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Introduction: The detailed risk assessment of the diagnosed HIV cases in Bhutan is an opportunity to carry out the risk analysis to generate evidence of wherein, under what context, and in which population groups most new infections are occurring. The evidence collected will help to test the current assumption of Bhutan experiencing diffused and generalized HIV epidemic. Methods: This is a cross-sectional study using a quantitative method to assess the risk behavior of the diagnosed HIV cases from 1993 to 2019. The study also included secondary data analysis of those cases already captured by the routine case-based surveillance from 2020 to 2021. The data collection was done from 1 to 30 January 2022 in all the twenty districts of Bhutan. Descriptive statistical analysis was used to analyze the characteristics of the study population, and relationships were established using the Chi-square Test. We have sought ethics approval and obtained participants' informed consent. Results: The risk attribution analysis showed that 81.94% of HIV infection among the reported HIV cases in Bhutan has occurred through high-risk heterosexuals and 8.88% through mother-to-child transmission, and parenteral transmission accounts for 1.58% and then 1.35% through homosexual. Of the 81.94% high-risk heterosexuals, 41.08% acquired through sex workers and clients of sex workers, 27.99% from HIV-infected persons, 12.64% from sex work, and 0.23% from injecting drug use. Conclusions: This study has shed some light on a gradual epidemic shift from the current perceived diffused and generalized to the concentrated epidemic among subpopulation groups like female sex workers and their clients.
RESUMEN
BACKGROUND: Knowing the number of persons at risk for sexually transmitted diseases (STDs) and their risk behaviors are needed to allocate limited resources, set targets for prevention and care activities, gauge the reach of programs, and assess their impact. Female sex workers (FSWs) are a population at high risk for STD worldwide; little is known about FSW in Bhutan. METHODS: We conducted a community-based survey and population size exercise of FSW in Bhutan. The survey used a hybrid venue-based/peer-referral sampling method. Population size estimation methods were key informant mapping, census and enumeration, unique object multiplier, and capture-recapture. RESULTS: Of 517 women surveyed, 67.5% provided sex for money in the last year. Compared with FSWs at venues, FSWs referred by peers were more likely to have sex with alcohol (80.1% vs. 51.5%, P < 0.001) and more paying partners (mean, 3.5 vs. 2.0; P = 0.001), and less likely to have tested for an STD (28.3% vs. 51.0%, P < 0.001) or have outreach worker contact (27.6% vs. 41.5%, P = 0.007). The estimated number of FSWs in the 9 districts was 353 (95% confidence interval, 345-362). Extrapolation to the whole country projected 597 (417-777) FSWs nationally. CONCLUSIONS: Our estimate of the number of FSW in Bhutan corresponds to 0.71% of adult urban women, a figure in line with other countries in South and Southeast Asia. Our data highlight the need for outreach beyond venues where women are employed to reach FSW at higher risk for STD but who have less access to interventions.