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Comprehensive services for sex workers reduce detectable viral load, but enhanced ARV services provide no extra benefit
Roger Pebody, 2016-07-19 21:00:00
A randomised trial in female sex workers in Zimbabwe,
offering enhanced access to HIV treatment and PrEP, has failed to show that the
extra services helped reduce the proportion with detectable viral load, Frances Cowan told the 21st International AIDS Conference (AIDS 2016) in Durban today.
It appears that the comprehensive set of sex worker-friendly
services which were offered in the control arm may have already been enough to substantially
improve the health of participants.
While this set of services was described as the ‘usual care’
and is in line with World Health Organization guidelines, the reality is that a
comprehensive package of quality services for sex workers is rarely fully
delivered. The services
included free condoms and
contraception, HIV testing and counselling, referral to government clinics for HIV treatment, management of sexually transmitted infections, health
education and legal advice supported by a network of peer educators.
In seven communities
- forming the control group - this package of care was provided.
further seven communities - forming the intervention group - the same services
were provided, as well as the following additional elements:
- HIV treatment available at the sex worker clinic (rather
than referral to a government clinic)
- For women testing HIV-negative, SMS reminders to encourage
repeat HIV testing
- For women testing HIV-negative, the offer of PrEP
- Adherence support programme for women taking HIV treatment
- Intensified community mobilisation activities
The communities, spread across Zimbabwe, were locations
where several hundred women
sold sex and where there was a primary care clinic providing dedicated
services to sex workers.
The primary endpoint was the proportion of female sex
workers who could be infectious with HIV, in other words with an HIV viral load above 1000 copies/ml. The trial was therefore innovative
in considering a woman with an undetectable viral load as equivalent to a woman
who does not have HIV.
When the trial began in 2013, approximately 200 female sex
workers were recruited in each community and tested for HIV antibodies and viral
load. In April this year, 200 female sex workers in each community (not necessarily the same
individuals) were recruited and tested in the same way.
The women were recruited through respondent-driven sampling
(RDS), in which the first women recruited by the researchers invite their peers
to participate too. Women who took part in the surveys were not necessarily
clients of the interventions, but were women living and working in the area.