Prevalence of Sexually Transmitted Infections (STIs) and HIV in Economically Vulnerable Women Engaged in Sex Work in Uganda: Implications for HIV Care and Treatment Engagement

Background and Purpose: In sub-Saharan Africa (SSA), women engaged in sex work (WESW) are disproportionately affected by HIV as compared to women in the general population. The most recent statistics in Uganda indicate that HIV prevalence among WESW is 37% compared to the national prevalence of 5.7%. Social and structural factors, including poverty and gender-based violence are common reported reasons for engaging in sex work. Transactional sex is associated with higher risk of contracting and transmitting HIV and other sexually transmitted infection (STIs). Yet, economically-vulnerable women rely on sex work to earn income for their families with few alternative income-generating activities. This study examined baseline HIV status and baseline HIV care and treatment engagement in economically-vulnerable WESW in Uganda who recently enrolled in a randomized clinical trial to test the impact of a combination HIV risk reduction and economic empowerment intervention, known as Kyaterekera Project (clinicaltrials.gov, NCT03583541).

Methods: Five hundred forty-two (n=542) WESW were enrolled in the Kyaterekera Project across 19 high HIV-prevalent geographical areas in fishing regions of Lake Victoria, the Uganda-Tanzania border, and the Uganda-Rwanda highway system. Women are eligible to participate if they meet the following conditions: 1) 18+ years; 2) reported engagement in unsafe transactional sex (defined as 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. Biological samples for HIV and other sexually transmitted infection (STIs) were collected at the time of enrollment and tested using blood samples. Women who test HIV positive, and not enrolled on antiretroviral therapy (ART), are initiated on ART; women who test positive for STIs are offered single dose STI treatment; and women who test HIV negative, and not enrolled on PrEP, are connected to PrEP services. Baseline data were collected between June 2019 to March 2020. Descriptive statistics were used to assess prevalence of HIV infection, STI infection, and ART.

Results: At the time of study enrollment, 41% (n=220) of enrolled WESW were living with HIV, and 89% (n=195) of WESW living with HIV were enrolled on ART. An additional 10% (n=19) of WESW living with HIV were initiated on ART following trial enrollment. STI prevalence rates among all WESW were lower than HIV prevalence. Seven percent (7%, n=40) of all WESW tested positive for trichomonas, 3% (n=14) for Chlamydia, and 1% (n=7) for gonorrhea. For women who are HIV positive, we find the majority are already accessing treatment (89%) and 82% report suppressed viral load (defined as having a viral load of less than 40 copies of HIV RNA per milliliter)

Conclusions: Although STI prevalence among enrolled WESW is low, findings indicated that HIV prevalence was disturbingly high, approximately 8 times the national average. Findings also highlight a need for programs engaged in HIV care and support for WESW to improve services for ART adherence, particularly as it applies economically-vulnerable women relying on sex work.