nonsuppressed. The prevalence ratio for viral nonsuppression was 2.0 (95% CI: 0.6, 6.5) for harmful drinkers and alcohol-dependent FSW. Over 30% of ART-eligible FSW reported using marijuana. Marijuana-using FSW were 1.9 (95% CI: 0.8, 4.6) times as likely to not use ART compared to FSW who were not using marijuana. Given the high prevalence of alcohol use and its association with lack of ART use, ART uptake and alcohol reduction strategies should be tailored for alcohol-using FSW in Malawi.