Étude des anomalies de la flore vaginale : facteurs de risque, prédicteurs de la récurrence et association avec l'infection à VIH chez des travailleuses du sexe recrutées dans un essai clinique en Inde et dans deux pays africains

Objectifs : Le présent travail, qui a consisté en l’analyse secondaire des données provenant des travailleuses de sexe (TS) recrutées au niveau de 2 sites Africains et 2 sites Indiens, dans le cadre de l’essai clinique sur le gel vaginal de sulfate de cellulose, avait pour objectifs : 1) d’identifier les facteurs de risque de la flore vaginale intermédiaire (FVI) et de la vaginose bactérienne (VB), 2) d’étudier l’association entre les anomalies de la flore vaginale et l’infection à VIH, 3) d’identifier les prédicteurs de la récurrence de la VB. Méthodes : L’étude comprend deux analyses transversales et une longitudinale. Les deux analyses transversales ont exploité les données sociodémographiques, comportementales et biologiques de la visite de dépistage de 1367 participantes. La première analyse transversale a combiné les régressions logistiques polytomique et dichotomique pour examiner les facteurs de risque de la FVI en rapport avec ceux de la VB tandis que la seconde analyse a utilisé la régression log-binomiale pour étudier l’association entre les anomalies de la flore vaginale et l’infection par le VIH. L’analyse longitudinale, quant à elle, a exploité les données de base et de suivi de 440 TS enrôlées dans l’essai clinique et a utilisé le modèle de risque proportionnel de Andersen-Gill pour identifier les prédicteurs de la récurrence de la VB. Résultats : La FVI partage avec la VB, la plupart de ses facteurs de risque ou de protection et ceci supporte l’idée que les deux ne constituent qu’une seule et même maladie. Les facteurs de risque communs à la FVI et à la BV, et particulièrement ceux qui sont plus fortement associés à la FVI qu’à la VB, sont peu révélés par la régression dichotomique regroupant la FVI et la flore normale comme catégorie de référence. Par ailleurs, la FVI est associée à l’infection à VIH aussi fortement que la VB avec respectivement des rapports de prévalences ajustés (RPa) = 1,56 [intervalle de confiance (IC) à 95%=1,22-1,98] et RPa=1,48 (IC à 95%=1,20-1,84). Enfin, la douche vaginale récente et l’utilisation constante de condom avec le partenaire régulier se sont révélées être les principaux prédicteurs de la récurrence de la VB avec respectivement des rapports de taux d’incidence ajustés (RTIa)= 1,30 (IC à 95%=1,02 – 1,64) et RTIa=0,68 (IC à 95%=0,49 - 0,93). Conclusion : La dichotomisation des anomalies de flore vaginale isolant la FVI de la VB mérite d’être reconsidérée. La FVI devrait être considérée au même titre que la VB et traitée en tant que telle dans les stratégies de prévention qui devraient mettre l’accent sur les méfaits de la douche vaginale et l’effet protecteur de l’utilisation constante de condom avec tous les types de partenaires sexuels.Objectives: The present work consisted in the secondary analysis of data from female sex workers (FSW) recruited at two African and two Indian sites, in the context of a clinical trial on the cellulose sulfate vaginal gel, and had as objectives: 1) to identify risk factors for intermediate vaginal flora (IVF) and bacterial vaginosis (BV), 2) to study the association between vaginal flora abnormalities and HIV infection, 3) to identify predictors of recurrence of BV. Methods: The study included two cross-sectional and one longitudinal analyses. Both cross-sectional analyses used socio-demographic, behavioral and biological data from the screening visit of 1367 participants. The first cross-sectional analysis combined the dichotomous and polytomous logistic regressions to examine risk factors for the IVF in connection with those for BV, while the second analysis used the log-binomial regression to investigate the association between abnormal vaginal flora and HIV. The longitudinal analysis used baseline and follow-up data from 440 FSW enrolled in the clinical trial and used Andersen-Gill proportional hazard model to identify predictors of BV recurrence. Results: IVF shares most of its risk or protective factors with BV, and this supports the idea that both are parts of the same disease. Risk factors common to BV and FVI, and particularly those which are more strongly associated with IVF than with BV, are unlikely to be revealed by dichotomous regressions grouping IVF and normal flora as reference category. IVF was associated with HIV infection as strongly as BV with adjusted prevalence ratios (aPR) = 1.56 [95% confidence interval (CI) = 1.22 to 1.98] and aPR = 1.48 (95% CI = 1.20 to 1.84) respectively. Finally, recent vaginal douching and consistent condom use (CCU) with regular partner proved to be the main predictors of recurrence of BV with adjusted hazard ratio (aHR) = 1.30 (95% CI = 1.02 - 1.64) and aHR = 0.68 (95% CI = 0.49 to 0.93) respectively. Conclusion: The dichotomization of abnormal vaginal flora isolating IVF from BV needs to be reconsidered. IVF should be considered alongside BV and treated as such in preventive strategies which should focus on the adverse effects of vaginal douching and the protective effect of CCU with all types of sexual partners

