Witte Susan S, Filippone Prema, Ssewamala Fred M, Nabunya Proscovia, Bahar Ozge Sensoy, Mayo-Wilson Larissa Jennings, Namuwonge Flavia, Damulira Christopher, Tozan Yesim, Kiyingi Joshua, Nabayinda Josephine, Mwebembezi Abel, Kagaayi Joseph, McKay Mary
Columbia University School of Social Work, 1255 Amsterdam Avenue, New York, NY 10027, United States.
International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, St. Louis, MO 63130, United States.
EClinicalMedicine. 2022 Jan 28;44:101278. doi: 10.1016/j.eclinm.2022.101278. eCollection 2022 Feb.
Women engaged in sex work (WESW) are disproportionately affected by HIV. In Uganda, HIV prevalence among WESW is estimated at 37%, accounting for 18% of all new infections in the country. WESW experience poverty, gender-based violence, and other issues that reduce their power and limit their ability to negotiate condom use. Female-controlled strategies, including pre-exposure prophylaxis (PrEP), may afford women more transmission protection, but barriers to access and use persist. This cross-sectional study examined baseline PrEP acceptability and initiation among WESW recently enrolled in a randomized clinical trial in Uganda to test the impact of a combination HIV risk reduction and economic empowerment intervention on sexual risk outcomes (clinicaltrials.gov, NCT03583541).
A total of 542 WESW from 19 high HIV-prevalent geographical areas were enrolled in the Kyaterekera study between June 2019 and March 2020. Women were eligible for the study if they: (1) were age 18 or over; (2) reported engagement in transactional sex (a sex act in exchange for pay) in the past 30 days; and (3) reported engagement in one or more episodes of unprotected sex in the past 30 days. Women completed a baseline assessment, were tested for HIV and other sexually transmitted infections (STIs) at enrollment, and were connected with antiretroviral therapy (ART), STI treatment, or PrEP, based on need and interest. Descriptive statistics examined baseline data on PrEP acceptability and initiation. Independent variables (i.e. years in sex work, recent sexual coercion, perceived HIV and sex work stigmas, harmful alcohol use, barriers to medical care, and social support) were derived from the empirical literature and women's self-report. Bivariate analysis was performed to test associations between main effects of these variables. Using binomial logistic regression, predictive models were evaluated for two distinct outcomes-PrEP acceptability and PrEP initiation/uptake.
At baseline, 59% of women ( = 322) tested HIV negative. Among WESW testing negative, 11% ( = 36) were already PrEP enrolled. Most women reported willingness to use PrEP ( = 317; 91%). Slightly over half of WESW not already on PrEP agreed to initiate PrEP ( = 158; 55%). Logistic regression models demonstrate that acceptability of or willingness to use PrEP was significantly associated with fewer years engaged in sex work (AOR= ·18, 95% CI 0·05-·66, <·01) and greater perceived social support from family (AOR= 1·39, 95% CI 1·03 -1.88, <·05). PrEP initiation was negatively associated with greater perceived social support from friends (AOR=·81, 95% CI ·68-0·97, <·05) and positively associated with higher perceived stigma due to sex work among family members (AOR=2·20, 95% CI 1·15-4·22, <·05).
Despite endorsing PrEP use, many WESW remain reluctant to use it. This gap in prevention practice highlights the heart of a failing PrEP prevention cascade. Findings point to the important role family and friend support may play in destigmatizing sex work and PrEP use for women. Social and structural-level efforts are needed to improve educational messaging and to integrate positive messaging into health promotion campaigns for women and their families, while also working toward decriminalizing sex work.
This paper was made possible with funding from United States National Institute of Mental Health (Grant number: R01MH116768).
从事性工作的女性（WESW）受艾滋病毒影响的比例过高。在乌干达，WESW中的艾滋病毒流行率估计为37%，占该国所有新感染病例的18%。WESW面临贫困、性别暴力和其他问题，这些问题削弱了她们的权力，限制了她们协商使用避孕套的能力。包括暴露前预防（PrEP）在内的女性主导策略可能为女性提供更多的传播保护，但获取和使用方面的障碍仍然存在。这项横断面研究调查了最近在乌干达参加一项随机临床试验的WESW中PrEP的基线可接受性和启动情况，以测试降低艾滋病毒风险和经济赋权干预措施相结合对性风险结果的影响（clinicaltrials.gov，NCT03583541）。
2019年6月至2020年3月期间，共有来自19个艾滋病毒高流行地理区域的542名WESW参加了基亚泰雷凯拉研究。符合以下条件的女性有资格参加该研究：（1）年龄在18岁及以上；（2）报告在过去30天内从事过交易性行为（以性行为换取报酬）；（3）报告在过去30天内有过一次或多次无保护性行为。女性完成了基线评估，在入组时接受了艾滋病毒和其他性传播感染（STI）检测，并根据需求和兴趣接受了抗逆转录病毒治疗（ART）、STI治疗或PrEP。描述性统计分析了PrEP可接受性和启动的基线数据。自变量（即从事性工作的年限、近期性胁迫、感知到的艾滋病毒和性工作耻辱感、有害饮酒、医疗保健障碍和社会支持）来自实证文献和女性的自我报告。进行双变量分析以测试这些变量主要效应之间的关联。使用二项逻辑回归，评估了两个不同结果的预测模型——PrEP可接受性和PrEP启动/采用情况。
在基线时，59%的女性（n = 322）艾滋病毒检测呈阴性。在检测呈阴性的WESW中，11%（n = 36）已经登记接受PrEP。大多数女性报告愿意使用PrEP（n = 317；91%）。未接受PrEP的WESW中略超过一半同意启动PrEP（n = 158；55%）。逻辑回归模型表明，PrEP的可接受性或使用意愿与从事性工作的年限较少显著相关（调整后比值比[AOR]=0.18，95%置信区间[CI]0.05 - 0.66，P<0.01），以及来自家庭的更大感知社会支持显著相关（AOR = 1.39，95% CI 1.03 - 1.88，P<0.05）。PrEP启动与来自朋友的更大感知社会支持呈负相关（AOR = 0.81，95% CI 0.68 - 0.97，P<0.05），与家庭成员中因性工作而感知到的更高耻辱感呈正相关（AOR = 2.20，95% CI 1.15 - 4.22，P<0.05）。
尽管认可使用PrEP，但许多WESW仍然不愿意使用它。这种预防实践中的差距凸显了失败PrEP预防级联的核心问题。研究结果指出了家庭和朋友支持在消除女性性工作耻辱感和PrEP使用方面可能发挥的重要作用。需要在社会和结构层面做出努力，以改善教育信息传递，并将积极信息纳入针对女性及其家庭的健康促进活动中，同时努力使性工作合法化。
本文由美国国立精神卫生研究所资助（资助编号：R01MH116768）得以完成。
