Feasible, efficient and necessary, without exception - Working with sex workers interrupts HIV/STI transmission and brings treatment to many in need

Background and Overview. High rates of partner change in sex work-whether in professional, 'transactional' or other context-disproportionately drive transmission of HIV and other sexually transmitted infections. Several countries in Asia have demonstrated that reducing transmission in sex work can reverse established epidemics among sex workers, their clients and the general population. Experience and emerging research from Africa reaffirms unprotected sex work to be a key driver of sexual transmission in different contexts and regardless of stage or classification of HIV epidemic. This validation of the epidemiology behind sexual transmission carries an urgent imperative to realign prevention resources and scale up effective targeted interventions in sex work settings, and, given declining HIV resources, to do so efficiently. Eighteen articles in this issue highlight the importance and feasibility of such interventions under four themes: 1) epidemiology, data needs and modelling of sex work in generalised epidemics; 2) implementation science addressing practical aspects of intervention scaleup; 3) community mobilisation and 4) the treatment cascade for sex workers living with HIV. Conclusion. Decades of empirical evidence, extended by analyses in this collection, argue that protecting sex work is, without exception, feasible and necessary for controlling HIV/STI epidemics. In addition, the disproportionate burden of HIV borne by sex workers calls for facilitated access to ART, care and support. The imperative for Africa is rapid scale-up of targeted prevention and treatment, facilitated by policies and action to improve conditions where sex work takes place. The opportunity is a wealth of accumulated experience working with sex workers in diverse settings, which can be tapped to make up for lost time. Elsewhere, even in countries with strong interventions and services for sex workers, an emerging challenge is to find ways to sustain them in the face of declining global resources

How should HIV resources be allocated? Lessons learnt from applying Optima HIV in 23 countries.

INTRODUCTION: With limited funds available, meeting global health targets requires countries to both mobilize and prioritize their health spending. Within this context, countries have recognized the importance of allocating funds for HIV as efficiently as possible to maximize impact. Over the past six years, the governments of 23 countries in Africa, Asia, Eastern Europe and Latin America have used the Optima HIV tool to estimate the optimal allocation of HIV resources. METHODS: Each study commenced with a request by the national government for technical assistance in conducting an HIV allocative efficiency study using Optima HIV. Each study team validated the required data, calibrated the Optima HIV epidemic model to produce HIV epidemic projections, agreed on cost functions for interventions, and used the model to calculate the optimal allocation of available funds to best address national strategic plan targets. From a review and analysis of these 23 country studies, we extract common themes around the optimal allocation of HIV funding in different epidemiological contexts. RESULTS AND DISCUSSION: The optimal distribution of HIV resources depends on the amount of funding available and the characteristics of each country's epidemic, response and targets. Universally, the modelling results indicated that scaling up treatment coverage is an efficient use of resources. There is scope for efficiency gains by targeting the HIV response towards the populations and geographical regions where HIV incidence is highest. Across a range of countries, the model results indicate that a more efficient allocation of HIV resources could reduce cumulative new HIV infections by an average of 18% over the years to 2020 and 25% over the years to 2030, along with an approximately 25% reduction in deaths for both timelines. However, in most countries this would still not be sufficient to meet the targets of the national strategic plan, with modelling results indicating that budget increases of up to 185% would be required. CONCLUSIONS: Greater epidemiological impact would be possible through better targeting of existing resources, but additional resources would still be required to meet targets. Allocative efficiency models have proven valuable in improving the HIV planning and budgeting process

Common ‘upstream—downstream‘ transmission pathways in heterosexual networks.

<p>High-incidence transmission ‘upstream’ in sex work networks is the source of many secondary or ‘downstream’ infections among lower-risk populations.</p

Mapping and size estimates of female sex workers in Cameroon: Toward informed policy for design and implementation in the national HIV program.

BackgroundDue to high HIV prevalence among Female Sex Workers (FSWs) in Cameroon (36.5%), this population is especially vulnerable to HIV acquisition and transmission nationwide. Though being prioritized in the national HIV response, it would be relevant to generate statistics on the number of FSWs in order to guide HIV interventions among FSWs. Our objective was to estimate the size of FSWs within hotspots of Cameroon.MethodsA cross-sectional study was conducted from September-November 2015 in selected cities in Cameroon: Bafoussam, Bamenda, Bertoua, Buea, Douala, Kribi, Limbé, and Yaoundé. A programmatic mapping was used, consisting of interviews with secondary key informants (KI) to identify hotspots of FSWs and their respective estimated numbers. Validation of size estimates was done by interviews with FSW at each hotspot. Size estimations in the councils mapped were extended to others not mapped using a Poisson regression model.ResultsA total of 2,194 hotspots were identified: Douala (760), Yaoundé (622), Bamenda (263), Bafoussam (194), Kribi (154), Bertoua (140), Limbé (35), and Buea (26). The estimated total number (range) of FSWs was 21,124 (16,079-26,170), distributed per city as follows: Douala 7,557 (5,550-9,364), Yaoundé 6,596 (4,712-8,480), Bafoussam 2,458 (1,994-2,923), Bamenda 1,975 (1,605-2,345), Kribi 1,121 (832-1,408), Bertoua 1,044 (891-1,198), Buea 225 (185-266), and Limbé 148 (110-148). The variability of estimates among cities was also observed within the councils of each city. The national predicted estimate of FSW population was 112,580 (103,436-121,723), covering all councils of Cameroon. An estimate of 1.91% (112,580/5,881,526; 0.47%-3.36%) adult female population in Cameroon could be sex workers.ConclusionThere are considerable numbers of FSW in major cities in Cameroon. There is a need to prioritize interventions for HIV prevention toward this population in order to limit the burden of HIV sexual transmission nationwide

Number of key informants by type of key informant and by state.

<p>Number of key informants by type of key informant and by state.</p

Number of FSW spots by state.

<p>Number of FSW spots by state.</p

Number of Key Informant Interviews by State, Sex and Educational level.

<p>Number of Key Informant Interviews by State, Sex and Educational level.</p

Percentage distribution of FSWs by type of spot by state, Nigeria, 2012.

<p>Percentage distribution of FSWs by type of spot by state, Nigeria, 2012.</p

Estimated number of FSWs by state, by LGA and average number of FSWs/1000 adult men per state, Nigeria, 2012.

<p> Per 1000 adult men refers to men age >18 years of age.</p