Do female sex workers have lower uptake of HIV treatment services than non-sex workers? A cross-sectional study from east Zimbabwe.

OBJECTIVE: Globally, HIV disproportionately affects female sex workers (FSWs) yet HIV treatment coverage is suboptimal. To improve uptake of HIV services by FSWs, it is important to identify potential inequalities in access and use of care and their determinants. Our aim is to investigate HIV treatment cascades for FSWs and non-sex workers (NSWs) in Manicaland province, Zimbabwe, and to examine the socio-demographic characteristics and intermediate determinants that might explain differences in service uptake. METHODS: Data from a household survey conducted in 2009-2011 and a parallel snowball sample survey of FSWs were matched using probability methods to reduce under-reporting of FSWs. HIV treatment cascades were constructed and compared for FSWs (n=174) and NSWs (n=2555). Determinants of service uptake were identified a priori in a theoretical framework and tested using logistic regression. RESULTS: HIV prevalence was higher in FSWs than in NSWs (52.6% vs 19.8%; age-adjusted OR (AOR) 4.0; 95% CI 2.9 to 5.5). In HIV-positive women, FSWs were more likely to have been diagnosed (58.2% vs 42.6%; AOR 1.62; 1.02-2.59) and HIV-diagnosed FSWs were more likely to initiate ART (84.9% vs 64.0%; AOR 2.33; 1.03-5.28). No difference was found for antiretroviral treatment (ART) adherence (91.1% vs 90.5%; P=0.9). FSWs' greater uptake of HIV treatment services became non-significant after adjusting for intermediate factors including HIV knowledge and risk perception, travel time to services, physical and mental health, and recent pregnancy. CONCLUSION: FSWs are more likely to take up testing and treatment services and were closer to achieving optimal outcomes along the cascade compared with NSWs. However, ART coverage was low in all women at the time of the survey. FSWs' need for, knowledge of and proximity to HIV testing and treatment facilities appear to increase uptake

A reconfiguration of the sex trade: how social and structural changes in eastern Zimbabwe left women involved in sex work and transactional sex more vulnerable

Understanding the dynamic nature of sex work is important for explaining the course of HIV epidemics. While health and development interventions targeting sex workers may alter the dynamics of the sex trade in particular localities, little has been done to explore how large-scale social and structural changes, such as economic recessions–outside of the bounds of organizational intervention–may reconfigure social norms and attitudes with regards to sex work. Zimbabwe’s economic collapse in 2009, following a period (2000–2009) of economic decline, within a declining HIV epidemic, provides a unique opportunity to study community perceptions of the impact of socio-economic upheaval on the sex trade. We conducted focus group discussions with 122 community members in rural eastern Zimbabwe in January-February 2009. Groups were homogeneous by gender and occupation and included female sex workers, married women, and men who frequented bars. The focus groups elicited discussion around changes (comparing contemporaneous circumstances in 2009 to their memories of circumstances in 2000) in the demand for, and supply of, paid sex, and how sex workers and clients adapted to these changes, and with what implications for their health and well-being. Transcripts were thematically analyzed. The analysis revealed how changing economic conditions, combined with an increased awareness and fear of HIV–changing norms and local attitudes toward sex work–had altered the demand for commercial sex. In response, sex work dispersed from the bars into the wider community, requiring female sex workers to employ different tactics to attract clients. Hyperinflation meant that sex workers had to accept new forms of payment, including sex-on-credit and commodities. Further impacting the demand for commercial sex work was a poverty-driven increase in transactional sex. The economic upheaval in Zimbabwe effectively reorganized the market for sex by reducing previously dominant forms of commercial sex, while simultaneously providing new opportunities for women to exchange sex in less formal and more risky transactions. Efforts to measure and respond to the contribution of sex work to HIV transmission need to guard against unduly static definitions and consider the changing socioeconomic context and how this can cause shifts in behavior

Variations in concerns reported on the Patient Concerns Inventory (PCI) in head and neck cancer patients from different health settings across the world

Background: The aim was to collate and contrast patient concerns from a range of different head and neck cancer follow-up clinics around the world. Also, we sought to explore the relationship, if any, between responses to the patient concerns inventory (PCI) and overall quality of life (QOL). Methods: Nineteen units participated with intention of including 100 patients per site as close to a consecutive series as possible in order to minimize selection bias. Results: There were 2136 patients with a median total number of PCI items selected of 5 (2-10). “Fear of the cancer returning” (39%) and “dry mouth” (37%) were most common. Twenty-five percent (524) reported less than good QOL. Conclusion: There was considerable variation between units in the number of items selected and in overall QOL, even after allowing for case-mix variables. There was a strong progressive association between the number of PCI items and QOL

