Sexual and reproductive health outcomes among female sex workers in Johannesburg and Pretoria, South Africa: Recommendations for public health programmes

Abstract Background The sexual and reproductive health (SRH) status of female sex workers is influenced by a wide range of demographic, behavioural and structural factors. These factors vary considerably across and even within settings. Adopting an overly standardised approach to sex worker programmes may compromise its impact on some sub-groups in local areas. Methods Records of female sex workers attending clinic-, community-, or hotel-based health services in Johannesburg (n = 1422 women) and Pretoria (n = 408 women), South Africa were analysed. We describe the population’s characteristics and identified factors associated with sexual and reproductive health outcomes, namely HIV status; previous symptomatic sexually transmitted infection (STI); modern contraceptive use and number of child dependents. Results The women in Johannesburg were less likely than those in Pretoria to have HIV (42.2% vs 52.9%), or previous symptomatic STIs (44.3% vs. 8.3%), and were 1.4 fold less likely to have child dependents (20.1% vs. 15.3%). About 43% of women in Johannesburg were Zimbabwean and 40% in Pretoria. Of concern, only about 15% of women in both sites were using modern contraceptives. Johannesburg women were also more likely to access health services at a hotel (85.0% vs. 80.6%) or clinic (5.7% vs. 0.5%), to have completed secondary education (57.1% vs. 36.0%), and moved house more than twice during the past year (19.6 vs. 2.0%). In both cities, risk of HIV rose rapidly with age (23.8%–58.2% vs. 22.0%–64.8%). Of interest, HIV prevalence was considerably higher in those with consistent condom use with one’s main partner than inconsistent users. Conclusions Sex worker populations are heterogeneous. Local health programmes must prioritise services that reflect the variety and complexity of sex worker needs and behaviours, and should be designed in consultation with sex workers. Segmenting sex worker populations according to age, country of origin and place of service delivery, and training healthcare providers accordingly, could help prevent new HIV infections, improve adherence to antiretroviral treatment and increase uptake of SRH services

Sexual and reproductive health outcomes among female sex workers in Johannesburg and Pretoria, South Africa: Recommendations for public health programmes

Abstract Background The sexual and reproductive health (SRH) status of female sex workers is influenced by a wide range of demographic, behavioural and structural factors. These factors vary considerably across and even within settings. Adopting an overly standardised approach to sex worker programmes may compromise its impact on some sub-groups in local areas. Methods Records of female sex workers attending clinic-, community-, or hotel-based health services in Johannesburg (n = 1422 women) and Pretoria (n = 408 women), South Africa were analysed. We describe the population’s characteristics and identified factors associated with sexual and reproductive health outcomes, namely HIV status; previous symptomatic sexually transmitted infection (STI); modern contraceptive use and number of child dependents. Results The women in Johannesburg were less likely than those in Pretoria to have HIV (42.2% vs 52.9%), or previous symptomatic STIs (44.3% vs. 8.3%), and were 1.4 fold less likely to have child dependents (20.1% vs. 15.3%). About 43% of women in Johannesburg were Zimbabwean and 40% in Pretoria. Of concern, only about 15% of women in both sites were using modern contraceptives. Johannesburg women were also more likely to access health services at a hotel (85.0% vs. 80.6%) or clinic (5.7% vs. 0.5%), to have completed secondary education (57.1% vs. 36.0%), and moved house more than twice during the past year (19.6 vs. 2.0%). In both cities, risk of HIV rose rapidly with age (23.8%–58.2% vs. 22.0%–64.8%). Of interest, HIV prevalence was considerably higher in those with consistent condom use with one’s main partner than inconsistent users. Conclusions Sex worker populations are heterogeneous. Local health programmes must prioritise services that reflect the variety and complexity of sex worker needs and behaviours, and should be designed in consultation with sex workers. Segmenting sex worker populations according to age, country of origin and place of service delivery, and training healthcare providers accordingly, could help prevent new HIV infections, improve adherence to antiretroviral treatment and increase uptake of SRH services

Increasing age and duration of sex work among female sex workers in South Africa and implications for HIV incidence estimation: Bayesian evidence synthesis and simulation exercise.

