title: Epidemic impacts of a community empowerment intervention for HIV prevention among female sex workers in generalized and concentrated epidemics.
abstract: BACKGROUND
  Sex workers have endured a high burden of HIV infection in and across HIV epidemics. A comprehensive, community empowerment-based HIV prevention intervention emphasizes sex worker organization and mobilization to address HIV risk and often includes community-led peer education, condom distribution, and other activities. Meta-analysis of such interventions suggests a potential 51% reduction in inconsistent condom use. Mathematical modeling exercises provide theoretical insight into potential impacts of the intervention on HIV incidence and burden in settings where interventions have not yet been implemented.
  
  
  METHODS
  We used a deterministic model, Goals, to project the impact on HIV infections when the community empowerment interventions were scaled up among female sex workers in Kenya, Thailand, Brazil, and Ukraine. Modeling scenarios included expansion of the comprehensive community empowerment-based HIV prevention intervention from baseline coverage over a 5-year period (5-65% in Kenya and Ukraine; 10-70% in Thailand and Brazil), while other interventions were held at baseline levels. A second exercise increased the intervention coverage simultaneously with equitable access to ART for sex workers. Impacts on HIV outcomes among sex workers and adults are observed from 2012-2016 and, compared to status quo when all interventions are held constant.
  
  
  RESULTS
  Optimistic but feasible coverage (65%-70%) of the intervention demonstrated a range of impacts on HIV: 220 infections averted over 5 yrs. among sex workers in Thailand, 1,830 in Brazil, 2,220 in Ukraine, and 10,800 infections in Kenya. Impacts of the intervention for female sex workers extend to the adult population, cumulatively averting 730 infections in Thailand to 20,700 adult infections in Kenya. Impacts vary by country, influenced by HIV prevalence in risk groups, risk behaviors, intervention use, and population size.
  
  
  CONCLUSIONS
  A community empowerment approach to HIV prevention and access to universal ART for female sex workers is a promising human rights-based solution to overcoming the persistent burden of HIV among female sex workers across epidemic settings.
authors: Center for Public Health and Human Rights, Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America ; Department of Emergency Medicine, Johns Hopkins Medical Institute, Baltimore, Maryland, United States of America.
authors: Andrea L
authors: AL
authors: Wirtz
authors: Futures Institute, Glastonbury, Connecticut, United States of America.
authors: Carel
authors: C
authors: Pretorius
authors: Center for Public Health and Human Rights, Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America.
authors: Chris
authors: C
authors: Beyrer
authors: Center for Public Health and Human Rights, Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America.
authors: Stefan
authors: S
authors: Baral
authors: Center for Public Health and Human Rights, Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America ; Department of Population, Family, and Reproductive Health, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America.
authors: Michele R
authors: MR
authors: Decker
authors: Center for Public Health and Human Rights, Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America.
authors: Susan G
authors: SG
authors: Sherman
authors: Medical University of South Carolina, Charleston, South Carolina, United States of America.
authors: Michael
authors: M
authors: Sweat
authors: Center for Public Health and Human Rights, Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America.
authors: Tonia
authors: T
authors: Poteat
authors: HIV and Key Populations, United Nations Population Fund, New York, New York, United States of America.
authors: Jennifer
authors: J
authors: Butler
authors: Human Development Network, The World Bank, Washington, District of Columbia, United States of America.
authors: Robert
authors: R
authors: Oelrichs
authors: Human Development Network, The World Bank, Washington, District of Columbia, United States of America.
authors: Iris
authors: I
authors: Semini
authors: Center for Public Health and Human Rights, Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America ; Department of Health, Behavior & Society, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America.
authors: Deanna
authors: D
authors: Kerrigan
mesh_terms: D000328:Adult; D023241:Antiretroviral Therapy, Highly Active; D001519:Behavior; D001938:Brazil / Q000453:epidemiology; D058872:Epidemics / Q000517:prevention & control* / Q000706:statistics & numerical data*; D005260:Female; D015658:HIV Infections / Q000188:drug therapy / Q000453:epidemiology* / Q000517:prevention & control*; D006801:Humans; D015994:Incidence; D007630:Kenya / Q000453:epidemiology; D011209:Power, Psychological; D012111:Residence Characteristics / Q000706:statistics & numerical data*; D060386:Sex Workers / Q000706:statistics & numerical data*; D013785:Thailand / Q000453:epidemiology; D014455:Ukraine / Q000453:epidemiology