Background
Women who engage in sex work (WESW) and their partners have an elevated risk of exposure to sexually transmitted infections (STI) and account for an increasing proportion of new HIV infections globally. In Uganda, HIV prevalence among WESW is over 30%. Oral pre-exposure prophylaxis (PrEP) could substantially reduce HIV incidence among WESW and is available through public health facilities in Uganda, but stigma and lack of flexible services at health facilities are barriers to PrEP use. Moreover, data are limited on STI prevalence among WESW in Uganda given that syndromic management is routinely used for diagnosis and treatment. We aimed to quantify PrEP use and STI prevalence among WESW in southwestern Uganda.
Methods
We assessed demographic characteristics and prior PrEP use at enrollment into the Peers for PrEP (P4P) study (NCT06353295), which is testing a peer-led PrEP delivery strategy for cisgender WESW in two communities in southwestern Uganda. We tested urine samples for Neisseria gonorrhea (GC) and Chlamydia trachomatis (CT) via GeneXpert (Cepheid). We used descriptive statistics to summarize self-reported use of oral PrEP (TDF/XTC) in the last 0-3 and 4-6 months prior to enrollment as well as STI prevalence.
Results
Among 140 participants, the median age was 23 years (range 15-42; IQR 20-27); 138 (99%) reported exchanging sex for goods or money in last 3 months; 91 (65%) reported commercial sex work; 69 (49%) reported alcohol use >=4 times per week. 37/140 (26%) reported using oral PrEP in the 3 months before study enrollment; 13 (9%) reported using PrEP in the 4-6 months before enrollment. Among a subset of 78 participants with STI testing completed, 31 (40%) had at least one STI detected: 22/78 (28%) CT and 17/78 (22%) GC. Among the 31 participants with CT or GC detected, 7 (23%) reported PrEP use in the 3 months prior to enrollment, whereas 17/47 (36%) of participants with no STI detected had recently used PrEP.
Conclusions
In this HIV prevention study for WESW in southwestern Uganda, 40% of women had prevalent gonorrhea or chlamydia – double the rates of STIs in prior surveys in the region. Despite high STI prevalence and all participants having a PrEP indication, only one-quarter of women reported using PrEP in the last 3 months, while less than 10% had used PrEP 4-6 months prior to enrollment. Innovative strategies are needed to expand access to integrated STI and biomedical HIV prevention services to reduce the burden of HIV and STIs among women who engage in sex work.