2014

Combination HIV prevention for Female Sex Workers: What is the evidence? Linda-Gail Bekker, Leigh Johnson, Frances

Cowan, Cheryl Overs, Donela Besada, Sharon Hillier, Ward Cates Jnr.

Desmond Tutu HIV Centre, S Africa School of Public Health, UCT, S Africa

Centre for Sexual Health and HIV/AIDS Research, Zimbabwe Michael Kirby Centre for Public Health and Human Rights, Australia

The Desmond Tutu HIV Foundation, S AfricaUniversity of Pittsburgh, USA

FHI 360,USA

18 July …….we remember-

“ We need bold initiatives to prevent new infections……”

“To deny people their human rights is to deny their very humanity……”

• Immuno-pathogenenesis– Exposure without infection studies

• Early microbicide trials– Nonoxynol –9 studies

• Role of community participation – Thai 100% Condom uptake program

• Good participatory guidelines – Early Pre-exposure prophylaxis trials.

Sex Workers and HIV Research

FSW: What works for prevention?

• Reviewed medical work (English) from 2000 to present related to Female Sex Worker (FSW) and HIV prevention (2300 articles).

• Included Peer reviewed observational studies, RCTs, consensus papers and program reports.

• Information specifically related to HIV Prevention in FSW sparse-

• Inclusion criteria broadened to ensure a comprehensive understanding of potential HIV prevention interventions available.

Prevention Framework

Risk level 5 : Environment

Risk level 4 : Public policy

Risk level 3 :Community

Risk level 2 : Network

Risk level 1 : Individual

Tailored Combination Prevention

Tailored combination prevention

• Effective prevention requires knowledge of SW setting and environment

• Recognises SW autonomy and freedom to choose• Has full involvement of peers in design and

implementation• Employs a layered combination approach• Includes careful monitoring and evaluation to

measure impact and also any unanticipated harms….

Established Interventions

• Condoms:– Male and female– condom-compatible lubricant– Access and cost

• Voluntary testing and linkage to services.– Poor coverage in FSW but improving globally– Additional barriers: disclosure and fear issues.

• Sex worker friendly health services, including sexual and reproductive health services.– STI treatment, contraception.

Voice from Zimbabwe….

”The nurse said to me how can you, a sex worker even have high blood pressure, its high because of too much sex...you are wasting our drugs

instead of us giving them to those who have proper high blood pressure caused by women like you when you take and infect their husbands and them eventually..."

In response : Sister with a Voice set up in 2009 by ZNAC. Now in 36 districts .

Established Interventions

• Economic strengthening and supplemental income.• Exploring conditional cash transfers

• Behaviour change through peer education and community-based counselling

• Harm reduction in FSW-WID

In a survey of its national programme in 2013, the Sex

Workers Education and Advocacy Taskforce (Sweat) found that sex workers named the police as the perpetrators of violence 53% of

the time.

Established Interventions:

• Gender-based and police violence, stigma, and discrimination.– Rights, legal and protection

services.• Community empowerment:

– promotion of social cohesion and capital, inclusion and leadership skills.

• Advocacy and community mobilization: – policy, programme, and services.

The late General Maswangane

Newer Interventions

• Post Exposure Prophylaxis services – Sexual assault, unintended exposures

• Pre Exposure Prophylaxis services – Oral (PrEP) – Topical (microbicides)

• SWF HIV care and treatment:– Antiretroviral treatment services– Prevention of vertical transmission

PrEP trials and protection estimates

Clinical trial Gender SW Drug detection in blood and vaginal samples from non-seroconverters

HIV protection estimate as related to high adherence

Partners PrEP (oral) M/F ✗ 81% 86-90%

TDF2 (oral) M/F ✗ 79% 78%

FEM-PrEP (oral) F TS (12.6%)

26% at two visits Too low

Global iPrEx (oral) MSM/TG

TS (41%) 51% 92%

Bangkok Tenofovir (oral)

M/FIDU

SW/TS partners(38%)

66% 74%

VOICE (oral and topical)

F TS (6.1%)

50% had no detectable levels Too low

CAPRISA 004 (topical)

F TS (1.9%)

54% in high adherers

(TS= Transactional sex)

Factors associated with SW that may affect PrEP effectiveness

Newer interventions: Secondary prevention

• Access to ARV Treatment critical for +SW health• Regular VCT and commencement of ART at earlier

stages of infection (higher CD4 counts)– HPTN 052 : 96% reduction in HIV transmission between

linked discordant couples where treated partner was suppressed on ART.

• Important for HIV prevention in negative clients or intimate partners

• Effective PMTCT services to reduce vertical transmission

Combination prevention: RSA case study.

From 2015-2025

(Topical PrEP) (Oral PrEP)

Combination prevention: RSA case study.

Effect of uptake and efficacy on % reduction in new HIV infections 2015-2025

Oral PrEP TasP

Prevention Framework 5:Know your SW epidemic, know

your SW response

Prevention Framework 4: Policy reform and decriminalisation:

safer working conditions; < police

brutality; FSW empowerment

Prevention Framework

3: Community based and led services,

advocacy and mobilisation: <stigma, discrimination. Peer

led behaviour change

Prevention Framework

2: Networks : social, sexual, drug injection.

STI control, condom promotion, harm

reduction and reduction in GBV all important.

Prevention Framework

1: Behavioural and biomedical interventions:

Condom usage, regular sexual and reproductive

health care, VCT, PEP, PrEP (future of injectables, depot

vaginal rings, rectal microbicides).

Early Treatment for health and clients.

Conclusions

• Effective HIV prevention interventions for FSWs have not been taken to scale in most parts of the world

• Stigma and criminalization form barriers to existing effective interventions

• FSW prevention packages MUST include SWs in design and implementation

• Newer biomedical technologies should be additive to and not replacements for established interventions.– PrEP has been shown to be effective in men and women although sparse evidence in

SWs.– ART critical for SWs living with HIV– Earlier ART in positive FSWs will benefit clients directly and FSW indirectly.

• Tailored combination prevention interventions for FSWs are likely to have greatest benefit in SWs, clients and wider population.

Final word:

“Where sex workers organize, where the police do not harass them and they are free to avail themselves of quality HIV services, sex workers have lower rates of STIs, more economic power and a greater ability to get education for their children”. The Global Commission on HIV and the law: Sex Workers 2012.

Thank You

• Guest editors (Chris Beyrer, Jenny Butler, Anna-Louise Crago, Steff Strathdee) and Editors.

• Co-authors: Leigh Johnson, Frances Cowan, Cheryl Overs, Donela Besada, Sharon Hillier, Ward Cates Jnr.

• Valuable comments: Cate Hankins, Ken Mayer, Stef Strathdee, Chris Beyrer.

• Visuals: Maria Stacey (SWEAT), Andy Lambert (TB/HIV).• Quote: Sisters with a Voice- Frances Cowan (Zim)• Funding:

– The Bill and Melinda Gates Foundation– The United Nations Family Planning Association.