Examining Prevalence of HIV Infection and Risk Factors Among Female Sex Workers (FSW) and Men Who Have Sex with Men (MSM) in Swaziland

According to this 50-page report, published by the Research to Prevention (R2P) project, there is limited data on Female Sex Workers (FSW) and Men Who Have Sex with Men (MSM) in Swaziland, making it difficult to accurately gauge the role of these populations in larger transmission dynamics, as well as the biological, behavioural, and structural risk factors that contribute to their heightened vulnerability. "This study sought to estimate HIV prevalence among these key populations (KP) in Swaziland, describe behavioural risk factors associated with HIV infection, and examine the influences of social and structural factors on HIV related behaviours and risk for infection among these populations." According to the report, MSM and FSW demonstrate a heightened risk for HIV infection in Swaziland, particularly FSW. The data presented highlights the need for a multifaceted, targeted HIV prevention strategy that integrates behavioural, biomedical, and structural components. As both MSM and FSW face unique social and structural hurdles such as high levels of stigma and discrimination, programmes and policies must take into account the social and political context of HIV infection in these populations.

The report outlines the following findings as outlined in the Executive Summary:

• HIV and STI prevalence: The research showed that HIV prevalence among key populations in the study sample was high, with FSW showing higher prevalance than MSM.
  
  
• Biological and behavioral risk factors: "In general, MSM and FSW reported multiple sexual partners. One-third of all FSW (33.5%) reported an average of six or more clients per week, and one-quarter of all MSM reported having both male and female partners in the past year (25.5%), providing evidence that the heightened risk ascribed to MSM may have a direct link to the general population. Encouragingly, condom use with all types of partners was high for both MSM and FSW, generally comparable to or higher than the general population; this suggests that population-level condom promotion has been somewhat effective in Swaziland.
  
  

  There was a lack of HIV-related knowledge among both populations, as only 18.3% of MSM and 10% of FSW in the study knew of the heightened risk of contracting HIV from receptive anal sex. Over 96% of FSW in the study answered that you could get HIV from using a needle to inject illegal drugs (though the question did not specify whether this was a needle that had previously been used by someone else). Just over 21% of FSW responded that water-based lubricants were the safest to use during vaginal and anal sex. Less than 40% of MSM reported using condom-compatible lubricants, and over 80% of FSW did not use lubricants at all. Importantly, questions did not define “safe” as specifically relating to the prevention of HIV, and did not specify that this meant with latex condoms."

• Structural risk factors: "Behavioral and structural risk factors appeared to be intricately related within these populations. More than half of all FSW reported that it was somewhat or very difficult to insist on condom use if a client offered more money not to use one (61.8%), and 57.8% of MSM reported the same for male sexual partners who provide regular economic support. There were also high levels of human rights violations reported, with around one-third of both MSM and FSW reporting legal discrimination. FSW reported strained interactions with law enforcement, including being refused police protection (37.1%).
  
  
  In general, MSM indicated that they had strong social networks with approximately three-quarters reporting that they could trust the majority of MSM in their community. However, social cohesion among FSW was less clear. For example, while 60% of FSW could count on fellow FSW to talk to about their problems, only 38% reported that they could trust the majority of their sex worker colleagues."
• Associations with HIV infection: Student's t-tests "revealed few significant differences between participants who tested positive and those who tested negative for HIV within both populations. "Participants who tested positive for HIV were more likely to be older than participants who tested negative in both populations. This could be due to the fact that older persons have been exposed to HIV for longer than younger persons. FSW with HIV were also more likely to have one or more children than FSW who tested negative for HIV. Over three-quarters of our overall sample reported having children (74.1%), indicating that interventions may do well to capitalise on the existing reproductive health infrastructure in Swaziland.
  
  

  It is important to note that the limited number of significant differences between groups does not necessarily indicate that the selected variables do not contribute to HIV risk in MSM and FSW. This may instead suggest that it is not individual risk factors but rather combinations of factors that characterise the heightened risk of KP in Swaziland."

Based on the study findings, the report makes the following programmatic recommendations:

• "Develop and implement comprehensive, evidence-based, multi-level interventions for KP: This study identified key gaps in HIV-related knowledge, behaviors, and access to services for KP. However, it also identified overarching structural constraints to accessing services and engaging in effective HIV prevention. Interventions for KP should be developed and implemented that consider how to address important factors at all levels, including structural factors such as discrimination from health care settings and law enforcement, and the availability of condoms, lubricant, and other services." The report recommends following the recently developed World Health Organization (WHO) guidelines for the prevention and treatment of HIV and STIs among both MSM, which promote a combination of evidence-based interventions for MSM and FSW at multiple levels, framed within a strong empowerment and rights-based approach.
• Tailor intervention efforts to the needs of KP in Swaziland, recognising differences between groups

: While both MSM and FSW demonstrated high levels of risk for HIV infection, there were key differences between these populations around, for example, HIV infection, testing, social cohesion, and dependants. The differences in populations underscore the notion that no uniform intervention effectively addresses all problems facing different KPs.


The report recommends that programme administrators consider the specific vulnerabilities of each group when designing and implementing interventions specifically around the areas of HIV and STI prevalence, biological and behavioral risk factors, and structural risk factors.

• Include MSM and FSW in national HIV surveillance: "HIV surveillance in Swaziland utilizes population-based mathematical models that do not adequately capture the nuances of the country's epidemic. While this study provides the first unbiased estimate of HIV-prevalence in these KP, Swaziland must develop and adopt surveillance systems that continue to collect this type of data in order to monitor the epidemic among KP and better understand the role KP play in larger transmission dynamics."

The report also makes recommendations around research and cites the need to conduct a systematic assessment of the size of MSM or FSW populations in Swaziland, the need for research to explore the feasibility of biological interventions (as this study supports mainly the need for structural and behavioural programming), and the need for research to examine other KP such as people who use drugs.