Background:HIV transmission in concentrated HIV epidemics has been reduced by focused HIV prevention programming for female sex workers (FSWs) and clients, particularly in countries in Asia. Yet only a few sub-Saharan Africa (SSA) countries are implementing HIV prevention programs for FSWs and clients to scale. In this paper, we explore the rationale for focused HIV prevention programming in African countries.
Methods:We globally reviewed available data and conducted mathematical modeling analysis to explore the rationale for focused HIV programming for FSWs and clients in SSA. We review existing data from 48 countries in SSA, and use examples from West Africa (Benin, Burkina Faso, Nigeria), East Africa (Kenya), and South Africa.
Results:Our findings suggest that formal commercial sex account for a larger burden of HIV acquisition and onward transmission than would be suggested by existing approaches of appraising HIV epidemics. For example, whereas data from the 2006 Benin demographic and health survey (DHS) reports that only 0.7% of men living in Cotonou paid for sex in the last year, polling booth surveys (PBS) carried out in 2008 showed that this proportion was 19.9%. The resulting classic population attributable fractions (PAF) for prevalent HIV among men due to contacts with FSWs were 1.4% using DHS data and 49.2% using PBS data. For women, corresponding reports of sex work were 1.3% and 13.2%, respectively, with classic PAF of only 10.9% based on DHS and of 54.9% based on PBS. Mathematical modeling shows a “transmission” PAF related to sex work for incident infections over 20 years, among men and women combined, of 58.3% in Cotonou, 61.2% in Kisumu, Kenya, and 88.9% in Bobo-Dioulasso, Burkina Faso.
Conclusions: HIV prevention programming among FSWs and clients remains critical to the HIV response in most African countries that have been labeled as experiencing “generalized” HIV epidemics.