HIV-Associated Genital Immune Biomarkers in the Female Sex Worker Population: A Pilot Study.

PROBLEM: Female sex workers (FSW) experience a disproportionately high burden of HIV infection, yet characterization of the vaginal immune microenvironment that may impact biological risk is not well studied among FSW in the United States. Additionally, feasible methodology for collecting biological materials has not been evaluated in this population. METHODS: We enrolled 10 FSW (5 premenopausal, 5 postmenopausal) who participated in a survey and provided vaginal swabs. Biomarkers were assessed by ELISA, and included cytokines, chemokines, and antimicrobial/wound-healing mediators. RESULTS: One hundred percent of FSW were African American, with a median age of 43.5. The median age when participants started sex work was 17.5, with 60% working 7 days per week and seeing up to 10 clients per night. Eighty percent reported recent unprotected sex and only 30% used some form of contraception. One self-reported sexually transmitted infection at the time of visit and two reported living with HIV. Vaginal secretions showed detectable levels of all biomarkers tested, except MIP3α and MIP1α, which were undetectable in all samples. When stratified by age/menopause status, no significant changes were observed except for Serpin A1 with higher median levels in premenopausal compared to postmenopausal FSW (median 5.79 vs. 5.205 log pg/mL, p = 0.016). Comparison with samples from an existing repository of non-FSW women showed significantly reduced chemokines IL8 (p = 0.045), MIP3α (p ≤ 0.001), and MIP1ß (p = 0.015) in the FSW group. CONCLUSIONS: We report characterization of the vaginal secretome in a cohort of FSW in the United States. Understanding of the genital immune microenvironment can inform future research in HIV prevention and therapeutic options in this population.

Sex work, syndemic conditions and condomless anal intercourse among men who have sex with men who engage in sex work in Latin America.

Background In Latin American countries and Suriname, sexual transmission is one of the most common modes of HIV transmission, and men who have sex with men (MSM) who engage in sex work constitute a key population. Methods In a sample of MSM (N =53,166) from the Latin American Internet Survey (2018) across 18 countries, we examined how sex work engagement is associated with syndemic conditions (multidrug use, homophobic abuse, depression/anxiety, alcohol dependency (CAGE alcohol questionnaire) and internalised homonegativity) and condomless anal intercourse with non-steady male partners using separate logistic regressions. We then used a structural equation model to determine if and how syndemic conditions mediate the relationship between sex work engagement and non-steady male partners. Results We found that getting paid for sex was associated with less condom use for anal intercourse with non-steady male partners and particular syndemic conditions, such as multidrug use, homophobic abuse and alcohol dependency. In our structural equation model, the results showed that the direct relationship between sex work engagement and non-steady male partners was positive and significant, and syndemic conditions partially mediated this relationship. Conclusion Our results highlight the continuing need for including MSM who engage in sex work and those who experience syndemic conditions in the prevention strategies targeted to MSM in Latin America and Suriname, to prevent the transmission of HIV.

HIV testing among female sex workers and associated factors in Burkina Faso: findings from a respondent-driven sampling survey.

BACKGROUND: In Burkina Faso, only 70% of people living with HIV knew their status in 2018, while the first 95 target of the UNAIDS suggests that by 2025 at least 95% of people living with HIV (PLHIV) know their HIV status. Female sex workers (FSW) are one of the most HIV-vulnerable groups, making it crucial to estimate the rate and associated factors of HIV testing among FSW. METHODS: We conducted a cross-sectional study focused on FSW in five main cities of Burkina Faso (Ouagadougou, Bobo-Dioulasso, Koudougou, Tenkodogo, and Ouahigouya). A respondent-driven sampling (RDS) approach was used to recruit participants. Data were collected through in-person interviews between June and August 2022. The HIV testing rate in the past twelve months was examined by sociodemographic characteristics and risky behaviors. A modified Poisson regression in a generalized estimating equation with an exchangeable correlation structure was used to explore the associated factors of HIV testing. RESULTS: Of 1338 FSW (average age: 27.6 ± 7.25 years) HIV negative, 57.8% (95% CI: 54.2-61.3) reported having been tested for HIV in the last 12 months. Among those who started sex work before the age of 18, 48.0% (95% CI: 39.1-57.1) reported having been tested for HIV in the last 12 months. The HIV testing rate among FSWs within the last 12 months was independently associated with age, education level, and being member of an FSW supportive association. Indeed, FSW aged 25 years and more had a 14% higher rate of being tested for HIV within 12 months compared to those 15 to 24 years old (adjusted prevalence ratio (aPR): 1.14 [95%CI: 1.05-1.24]). The HIV testing rate among those who are not members of an FSW supportive association was 16% lower (aPR: 0.84 [95%CI: 0.72-0.97]) than those who are members of FSW supportive associations. CONCLUSION: The HIV testing rate among FSW is low in Burkina Faso, suggesting an important challenge to reach the first 95% target of UNAIDS among FSW. Innovative diagnostic strategies for the early identification of HIV-infected FSW are essential to achieve the first 95 target by 2025 in Burkina Faso.

Comparing the Efficacy of 2 WeChat Mini Programs in Reducing Nonmarital Heterosexual Contact by Male Factory Workers: Randomized Controlled Trial.