INTRODUCTION In sub-Saharan Africa, accurate estimates of the HIV epidemic in female sex workers are crucial for effective prevention and care strategies. These estimates are typically derived from mathematical models that assume certain demographic and behavioural characteristics like age and duration of sex work to remain constant over time. We reviewed this assumption for female sex workers in South Africa. METHODS We reviewed studies that reported estimates on either the age or the duration of sex work among female sex workers in South Africa. We used Bayesian hierarchical models to synthesize reported estimates and to study time trends. In a simulation exercise, we also investigated the potential impact of the "constant age and sex work duration"-assumption on estimates of HIV incidence. RESULTS We included 24 different studies, conducted between 1996 and 2019, contributing 42 estimates on female sex worker age and 27 estimates on sex work duration. There was evidence suggesting an increase in both the duration of sex work and the age of female sex workers over time. According to the fitted models, over each decade the expected duration of sex work increased by 55.6% (95%-credible interval [CrI]: 23.5%-93.9%) and the expected age of female sex workers increased by 14.3% (95%-CrI: 9.1%-19.1%). Over the 23-year period, the predicted mean duration of sex work increased from 2.7 years in 1996 to 7.4 years in 2019, while the predicted mean age increased from 26.4 years to 32.3 years. Allowing for these time trends in the simulation exercise resulted in a notable decline in estimated HIV incidence rate among sex workers over time. This decline was significantly more pronounced than when assuming a constant age and duration of sex work. CONCLUSIONS In South Africa, age and duration of sex work in female sex workers increased over time. While this trend might be influenced by factors like expanding community mobilization and improved rights advocacy, the ongoing criminalisation, stigmatisation of sex work and lack of alternative employment opportunities could also be contributing. It is important to account for these changes when estimating HIV indicators in female sex workers

Improving HIV prevention programs : the role of identity in shaping healthy sexual behavior of rural adolescents in South Africa

A large body of literature highlights the role of culture and identity in how individuals manage and maintain health. Disappointingly there was no statistically significant decline in HIV prevalence in the 15–24 years age group in South Africa since 2007, Millennium Development Goal 6 indicator. This warrants a new approach to youth HIV prevention, which considers identity and culture, in male-dominant environments. We used identity-based motivation theory, which predicts that possible identities have a crucial influence on health-promoting behavior, to argue that girls are not currently attaining their low risk possible identities because sociocultural factors influence their behavior and compromise their health and economic outcomes. This study employed a cross-sectional survey among 285 rural black South African adolescents (mean age 16.7 years; 48.8% boys) to determine the salient social identity and the associated possible identities. We then tested whether youth behave in accordance with their possible identities. The dependent variables are non-risky behavior, risky behavior, and confidence to discuss sex. The independent variables are age, previous sex experience, and poverty. The adolescents chose gender as the most prominent social identity. Girls chose a safer possible identity than boys did, and girls do not actualize their possible identities while boys do. For girls, no dependent variables were significant. These results show that sociocultural barriers prevent the girls from actualizing their non-risky possible identity. Future adolescent HIV prevention programs aimed at reducing HIV should promote rights and responsibilities and consider cultural norms and beliefs to create a more gender-equal society that embraces less risky sexual behavior, in line with the idealized identity of girls. This to convince both male and female adolescents of the benefits, risks, and social harms embedded in certain traditional practices in a high HIV-prevalent environment

Improving HIV prevention programs: the role of identity in shaping healthy sexual behavior of rural adolescents in South Africa

A large body of literature highlights the role of culture and identity in how individuals manage and maintain health. Disappointingly there was no statistically significant decline in HIV prevalence in the 15–24 years age group in South Africa since 2007, Millennium Development Goal 6 indicator. This warrants a new approach to youth HIV prevention, which considers identity and culture, in male-dominant environments. We used identity-based motivation theory, which predicts that possible identities have a crucial influence on health-promoting behavior, to argue that girls are not currently attaining their low risk possible identities because sociocultural factors influence their behavior and compromise their health and economic outcomes. This study employed a cross-sectional survey among 285 rural black South African adolescents (mean age 16.7 years; 48.8% boys) to determine the salient social identity and the associated possible identities. We then tested whether youth behave in accordance with their possible identities. The dependent variables are non-risky behavior, risky behavior, and confidence to discuss sex. The independent variables are age, previous sex experience, and poverty. The adolescents chose gender as the most prominent social identity. Girls chose a safer possible identity than boys did, and girls do not actualize their possible identities while boys do. For girls, no dependent variables were significant. These results show that sociocultural barriers prevent the girls from actualizing their non-risky possible identity. Future adolescent HIV prevention programs aimed at reducing HIV should promote rights and responsibilities and consider cultural norms and beliefs to create a more gender-equal society that embraces less risky sexual behavior, in line with the idealized identity of girls. This to convince both male and female adolescents of the benefits, risks, and social harms embedded in certain traditional practices in a high HIV-prevalent environment