Prevalence and factors associated with HIV and sexually transmitted infections among female sex workers in Bamako, Mali

Background: We aimed to (1) estimate the prevalence of HIV and other sexually transmitted infections (STIs) among female sex workers (FSWs) in Bamako, Mali, and (2) identify factors associated with STIs including HIV infection in this population. Methods: We analyzed baseline data from a prospective observational cohort study on cervical cancer screening, human papillomavirus, and HIV infections among FSWs 18 years or older recruited in Bamako. Multivariable log-binomial regression was used to estimate the adjusted prevalence ratios (APRs) with 95% confidence interval (95% CI) for HIV infection and STIs versus associated factors. Results: Among 353 women participating in the study, mean age was 26.8 (±7.6) years. HIV prevalence was 20.4%, whereas 35.1% of the FSWs had at least one STI. Factors significantly associated with HIV were older age (P < 0.0001, test for trend), duration of sex work ≥6 years (APR, 1.92; 95% CI, 1.22-3.02), uneducated status (APR, 2.24; 95% CI, 1.16-4.34), less than 10 clients in the last 7 days (APR, 1.55; 95% CI, 1.02-2.34), and gonococcal (APR, 1.85; 95% CI, 1.21-2.82) and chlamydial (APR, 2.58; 95% CI, 1.44-4.62) infections. Younger age (P = 0.018, test for trend), having ≥10 clients in the last week (APR, 1.47; 95% CI, 1.11-1.94), and HIV infection (APR, 2.00; 95% CI, 1.49-2.69) were significantly associated with STIs. Conclusions: HIV and curable STI prevalence are high among FSWs in Bamako. There is thus a need to enhance the efficiency of interventions toward FSWs in Mali to reduce the burden of HIV and STIs among them and prevent HIV spread to the general population

Prevalence and Factors Associated With HIV and Sexually Transmitted Infections Among Female Sex Workers in Bamako, Mali

Background: We aimed to (1) estimate the prevalence of HIV and other sexually transmitted infections (STIs) among female sex workers (FSWs) in Bamako, Mali, and (2) identify factors associated with STIs including HIV infection in this population. Methods: We analyzed baseline data from a prospective observational cohort study on cervical cancer screening, human papillomavirus, and HIV infections among FSWs 18 years or older recruited in Bamako. Multivariable log-binomial regression was used to estimate the adjusted prevalence ratios (APRs) with 95% confidence interval (95% CI) for HIV infection and STIs versus associated factors. Results: Among 353 women participating in the study, mean age was 26.8 (±7.6) years. HIV prevalence was 20.4%, whereas 35.1% of the FSWs had at least one STI. Factors significantly associated with HIV were older age (P < 0.0001, test for trend), duration of sex work ≥6 years (APR, 1.92; 95% CI, 1.22-3.02), uneducated status (APR, 2.24; 95% CI, 1.16-4.34), less than 10 clients in the last 7 days (APR, 1.55; 95% CI, 1.02-2.34), and gonococcal (APR, 1.85; 95% CI, 1.21-2.82) and chlamydial (APR, 2.58; 95% CI, 1.44-4.62) infections. Younger age (P = 0.018, test for trend), having ≥10 clients in the last week (APR, 1.47; 95% CI, 1.11-1.94), and HIV infection (APR, 2.00; 95% CI, 1.49-2.69) were significantly associated with STIs. Conclusions: HIV and curable STI prevalence are high among FSWs in Bamako. There is thus a need to enhance the efficiency of interventions toward FSWs in Mali to reduce the burden of HIV and STIs among them and prevent HIV spread to the general population

Structural determinants of health : a qualitative study on female sex workers in Benin