BACKGROUND: Male factory workers in China are vulnerable to HIV transmission. Commercial and nonmarital noncommercial contacts are the driving forces of heterosexual HIV transmission among male factory workers in China. There is a lack of effective HIV interventions for male factory workers in China. OBJECTIVE: The primary objective of this randomized controlled trial was to compare the efficacy of an enhanced versus the standard version of a WeChat mini program in reducing sexual intercourse with nonregular female sex partners and female sex workers among male factory workers in Shenzhen, China. METHODS: A nonblinded 2-arm parallel randomized controlled trial was conducted between December 2021 and April 2023. Participants were adult male factory workers in Shenzhen who had access to a smartphone and WeChat. Those who had oral or anal sex with a man or self-reported as HIV positive were excluded. A total of 247 participants were randomly assigned to the intervention group (n=125, 50.6%) or the control group (n=122, 49.4%); 221 (89.5%) and 220 (89.1%) completed follow-up surveys at T1 (6 months after completion of the interventions) and T2 (6 months after T1). Participants in the control group had access to the standard WeChat mini program that provided basic HIV-related knowledge and information about local free HIV testing services. Participants in the intervention group had access to the enhanced WeChat mini program. The enhanced mini program covered all the information in the standard mini program. In addition, the enhanced mini program assessed users' behaviors and invited users to watch different web-based videos on reducing nonmarital sexual contacts and promoting HIV testing based on their behavioral characteristics at months 0 and 1. The videos were developed based on in-depth interviews with male factory workers. Intention-to-treat analysis was used for outcome analyses. Multiple imputation was used to replace missing outcome values at T1 and T2. RESULTS: At T1, fewer participants in the intervention group reported sexual intercourse with a nonregular female sex partner in the past 6 months compared with the control group (1/125, 0.8% vs 8/122, 6.6%; relative risk=0.12, 95% CI 0.02-0.96; P=.02). However, there were no between-group differences in sexual intercourse with a nonregular female sex partner at T2 (10/125, 8% vs 14/122, 11.5%; P=.36) or sexual intercourse with a female sex worker at T1 (2/125, 1.6% vs 2/122, 1.6%; P=.98) or T2 (8/125, 6.4% vs 8/122, 6.6%; P=.96). CONCLUSIONS: The enhanced WeChat mini program was more effective than the standard WeChat mini program in reducing sexual intercourse with nonregular female sex partners among male factory workers in the short term but not in the longer term. Improvements should be made to the WeChat mini program before implementation. TRIAL REGISTRATION: ClinicalTrials.gov NCT05811611; https://clinicaltrials.gov/study/NCT05811611.

[Sex workers in the Brazilian pandemic: effects on and relations with health]. / Trabalhadoras sexuais no marco pandêmico brasileiro: efeitos em e relações com a saúde.

This paper describes the results of the study I Want More! The Lives of Sex Workers During the COVID-19 Pandemic, which is part of the EPIC community research program. The study analyzed the effects of the pandemic on the lives of cis, trans and travesti sex workers in nine Brazilian states and 11 cities throughout 2020 and 2021. This article focuses on the qualitative component of the study, which was based on semi-structured, remote and face-to-face interviews carried out with 43 sex workers, and its comparison with the quantitative component. The effects are analyzed in relation to the Brazilian pandemic framework, considering the social, economic and political dimensions of the COVID-19 virus. Some of the key themes of the analysis are cases of illness, specific social isolation practices, prevention and care management practices, individual vaccination and collective vaccination strategies. We also share the daily and activist responses drawn up by sex workers in a political agenda that opposes the individualistic, familialist, domestic, and neoliberal logic of isolation by adopting community care perspectives, which was the only line of health action for this work category during the pandemic. Collective actions reposition sex work at the interface between public health and human rights and take as their principle the "street knowledge", from activism, and the workers' power of decision over their own bodies.

Este trabalho apresenta os resultados do estudo Eu Quero é Mais! A Vida de Profissionais do Sexo Durante a Pandemia da COVID-19, integrante do programa de investigação comunitária EPIC. O estudo analisou os efeitos da pandemia nas vidas de trabalhadoras sexuais cis, trans e travestis em nove Unidades da Federação e 11 cidades brasileiras ao longo de 2020 e 2021. O artigo tem como foco o componente qualitativo do estudo baseado em entrevistas semiestruturadas realizadas de forma presencial e remota com 43 trabalhadoras sexuais, e seu cotejamento com o componente quantitativo. Os efeitos são analisados em relação com o marco pandêmico brasileiro, considerando as dimensões sociais, econômicas e políticas do vírus da COVID-19. Entre as temáticas chaves da análise, se destacam: casos de adoecimento, práticas localizadas de isolamento social, práticas de prevenção e gerenciamento de cuidado, vacinação individual e estratégias coletivas de vacinação. Compartilhamos também as respostas cotidianas e ativistas traçadas por trabalhadoras sexuais numa agenda política que se contrapõe à lógica individualista, familiarista, doméstica e neoliberal de isolamento, por meio de perspectivas comunitárias de cuidado, o que se desenhou como a única linha de ação em saúde para a categoria durante a pandemia. As ações coletivas reposicionam o trabalho sexual na interface entre a saúde pública e os direitos humanos e tomam como princípio os conhecimentos das ruas, desde os ativismos, e o poder de decisão delas próprias sobre seus corpos.

