WHO recommendations for prevention and treatment of HIV and other STIs for sex workers in low- and middle-income countries (draft)

Matthew Chersich

Presentation outline• Recommendations (draft) ▫ PPT evidence summary

• Alcohol and sexual behaviour• Guidelines process

Decriminalisation and proactive responses

• As recommended in International Guidelines on HIV/AIDS and Human Rights, the report of UNAIDS Advisory Group on HIV and Sex Work and report presented to Human Rights Council by UN Special Rapporteur on Right to Health, all countries should work toward decriminalization of sex work and elimination of unjust application of non-criminal laws and regulations against sex workers.

• Governments should establish antidiscrimination and other rights-respecting laws to protect against discrimination and violence faced by sex workers in order to realize their human rights and reduce their vulnerability to HIV infection and the impact of AIDS. (Good practice recommendations)

1. “We are despised in the hospitals”: Sex workers’ experiences of accessing health care in four African countries (submitted CHS) F Scorgie, D Nakato, E Harper, M Richter, S Maseko, P Nare, J Smit, MF Chersich

2. Human rights abuses and collective resilience among sex workers in four African countriesF Scorgie, D Nakato, E Harper, M Richter, S Maseko, P Nare, J Smit, MF Chersich

Types of health services• Health services should be made available,

accessible and acceptable to sex workers based on the principles of non-discrimination and right to health (Good practice recommendation)

1.Health services for sex workers: a comparison of service package and delivery models in Africa and India

• WHO recommend interventions to enhance community empowerment among sex workers. (strong recommendation, very low quality of evidence)

1.Socio-Demographic Characteristics and Behavioral Risk Factors of Female Sex Workers in Sub-Saharan Africa: A Systematic Review AIDS & Behaviour 2012 F Scorgie, MF Chersich, I Ntaganira, A Gerbase, F Lule, YR Lo

General HIV prevention and treatment

•WHO recommends consistent condom use among sex workers and their clients. (strong recommendation, moderate quality of evidence)

•WHO recommend offering voluntary HIV counselling and testing to sex workers. (in line with existing WHO guidance)

•WHO recommend using the current WHO recommendations on ART use for HIV-positive general populations for sex workers.

STI services: care for symptomatic and asymptomatic sex workers

• We recommend using the current WHO STI syndromic management guidelines for symptomatic STIs among sex workers and their clients. (in line with existing WHO guidance)

• WHO suggest offering periodic screening for asymptomatic STI in female sex workers (conditional recommendation, low quality of evidence)

• WHO suggest offering female sex workers periodic presumptive treatment, where prevalence high, as a temporary measure (conditional recommendation, moderate‐to‐high quality of evidence)

Lesedi: Condom use and STI prevalence among women using the services

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Gonorrhea Chlamydia Genital ulcer Condom use with clients

Rapid reduction of curable STIsCondom use rises with programme

Lesedi

Miner STI prevalenc

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6.2% 5.8%

1.3%

10.9%

0%

5%

10%

15%NG &/or CT Genital ulcer STI declines

measured in miners as well(intervention targeted only women)

Bringing STI services to sex workers

Angeles City, Philippines

One-time PT with and without improved services

RCT results: 1. R Steen, M Chersich, A Gerbase, G Neilsen, A Wendland, F Ndowa, EA Akl, YR Lo, SJ de Vlas. Periodic presumptive treatment of curable STIs among sex workers: a systematic review. AIDS. 2012 2. R Steen, M Chersich, SJ. de Vlas Periodic presumptive treatment of curable sexually transmitted infections among sex workers: recent experience with implementation. Current Opinion in Infectious Diseases 2012

Neisseria gonorrhoea

Chlamydia trachomatis

PPT implementationFeasibility: Feasible to introduce PPT for sex workers in range of settings

Frequency and duration of PPT may vary depending on STI prevalence (existing burden) and incidence (rate of reinjection).

Screening for syphilis, using accurate and affordable tests, should be available to sex workers whether or not PPT is provided.

In settings where interventions have reduced sex worker STI prevalence and increased condom use, PPT can be phased out or withdrawn.

Azithromycin!

Substance use

•WHO recommend using current WHO recommendations on harm reduction for sex workers who inject drugs.

•WHO recommend including unvaccinated sex workers at higher risk for acquiring hepatitis B virus (HBV) infection as targets of catch‐up HBV immunization strategies in settings where immunization has not reached full coverage.

Alcohol and sex work•Hazardous and harmful drinking changes

sexual behaviour (?)•Pathways include: condom use & accidents,

choice and number of partners, vulnerability to sexual violence, type of sex act

• Intervention evidence lacking

• Neuman M, Schneider M, Nanau RM, Parry C, Chersich M. The Relationship Between Alcohol Consumption and HIV Infection and Risk Behaviour: A Systematic Literature Review of High-Risk Groups, with a Focus on South Africa. Book title: Public Health - Social and Behavioral Health. 2012

What’s new in WHO guidelines

•Access means more than being available (coverage, integrated, stand-alone, diagonal services)

•Considerable focus on structural changes: laws and empowerment (aims to reduce social vulnerability and raise service utilization)

•Missing is emotional partners and alcohol use in sex work settings

•New processes...

Process Process• Began in mid 2010....• Leadership of community

representatives in guidelines, “extensive consultation”

• Emotional partners excluded• Systematic review of low-quality

evidence