The objective of this paper is to expose those socio-structural contexts revealing the social injustice and human rights violations that sub-Saharan women face every day when forced into sex work by unemployment or sickness. Results of a qualitative study highlighting some key structural determinants of sex work and HIV infection among FSWs will be presented and examined through the lens of the WHO conceptual framework for action on the social determinants of health. The results showed that most FSWs had lacked the necessary financial support at some point in their lives. Also, both the socioeconomic and political context failed to provide proper support to prevent involvement in sex work and the consequent risks of HIV. The cultural and societal values placed on the health and well-being of FSWs in Benin appear to depend on the degree to which sexual violence and adultery are perceived as a collective social concern. This portrait of FSWs calls for both long-term interventions through a structural determinant approach to HIV prevention, targeting all the women who could face such a financial situation well before their entry into sex work, while maintaining short and medium-term interventions on the intermediary determinants

Acceptability of pre-exposure prophylaxis (PrEP) among men who have sex with men (MSM) in Benin : a qualitative study

In Benin, consistent condom use among men who have sex with men (MSM) is relatively low and providing them with Pre-exposure prophylaxis (PrEP) could be of great relevance. We aimed to describe PrEP knowledge and intention to use it; identify key facilitators and barriers to PrEP; and describe the perceived impact of PrEP on unsafe sexual behavior. MSM, 18 years or older, HIV-negative or of unknown status, were enrolled in five cities of Benin. Intention to use PrEP was assessed through five focus groups (FG). Data were analyzed using manual thematic sorting. Thirty MSM (six per city) participated in the FG. Mean age (standard deviation) was 27.1 (5.0) years. All participants expressed the intention to use PrEP if made available. Facilitators of PrEP use were: availability of medication, safety, absence of constraints as well as freedom to have multiple sex partners and sex with HIV-positive friends. Barriers were: complex procedures for obtaining medication, size and taste of medication, cost of medication, poor PrEP awareness.. Eighteen men admitted that PrEP could lead to decrease in or even abandonment of condom use. In conclusion, MSM showed openness to use PrEP if available, although they recognized that it could lead to risk compensation

HIV prevention and treatment cascades among female sex workers in Benin, West Africa

Background & Objectives Benin has a long-standing history of HIV prevention programs aimed at female sex workers (FSWs). We used data from a national survey among FSWs (2017) to assess the prevention and care cascades in this population. Methods FSWs were recruited through cluster sampling of sex work sites. A questionnaire was administered, and HIV tested. HIV-positive participants were asked to provide dried-blood spots (DBS), tested for ARV and viral load. We assessed two prevention cascades (HIV testing and safer sex) and the treatment cascade, using a combination of self-reported and biological variables. Results Mean age of the 1086 FSWs was 30 years. Half of them were Beninese and two-thirds had a primary school education level or less. Almost all FSWs had ever heard of HIV/AIDS. 79.1% had ever been tested, and 84.1% of the latter had been tested in the last year. In the previous six months, 90.1% were exposed to prevention messages. Women exposed to any HIV prevention message reported a higher level of consistent condom use in the last month (69.0%) than those who were not (48.5%, p<0.0001). HIV prevalence was 7.7%. Among HIV-positive women, 60.6% knew their status; among those, 90.5% were on ARV and 81.8% of them had a suppressed viral load. Conclusions Despite long-standing HIV prevention programs for FSWs, the prevention indicators were often low. Linkage to care was good, viral suppression was sub-optimal, but knowledge of HIV-positive status was low. Exposing women to prevention messages is necessary, as to increase HIV testing

Longitudinal study of pregnancy intention and its association with pregnancy occurrence among female sex workers in Benin and Mali

Plain Language Summary The intention of becoming pregnant has an evident impact on the prenatal and postnatal period. For female sex workers (FSWs) in West Africa, among whom pregnancies are frequent, a better understanding of their pregnancy intention and its influence on pregnancy occurrence could help prevent unwanted pregnancies and adverse effects of wanted pregnancies. We recruited 330 FSWs in Benin and 322 in Mali and we followed them for 12 months. We evaluated their pregnancy intention at recruitment and at 6-month follow-up. We assessed pregnancy occurrence with a pregnancy urine test and with a retrospective questionnaire asking on pregnancy occurrence at 6 and 12 months. With these data we estimated the association between intention and pregnancy. 407 FSWs were included in the first 6-month analysis and 284 at 12 months. Sixteen percent of the FSWs had a positive intention of having a pregnancy in the next 6 months in both the first 6-month and 12 months. One out of four were ambivalent and almost 60% had a negative intention. For 38.2% of the FSWs the intention changed between the two periods. Women with an ambivalent intention compared to those with positive intention, had 30% less pregnancies whereas for negative intention, women had 54% less pregnancies during the study follow-up. As for any woman, the level of pregnancy intention influences its occurrence. Moreover, nearly one out of six FSWs wants a baby despite working in the sex trade. Programmatically, early identification of these women could facilitate provision of quality antenatal and postnatal care