Este trabajo presenta los resultados del estudio ¡Yo Quiero Más! La Vida de las Profesionales del Sexo Durante la Pandemia de la COVID-19, parte del programa de investigación comunitaria EPIC. El estudio analizó los efectos de la pandemia en la vida de trabajadoras sexuales cis, trans y travestis en 9 estados y 11 ciudades brasileñas a lo largo del 2020 y del 2021. El artículo se centra en el componente cualitativo del estudio basado en entrevistas semiestructuradas realizadas de forma presencial y remota a 43 trabajadoras sexuales y su comparación con el componente cuantitativo. Los efectos se analizan con relación al marco pandémico brasileño, considerando las dimensiones sociales, económicas y políticas del virus de la COVID-19. Entre las temáticas clave del análisis, destacan: casos de enfermedad, prácticas localizadas de aislamiento social, prácticas de prevención y gestión del cuidado, vacunación individual y estrategias colectivas de vacunación. Compartimos también las respuestas cotidianas y activistas esbozadas por las trabajadoras sexuales en una agenda política que se opone a la lógica individualista, familiarista, doméstica y neoliberal del aislamiento, por medio de perspectivas comunitarias de cuidado, lo que se diseñó como la única línea de acción en salud para la categoría durante la pandemia. Las acciones colectivas reposicionan el trabajo sexual en la interfaz entre la salud pública y los derechos humanos y toman como principio el conocimiento de la calle, desde el activismo, y su poder de decisión sobre sus cuerpos.

Reproductive healthcare utilization for women in the sex trade: a qualitative study.

BACKGROUND: Women in the sex trade encounter significant challenges in obtaining reproductive healthcare. Reports of reproductive healthcare for women in the sex trade center on the prevention and termination of pregnancies, yet most women in the sex trade globally experience full term pregnancies and bear children. This study aimed to explore barriers and enabling factors to providing reproductive healthcare for women in the sex trade in Israel. METHODS: We conducted a qualitative study utilizing a grounded theory method. Data were collected through semi-structured interviews, conducted between June 2021 and July 2022. Interviews were conducted with practitioners in healthcare settings (n = 20), practitioners in social services settings (n = 15), and women in the sex trade who received reproductive health care-related medical services (n = 13) in Israel. The interviews were audiotaped, transcribed, and thematically analyzed. RESULTS: The findings indicated a multilayered structure of healthcare system-related factors and women-related factors. Stigma was noted as a multidimensional barrier, reflected in service providers' attitude towards women in the sex trade, impairing the patient-provider relationship and impeding women's help-seeking. However, the creation of a relationship of trust between the women and healthcare providers enabled better health outcomes. CONCLUSIONS: Based on the findings, we propose recommendations for designing and implementing reproductive healthcare services for women in the sex trade. The recommendations offer to (a) include women with lived experiences in planning and providing reproductive healthcare services, (b) adopt a trauma-informed approach, (c) emphasize nonjudgmental care, (d) train healthcare providers to reduce stigma and bias, and (e) enhance the affordability of health services for women experiencing marginalization.

Sexual practices, their influencers, and utilization of HIV services among female sex workers in Mombasa County, Kenya.

Introduction: female sex workers (FSWs) are vulnerable to acquiring HIV and other sexually transmitted infections due to unprotected sex. Understanding and addressing the gaps in safer sex among FSWs can help to reduce HIV acquisition and transmission. This study described sexual practices, their correlates and use of HIV services among FSWs in Mombasa County, Kenya. Methods: participants were recruited for a baseline survey by a time-location cluster randomized design at predetermined intervals from five bars and five clubs in Mombasa County until a sample size of 160 was reached. Descriptive statistics and inferential analysis using R were conducted, and p<0.05 was regarded as statistically significant. Results: nearly all (99%) of the participants were unmarried, and 11% had tertiary education. Ninety-eight percent (98%) reported vaginal intercourse, 51% reported using alcohol/drugs before sex, and 28% practiced unprotected intercourse. About 64% had tested for HIV within three months, 14% believed that it is safe to reuse condoms, and 10% that it is safe to engage in unprotected sex. In bi-variate analysis, FSWs were more likely to engage in unprotected intercourse if they reported more frequent sex, more frequent sex with regular clients, poor HIV knowledge, alcohol/drug use, and violence. In multivariate analysis, risky sexual practices were associated with frequency of sexual intercourse, alcohol/drug use, and poor HIV knowledge. Conclusion: female sex workers engage in unprotected sex while under the influence of substances, belief in re-using condoms and have high frequency of sexual intercourse. Inadequate knowledge of HIV and substance use significantly correlated with unprotected sex. Interventions to address these modifiable factors are needed to mitigate the risk of HIV among FSWs.

Mixed-methods protocol for the WiSSPr study: Women in Sex work, Stigma and psychosocial barriers to Pre-exposure prophylaxis in Zambia.

