Relationships Between Stigma and Intimate Partner Violence Among Female Sex Workers Living With HIV: Social and Economic Exclusion.

Violence against female sex workers (FSWs) perpetrated by their intimate (i.e., non-commercial) partners, particularly against FSWs living with HIV, is understudied. Stigma can deplete the economic resources, social relationships, and mental well-being of stigmatized people, which may increase their intimate partner violence (IPV) risk. We quantitatively assessed relationships between HIV stigma and sex work stigma and IPV victimization among FSWs living with HIV in the Dominican Republic (n = 266). Enacted HIV stigma, in the form of job loss, and anticipated HIV stigma, in the form of fear of exclusion by family, were associated with increased IPV risk. Potential association mechanisms, including increased economic vulnerability and social isolation, and programmatic responses are discussed.

Tuberculosis (TB) Aftermath: study protocol for a hybrid type I effectiveness-implementation non-inferiority randomized trial in India comparing two active case finding (ACF) strategies among individuals treated for TB and their household contacts.

BACKGROUND: Approximately 7% of all reported tuberculosis (TB) cases each year are recurrent, occurring among people who have had TB in the recent or distant past. TB recurrence is particularly common in India, which has the largest TB burden worldwide. Although patients recently treated for TB are at high risk of developing TB again, evidence around effective active case finding (ACF) strategies in this population is scarce. We will conduct a hybrid type I effectiveness-implementation non-inferiority randomized trial to compare the effectiveness, cost-effectiveness, and feasibility of two ACF strategies among individuals who have completed TB treatment and their household contacts (HHCs). METHODS: We will enroll 1076 adults (≥ 18 years) who have completed TB treatment at a public TB unit (TU) in Pune, India, along with their HHCs (averaging two per patient, n = 2152). Participants will undergo symptom-based ACF by existing healthcare workers (HCWs) at 6-month intervals and will be randomized to either home-based ACF (HACF) or telephonic ACF (TACF). Symptomatic participants will undergo microbiologic testing through the program. Asymptomatic HHCs will be referred for TB preventive treatment (TPT) per national guidelines. The primary outcome is rate per 100 person-years of people diagnosed with new or recurrent TB by study arm, within 12 months following treatment completion. The secondary outcome is proportion of HHCs < 6 years, by study arm, initiated on TPT after ruling out TB disease. Study staff will collect socio-demographic and clinical data to identify risk factors for TB recurrence and will measure post-TB lung impairment. In both arms, an 18-month "mop-up" visit will be conducted to ascertain outcomes. We will use the RE-AIM framework to characterize implementation processes and explore acceptability through in-depth interviews with index patients, HHCs and HCWs (n = 100). Cost-effectiveness will be assessed by calculating the incremental cost per TB case detected within 12 months and projected for disability-adjusted life years averted based on modeled estimates of morbidity, mortality, and time with infectious TB. DISCUSSION: This novel trial will guide India's scale-up of post-treatment ACF and provide an evidence base for designing strategies to detect recurrent and new TB in other high burden settings. TRIAL REGISTRATION: NCT04333485 , registered April 3, 2020. CTRI/2020/05/025059 [Clinical Trials Registry of India], registered May 6 2020.

"It made me more confident that I have it under control": Patient and provider perspectives on moving to a two-drug ART regimen in the United States and Spain.

BACKGROUND: Two-drug regimens (2DR) to treat HIV infection have the potential to reduce long-term toxicity and increase therapeutic options for people living with HIV (PLHIV). Prior phase III trials, SWORD-1 and SWORD-2, as well as GEMINI-1 and GEMINI-2, have demonstrated that a dolutegravir-based 2DR is as effective as three- or four-drug regimens among virologically suppressed patients. Limited information exists, however, on patient and provider experiences with 2DR to inform roll-out and integration into routine clinical care. METHODS: We conducted 39 in-depth interviews with PLHIV currently on 2DR in the context of routine care and 8 of their clinical care providers in the United States (U.S.) and Spain. Participants included 33 male and 6 female PLHIV and 8 providers. Interview topics explored perceptions of and experiences with 2DR compared to prior anti-retroviral regimens (ARVs), side effects, patient satisfaction, and clinical performance. Interviews were audio-recorded, transcribed and analyzed using thematic content analysis. RESULTS: Participants viewed 2DR as a significant and positive advance, in terms of its ability to effectively treat HIV with reduced toxicity and essentially no reported side effects. Patients noted the central role providers played in the decision to switch to a 2DR regimen and, among U.S. participants, the importance of insurance coverage making this preferred option feasible. Patients and providers agreed that a 2DR regimen would be appropriate for any PLHIV regardless of whether they were treatment naïve or had significant experience with ARVs. CONCLUSIONS: Participants' experiences with a 2DR regimen were positive with no participants, reporting side effects and all reporting continued viral suppression. Providers valued the reduced toxicity offered by 2DR and served as the primary gateway to a transition to 2DR for patients in both settings. This study provides a foundation for further research on the transition to 2DR regimens in other populations and contexts including low- and middle-income settings.

