Susan G. Sherman

Burden of HIV among female sex workers in low-income and middle-income countries: a systematic review and meta-analysis

BACKGROUND Female sex workers are a population who are at heightened risk of HIV infection secondary to biological, behavioural, and structural risk factors. However, three decades into the HIV pandemic, understanding of the burden of HIV among these women remains limited. We aimed to assess the burden of HIV in this population compared with that of other women of reproductive age. METHODS We searched PubMed, Embase, Global Health, SCOPUS, PsycINFO, Sociological Abstracts, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Web of Science, and POPLine for studies of female sex workers in low-income and middle-income countries published between Jan 1, 2007, and June 25, 2011. Studies of any design that measured the prevalence or incidence of HIV among female sex workers, even if sex workers were not the main focus of the study, were included. Meta-analyses were done with the Mantel-Haenszel method with a random-effects model characterising an odds ratio for the prevalence of HIV among female sex workers compared with that for all women of reproductive age. FINDINGS Of 434 selected articles and surveillance reports, 102 were included in the analyses, representing 99,878 female sex workers in 50 countries. The overall HIV prevalence was 11·8% (95% CI 11·6-12·0) with a pooled odds ratio for HIV infection of 13·5 (95% CI 10·0-18·1) with wide intraregional ranges in the pooled HIV prevalence and odds ratios for HIV infection. In 26 countries with medium and high background HIV prevalence, 30·7% (95% CI 30·2-31·3; 8627 of 28,075) of sex workers were HIV-positive and the odds ratio for infection was 11·6 (95% CI 9·1-14·8). INTERPRETATION Although data characterising HIV risk among female sex workers is scarce, the burden of disease is disproportionately high. These data suggest an urgent need to scale up access to quality HIV prevention programmes. Considerations of the legal and policy environments in which sex workers operate and actions to address the important role of stigma, discrimination, and violence targeting female sex workers is needed. FUNDING The World Bank, UN Population Fund.

HIV prevention among drug users: Outcome of a network-oriented peer outreach intervention

A network-oriented HIV prevention intervention based on social identity theory and peer outreach was implemented for HIV positive and negative drug users. A community sample of 250 were randomly assigned to an equal-attention control condition or a multisession, small-group experimental condition, which encouraged peer outreach; 94% of participants were African American, and 66% used cocaine or opiates. At follow-up, 92% of participants returned, and experimental compared with control group participants were 3 times more likely to report reduction of injection risk behaviors and 4 times more likely to report increased condom use with casual sex partners. Results suggest that psychosocial intervention emphasizing prosocial roles and social identity, and incorporating peer outreach strategies, can reduce HIV risk in low-income, drug-using communities.

The role of sexual transmission of HIV infection among injection and non-injection drug users.

Many early studies of injecting drug users (IDUs) suggested that most HIV infections in this population were due to needle sharing and that sexual transmission was negligible or was overshadowed by parenteral routes. A few of the early studies suggested a potentially important role for heterosexual transmission, but these tended to be limited to cross-sectional data or had only a few years of prospective follow-up. Studies of sexual risk factors for HIV infection among non-injecting drug users (NIDUs) are similarly sparse. Recently, investigators prospectively examined both drug-related and sexual risk factors for HIV seroconversion among male and female IDUs with an adequate number of person-years to identify statistically significant associations. Other studies among never and former IDUs have identified associations suggesting that sexual transmission accounts for a substantial number of HIV seroconversions in these populations. Herein, highlights are discussed from recent investigations among IDUs in Baltimore, Maryland, and corroborating findings from the literature. Results from a 10-year prospective analysis of the ALIVE study and an analysis of the REACH studies spanning a 7-year period indicate that sexual risk factors for HIV infection are important in both female and male IDUs. These findings underscore the need for HIV interventions among drug users that incorporate sexual risk reduction. Based on the existing literature, a narrow focus on injection-related risks is an ineffective prevention strategy. Interventions that target specific subgroups of high-risk IDUs, such as men who have sex with men and inject drugs (MSM-IDUs), sex worker-IDUs and HIV-infected IDUs, deserve special attention.

Norms, social networks, and HIV-related risk behaviors among urban disadvantaged drug users

Altering norms may be an important approach to introducing and sustaining health protective behavior change. This study sought to examine the relationship between condom use, condom norms, and social network characteristics among a sample of economically impoverished individuals at risk for acquiring and transmitting HIV. Participants were 1051 individuals from a drug-using community in the USA. Eighty percent were current drug users; 17% were HIV seropositive. Reported condom use was strongly associated with peer norms about condom use (friends talking about condoms, encouraging condom use, and using condoms). Women were less likely than men to report that their friends used condoms. Injection drug use was negatively associated with peer norms about condom use, while church attendance and network characteristics were positively associated with condom-promoting norms. The size of the health advice and the financial support networks was most positively related to condom norms. Network methodology may aid in the identification of specific ties that promote condom use norms in a population. The findings of this study may have implications for norm change interventions among disadvantaged communities at high risk for HIV/AIDS.