INTRODUCTION: Women engaging in sex work (WESW) have 21 times the risk of HIV acquisition compared with the general population. However, accessing HIV pre-exposure prophylaxis (PrEP) remains challenging, and PrEP initiation and persistence are low due to stigma and related psychosocial factors. The WiSSPr (Women in Sex work, Stigma and PrEP) study aims to (1) estimate the effect of multiple stigmas on PrEP initiation and persistence and (2) qualitatively explore the enablers and barriers to PrEP use for WESW in Lusaka, Zambia. METHODS AND ANALYSIS: WiSSPr is a prospective observational cohort study grounded in community-based participatory research principles with a community advisory board (CAB) of key population (KP) civil society organi sations (KP-CSOs) and the Ministry of Health (MoH). We will administer a one-time psychosocial survey vetted by the CAB and follow 300 WESW in the electronic medical record for three months to measure PrEP initiation (#/% ever taking PrEP) and persistence (immediate discontinuation and a medication possession ratio). We will conduct in-depth interviews with a purposive sample of 18 women, including 12 WESW and 6 peer navigators who support routine HIV screening and PrEP delivery, in two community hubs serving KPs since October 2021. We seek to value KP communities as equal contributors to the knowledge production process by actively engaging KP-CSOs throughout the research process. Expected outcomes include quantitative measures of PrEP initiation and persistence among WESW, and qualitative insights into the enablers and barriers to PrEP use informed by participants' lived experiences. ETHICS AND DISSEMINATION: WiSSPr was approved by the Institutional Review Boards of the University of Zambia (#3650-2023) and University of North Carolina (#22-3147). Participants must give written informed consent. Findings will be disseminated to the CAB, who will determine how to relay them to the community and stakeholders.

PrEP discontinuation, cycling, and risk: Understanding the dynamic nature of PrEP use among female sex workers in South Africa.

PrEP cycling among women is thought to be safe when there are distinct "seasons of risk." However, cyclical PrEP use over short periods may be associated with increased risk of HIV acquisition. We aimed to characterize key social ecological factors contributing toward PrEP cycling among female sex workers (FSW) in the context of high HIV risk. Semi-structured, in-depth interviews were conducted with 36 FSW at risk for HIV acquisition and 12 key informant (KI) service providers in eThekwini (Durban), South Africa from January-October 2020. FSW identified key factors driving temporary discontinuation of PrEP including relocation, lack of information on or difficulty coping with side effects, and delays in accessing PrEP. In many cases, FSW were motivated to restart PrEP once barriers were overcome. In contrast, KIs emphasized the importance of individual adherence to PrEP and reliance on personal risk assessments when counselling FSW on cycling decisions. FSW and KI perspectives highlight a disconnect between providers' recommendations on the potential for cyclical use of PrEP during periods of minimal risk and actual drivers among FSW causing temporary PrEP discontinuation. Further interventions supporting safe PrEP cycling are needed to ensure decisions around cycling are deliberate and guided by changes in HIV risk rather than external factors.

Public health response to Mpox: Safeguarding vulnerable Key Populations and People Living with HIV in Zanzibar.

Mpox, caused by the Monkeypox virus (MPXV), has emerged as a significant global public health concern, particularly affecting vulnerable populations. The recent outbreak in the Democratic Republic of the Congo (DRC) is the largest recorded, driven by the highly virulent clade 1 strain. Transmission has shifted from animal contact to primarily sexual contact among Key Populations (KPs) such as Sex Workers (SW) and Men who have Sex with Men (MSM). In Zanzibar, where HIV prevalence is significantly higher among Key Populations, People Living with Human Immunodeficiency Virus (PLHIV) are at increased risk of Mpox infection due to socioeconomic challenges and immunosuppression. Despite no reported cases in Zanzibar, the spread of Mpox in non-endemic areas highlights the need for proactive measures. Leveraging Zanzibar's strengthened public health infrastructure, key strategies include tailored awareness campaigns, improved vaccine access through existing COVID-19 vaccination models, healthcare infrastructure enhancement, and mental health support. These targeted actions aim to protect Zanzibar's most vulnerable populations and bolster preparedness against Mpox, emphasizing the importance of resource-appropriate interventions to mitigate potential outbreaks.

The impact of COVID-19 restrictions on HIV prevention and treatment services for key populations in South Africa: an interrupted time series analysis.