Rites of Resistance: Sex Workers' Fight to Maintain Rights and Pleasure in the Centre of the Response to HIV in Brazil.

Drawing on ethnographic research conducted from 2011 to 2015 and the authors' long-term engagement in diverse aspects of HIV and human rights advocacy in Brazil, this paper explores key elements of the Brazilian sex workers' movement response to HIV and the broader political factors that profoundly influenced its trajectory. We argue that the movement has constantly challenged representations of prostitution by affirming sex workers' roles as political actors, not just peer educators, in fighting the HIV epidemic and highlight their development of a sex positive and pleasure centred response that fought stigma on multiple fronts. Moments of tension such as the censorship of an HIV prevention campaign and implementation of 'test and treat' projects are analysed, as are the complex questions that Brazil's 2016 political and economic crisis evokes in terms of how to develop and sustain responses to HIV driven by communities but with material commitment from the State. We conclude with what we see to be the unique, central components of Brazilian sex workers' approach to HIV prevention and what lessons can be learned from it for broader collective health movements in Latin America and beyond.

'That's how we help each other': Community savings groups, economic empowerment and HIV risk among female sex workers in Iringa, Tanzania.

Female sex workers (FSW) are a socially and economically marginalized population heavily affected by HIV. Community empowerment approaches focus on FSW taking collective action to address structural barriers to their health and have demonstrated effectiveness in reducing HIV risk. This study examines the potential for community savings groups (locally called michezo) among FSW in Iringa, Tanzania to reduce HIV risk and promote economic and community empowerment. We conducted 27 in-depth interviews (IDIs) with 15 FSW over time and 4 focus group discussions (FGDs) with 35 FSW participating in michezo, and 10 key informant interviews (KIIs) with group collectors. Content analysis was used to identify salient themes around participants' sex work and financial realities; the role of savings groups in their lives and work; and experiences with social cohesion associated with group participation. Michezo were described as providing a safety net for times of financial need, allowing FSW to create greater financial security for themselves and their families. Participation in the groups was also reported to facilitate both individual agency, resulting in members' ability to negotiate condom use and be selective about clients, and a sense of collective identity and solidarity. Participants described group challenges including high mobility and low income of FSW making it difficult for women to fulfill their financial obligations to the group. As a result, participants reported preferences for joining michezo whose members were perceived as more stable (e.g. older, married, from more established venues). Group collectors and members were eager to have michezo formally registered and become recognized by the broader community. Findings indicate that savings groups promote individual agency to reduce sexual risk behaviors and foster community empowerment among FSW. The groups hold potential as an empowerment strategy to enable sex workers to address structural sources of HIV vulnerability and help them achieve socioeconomic inclusion.

The global response and unmet actions for HIV and sex workers.

Female, male, and transgender sex workers continue to have disproportionately high burdens of HIV infection in low-income, middle-income, and high-income countries in 2018. 4 years since our Lancet Series on HIV and sex work, our updated analysis of the global HIV burden among female sex workers shows that HIV prevalence is unacceptably high at 10·4% (95% CI 9·5-11·5) and is largely unchanged. Comprehensive epidemiological data on HIV and antiretroviral therapy (ART) coverage are scarce, particularly among transgender women. Sustained coverage of treatment is markedly uneven and challenged by lack of progress on stigma and criminalisation, and sustained human rights violations. Although important progress has been made in biomedical interventions with pre-exposure prophylaxis and early ART feasibility and demonstration projects, limited coverage and retention suggest that sustained investment in community and structural interventions is required for sex workers to benefit from the preventive interventions and treatments that other key populations have. Evidence-based progress on full decriminalisation grounded in health and human rights-a key recommendation in our Lancet Series-has stalled, with South Africa a notable exception. Additionally, several countries have rolled back rights to sex workers further. Removal of legal barriers through the decriminalisation of sex work, alongside political and funding investments to support community and structural interventions, is urgently needed to reverse the HIV trajectory and ensure health and human rights for all sex workers.

