More than 90% of female sex workers (FSWs) working in South Africa’s three largest cities areas – Johannesburg, Cape Town and Durban – report having previously tested for HIV; in addition, reported condom use with clients is relatively high, but HIV prevalence ranges between 40% to 72%. Behavioural indicators reveal high levels of unrecognised HIV infections and rates of recent HIV seroconversions, according to the recent South Africa National Health Monitoring Study (SAHMS.)
These are some of the key findings of the very first integrated biological and behavioral survey (IBBS) conducted with FSWs in South Africa. The survey was led by the University of California, San Francisco (UCSF) collaborating with the Wits Reproductive Health and HIV Institute (WRHI), Anova Health Institute, and supported by the US Centres for Disease Control and Prevention, South Africa (CDC-SA) and the US President’s Emergency Plan for AIDS Relief (PEPFAR).
More than 2,000 FSWs in South Africa’s three largest metropolitan areas were surveyed to estimate the size of the FSW population in each city, establish HIV and syphilis prevalence, and to determine associated HIV risk factors and determinants of access to and utilisation of health programmes by FSWs in these areas. The IBBS estimated that there were approximately 7,500 FSWs in Johannesburg, 6,500 in Cape Town, and 9,500 in Durban.
Sex workers are highly vulnerable to HIV infection, but little data exist regarding the size of the population and the epidemiological, behavioural, and social factors that drive the epidemic in South Africa. This information is crucial to understanding the burden and scale of the epidemic among a high-risk and marginalised population so that relevant prevention, care and treatment resources are effectively allocated to reduce the rates of HIV infection among FSWs, to ensure adequate services are being tailored to the needs of FSWs – both those who are HIV negative as well as those who are HIV positive – as well as the onward transmission to the general population.
While the results of the study demonstrate that the general and targeted efforts to encourage HIV testing among FSWs have shown some success, they also demonstrate that greater effort is required to mobilise HIV-negative and untested FSWs to test regularly. Moreover, many HIV-positive FSWs are not adequately linked to care, and even fewer are effectively accessing HIV treatment.
At least one in five FSWs have an undiagnosed HIV infection. Of additional concern is the relatively high numbers of new HIV infections observed among FSWs who had tested HIV-negative within the year prior to the survey – 8.8% in Johannesburg, 18.3% in Cape Town, and 8.7% in Durban. “The high rates of new infections in the last year and poor uptake of treatment shows that more must be done to link and retain HIV-positive FSWs in HIV care,” explained principal investigator, Professor Tim Lane.
“While it is encouraging that the overwhelming majority of FSWs report having previously tested for HIV (over 90% in each site), results still show an extraordinarily high burden of HIV among FSWs, suggesting that HIV is still spreading rapidly among those FSWs who are not infected. The response therefore needs scaling up of a comprehensive package of HIV prevention and treatment services,” said Dr Nancy Knight, country director, Centres for Disease Control and Prevention, South Africa.
Additional challenges facing the community include high rates of alcohol and non-medical drug use, and physical and sexual assault. In all three cities nearly one in five FSWs were survivors of sexual assault in the prior year.
Professor Helen Rees, of the Wits Reproductive Health Institute comments: “These psychosocial factors enhance the risk of acquiring HIV and interfere with care and treatment efforts. South African HIV prevention care and treatment interventions for FSWs should always incorporate interventions that address these psychosocial co-morbidities.”
The study concludes that, despite the challenges faced by the FSW community, they were highly mobilised and enthusiastic participants and the SAHMS therefore demonstrates the feasibility of conducting second generation HIV and STI surveillance in FSW in South Africa.
“Ensuring that a culture of surveillance – including high quality data collection and the timely use of results to inform programs and identify gaps – is an essential component to controlling the HIV epidemic and reaching the 90/90/90 goals,” commented Professor James McIntyre, CEO, ANOVA Health Institute.