BACKGROUND: Key populations (KP), including men who have sex with men (MSM), female sex workers (FSW), and transgender women (TGW), experience a disproportionate burden of HIV, even in generalized epidemics like South Africa. Given this disproportionate burden and unique barriers to accessing health services, sustained provision of care is particularly relevant. It is unclear how the COVID-19 pandemic and its associated restrictions may have impacted this delivery. In this study, we aimed to describe patterns of engagement in HIV prevention and treatment services among KP in South Africa and assess the impact of different COVID-19 restriction levels on service delivery. METHODS: We leveraged programmatic data collected by the US President's Emergency Plan for AIDS Relief (PEPFAR)-supported KP partners in South Africa. We divided data into three discrete time periods based on national COVID-19 restriction periods: (i) Pre-restriction period, (ii) High-level restriction period, and (iii) After-high level restriction period. Primary outcomes included monthly total HIV tests, new HIV cases identified, new initiations of pre-exposure prophylaxis (PrEP), and new enrollments in antiretroviral therapy (ART). We conducted interrupted time series segmented regression analyses to estimate the impact of COVID-19 restrictions on HIV prevention and treatment service utilization. RESULTS: Between January 2018 and June 2022, there were a total of 231,086 HIV tests, 27,051 HIV positive cases, 27,656 pre-exposure prophylaxis (PrEP) initiations, and 15,949 antiretroviral therapy initiations among MSM, FSW and TGW in PEPFAR-supported KP programs in South Africa. We recorded 90,457 total HIV tests during the 'pre-restriction' period, with 13,593 confirmed new HIV diagnoses; 26,134 total HIV tests with 2,771 new diagnoses during the 'high-level restriction' period; and 114,495 HIV tests with 10,687 new diagnoses during the after high-level restriction period. Our Poisson regression model estimates indicate an immediate and significant decrease in service engagement at the onset of COVID-19 restrictions, including declines in HIV testing, treatment, and PrEP use, which persisted. As programs adjusted to the new restrictions, there was a gradual rebound in service engagement, particularly among MSM and FSW. Towards the end of the high-level restriction period, with some aspects of daily life returning to normal but others still restricted, there was more variability. Some indicators continued to improve, while others stagnated or decreased. CONCLUSION: Service provision rebounded from the initial shock created by pandemic-related restrictions, and HIV services were largely maintained for KP in South Africa. These results suggest that HIV service delivery among programs designed for KP was able to be flexible and resilient to the evolving restrictions. The results of this study can inform plans for future pandemics and large-scale disruptions to the delivery of HIV services.

Application of 'CDC- Public Security Bureau-NGO' Joint Prevention and Control Mechanism Allied AIDS prevention and control in Guigang, Guangxi.

BACKGROUND: HIV/AIDS has emerged as a nationwide epidemic and has taken the forefront position as the primary infectious killer of adults in China. The control and prevention of the disease have been hampered by a weak link in the form of heterosexual transmission. However, conventional intervention measures have demonstrated suboptimal efficacy in reducing the incidence of new HIV infections. In light of the current epidemiological characteristics, we have developed and executed an innovative intervention model known as the Joint Prevention and Control Mechanism of the 'CDC-Public Security Bureau-NGO'. The purpose of this research is to assess the impact of this model on the AIDS awareness, HIV infection rates, sexual behavior, and associated factors among female sex workers and elderly clients. Through the provision of robust evidence of the efficacy of this innovative model, we seek to advocate for its implementation in future interventions. METHODS: The research design of this study incorporates both a serial cross-sectional study and time-series analysis from 2014 to 2021, including a 4-year traditional intervention (2014-2017) and the 4-year 'CDC-Public Security Bureau-NGO' innovative intervention (2018-2021), was conducted to evaluate the effects of the new intervention. The GM(1, 1) model was performed to predict the proportion of HIV infection without implementing the innovative intervention in 2018-2021; P and C values were used to evaluate the performance of the model. Mann-Kendall test and descriptive methods were used to analyzed the trend of traditional and innovative interventions models on HIV positive detection rate in FSWs and elderly clients. RESULTS: The condom usage rates during the last commercial sexual encounter for FSWs and elderly clients improved from 74.9% and 9.1%, respectively, to 96.9% and 28.1%. (P < 0.05), newly reported cases of HIV have decreased by 15.56% yearly and the HIV positive detection rate among middle-aged and elderly people has dropped by 14.47%. The innovative intervention model has significantly reduced the HIV infection rates. CONCLUSIONS: The 'CDC-Public Security Bureau-NGO' innovative intervention has achieved beneficial effects on HIV/AIDS prevention and control and provides a good reference for Guangxi, China.

A risk-differentiated, community-led intervention to strengthen uptake and engagement with HIV prevention and care cascades among female sex workers in Zimbabwe (AMETHIST): a cluster randomised trial.

