Understanding HIV in West and Central Africa (WCA) is limited to data from a few cities in a region that covers 24 countries and over 350 million people. WCA has over 6.5 million people living with HIV, representing 19% of the global burden, and yet, only 21% eligible for treatment have coverage.1 HIV in WCA averages 4.9%, ranging from less than 1% to 5%.2
Key populations, including female sex workers (FSWs), men who have sex with men (MSM), transgender persons, and people who inject drugs (PWIDs) confront high HIV prevalence and incidence rates globally.3–6 Limited studies among key populations in WCA show HIV prevalence among MSM in West African countries between 13.5% and 25.3%, and HIV among FSWs at least 8-folds higher than the general population; scant studies exist for PWIDs or transgender women.2,5,7 Findings from the region presented in this special issue of JAIDS argue that we must urgently scale key populations tailored responses in WCA.2,8,9
Many WCA countries are classified as having generalized epidemics (HIV prevalence in general population over 1%), which is interpreted to mean HIV responses need not focus on key populations.10,11 This crude classification is reinforced by Modes of Transmission studies that systematically underestimate the contribution of key populations to new HIV infections as they are not designed to use the limited subnational data available on key populations size, prevalence, or risk; accurate estimates of the number of FSW clients are not available; and Modes of Transmission studies fail to factor in onward transmission beyond a year from a single source.12,13 In this special issue, more robust modeling designed to reflect onward transmission from sex work over time was done by Mishra et al,14 using FSW data from Benin, Burkina Faso, and Kenya. Considering where the greatest impact on onwards transmission can be made, Boily et al15 model data from WCA to show that coverage of all active FSWs with prevention and treatment programs was far more efficient than spreading programming throughout the general population, which would require an investment more than 96 times greater.
Better Strategic Planning and Investment
This special issue provides insights into strategic planning and investment in WCA. In a systematic review of existing data and policy gaps in 7 selected WCA countries, MacAlister et al16 assessed national target setting, surveillance, and essential services for key populations. Key population estimation data were found only in Ghana and Nigeria, and there was a wide variation in key population programming in National Strategic Plans. A minimum package of services was just recently defined in Cote d'Ivoire, Ghana, and Nigeria. Most programming did not address structural vulnerabilities such as harm reduction and violence.
A lack of understanding of key populations coupled with stigma and discrimination hampers effective responses.11,17 Findings from many countries show that even with strong epidemiological data and existence of supportive policies, resources are not allocated or existing policies implemented.17,18 In light of this, Nicole et al implemented the Optima Tool.19,20 Using local demographic, epidemiologic, program, cost, and expenditure data, the team determined the best allocation of available resources for minimizing HIV incidence and disability-adjusted life years over 10 years. The conclusion, to increase expenditure for FSW interventions (from 1% to 4%–5%), double expenditures for antiretroviral treatment and prevention of mother-to-child transmission, and reduce expenditure for the general population.
Modeling from a long-standing sex worker cohort in Burkina Faso by Low et al21 suggest that targeting antiretroviral therapy (ART) to full-time FSWs can be highly efficient in controlling the epidemic when complementing condom promotion and sexually transmitted infection control. Targeting FSWs would require comparatively less resources; although the authors caution that addressing sex workers' needs is complex, requiring more investment through dedicated clinics, adherence support, and other structural interventions not done in general population HIV programs. This work was the first of its kind in West Africa but reflected findings that were similar in models done in Kenya and India.22,23
Two articles describe decreasing HIV associated with increased condom use. From Mali, Trout et al24 analyzed 4 surveys from 2000 to 2009 showing declines in both Malian and foreign FSWs. Despite declines associated with increasing condom use and HIV testing from a high of 35.3%–24.1%, they note important differences between nationalities and vulnerabilities related to high turnover and mobility. In Ghana, from 1986 to 2013, Wondergem et al25 describe national expansion of services, including condoms, drop-in centers, HIV care, and gender-based violence, concurrent with declining sexually transmitted infection and HIV among FSWs amidst fragmented funding.
Duvall et al explore structural barriers restricting key populations from accessing services in Burkina Faso and Togo using the Policy Assessment and Advocacy Decision Model.26,27 They found that criminalizing laws targeting MSM and FSWs resulted in harassment and arrests and recommend accountability mechanisms including monitoring of policy implementation with measurable key population inclusion in decision making and funding allocation. The study offers a pragmatic approach to address the enabling environment and improve HIV service access and human rights.
