Advances in biomedical
interventions to prevent HIV offer great promise in reducing the number of new
infections across sub-Saharan Africa, particularly among vulnerable populations
such as female sex workers. Several recent trials testing pre-exposure
prophylaxis (PrEP) have demonstrated efficacy, although others have been
stopped early for futility. Given the importance and complexities of social and
behavioural factors that influence biomedical approaches to prevention, we discuss
several key areas of consideration moving forward, including trial
participation, adherence strategies, social relationships, and the structural
factors that shape PrEP interest, use, and potential effectiveness among female
sex workers in sub-Saharan Africa. Our review highlights the importance of
involving social scientists in clinical and community-based research on PrEP.
We advocate for a shift away from a singular “re-medicalization” of the HIV
epidemic to that of a “reintegration” of interdisciplinary approaches to
prevention that could benefit female sex workers and other key populations at
risk of acquiring HIV...
Although female sex workers in sub-Saharan Africa experience
heightened risk for HIV, few PrEP trials have specifically recruited from this
population. In the Fem-PrEP trial, 12.6% of women reported recently exchanging
sex35. For
unspecified reasons, an exploratory study of adherence to intermittent PrEP
dosing in Kenya that included 67 men who have sex with men only included 5
female sex workers36.
Given the fluid boundaries of sex work in many African contexts, including
formal sex work, transactional sex, and other informal types of exchange,
researchers should consider expanding recruitment and eligibility terminology.
Thus, a greater diversity of women could be reached, ultimately informing
science on the range of sexual partnerships and practices in the context of
PrEP use.
Studies suggest that many female sex workers are
interested in using PrEP37-39.
While much of this work has been survey research, Robertson et al. (2013)
integrated survey data with qualitative interviews with female sex workers and
their non-commercial male partners in Northern Mexico in an iterative
investigation of potential interest in PrEP use and trial participation. This
work revealed the tension in positive and negative aspects of microbicide gel
use, including its potential to alter intimate relationships dynamics by
creating suspicion of infidelity and contributing to conflict. Findings suggest
that researchers should consider the subjective meanings that sex workers
ascribe to their intimate relationships rather than framing PrEP trial participation
solely around constructs of risk and disease38.
Once women are enrolled in trials, mixed methods
approaches can elucidate experiences of participation. Within one large
microbicide trial in South Africa, Stadler and Saethre (2010) used in-depth
interviews with female participants and their partners, focus groups with
community members, and participant observation in clinics to understand
perceptions surrounding cash payments and reasons for collecting blood samples40.
Through data triangulation, this work revealed a complex picture of how
conflicting understandings of the nature and intent of research differentially
reflect power relations among participants, local communities, and foreign
researchers40.
Such work reminds us of the importance of the
historical and social contexts in which Western clinical research has been
viewed as exploitative in developing nations. Researchers should be
particularly sensitive to such issues while recruiting vulnerable groups,
including sex workers, whose exploitation has been well documented. Earlier
controversies include the 2004 shutdown of a PrEP trial by sex workers in
Cambodia over lack of community involvement in trial planning, drug safety
concerns, and confusion over rights to treatment. Shortly afterwards, a trial
targeting at-risk women in Cameroon was also closed due to concerns over
treatment for women who seroconverted (they were to be referred to an already
overburdened clinic) and rumours that the investigators wanted to inject HIV
into subjects (see41 for
an excellent discussion of PrEP trial ethics, including these cases). Rather
than viewing such activism around ethical issues as impeding scientific progress25,
these cases serve as stark reminders to include the ongoing perspectives and
concerns of communities in PrEP research. Long-term ethnographic engagement is
needed from the outset of clinical research, including efforts to build trust
and transparency, share study results with affected communities, and promote
participatory efforts in translating PrEP into an effective and available
intervention in diverse communities. We advocate for genuine participation of
communities using a human rights-focused approach anchored in a “Nothing About
Us Without Us” framework42,43...
Full article at:
By:
1Department of Anthropology, The Ohio State University, 4034 Smith Laboratory, 174 W. 18th Avenue, Columbus, OH 43210, USA
2Department of Community Health Sciences, Boston University School of Public Health, 801 Massachusetts Ave, Crosstown 4th floor, Boston MA USA
3Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Cape Town, South Africa
4HIV and AIDS Division, Population Council, 16 Mafemi Crescent, Utako District Abuja, Nigeria
5Division of Global Public Health, School of Medicine, University of California at San Diego, 9500 Gilman Drive, Mail Code 0507, La Jolla, CA 92093-0507, USA
6RTI International, Research Triangle Park, NC, 27709-2194, USA
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