BACKGROUND: Female sex workers remain disproportionately affected by HIV. The aim of this study was to determine the effect of risk-differentiated, peer-led support for female sex workers in Zimbabwe on the risk of HIV acquisition and HIV transmission from sex among female sex workers. METHODS: In this cluster randomised, open-label, controlled study, 22 clinics dedicated to female sex workers co-located in government health facilities throughout Zimbabwe were allocated (1:1, through restricted randomisation) to usual care or AMETHIST intervention. Usual care comprised HIV testing, pre-exposure prophylaxis (PrEP), referral to government antiretroviral therapy (ART) services, contraception, condoms, syndromic management of sexually transmitted infections, health education, legal advice, and peer support. AMETHIST added peer-led microplanning tailored to individuals' risk and participatory self-help groups. All cisgender women (aged >18 years) who had sold sex within the past 30 days and lived or worked within trial cluster areas were eligible. Intervention status was not masked to programme implementers but was masked to survey teams and laboratory staff. After 28 months, a respondent-driven sampling (RDS) survey was done in the female sex worker population around each clinic, which measured the primary outcome, the combined proportion of female sex workers in the surveyed population at risk of transmitting HIV (ie, were HIV positive, not virally suppressed, and not consistently using condoms) or at risk of acquiring HIV (ie, were HIV negative and not consistently using condoms or PrEP). We report prespecified analyses of the disaggregated proportions of female sex workers in the surveyed population at risk of either transmission or acquisition of HIV. Analyses were prespecified, RDS-weighted, and age-adjusted. This trial is registered with the Pan African Clinical Trials Registry, PACTR202007818077777. FINDINGS: The AMETHIST intervention was started on May 15, 2019, and data were collected from June 1, 2019, until Dec 13, 2021. The RDS survey was done from Oct 18 to Dec 13, 2021, with 2137 women included in the usual care group (11 clusters) and 2131 in the AMETHIST intervention group (11 clusters) after excluding survey seeds (n=132) and women with missing key data (n=44). 1973 (46·2%) of the 4268 female sex workers surveyed were living with HIV; of these, 863 (93·5%; RDS-adjusted) of 931 women in the intervention group and 927 (88·8%) of 1042 in the usual care group were virologically suppressed. 287 (22·4%) of 1200 HIV-negative women in the intervention group and 194 (15·7%) of 1096 in the usual care group reported currently taking PrEP, of whom only two (0·4%) of 569 had protective tenofovir diphosphate concentrations in dried blood spots (>700 fmol/dried blood punch). There was no effect of the intervention on the primary endpoint of risk of both HIV transmission and acquisition (intervention group n=1156/2131, RDS-adjusted proportion 55·3%; usual care group n=1104/2137, RDS-adjusted proportion 52·7%; age-adjusted risk difference -0·9%, 95% CI -5·7% to 3·9%, p=0·70). For the secondary outcomes, the proportion of women living with HIV at risk of transmission was low and significantly reduced in the intervention group (n=63/931, RDS-adjusted proportion 5·8%) compared with the usual care group (103/1041, 10·4%), with an age-adjusted risk difference of -5·5% (95% CI -8·2% to -2·9%, p=0·0003). Risk of acquisition among HIV-negative women was similar in the intervention (n=1093/1200, RDS-adjusted proportion 92·1%) and the usual care group (1001/1096, 92·2%), with an age-adjusted risk difference of -0·6% (95% CI -4·6 to 3·4, p=0·74). INTERPRETATION: There was no overall benefit of the intervention on combined risk of transmission or acquisition. Viral load suppression in women living with HIV was high and appeared to be further improved by AMETHIST, suggesting potential for impressive uptake and adherence to ART in vulnerable and mobile populations. Sustaining treatment and reinvigorating prevention remain crucial. FUNDING: The Wellcome Trust and the Bill & Melinda Gates Foundation. TRANSLATIONS: For the Shona and Ndebele translations of the abstract see Supplementary Materials section.

Population size, HIV prevalence, and antiretroviral therapy coverage among key populations in sub-Saharan Africa: collation and synthesis of survey data, 2010-23.

BACKGROUND: Key population HIV programmes in sub-Saharan Africa require epidemiological information to ensure equitable and universal access to effective services. We aimed to consolidate and harmonise survey data among female sex workers, men who have sex with men, people who inject drugs, and transgender people to estimate key population size, HIV prevalence, and antiretroviral therapy (ART) coverage for countries in mainland sub-Saharan Africa. METHODS: Key population size estimates, HIV prevalence, and ART coverage data from 39 sub-Saharan Africa countries between 2010 and 2023 were collated from existing databases and verified against source documents. We used Bayesian mixed-effects spatial regression to model urban key population size estimates as a proportion of the gender-matched, year-matched, and area-matched population aged 15-49 years. We modelled subnational key population HIV prevalence and ART coverage with age-matched, gender-matched, year-matched, and province-matched total population estimates as predictors. FINDINGS: We extracted 2065 key population size data points, 1183 HIV prevalence data points, and 259 ART coverage data points. Across national urban populations, a median of 1·65% (IQR 1·35-1·91) of adult cisgender women were female sex workers, 0·89% (0·77-0·95) were men who have sex with men, 0·32% (0·31-0·34) were men who injected drugs, and 0·10% (0·06-0·12) were women who were transgender. HIV prevalence among key populations was, on average, four to six times higher than matched total population prevalence, and ART coverage was correlated with, but lower than, the total population ART coverage with wide heterogeneity in relative ART coverage across studies. Across sub-Saharan Africa, key populations were estimated as comprising 1·2% (95% credible interval 0·9-1·6) of the total population aged 15-49 years but 6·1% (4·5-8·2) of people living with HIV. INTERPRETATION: Key populations in sub-Saharan Africa experience higher HIV prevalence and lower ART coverage, underscoring the need for focused prevention and treatment services. In 2024, limited data availability and heterogeneity constrain precise estimates for programming and monitoring trends. Strengthening key population surveys and routine data within national HIV strategic information systems would support more precise estimates. FUNDING: UNAIDS, Bill & Melinda Gates Foundation, and US National Institutes of Health.

Transactional sex and risky sexual practices in Jamaica.

