title: Engagement in the HIV care cascade and barriers to antiretroviral therapy uptake among female sex workers in Port Elizabeth, South Africa: findings from a respondent-driven sampling study.
abstract: BACKGROUND
  Female sex workers (FSWs) are disproportionately affected by HIV, even in the context of broadly generalised HIV epidemics such as South Africa. This has been observed in spite of the individual and population-level benefits of HIV treatment. We characterise the HIV care cascade among FSWs and relationships with antiretroviral therapy (ART) use.
  
  
  METHODS
  FSWs ≥18 years were recruited through respondent-driven sampling into a cross-sectional study in Port Elizabeth, South Africa. Participants completed questionnaires and received HIV and syphilis testing; CD4 counts were assessed among women living with HIV. Engagement in the HIV care cascade is described, and correlates of self-reported ART use among treatment-eligible previously diagnosed FSWs were estimated using robust Poisson regression.
  
  
  RESULTS
  Between October 2014 and April 2015, 410 FSWs participated in study activities. Overall, 261/410 were living with HIV (respondent-driven sampling-weighted prevalence 61.5% (95% bootstrapped CI 54.1% to 68.0%)). Prior diagnosis of HIV was relatively high (214/261, 82%); however, ART coverage among FSWs living with HIV was 39% (102/261). In multivariate analyses, FSWs were less likely to be on ART if they had not disclosed their HIV status to non-paying partners (adjusted prevalence ratio (aPR) 0.43, 95% CI 0.22 to 0.86, where the reference is FSWs without non-paying partners), and also if they engaged in mobile healthcare services (aPR 0.71, 95% CI 0.57 to 0.89).
  
  
  CONCLUSIONS
  HIV testing and awareness of HIV status were high, but substantial losses in the cascade occur at treatment initiation. Given that FSWs engaged in mobile HIV testing and peer education programmes have unmet HIV treatment needs, models of decentralised treatment provision such as mobile-based ART care should be evaluated.
authors.affiliation: Department of Epidemiology, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
authors.forename: Sheree
authors.initials: S
authors.lastname: Schwartz
authors.affiliation: The TB/HIV Care Association, Cape Town, South Africa.
authors.forename: Andrew
authors.initials: A
authors.lastname: Lambert
authors.affiliation: The Human Sciences Research Council, Port Elizabeth, South Africa.|Nelson Mandela Metropolitan University, Port Elizabeth, South Africa.
authors.forename: Nancy
authors.initials: N
authors.lastname: Phaswana-Mafuya
authors.affiliation: The Human Sciences Research Council, Port Elizabeth, South Africa.
authors.forename: Zamakayise
authors.initials: Z
authors.lastname: Kose
authors.affiliation: The TB/HIV Care Association, Port Elizabeth, South Africa.
authors.forename: Mfezi
authors.initials: M
authors.lastname: Mcingana
authors.affiliation: Department of Epidemiology, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
authors.forename: Claire
authors.initials: C
authors.lastname: Holland
authors.affiliation: Department of Epidemiology, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
authors.forename: Sosthenes
authors.initials: S
authors.lastname: Ketende
authors.affiliation: The Human Sciences Research Council, Port Elizabeth, South Africa.
authors.forename: Clarence
authors.initials: C
authors.lastname: Yah
authors.affiliation: Department of Epidemiology, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
authors.forename: Stephanie
authors.initials: S
authors.lastname: Sweitzer
authors.affiliation: The TB/HIV Care Association, Cape Town, South Africa.
authors.forename: Harry
authors.initials: H
authors.lastname: Hausler
authors.affiliation: Department of Epidemiology, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
authors.forename: Stefan
authors.initials: S
authors.lastname: Baral
mesh_terms: D019380:Anti-HIV Agents / Q000627:therapeutic use*; D017280:Condoms / Q000706:statistics & numerical data; D003430:Cross-Sectional Studies; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000453:epidemiology; D006801:Humans; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D015995:Prevalence; D012494:Sampling Studies; D060386:Sex Workers / Q000523:psychology*; D012725:Sexual Behavior; D013019:South Africa / Q000453:epidemiology; D011795:Surveys and Questionnaires; D013587:Syphilis / Q000188:drug therapy* / Q000453:epidemiology
chemical_list: D019380:Anti-HIV Agents
keywords: AFRICA; COMMERCIAL SEX; HIV WOMEN; SYPHILIS