Female sex workers are at very high risk of acquiring and transmitting HIV infection. In Africa, female sex workers have 11 times higher odds of having HIV than women in the general population. Modelling suggests that across Africa, 40% of new infections within the population are likely attributable to unsafe sex work, suggesting that 40% of new infection could be prevented if sex workers could be supported to be full engaged with prevention and care services. However, FSW are marginalised, sex work is illegal in many countries and female sex workers are often stigmatised by communities and health workers. Typically, female sex workers are also highly mobile. In Zimbabwe, where prevalence among sex workers is 58%, analysis of programme data from 2009-2014 suggests annual HIV incidence is over 10% (ten times that in the adult female population) and that only 67% are aware of their HIV status and that less than half of all FSW living with HIV have a viral load
Current studies and programmes under Key Populations:
1. National Sex Work Programme on Behalf of the National AIDS Council and the Ministry of Health and Child Care
Funding Source: Integrated Support Programme, through UNFPA Zimbabwe
Funding Period: June 2009 to December 2016
The Sisters with a Voice Programme is run by CeSHHAR Zimbabwe on behalf of the National AIDS Council and Ministry of Health and Child Care. Initiated in 2009, the goal of the programme is to reduce HIV acquisition among sex workers and reduce HIV transmission to their clients. The programme provides support and services to sex workers to improve their sexual and reproductive health; provide access to HIV prevention and referral to HIV treatment and care where appropriate and, where necessary, access to legal advice. The programme follows WHO guidelines and was cited in UNAIDS 2015 Global Report and in the WHO Prevention, Treatment and care guidelines for key populations.
2. The Sisters Antiretroviral Programme for Prevention of HIV – an integrated response (SAPPH-IRe trial)
Funding Source: Integrated Support Programme, through UNFPA Zimbabwe
Funding Period: January 2013 to December 2016
The SAPPH-IRe trial (“Sisters Antiretroviral Programme for Prevention of HIV – an Integrated Response”) was run between April 2014 and March 2016. The aim of this cluster randomised trial was to estimate the population effect of a comprehensive ‘SAPPH-IRe’ intervention, designed to strengthen engagement with both the treatment and prevention cascades, on the proportion of Zimbabwean FSW who have HIV viral load ≥ 1000 copies/mL compared to the standard ‘Sisters with a Voice programme’.
The SAPPH-IRe intervention enhances engagement with HIV treatment and prevention among sex workers attending outreach clinics in Zimbabwe by strengthening the existing targeted Sisters programme to increase the uptake and frequency of HIV testing, demonstrate the importance of delivering pre-exposure prophylaxis (PrEP) to HIV-negative sex workers, maximize retention in care of HIV-infected women, promote timely initiation of ART, and promote adherence to ART and PrEP, thereby establishing a positive foundation for future engagement with medical services and reducing HIV transmission through transactional sex. The SAPPH-IRe trial has a number of aims. These are:
1. To estimate the effect of the SAPPH-IRe intervention on the proportion of sex workers who are infectious with HIV.
2. To ascertain the pattern and duration of use, and the adherence to PrEP in a sex worker population.
3. To estimate the potential impact of the SAPPH-IRe interventionon HIV transmission in Zimbabwe.
4. To estimate the cost and cost-effectiveness of the SAPPH-IRe intervention in Zimbabwe through a cost-effectiveness analysis.
3. National Size Estimation of Female Sex Workers in Zimbabwe
Funding Source: Key Populations Challenge Fund, through CDC to RTI Zimbabwe
Funding Period: April 2015 to June 2017
The primary objective of this study is to build on existing research among female sex workers in Zimbabwe by estimating the size of the female sex worker populations in Harare, Bulawayo and two communities in Mashonaland Central, Shamva and Mazowe. Data will be collected on the awareness and prevalence of a number of STI’s, including HIV, syphilis and chlamydia, as well as access to health services including the history of HIV testing, the use of reproductive health services for contraception and elimination of mother-to-child transmission (eMTCT) services, and mental health and alcohol use. All women found to be HIV infected and not already receiving care will be referred to treatment and care services. The overall objective of these activities is to generate information which can be used to advocate and plan for targeted HIV prevention, care, and treatment services for FSW in Zimbabwe.
4. Implementation of DREAMS (Determined Resilient Empowered AIDS-free Mentored and Safe) – Community support for high risk young women to take up and adhere to HIV prevention including PrEP
Funding Source: USAID, subcontracted through PSI Zimbabwe
Funding Period: August 2016 to September 2017
Studies of young women who sell sex or are engaged in transactional sex (YWSS) suggest that young women are more vulnerable to HIV, gender-based violence and adverse sexual and reproductive health outcomes than their older counterparts. In addition, they are less engaged with HIV prevention and care services. Adolescents with HIV on ART are often poorly adherent to medication and require additional support to remain in care. Community empowerment interventions have been shown to reduce HIV and STI risk, improve condom use and can be used to support uptake and retention in care. DREAMS (Determined, Resilient, Empowered, AIDS free, Mentored, Safe) is a US government PEPFAR initiative targeting young women in countries across Africa. CeSHHAR will provide services for young women who sell sex within the 6 DREAMS districts in Zimbabwe (Mutare, Chipinge, Makoni, Mazowe, Gweru and Bulawayo) through the Sisters with a Voice programme with the aim of building community empowerment and social cohesion among YWSS and the sisterhood of sex workers more broadly. The Young Sisters programme works closely with Ministry of Health and Social Services and recruits, trains and supports young (aged 15-24) peer educators, around half of whom will also be trained as lay child protection officers (case care workers). The programme for young sex workers uses age-specific materials that were developed and piloted by CeSHHAR. The programme activities encourage mobilisation around HIV prevention and treatment and the health and well-being of young women who sell sex. This enables young women who sell sex to engage in risk reduction and the use of health services. The programme will have 48 peer educators who will be trained across all sites and 21 of the 48 will be trained to be lay care case workers. In addition, youth peer educators supported by young sex worker interns and outreach workers will be trained to undertake microplanning. Microplanning is when peer educators map and monitor at risk YWSS in order to ensure they are engaged with child protection and HIV prevention and care services as appropriate.
5. Impact Evaluation of DREAMS in Zimbabwe –focusing on impact in young women who sell sex
Funding Source: Bill and Melinda Gates Foundation subcontracted by London School of Hygiene and Tropical Medicine
Funding Period: January 2016 to December 2018
DREAMS is a combined package of interventions that aims to reduce the risk of HIV among the most vulnerable adolescent girls and young women (AGYW). The package combines strategies to reduce the biological risk of infection, through the provision of condoms, STI treatment and oral pre-exposure prophylaxis (PrEP) to AGYW at highest risk of infection. DREAMS encourages AGYW to use and access these services through the provision of socioeconomic empowerment interventions, including transport vouchers and cash transfers, with strategies to change community-level norms around violence against AGYW and access to school, social and financial assets. This impact evaluation aims to estimate the impact of the DREAMS combined package (which includes an offer of PrEP) on the risk of HIV infection among AGYW at highest risk of HIV in Zimbabwe. The overall aim of this impact evaluation is to estimate the impact of the DREAMS combination package of HIV prevention interventions, which includes an offer of PrEP, on HIV incidence among YWSS in Zimbabwe, including young women who engage in transactional sex and therefore at high risk of entry into sex work.