Refocussing on sex workers in Swaziland - even in generalized epidemics

Reconceptualizing the HIV epidemiology and prevention needs of female sex workers (FSW) in Swaziland.

Baral S, Ketende S, Green JL, Chen PA, Grosso A, Sithole B, Ntshangase C, Yam E, Kerrigan D, Kennedy CE, Adams D. PLoS One. 2014 Dec 22;9(12):e115465. doi: 10.1371/journal.pone.0115465. eCollection 2014

Background: HIV is hyperendemic in Swaziland with a prevalence of over 25% among those between the ages of 15 and 49 years old. The HIV response in Swaziland has traditionally focused on decreasing HIV acquisition and transmission risks in the general population through interventions such as male circumcision, increasing treatment uptake and adherence, and risk-reduction counseling. There is emerging data from Southern Africa that key populations such as female sex workers (FSW) carry a disproportionate burden of HIV even in generalized epidemics such as Swaziland. The burden of HIV and prevention needs among FSW remains unstudied in Swaziland.

Methods: A respondent-driven-sampling survey was completed between August-October, 2011 of 328 FSW in Swaziland. Each participant completed a structured survey instrument and biological HIV and syphilis testing according to Swazi Guidelines.

Results: Unadjusted HIV prevalence was 70.3% (n = 223/317) among a sample of women predominantly from Swaziland (95.2%, n = 300/316) with a mean age of 21 (median 25) which was significantly higher than the general population of women. Approximately one-half of the FSW (53.4%, n = 167/313) had received HIV prevention information related to sex work in the previous year, and about one-in-ten had been part of a previous research project (n = 38/313). Rape was common with nearly 40% (n = 123/314) reporting at least one rape; 17.4% (n = 23/314) reported being raped 6 or more times. Reporting blackmail (34.8%, n = 113/314) and torture (53.2%, n = 173/314) was prevalent.

Conclusions: While Swaziland has a highly generalized HIV epidemic, reconceptualizing the needs of key populations such as FSW suggests that these women represent a distinct population with specific vulnerabilities and a high burden of HIV compared to other women. These women are understudied and underserved resulting in a limited characterization of their HIV prevention, treatment, and care needs and only sparse specific and competent programming. FSW are an important population for further investigation and rapid scale-up of combination HIV prevention including biomedical, behavioral, and structural interventions.

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Editor’s notes: In countries with high prevalence generalised epidemics, research and resources often focus on the general population, and the role of key populations is often ignored. This study, from Swaziland, illustrates how the sex worker population in Swaziland suffer from a concentrated epidemic within a generalized one. The study highlights the need for focused services to address the very high HIV prevalence, some 70%, in this population. The study further highlights the lack of services, education and support reaching sex workers in this setting. Given large sexual networks, high prevalence of HIV and limited condom use, this vulnerable population is likely to be contributing substantially to the widespread epidemic in Swaziland. In this and similar settings, HIV treatment and prevention services specifically for sex workers are necessary and should be a central plank of service delivery programming, and policy making. 

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