Findings from this special issue provide new information that support arguments made globally on situations where unprotected sex is accepted or forced, especially for protection, when FSWs are faced with discrimination, violence, and pressure to provide for dependents and under psychosocial stress.28 Indeed, the most immediate priority for FSWs and other key populations may not be HIV risk, but survival. Several articles describe varying profiles of sex workers across different cities within a country or across the WCA region; these risk profiles present different ways that access to services may best be ensured and their HIV risk reduced.
The experience of violence among FSWs by police, clients, partners, and strangers, including frequent rape (33%) and different episodes of violence was a common theme across Ghana, Burkina Faso, Cameroon, and Togo.29 For these FSWs, addressing violence is prioritized before safe sex. A qualitative assessment of structural-, social-, economic-, and individual-level vulnerabilities of adolescent and young FSWs in Kumasi, Ghana, done by Onyango et al30 reveals that drug and alcohol use, violence, and police harassment are among factors affecting condom use, even among those with accurate knowledge of HIV prevention and high intention to use condoms. Both violence and rape by clients were perceived by respondents as their greatest risk. In Cameroon, Lim et al,31 describe FSWs' ability to negotiate condom use and prevent violence from clients, police, and regular partners. FSWs predict situations where clients become violent and use individual and collective strategies to avoid violence. They describe less control in their interactions with police and particularly brutal violence and rape. An unanticipated finding is that sex workers seek out nonpaying partners for protection from violence, and unprotected sex is expected in these relationships. Wirtz's study in Togo and Burkina Faso shows that those who report sexual violence are twice as likely to report unprotected sex with all partners.29 Among those with a history of violence, self-efficacy or perceived ability to negotiate condom use with new clients, regular clients, and nonpaying partners is also significantly lower.
Two studies explore family planning needs of FSWs. Papworth et al32 illustrating how sex workers who are mothers, in 2 urban centers of Burkina Faso, may uniquely negotiate risk and services, calling for tailored interventions and integrated services. FSW mothers are more likely to have nonpaying partners and less likely to use condoms with these partners. They are however more likely to use condoms with clients and more likely to have been tested. Like most women, sex workers who are mothers are 4 times more likely to use hormonal contraception. Mothers reported that they entered sex work to provide for family and relied on sex work alone for income. Schwartz et al33 found that FSWs in Cote d'Ivoire are more likely to test for HIV (over half in the past year) than to use a hormonal contraceptive or other long-acting reversible contraception method (39%). The burden of unintended pregnancy among FSWs and maternal and infant outcomes in the context of HIV is largely unknown, but in this study, nearly half of all young 18- to 19-year-old FSWs reported that they have been pregnant and have had an unintended pregnancy (40%) or multiple unintended pregnancies (17%). By their mid-twenties, the wide majority of FSWs (65%) had an unintended pregnancy. This work demands integrating family planning into HIV services for FSWs.
Grosso showed the risk of young sex work entrants in Burkina Faso.34 In Bobo-Dioulasso and Ouagadougou, 31% and 24%, respectively, entered sex work under 18 years. Those FSWs who came from neighboring countries were older than Burkinabe sex workers. The younger entrants in both cities were twice as likely not to use a condom with a client when offered more money, and in Ouagadougou, they were half as likely to test for HIV more than once.
Access to and Quality of Prevention, Care, and Treatment Programming
Reaching key populations with HIV prevention, care, and treatment services in WCA requires not just a shift of budgets but strategy that builds their access to services. In the Democratic Republic of Congo, Mulongo et al35 describe abandoning a general population approach to free up budget to better access and serve MSM and FSWs. They recognized that population density, risk, and preferred service providers for key populations are different and used size estimation and mapping data to focus on urban networks of key populations across hotspots. They tailored their outreach, designed mobile and evening testing services, identified respectful referral services, and demonstrated a 3.4-fold increase in reach of MSM, a 1.8-fold increase in FSWs, and doubled their clinical attendance. In Nigeria, Baral et al explored recruitment of MSM into combination prevention and treatment services. They found respondent-driven sampling an effective approach to increasing access.36 In a related article, Charurat et al37 showed that after recruitment, slightly more than half of respondents returned for HIV testing. Among those HIV positive and not on ART, slightly more than half initiated treatment as prevention.
