Differentiated prevention and care to support virtual elimination of infectious HIV among sex workers in southern Africa

Community empowerment to support harm reduction and engagement with HIV prevention and care services has been a successful HIV control strategy among female sex workers (FSW) in “concentrated” HIV epidemics, especially in Asia. In the “generalised” epidemics of sub-Saharan Africa, most focus has been on general population approaches, although mathematical modelling suggests that a high fraction of transmissions are directly or indirectly attributable to commercial sex. In Africa, sex work is heterogeneous, stigmatised, and largely illegal. Risk and health service engagement appears to vary as women transition in and out of sex work. HIV prevalence and incidence in FSW are extremely high, and many studies show gaps in the “continuum of care” of HIV diagnosis, treatment and viral suppression. Efficacious HIV treatment and prevention technologies are widely available, yet strategies to maximise their population impact by ensuring high uptake and optimal use are lacking. We hypothesise that an intensified, risk-differentiated sex work programme, tailored for the African context, can raise uptake and adherence to prevention and treatment among FSW to levels that could lead to the virtual elimination of HIV transmission attributable to sex work: if so, then this could be a cost-effective and translatable component of HIV epidemic control.