The HIV care cascade and antiretroviral therapy in female sex workers: implications for HIV prevention

Abstract

To achieve viral suppression and fully benefit from antiretroviral therapy (ART), it is important that individuals with HIV know that they are HIV infected, link to and remain in HIV care, start and remain on ART and adhere to treatment. In HIV epidemics where female sex workers (FSWs) are key drivers of HIV transmission, the extent to which FSWs use ART and engage in the HIV care cascade could have a considerable impact on HIV transmission from FSWs to the wider population. In this article we review the spectrum of FSW engagement in the HIV care cascade, look at the impact of the HIV care cascade and ART use among FSWs on population-level HIV transmission and discuss HIV prevention for FSWs in the context of ART and the HIV care cascade.

Keywords::

• antiretroviral therapy
• female sex worker
• HIV care cascade
• mathematical modeling
• review

Financial & competing interests disclosure

This work was funded by the Canadian Foundation for AIDS Research (CANFAR) (Grant # 023-015) and UNAIDS. S Mishra is supported by a Canadian Institutes of Health Research Fellowship and a Royal College of Physicians and Surgeons of Canada Detweiler Fellowship. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Despite global efforts to roll-out antiretroviral therapy (ART) in the past decade and the growing body of literature on the HIV care cascade, there is limited data on the HIV care cascade and ART use among female sex workers (FSWs).

• The limited data suggest that a number of HIV-infected FSWs do test for HIV and start ART, and can achieve high levels of treatment retention, adherence and viral suppression, at least in the short term and within research settings.

• Information on long-term treatment outcomes, and the extent to which FSWs link to and remain in HIV care prior to ART initiation, is particularly sparse.

• Available information on ART uptake, retention, adherence and viral suppression among FSWs is limited to only a few research study settings in Africa, Asia, North America, South America, and Central America and the Caribbean.

• Program data on the FSW HIV care cascade should be actively collected and reported in a range of ‘nonresearch’ routine HIV care programs to enable the monitoring and evaluation of HIV care and treatment among FSWs.

• Qualitative data suggest that FSWs face multiple structural, psychosocial and individual barriers to engaging in the HIV care cascade. Further research is needed to identify and implement sustainable interventions that address these barriers and improve the HIV care cascade among FSWs.

• Modeling studies indicate that expanded testing and treatment strategies for FSWs may reduce HIV transmission from FSWs to the wider population, but in regions where other interventions have achieved high uptake among FSWs these strategies may only have minimal impact on HIV transmission.

• Our preliminary modeling results suggest the need to improve engagement of FSWs at multiple stages of the HIV care cascade to achieve greater reductions in HIV transmission.

• Carefully evaluating the impact and cost–effectiveness of new ART programs for FSWs as well as undertaking further modeling work on the FSW HIV care cascade tailored to specific epidemic contexts are important components of the future research agenda.

Notes