Community Savings Groups, Financial Security, and HIV Risk Among Female Sex Workers in Iringa, Tanzania.

This study assessed the association between community savings group participation and consistent condom use (CCU) among female sex workers (FSW) in Iringa, Tanzania. Using cross-sectional data from a survey of venue-based FSW (n = 496), logistic regression was used to examine the associations between financial indicators including community savings group participation and CCU. Over one-third (35%) of the women participated in a savings group. Multivariable regression results indicated that participating in a savings group was significantly associated with nearly two times greater odds of CCU with new clients in the last 30 days (aOR = 1.77, 95% CI 1.10-2.86). Exploratory mediation analysis indicated that the relationship between savings group participation and CCU was partially mediated by financial security, as measured by monthly income. Findings indicate that community savings groups may play an important role in reducing sexual risk behaviors of FSW and hold promise as part of comprehensive, community-led HIV prevention strategies among FSW.

Exploring Meaning and Types of Trust in Maternity Care in Peri-Urban Kenya: A Qualitative Cross-Perspective Analysis.

Trust offers a distinctive lens on facility responsiveness during labor and birth. Though acknowledged in prior literature, limited work exists linking conceptual and empirical spheres. This study explores trust in the maternity setting in Kenya through a theoretically driven qualitative approach. Focus groups ( n = 8, N = 70) with women who recently gave birth (WRB), pregnant women, and male partners, and in-depth-interviews ( n = 33) with WRB, frontline providers, and management, were conducted in and around a peri-urban public hospital. Combined coding and memo-writing showed that trust in maternity care is nested within understandings of institutional and societal trust. Content areas of trust include confidence, communication, integrity, mutual respect, competence, fairness, confidentiality, and systems trust. Trust is relevant, multidimensional, and dynamic. Examining trust provides a basis for developing quantitative measures and reveals structural underpinnings, repercussions for trust in other health areas, and health systems inequities, which have implications for maternal health policy, programming, and service utilization.

A mixed methods assessment of the barriers and readiness for meeting the SNAP depth of stock requirements in Baltimore's small food stores.

We sought to understand Baltimore corner store owners' awareness of and readiness for the then-approved Supplemental Nutrition Assistance Program depth of stock requirements and assess potential barriers and solutions. In-depth interviews and stocking observations were conducted in 17 corner stores in low-income food deserts of Baltimore City. Corner store owners conveyed little to no awareness of the pending depth of stock changes. Only two stores were currently ready for the requirements. Low customer demand, high amounts of potential spoilage, and unfair pricing at the wholesaler were identified by store owners as barriers to stocking required foods.

Experiences of structural vulnerability among exotic dancers in Baltimore, Maryland: Co-occurring social and economic antecedents of HIV/STI risk.

BACKGROUND: Women who grow up in economic scarcity often face limited opportunities for upward mobility, as a result of challenges securing stable housing, quality education, and steady employment. Chronic instability may limit the capacity of women to protect themselves against HIV/STI-related harm when engaging in sexual activity or drug use. Characterizing the structural contexts that facilitate HIV/STI risk among women are critical to effective design and implementation of drug and sexual harm reduction interventions. METHODS: Semi-structured in-depth interviews were completed with 25 female exotic dancers working in Baltimore City and County exotic dance clubs July 2014-May 2015. Using thematic analysis, interviews were examined to understand the nature of structural vulnerability experienced by dancers during their early lives through the initial months of exotic dancing, including an examination of the roles of drug use and social relationships in engagement of sexual risk behavior. RESULTS: Dancers depicted early experiences of social and economic disadvantage, which accumulated through early adulthood. Substance use emerged as an important subject for the majority of women, operating cyclically as both precursor to and product of accumulating social and economic hardship. Dancers revealed social strategies that buffered the effects of structural vulnerability and minimized exposure to workplace-related drug and sexual harms. CONCLUSION: This study provides insight on an understudied group of at-risk women with a unique demographic profile. Findings illustrate how the effects of structural vulnerability, substance abuse, social strategies, and opportunities for economic gain through sexual services in the workplace converge to produce varying levels of HIV/STI risk among exotic dancers.

Youth engagement in developing an implementation science research agenda on adolescent HIV testing and care linkages in sub-Saharan Africa.