Selected interview transcript quotes from: "A reconfiguration of the sex trade: How social and structural changes in eastern Zimbabwe left women involved in sex work and transactional sex more vulnerable"

Understanding the dynamic nature of sex work is important for explaining the course of HIV epidemics. While health and development interventions targeting sex workers may alter the dynamics of the sex trade in particular localities, little has been done to explore how large-scale social and structural changes, such as economic recessions–outside of the bounds of organizational intervention–may reconfigure social norms and attitudes with regards to sex work. Zimbabwe’s economic collapse in 2009, following a period (2000–2009) of economic decline, within a declining HIV epidemic, provides a unique opportunity to study community perceptions of the impact of socio-economic upheaval on the sex trade. We conducted focus group discussions with 122 community members in rural eastern Zimbabwe in January-February 2009. Groups were homogeneous by gender and occupation and included female sex workers, married women, and men who frequented bars. The focus groups elicited discussion around changes (comparing contemporaneous circumstances in 2009 to their memories of circumstances in 2000) in the demand for, and supply of, paid sex, and how sex workers and clients adapted to these changes, and with what implications for their health and well-being. Transcripts were thematically analyzed. The analysis revealed how changing economic conditions, combined with an increased awareness and fear of HIV–changing norms and local attitudes toward sex work–had altered the demand for commercial sex. In response, sex work dispersed from the bars into the wider community, requiring female sex workers to employ different tactics to attract clients. Hyperinflation meant that sex workers had to accept new forms of payment, including sex-on-credit and commodities. Further impacting the demand for commercial sex work was a poverty-driven increase in transactional sex. The economic upheaval in Zimbabwe effectively reorganized the market for sex by reducing previously dominant forms of commercial sex, while simultaneously providing new opportunities for women to exchange sex in less formal and more risky transactions. Efforts to measure and respond to the contribution of sex work to HIV transmission need to guard against unduly static definitions and consider the changing socioeconomic context and how this can cause shifts in behavior

A theoretical framework for the change in sex work in eastern Zimbabwe during the economic crisis.

<p>Solid arrows indicate a pathway of adjustment due to social and economic changes; the dashed arrow reflects the shift of local attitudes to the increase in transactional sex (TS). Social change: Economic collapse caused widespread unemployment from both formal and informal sectors. Hyperinflation meant that money ceased to have any value and a barter economy developed. Widespread fear of HIV resulted in scapegoating FSWs. Demands: Men in all communities suffered from the drop in regular income; they reduced visits to bars and visits to female sex workers (FSWs), creating a shortage of client demand for paid sex. Poverty, particularly in poorer households, intensified causing hunger. Institutional filtering: On the commercial forestry estate sex work was sustained because of continued pay, the campus-style onsite accommodation, migrant labor, inequality in employment opportunities and income between the sexes. In the roadside trading settlement (RTS), the community had taken a zero-tolerance approach to FSWs, banning them from bars. As a consequence, sex work was no longer conducted openly. Resources: FSWs met clients outside of bars and developed strategies to indicate they were available for sex. Adjustments: Growth in transactional sex among non-FSWs due to poverty. Prevailing social and economic conditions caused adjustments to the timing, location, terms (e.g. condom use and payments) of transactions. Dashed arrow: Rise in TS (where condom use was not as tolerated because of its association with sex work) shifted local attitudes towards FSWs who were seen as more responsible for using condoms.</p

The location and participant composition of the focus group discussions.

<p>The location and participant composition of the focus group discussions.</p

Thematic analysis of how social and structural changes in Zimbabwe have had an impact sex work.

<p>Thematic analysis of how social and structural changes in Zimbabwe have had an impact sex work.</p

The Jena Model of Social Change and Human Development conceptual framework, adapted for Zimbabwe.

<p>The Jena Model of Social Change and Human Development, developed by Silbereisen and Tomasik [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0171916#pone.0171916.ref030" target="_blank">30</a>] describes how communities experience and respond actively to the demands of social change. This model was adapted to the Zimbabwe context and is a conceptual framework for how economic collapse might produce changes to sex work organization. The economic crisis placed new demands on individuals (e.g. job loss, food insecurity). Factors such as gender or geographic context can modify the influence of this social change by reducing or enhancing the impact of these demands at the individual level. Resources form part of the process of adaptation to new challenges and mediate individuals’ to meet them. Adjustments are the individual-level and structural changes that occur in response to the macrolevel social change (i.e. economic collapse).</p