Prospective Evaluation of Community-Acquired Acute-Phase Hepatitis C Virus Infection

BACKGROUND More than two-thirds of hepatitis C virus (HCV) infections in Western countries are caused by injection drug use, but prospective clinical data regarding the most common mode of HCV acquisition are rare, in part because acute-phase HCV infection is usually asymptomatic. METHODS To characterize acute-phase HCV infection, 179 HCV antibody-negative injection drug users were prospectively evaluated; 62 (34%) of these patients had seroconverted. Twenty of the participants who seroconverted had long-term follow-up with consistent monthly sampling before and after seroconversion, allowing detailed study. RESULTS The first indication of HCV infection was the presence of HCV RNA in serum, which preceded elevation of alanine transaminase levels and total bilirubin levels to > or =2 times baseline in 45% and 77% of patients, respectively. No subjects had jaundice. The median time from initial viremia to seroconversion was 36 days (range, 32-46 days). In one instance, viremia was detected 434 days before seroconversion. However, in no other case was HCV RNA detected >63 days before seroconversion. In subjects with viral persistence, a stable level of HCV RNA in the blood was noted in some subjects within 60 days after the initial detection of viremia, but in others, it was not apparent until >1 year later. In subjects with long-term viral clearance, HCV became persistently undetectable as early as 94 and as late as 620 days after initial viremia. CONCLUSIONS These data underscore the importance of nucleic acid screening of blood donations to prevent HCV transmission and of long-term follow-up to ascertain whether there is viral persistence, at least among injection drug users.

The evaluation of the JEWEL project: An innovative economic enhancement and HIV prevention intervention study targeting drug using women involved in prostitution

Abstract The JEWEL (Jewellery Education for Women Empowering Their Lives) pilot study examined the efficacy of an economic empowerment and HIV prevention intervention targeting illicit drug-using women (n=50) who were involved in prostitution in Baltimore, Maryland. The intervention was comprised of six 2-hour sessions that taught HIV prevention risk reduction and the making, marketing and selling of jewellery. Bivariate comparisons examined behaviour change pre- and 3-months post-intervention. The interventions effect on the change in the number of sex trade partners from baseline to follow-up was explored with multiple linear regression. Participants were 62.0% African American, 5.0% were currently employed, and the median age was 39 years old (Inter Quartile Range [IQR]: 34–45). Women attended an average of six (IQR: 4.5–6.0) sessions. The women sold over

Human rights violations against sex workers: burden and effect on HIV

7,000 worth of jewellery in eleven sales. In comparing self-reported risk behaviours pre and 3-month post intervention participation, we found significant reductions in: receiving drugs or money for sex (100% versus 71.0%, p<0.0005); the median number of sex trade partners per month (9 versus 3, p=0.02); daily drug use (76.0% vs. 55.0%, p=0.003); the amount of money spent on drugs daily (US

Evaluation of the Staying Alive programme: Training injection drug users to properly administer naloxone and save lives

52.57 versus US

Public health and international drug policy.

46.71, p = 0.01); and daily crack use (27.3% versus 13.1.0%, p = 0.014). In the presence of other variables in a multivariate linear model, income from the jewelry sale was associated with a reduction in the number of sex trade partners at follow-up. The pilot indicated effectiveness of a novel, HIV prevention, economic enhancement intervention upon HIV sexual risk behaviours and drug utilization patterns.

The efficacy of a network intervention to reduce HIV risk behaviors among drug users and risk partners in Chiang Mai, Thailand and Philadelphia, USA

We reviewed evidence from more than 800 studies and reports on the burden and HIV implications of human rights violations against sex workers. Published research documents widespread abuses of human rights perpetrated by both state and non-state actors. Such violations directly and indirectly increase HIV susceptibility, and undermine effective HIV-prevention and intervention efforts. Violations include homicide; physical and sexual violence, from law enforcement, clients, and intimate partners; unlawful arrest and detention; discrimination in accessing health services; and forced HIV testing. Abuses occur across all policy regimes, although most profoundly where sex work is criminalised through punitive law. Protection of sex workers is essential to respect, protect, and meet their human rights, and to improve their health and wellbeing. Research findings affirm the value of rights-based HIV responses for sex workers, and underscore the obligation of states to uphold the rights of this marginalised population.