BACKGROUND: The importance of youth engagement in designing, implementing and evaluating programs has garnered more attention as international initiatives seek to address the HIV crisis among this population. Adolescents, however, are not often included in HIV implementation science research and have not had opportunities to contribute to the development of HIV-related research agendas. Project Supporting Operational AIDS Research (SOAR), a United States Agency for International Development-funded global operations research project, involved youth living with HIV in a meeting to develop a strategic implementation science research agenda to improve adolescent HIV care continuum outcomes, including HIV testing and counseling (HTC) and linkage to care. METHODS: Project SOAR convened a 2-day meeting of 50 experts, including four youth living with HIV. Participants examined the literature, developed research questions, and voted to prioritize these questions for the implementation science research agenda. This article presents the process of involving youth, how they shaped the course of discussions, and the resulting priority research gaps identified at the meeting. RESULTS: Youth participation influenced working group discussions and the development of the implementation science agenda. Research gaps identified included how to engage vulnerable adolescents, determining the role that stigma, peers, and self-testing have in shaping adolescent HTC behaviors, and examining the costs of different HTC and linkage to care strategies. CONCLUSION: The meeting participants developed the research agenda to guide future implementation science research to improve HIV outcomes among adolescents in sub-Saharan Africa. This process highlighted the importance of youth in shaping implementation science research agendas and the need for greater youth engagement.

Improving active case finding for tuberculosis in South Africa: informing innovative implementation approaches in the context of the Kharitode trial through formative research.

BACKGROUND: Tuberculosis (TB) is the leading infectious killer worldwide, with approximately 1.8 million deaths in 2015. While effective treatment exists, implementation of active case finding (ACF) methods to identify persons with active TB in a timely and cost-effective manner continues to be a major challenge in resource-constrained settings. Limited qualitative work has been conducted to gain an in-depth understanding of implementation barriers. METHODS: Qualitative research was conducted to inform the development of three ACF strategies for TB to be evaluated as part of the Kharitode cluster-randomised trial being conducted in a rural province of South Africa. This included 25 semi-structured in-depth interviews among 8 TB patients, 7 of their household members and 10 clinic health workers, as well as 4 focus group discussions (2 rural and 2 main town locations) with 6-8 participants each (n = 27). Interviews and focus group discussions explored the context, advantages and limitations, as well as the implications of three ACF methods. Content analysis was utilised to document salient themes regarding their feasibility, acceptability and potential effectiveness. RESULTS: Study participants (TB patients and community members) reported difficulty identifying TB symptoms and seeking care in a timely fashion. In turn, all stakeholder groups felt that more proactive case finding strategies would be beneficial. Clinic-based strategies (including screening all patients regardless of visit purpose) were seen as the most acceptable method based on participants' preference ranking of the ACF strategies. However, given the resource constraints experienced by the public healthcare system in South Africa, many participants doubted whether it would be the most effective strategy. Household outreach and incentive-based strategies were described as promising, but participants reported some concerns (e.g. stigma in case of household-based and ethical concerns in the case of incentives). Participants offered insights into how to optimise each strategy, tailoring implementation to community needs (low TB knowledge) and realities (financial constraints, transport, time off from work). CONCLUSIONS: Findings suggest different methods of TB ACF are likely to engage different populations, highlighting the utility of a comprehensive approach. TRIAL REGISTRATION: Clinicaltrials.gov ( NCT02808507 ). Registered June 1, 2016. The participants in this formative study are not trial participants.

Identifying Patterns of Social and Economic Hardship Among Structurally Vulnerable Women: A Latent Class Analysis of HIV/STI Risk.

Women who are structurally vulnerable are at heightened risk for HIV/STIs. Identifying typologies of structural vulnerability that drive HIV/STI risk behavior is critical to understanding the nature of women's risk. Latent class analysis (LCA) was used to classify exotic dancers (n = 117) into subgroups based on response patterns of four vulnerability indicators. Latent class regression models tested whether sex- and drug-related risk behavior differed by vulnerability subgroup. Prevalence of vulnerability indicators varied across housing instability (39%), financial insecurity (39%), limited education (67%), and arrest history (36%). LCA yielded a two-class model solution, with 32% of participants expected to belong to a "high vulnerability" subgroup. Dancers in the high vulnerability subgroup were more likely to report sex exchange (OR = 8.1, 95% CI, 1.9-34.4), multiple sex partnerships (OR = 6.4, 95% CI, 1.9-21.5), and illicit drug use (OR = 17.4, 95% CI, 2.5-123.1). Findings underscore the importance of addressing inter-related structural factors contributing to HIV/STI risk.

