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Engagement in HIV Care Among Young Female Sex Workers in Zimbabwe

Napierala, Sue PhD*; Chabata, Sungai Tafadzwa MSc; Fearon, Elizabeth PhD; Davey, Calum PhD; Hargreaves, James PhD; Busza, Joanna MSc; Mushati, Phillis MSc; Mtetwa, Sibongile MSc; Chiyaka, Tarisai MSc; Mugurungi, Owen MD§; Hanisch, Dagmar MPH; Hatzold, Karin MD; Phillips, Andrew PhD#; Cowan, Frances M. MD†,**

JAIDS Journal of Acquired Immune Deficiency Syndromes: November 1, 2018 - Volume 79 - Issue 3 - p 358–366
doi: 10.1097/QAI.0000000000001815
Implementation Science

Introduction: Young female sex workers (FSWs) are at greater HIV risk than their older counterparts. Yet, the extent of their engagement with HIV services is largely unknown. We compared engagement among FSWs aged 18–24 years with those 25 years and older.

Methods: We used respondent-driven sampling to recruit FSWs from 14 communities in Zimbabwe from November to December 2013. We collected data on demographics, behavior, service uptake, and HIV and viral load testing. Data were pooled and weighted using respondent-driven sampling-2 estimation. We analyzed HIV care cascade variables by age group. To identify potential drivers of younger FSW service use, we explored factors associated with knowing one's HIV status.

Results: Among 2617 participants, mean age was 31 years and 26% were 18–24 years. Over half of FSWs initiated sex work before the age of 25 years. Overall HIV prevalence was 59% but was lower among younger FSWs (35% vs 67%, P < 0.01). Younger HIV-infected FSWs were significantly less engaged at each step of the care cascade. Among younger FSWs reporting antiretroviral therapy use, 62% had an undetectable viral load compared with 79% in older FSWs. In multivariable regression, young FSWs encouraged to have an HIV test by another FSW (adjusted odds ratio = 2.54; 95% confidence interval: 1.44 to 4.50), and those with no recent clients (adjusted odds ratio = 4.31; 95% confidence interval: 1.30 to 14.33) were more likely to report knowing their status.

Conclusions: The high proportion of FSWs initiating sex work before the age of 25 years and their lower engagement in HIV services highlights the importance of considering this vulnerable population in HIV programming. Implementing targeted services tailored to the unique needs of young FSWs is a public health imperative.

*Women's Global Health Imperative, RTI International, San Francisco, CA;

Center for Sexual Health and HIV/AIDS Research (CeSHHAR), Harare, Zimbabwe;

Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, London, United Kingdom;

§AIDS and TB Programme, Ministry of Health and Child Care, Harare, Zimbabwe;

United Nations Poplulation Fund, Harare, Zimbabwe;

Popluation Services International, Harare, Zimbabwe;

#Institute for Global Health, University College London, London, United Kingdom; and

**Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom.

Correspondence to: Sue Napierala, PhD, Women's Global Health Imperative, RTI International, 351 California Street, San Francisco, CA 94104 (e-mail:

The SAPPH-IRe trial baseline survey was funded by United Nations Population Fund via Zimbabwe's Integrated Support Fund, which receives funds from DfID, Irish Aid, and Swedish SIDA. A small amount of funding for survey work was from GIZ.

Presented in part at the 8th IAS Conference on HIV Pathogenesis Treatment & Prevention; July 20, 2015; Vancouver, Canada.

The authors have no conflicts of interest to disclose.

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is permissible to download, share, remix, transform, and buildup the work provided it is properly cited. The work cannot be used commercially without permission from the journal.

Received February 15, 2018

Accepted May 20, 2018

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