BACKGROUND: Transactional sex relationships (TSRs) create financial and emotional support for men and women, as well as an increased sexual risk. Studies have reported high HIV and STI transmission rates among young women in transactional sex relationships. However, little is known about TSR prevalence in Jamaica and risky sexual practices among participants. This study investigates the sexual behaviour of Jamaicans in TSR. METHODS: Secondary data analysis of a national survey revealed that 586 participants (38%) self-reported being in at least one TSR in the last 12 months. We also identified a third category called "Benefluids", who play both roles of benefactor and beneficiary in transactional sex relationships. RESULTS: 59 percent of male Benefluids had two to five transactional sex relationship partners in the last 12 months, compared to 40% of female Benefluids. Twenty-eight percent of female Benefluids reported sexually transmitted infection symptoms in the last 12 months compared to 13.5% of male Benefluids. While females reported more sexually transmitted infection symptoms, young men had the highest sexual risk precursors. CONCLUSIONS: People in transactional sex relationships often play the role of beneficiaries and benefactors to meet material and sexual needs but this increases the risk of STI symptoms.

Realist evaluation of a community-based antiretroviral therapy (CBART) programme for key populations in Benue State in Nigeria.

BACKGROUND: World Health Organization recommended community-based ART (CBART) approaches to improve access to antiretroviral treatment (ART) and treatment outcomes among key populations living with (KPLHIV). Key populations (KP) are female sex workers, men who have sex with men, persons who inject drugs, and transgender people. How CBART for KP (KP-CBART) worked and why, for whom and in what circumstances it worked within KP communities or at community sites, are yet to be described. The aim of this study is to describe the different KP-CBART approaches or models in Nigeria, identifying the context conditions and mechanisms that are likely to produce the desired outcomes. METHOD: Building on our previous study eliciting an initial programme theory for KP-CBART, we used a multiple case design and cross-case analysis to evaluate 3 KP-CBART approaches, namely: One Stop Shop clinic; community drop-in centre; and outreach venue. Between 2021 and 2023, we conducted a retrospective cohort study, 99 indepth interviews and 5 focused group discussions with various actors. Using realist evaluation, we synthesised context-mechanism-outcome configurations (CMOCs) and developed programme theory for each of the cases and an overall theory. RESULT: The analysis showed the central importance of decentralizing ART service delivery to a safe place within the community for KPLHIV. The provision of ART in a KP friendly environment triggered a feeling of safety and trust in the healthcare workers among KPLHIV, resulting in KP-CBART acceptance and improved ART uptake, medication adherence and retention on ART. KP community engagement in ART delivery, peer support through support group meetings, and linkages with KP-led organizations improved self-efficacy, fostered solidarity and a sense of belonging among KP. These resources encouraged and motivated clients to engage with the KP-CBART model. However, fear of disclosure of HIV and KP status, and lack of trust between KP groups, demotivated and discouraged KPLHIV from initiating ART and continuing their treatment in KP-CBART. CONCLUSION: To optimise access to ART and treatment outcomes for KPLHIV, policy makers and health practitioners should ensure the provision of a safe place for ART service delivery that can be trusted by the clients and the KP communities.

Increases in housing rules and surveillance during COVID-19: impacts on overdose and overdose response in a community-based cohort of sex workers who use drugs in Vancouver, BC.

INTRODUCTION: Since the beginning of the COVID-19 pandemic, COVID-19 risk mitigation measures have expanded to include increased rules and surveillance in supportive housing. Yet, in the context of the dual public health emergencies of COVID-19 and the unregulated drug toxicity crisis, we have not evaluated the unintended health and social consequences of such measures, especially on criminalized women. In order to address this dearth of evidence, our aim was to assess the association between increased housing rules and surveillance during COVID-19 and (a) nonfatal overdose, and (b) administration of naloxone for overdose reversal among women sex workers who use drugs in Vancouver, BC. METHODS: This study is nested within An Evaluation of Sex Workers Health Access (AESHA), a community-based prospective cohort of women sex workers in Metro Vancouver (2010-present). Using cross-sectional data collected during the first year of COVID-19 (April 2020-2021), we developed separate multivariable logistic regression confounder models to examine the independent associations between experiencing increased housing rules and surveillance during COVID-19 on (a) nonfatal overdose, and (b) administration of naloxone for overdose reversal in the last 6 months. RESULTS: Amongst 166 participants, 10.8% reported experiencing a recent non-fatal overdose and 31.3% recently administered naloxone for overdose reversal. 56.6% reported experiencing increased rules and surveillance within their housing during COVID-19. The prevalence of non-fatal overdose and administering naloxone was significantly elevated among those exposed to increased housing rules and surveillance during COVID-19 versus those who were unexposed (83.3% vs. 52.1%; 75.0% vs. 48.2%, respectively). In separate multivariate confounder models, exposure to increased housing rules and surveillance during COVID-19 was independently associated with increased odds of administering naloxone [AOR: 3.66, CI: 1.63-8.21], and marginally associated with non-fatal overdose [AOR: 3.49, CI: 0.92-13.27]. CONCLUSION: Efforts to prioritize the right to safe, adequate and affordable housing must avoid reinforcing an overly coercive reliance on surveillance measures which, while often well-intended, can negatively shape residents' well-being. Furthermore, public health responses to pandemics must include criminalized populations so that measures do not exacerbate overdose risk. Implementation of a regulated drug supply is recommended, alongside housing policies that promote residents' rights, safety, and health.

What can PrEP do for female sex workers? Unpacking the "effectosphere" of biomedical HIV prevention in Dar es Salaam.

