title: A 15-year study of the impact of community antiretroviral therapy coverage on HIV incidence in Kenyan female sex workers.
abstract: OBJECTIVE
  To test the hypothesis that increasing community antiretroviral therapy (ART) coverage would be associated with lower HIV incidence in female sex workers (FSWs) in Mombasa District, Kenya.
  
  
  METHODS
  Prospective cohort study.
  
  
  METHODS
  From 1998 to 2012, HIV-negative FSWs were asked to return monthly for an interview regarding risk behavior and testing for sexually transmitted infections including HIV. We evaluated the association between community ART coverage and FSW's risk of becoming HIV infected using Cox proportional hazards models adjusted for potential confounding factors.
  
  
  RESULTS
  One thousand, four hundred and four FSWs contributed 4335 woman-years of follow-up, with 145 acquiring HIV infection (incidence 3.35/100 woman-years). The ART rollout began in 2003. By 2012, an estimated 52% of HIV-positive individuals were receiving treatment. Community ART coverage was inversely associated with HIV incidence (adjusted hazard ratio 0.77; 95% confidence interval 0.61-0.98; P = 0.03), suggesting that each 10% increase in coverage was associated with a 23% reduction in FSWs' risk of HIV acquisition. Community ART coverage had no impact on herpes simplex virus type-2 incidence (adjusted hazard ratio 0.97; 95% confidence interval 0.79-1.20; P = 0.8).
  
  
  CONCLUSIONS
  Increasing general population ART coverage was associated with lower HIV incidence in FSWs. The association with HIV incidence, but not herpes simplex virus type-2 incidence, suggests that the effect of community ART coverage may be specific to HIV. Interventions such as preexposure prophylaxis and antiretroviral-containing microbicides have produced disappointing results in HIV prevention trials with FSWs. These results suggest that FSWs' risk of acquiring HIV infection might be reduced through the indirect approach of increasing ART coverage in the community.
authors.affiliation: aDepartment of Medicine bDepartment of Epidemiology cDepartment of Global Health dDepartment of Biostatistics, University of Washington, Seattle, Washington, USA eInstitute of Tropical and Infectious Diseases fDepartment of Medical Microbiology, University of Nairobi, Nairobi, Kenya gDivision of Human Biology hDivision of Public Health Sciences iDivision of Vaccine and Infectious Disease, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA jNational AIDS and STD Control Programme, Nairobi kMombasa County Department of Policy and Research, Mombasa, Kenya.
authors.forename: R Scott
authors.initials: RS
authors.lastname: McClelland
authors.forename: Barbra A
authors.initials: BA
authors.lastname: Richardson
authors.forename: Peter
authors.initials: P
authors.lastname: Cherutich
authors.forename: Kishorchandra
authors.initials: K
authors.lastname: Mandaliya
authors.forename: Grace
authors.initials: G
authors.lastname: John-Stewart
authors.forename: Benard
authors.initials: B
authors.lastname: Miregwa
authors.forename: Katherine
authors.initials: K
authors.lastname: Odem-Davis
authors.forename: Walter
authors.initials: W
authors.lastname: Jaoko
authors.forename: Davies
authors.initials: D
authors.lastname: Kimanga
authors.forename: Julie
authors.initials: J
authors.lastname: Overbaugh
mesh_terms: D000328:Adult; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active; D004363:Drug Utilization; D005260:Female; D015658:HIV Infections / Q000453:epidemiology* / Q000517:prevention & control*; D006558:Herpes Genitalis / Q000453:epidemiology; D018258:Herpesvirus 2, Human; D006801:Humans; D015994:Incidence; D007630:Kenya / Q000453:epidemiology; D011446:Prospective Studies; D018570:Risk Assessment; D060386:Sex Workers; D055815:Young Adult
chemical_list: D044966:Anti-Retroviral Agents