title: Reconceptualizing the HIV epidemiology and prevention needs of Female Sex Workers (FSW) in Swaziland.
abstract: BACKGROUND
  HIV is hyperendemic in Swaziland with a prevalence of over 25% among those between the ages of 15 and 49 years old. The HIV response in Swaziland has traditionally focused on decreasing HIV acquisition and transmission risks in the general population through interventions such as male circumcision, increasing treatment uptake and adherence, and risk-reduction counseling. There is emerging data from Southern Africa that key populations such as female sex workers (FSW) carry a disproportionate burden of HIV even in generalized epidemics such as Swaziland. The burden of HIV and prevention needs among FSW remains unstudied in Swaziland.
  
  
  METHODS
  A respondent-driven-sampling survey was completed between August-October, 2011 of 328 FSW in Swaziland. Each participant completed a structured survey instrument and biological HIV and syphilis testing according to Swazi Guidelines.
  
  
  RESULTS
  Unadjusted HIV prevalence was 70.3% (n = 223/317) among a sample of women predominantly from Swaziland (95.2%, n = 300/316) with a mean age of 21(median 25) which was significantly higher than the general population of women. Approximately one-half of the FSW(53.4%, n = 167/313) had received HIV prevention information related to sex work in the previous year, and about one-in-ten had been part of a previous research project(n = 38/313). Rape was common with nearly 40% (n = 123/314) reporting at least one rape; 17.4% (n = 23/314)reported being raped 6 or more times. Reporting blackmail (34.8%, n = 113/314) and torture(53.2%, n = 173/314) was prevalent.
  
  
  CONCLUSIONS
  While Swaziland has a highly generalized HIV epidemic, reconceptualizing the needs of key populations such as FSW suggests that these women represent a distinct population with specific vulnerabilities and a high burden of HIV compared to other women. These women are understudied and underserved resulting in a limited characterization of their HIV prevention, treatment, and care needs and only sparse specific and competent programming. FSW are an important population for further investigation and rapid scale-up of combination HIV prevention including biomedical, behavioral, and structural interventions.
authors.affiliation: Key Populations Program, Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland, United States of America.
authors.forename: Stefan
authors.initials: S
authors.lastname: Baral
authors.affiliation: Key Populations Program, Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland, United States of America.
authors.forename: Sosthenes
authors.initials: S
authors.lastname: Ketende
authors.affiliation: Population Services International, Mbanane, Swaziland.
authors.forename: Jessie L
authors.initials: JL
authors.lastname: Green
authors.affiliation: Key Populations Program, Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland, United States of America.
authors.forename: Ping-An
authors.initials: PA
authors.lastname: Chen
authors.affiliation: Key Populations Program, Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland, United States of America.
authors.forename: Ashley
authors.initials: A
authors.lastname: Grosso
authors.affiliation: Rock Of Hope, Mbabane, Swaziland.
authors.forename: Bhekie
authors.initials: B
authors.lastname: Sithole
authors.affiliation: Swaziland National AIDS Program, Strategic Information Division, Ministry of Health, Mbabane, Swaziland.
authors.forename: Cebisile
authors.initials: C
authors.lastname: Ntshangase
authors.affiliation: Department of Population, Family, and Reproductive Health, Johns Hopkins School of Public Health, Baltimore, Maryland, United States of America.
authors.forename: Eileen
authors.initials: E
authors.lastname: Yam
authors.affiliation: Department of Health, Behavior, and Society, Johns Hopkins School of Public Health, Baltimore, Maryland, United States of America.
authors.forename: Deanna
authors.initials: D
authors.lastname: Kerrigan
authors.affiliation: Department of International Health, Johns Hopkins School of Public Health, Baltimore, Maryland, United States of America.
authors.forename: Caitlin E
authors.initials: CE
authors.lastname: Kennedy
authors.affiliation: Department of International Health, Johns Hopkins School of Public Health, Baltimore, Maryland, United States of America.
authors.forename: Darrin
authors.initials: D
authors.lastname: Adams
mesh_terms: D000293:Adolescent; D000328:Adult; D013541:Eswatini / Q000453:epidemiology; D005260:Female; D005500:Follow-Up Studies; D006678:HIV / Q000472:pathogenicity*; D015658:HIV Infections / Q000453:epidemiology* / Q000517:prevention & control*; D006301:Health Services Needs and Demand / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D015995:Prevalence; D011379:Prognosis; D040242:Risk Reduction Behavior; D060386:Sex Workers / Q000706:statistics & numerical data*; D055815:Young Adult