Pre-exposure prophylaxis (PrEP) is a drug with the power to prevent HIV transmission. This study delved into the broader implications of PrEP use among female sex workers in Dar es Salaam, Tanzania, a group disproportionately affected by HIV and socio-structural challenges. Through 46 in-depth interviews with 40 women who were either former or current PrEP users or intended to start PrEP between January 2021 and February 2022, we sought to explore the nuanced effects of PrEP. Inspired by Whyte et al. and "Social Life of Medicines", we asked what PrEP could do in the lives of female sex workers and analyzed the data using reflexive thematic analysis and an interpretative phenomenological approach. We found that PrEP had multiple and diverse effects in many domains of women's lives and refer to these collectively as the "effectosphere" of PrEP. The study identifies four key themes that jointly describe this effectosphere: (1) PrEP could promote human flourishing and empowerment by facilitating a feeling of freedom and confidence which could promote health, social relations, and economic and work opportunities, (2) PrEP could inflict harm (and fears of such harms), partially reflecting medical mistrust rooted in an understanding that sex workers were undesired in society, (3) PrEP could expose sensitive information about its users that could lead to stigma, arguments and needs for elaborate explanations, and (4) PrEP could medicalize daily life, evidenced through daily pill taking, clinical appointments, side-effects, becoming reliant on the medication, and the challenges of integrating PrEP use with other life priorities. We argue that investigating the full effectosphere of any medicine in particular geographic and sociocultural contexts can lead to a better understanding of its use and non-use, highlighting that engaging with medication extends beyond just "taking a pill."

"It's Almost Like Playing 'The Price is Right'": Factors Considered by Online Male Sex Workers When Setting the Price for Their Services.

Some men who have sex with men (MSM) engage in the exchange of sexual services for money, drugs, shelter or something else of value. There has been limited research examining the factors that influence how male sex workers (MSWs) determine their fees for their services. To learn more about this, qualitative interview data were analyzed from 180 MSM from 8 US cities who had recently engaged in exchange sex with clients they had primarily met through dating/hookup websites and apps. The primary factor that affected participants' fees was the type of services provided, with a higher price generally charged for anal sex than for oral sex, mutual masturbation or massage. Condomless anal sex, in particular, commanded a higher fee. Additionally, participants required more money for special kinks or fetishes or any services that they considered to be risky, demanding or physically or emotionally uncomfortable. Other factors that affected how much participants charged for a given encounter included the duration of the meeting, the level of client appeal, the perceived wealth of the client, and the participant's current financial situation. Participants varied in their approaches to fee setting, in terms of both their degree of flexibility when negotiating a price and whether they preferred to suggest a fee or have the client first state an amount they were willing to pay. Information about MSWs' approaches to fee setting provides greater understanding of their lived experiences and the risks they may accept for higher fees.

Prevalence of Paid Sex and Associated Factors Among Women and Men Attending HIV Voluntary Counseling and Testing in Kinshasa, Democratic Republic of the Congo: A Prospective Cohort.

Paid sex is associated with HIV and other sexually transmitted infections, which are highly prevalent in Sub-Saharan Africa (SSA). However, few data exist on this sexual practice among the general population in SSA, including the Democratic Republic of the Congo, where data on paid sex mainly comes from sex workers. In the DRC, most HIV Voluntary Counseling and Testing (VCT) centers do not discuss paid sex as a risk factor. Thus, we aimed to analyze the prevalence of paid sex, its associated factors and association with HIV among women and men attending HIV VCT at a reference hospital in Kinshasa. From 2016 to 2018, the Observational Kinshasa AIDS Initiative cohort analyzed the impact of HIV VCT on changes in HIV knowledge, attitudes, and sexual behaviors at follow-up. Participants aged 15-69 years were HIV tested and interviewed at baseline and at 6- and 12-month follow-ups. At baseline, participants were asked about their history of "ever" having had exchanged sex for money. At both follow-ups, the frequency of this practice was referred to as "the previous 6 months." Descriptive, bivariate, and multivariate logistic regression analyses were carried out to evaluate the prevalence of paid sex, its associated factors, and the association between paid sex and HIV. Statistical analyses were performed with Stata 15.1. Among 797 participants at baseline, 10% of those sexually experienced reported having ever had paid sex (18% men and 4% women, p < 0.001). At 6 and 12-month follow-ups, 5% and 2%, respectively. Paid sex was significantly and independently associated with being male (aOR = 2.7; 95% CI = 1.4-5.2), working or studying (aOR = 2.8; 95% CI = 1.5-5.0), daily newspaper reading (aOR = 4.4; 95% CI = 1.7-11.2); daily/weekly alcohol consumption (aOR = 3.3; 95% CI = 1.8-6.1), first sexual intercourse before age 15 years (aOR = 2.3; 95% CI = 1.1-5.0), multiple sexual partners (aOR = 4.1; 95% CI = 2.2-7.7), and extragenital sexual practices (aOR = 2.4; 95% CI = 1.3-4.4). A high religiosity (daily/weekly church attendance and praying) was inversely associated with paid sex (aOR = 0.1; 95% CI = 0.0-0.4). The high prevalence of paid sex among people attending HIV VCT in Kinshasa, associated with other sexual and consumption risk behaviors, highlights the need to include paid sex among the risk factors mentioned in HIV prevention counseling.