Economic Context and HIV Vulnerability in Adolescents and Young Adults Living in Urban Slums in Kenya: A Qualitative Analysis Based on Scarcity Theory.

Urban slum adolescents and young adults have disproportionately high rates of HIV compared to rural and non-slum urban youth. Yet, few studies have examined youth's perceptions of the economic drivers of HIV. Informed by traditional and behavioral economics, we applied a scarcity theoretical framework to qualitatively examine how poverty influences sexual risk behaviors among adolescents and young adults. Focus group discussions with one hundred twenty youth in Kenyan's urban slums were transcribed, coded, and analyzed using interpretive phenomenology. Results indicated that slum youth made many sexual decisions considered rational from a traditional economics perspective, such as acquiring more sex when resources were available, maximizing wealth through sex, being price-sensitive to costs of condoms or testing services, and taking more risks when protected from adverse sexual consequences. Youth's engagement in sexual risk behaviors was also motivated by scarcity phenomena explained by behavioral economics, such as compensating for sex lost during scarce periods (risk-seeking), valuing economic gains over HIV risks (tunneling, bandwidth tax), and transacting sex as an investment strategy (internal referencing). When scarcity was alleviated, young women additionally described reducing the number of sex partners to account for non-economic preferences (slack). Prevention strategies should address the traditional and behavioral economics of the HIV epidemic.

Stigma, discrimination and HIV outcomes among people living with HIV in Rio de Janeiro, Brazil: The intersection of multiple social inequalities.

Limited research has examined the social context surrounding stigma and discrimination and HIV outcomes among people living with HIV (PLHIV). We surveyed 900 PLHIV in Brazil and examined the relationship between stigma, discrimination and HIV outcomes utilising multivariable logistic regression. HIV stigma and discrimination were inversely associated with age (AOR Stigma 0.65, 95% CI 0.49-0.88; AOR Discrimination 0.72, 95% CI 0.54-0.95) and income (AOR Stigma 0.74, 95% CI 0.55-0.99; AOR Discrimination 0.62, 95% CI 0.46-0.82). Stigma was inversely associated with education (AOR 0.71, 95% CI 0.52-0.96) and no history of sex work (AOR 0.56, 95% CI 0.35-0.90), and positively associated with having children (AOR 1.71, 95% CI 1.18-2.48). Discrimination was inversely associated with no history of drug use (AOR 0.63, 95% CI 0.42-0.95). Stigma and discrimination were found to be inversely associated with overall health (AOR Stigma 0.54, 95% CI 0.40-0.74; AOR Discrimination 0.71, 95% CI 0.52-0.97). Discrimination was associated with having a sexually transmitted infection since HIV diagnosis (AOR 1.63, 95% CI 1.14-2.32). Findings suggest that future interventions should address multiple social inequalities faced by PLHIV to reduce HIV stigma and discrimination and improve health and HIV outcomes.

Project Shikamana: Baseline Findings From a Community Empowerment-Based Combination HIV Prevention Trial Among Female Sex Workers in Iringa, Tanzania.

BACKGROUND: Community empowerment approaches have been found to be effective in responding to HIV among female sex workers (FSWs) in South Asia and Latin America. To date, limited rigorous evaluations of these approaches have been conducted in sub-Saharan Africa. METHODS: A phase II community randomized controlled trial is being conducted in Iringa, Tanzania, to evaluate the effectiveness of a community empowerment-based combination HIV prevention model (Project Shikamana) among a stratified sample of HIV-infected and HIV-uninfected FSWs. Cohort members were recruited from entertainment venues across 2 communities in the region using time-location sampling. All study participants gave consent, and were surveyed and screened for HIV at baseline. Primary biological study outcomes are viral suppression among the HIV-infected and remaining free of HIV among HIV-uninfected women. RESULTS: A cohort of 496 FSWs was established and is currently under follow-up. Baseline HIV prevalence was 40.9% (203/496). Among HIV-infected FSWs, 30.5% (62/203) were previously aware of their HIV status; among those who were aware, 69.4% were on antiretroviral therapy (43/62); and for those on antiretroviral therapy, 69.8% (30/43) were virally suppressed. Factors associated with both HIV infection and viral suppression at baseline included community, age, number of clients, and substance use. Amount of money charged per client and having tested for sexually transmitted infection in the past 6 months were protective for HIV infection. Social cohesion among FSWs was protective for viral suppression. CONCLUSIONS: Significant gaps exist in HIV service coverage and progress toward reaching the 90-90-90 goals among FSWs in Iringa, Tanzania. Community empowerment approaches hold promise given the high HIV prevalence, limited services and stigma, discrimination, and violence.