In WCA, the context and practice of injecting drug use is largely not understood. In a study from 1 area in Ghana, Messersmith et al38 provided context through interviews with men and women who inject drugs. PWIDs in Ghana had limited knowledge of HIV transmission and described sharing injecting equipment, reusing needles with one another, and using injecting equipment found in hospital waste sites, in an environment with virtually no programming. The intimate partnerships between drug users, in particular women who reported being introduced to injecting by boyfriends and not using condoms, was complex. Both male and female respondents described selling sex and engaging in multiple sexual relationships.
Two studies examined FSW outreach, community mobilization, and HIV testing in Benin, a country with documented successful FSW programming but with significant gaps.39,40 Ethnographic field work among FSWs and health care providers by Dugas et al41 found that the main factors that hindered HIV testing were fears of accessing services, lack of accessibility, and perceived lack of quality of services. Batona et al42 looked more closely at intention to receive regular HIV testing among FSWs in Benin, applying the Theory of Planned Behavior to understand a sex worker's intentions and perceptions of control. This work applied methodological rigor in exploring peer support, addressing stigma, and providing information on services concluding that perceived support from peers, managers of sex work sites, and close family members is a key facilitating factor in acceptance of HIV testing and counseling. A low level of knowledge along with fear, anxiety, and perceived negative consequences (rejection, stigma, discrimination) are the main barriers. A study in the Gambia by Peitzmeier et al explored 3 types of stigma on health outcomes using the People Living with HIV Stigma Index.43,44 They found that enacted stigma in the health care setting was significantly associated with both delays in seeking care as well as with nonuse of ART.
HIV care and treatment coverage remains lower among key populations than in the general population, and adherence to ART for key populations is not well characterized. In Cameroon, Holland et al45 estimated ART coverage for FSWs and MSM, by conducting size estimations while mapping health services and conducting interviews at each site. ART coverage was variable but universally low (0%–25% among MSM and FSWs living with HIV). Male and FSWs, such as many key populations, do not often self-identify to providers for fear of stigma and discrimination; therefore, it is very difficult to track treatment coverage. In Cote d'Ivoire, Vuylsteke et al46 used retrospective cohort data and clinical records to assess retention of male and FSWs on ART in a routine setting. They found a retention rate of just 55% at 24 months, and 47% at 36 months. This poor retention was associated with low education, not receiving ART adherence counseling at initiation and a later entry into ongoing ART program compared with other entrants.
In WCA, key populations face stark challenges in accessing services. The exact magnitude of disparities faced by key populations, in terms of HIV incidence, distal determinants compounding their risk, and even population sizes are not well known. Much research to inform how we understand key populations is based on snapshots from limited geographic settings in WCA, and thus, the region has inherited approaches from other areas that may be less effective in the WCA context. This special issue expands the available data and experience on HIV and HIV programs in WCA to inform impactful responses to the region. Scaling targeted HIV prevention, care, and treatment services for key populations has been shown to be cost-effective.47,48
A number of priorities emerged in this body of work. They are as follows:
- Most importantly, all WCA countries need to define a specific key population strategy within their national HIV strategic and operation plans. This approach should actively engage key population communities as they will fill gaps where data do not exist to better inform the response. Key populations will also need to be involved in the development of HIV programs, from planning to implementation, through capacitated organizations and networks that will foster better accountability to ensure quality programs.
- In WCA where HIV budgets are constrained by the burden of economic, social, and other health constraints, resource mobilization strategies and budgeting priorities should address the disproportionate burden of HIV and poor access to services that key populations face. As HIV prevention, care, and treatment programs are better informed through more accurate understanding of transmission dynamics, learning from the articles in this supplement and other work can be used to better serve key populations needs.
- Key population interventions must be comprehensive. They will be effective only when they address both immediate access to treatment and prevention as well as broader health needs, such as reproductive health, and structural issues, such as discrimination, violence, and community empowerment. These structural factors influence risk reduction and condom use as well as health access and control over their environment.
- Laws criminalizing MSM, drug injecting, and sex work drive those most at risk away from programs and socially sanction their discrimination, which make it difficult to mount a comprehensive response and impossible to sustain HIV responses. Addressing the policy environment from the standpoint of human rights, access to HIV services, participation in HIV policy, and key population organizational development is vital.
The authors wish to acknowledge the contribution of Stefan Baral and Claire Holland.
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