The Quest to Extend Health Services to Vulnerable Substance Users in Rio de Janeiro, Brazil in the Context of an Unfolding Economic Crisis.

Calls to address crack-cocaine use in Brazil among homeless and street-frequenting populations who are in urgent need of health services have questioned the capacity of the Brazilian Unified Health System to attend to the nation's most marginalized citizens. In recent years, Brazil has launched several actions to escalate care for substance users, yet many obstacles hindering accessibility and effectiveness of services remain. Paradoxically, these actions have been implemented in the context of a growing economic crisis, and expanding services for a population of poor and stigmatized substance users while cutting other government programs tends to elicit harsh criticism from citizens. In consequence of such prospects, this commentary aims to discuss barriers marginalized substance users face in accessing health services that are at risk of worsening with government cutbacks. Using Rio de Janeiro as an example, we explore two primary issues: the resource-strained, under-staffed and decentralized nature of the Brazilian Unified Health System and the pervading stigma that bars vulnerable citizens from official structures and services. Abandoning initiated government efforts to increase access to health services would risk maintaining vulnerable citizens at the margins of public structures, inhibiting the opportunity to offer this population humane and urgently needed treatment and care.

Factors Related to Pregnancy Among Female Sex Workers Living with HIV in the Dominican Republic.

Female sex workers (FSWs) living with HIV are a vulnerable population for multiple health concerns and have been vastly understudied in public health literature. This study analyzes factors related to pregnancy among 268 FSWs living with HIV in the Dominican Republic. Results indicate that 34 % of participants had been pregnant since HIV diagnosis. Multivariate analysis revealed significant associations between pregnancy after HIV diagnosis and ART interruption (AOR 2.41; 95 % CI 1.19, 4.94), knowledge of mother-to-child transmission (AOR 2.12; 95 % CI 0.99, 4.55), serostatus disclosure to a sex partner (AOR 2.46; 95 % CI 1.31, 4.62), older age (AOR 0.91; 95 % CI 0.87, 0.95) and a more negative perception of their health provider (AOR 0.56; 95 % CI 0.34, 0.93). Results indicate noteworthy associations between having been pregnant and the health provider experience and ART interruption, indicating a significant need for further research on this population to ensure both maternal and child health.

Female sex workers' experiences with intended pregnancy and antenatal care services in southern Tanzania.

Understanding the pregnancy experiences of female sex workers (FSWs), especially in the context of high rates of HIV and sexually transmitted infections (STIs), is essential to tailoring services to meet their needs. This study explores FSWs' experiences with intended pregnancy and access to antenatal care and HIV testing in two regions of Tanzania. Thirty in-depth interviews and three focus group discussions were conducted. FSWs sought to become pregnant to gain respect as mothers, to avoid stigma, and/or to solidify relationships, sometimes posing risks to their own and their partners' health. Pregnant FSWs generally sought antenatal care (ANC) services but rarely disclosed their occupation, complicating provision of appropriate care. Accessing ANC services presented particular challenges, with health care workers sometimes denying all clinic services to women who were not accompanied by husbands. Several participants reported being denied care until delivery. The difficulties participants reported in accessing health care services as both sex workers and unmarried women have potential social and health consequences in light of the high levels of HIV and STIs among FSWs in sub-Saharan Africa.

Retention in HIV care among female sex workers in the Dominican Republic: implications for research, policy and programming.

There are clear benefits of retention in HIV care, yet millions of people living with HIV are sub-optimally retained. This study described factors from Andersen's behavioral model that were associated with retention in HIV care among 268 female sex workers (FSWs) living with HIV in the Dominican Republic using two measures of retention: a 6-month measure of HIV clinic attendance and a measure that combined clinic attendance and missed visits. FSWs who ever attended HIV care reported high rates (92 %) of 6-month attendance, but 37 % reported missed visits. Using the combined retention measure, the odds of being retained in HIV care were higher among FSWs with more positive perceptions of HIV service providers [adjusted odds ratio (AOR) 1.17; 95 % confidence interval (CI) 01.09, 1.25] and lower among women who reported recent alcohol consumption (AOR 0.50; 95 % CI 0.28, 0.92) and self-stigmatizing beliefs related to sex work (AOR 0.93; 95 % CI 0.88, 0.98). These findings support the hypothesis that retention in HIV care may be best determined through a combined measure as missed visits are an important mechanism to identify in-care patients who require additional support.