National epidemics in sub-Saharan Africa become increasingly concentrated among high risk populations. In Zimbabwe, HIV prevalence is 13.3% in the general population compared to 56.5% amongst female sex workers. HIV services have been successfully set up for female sex workers (FSW) and reached over 45.000 women. However, male and transgender sex workers remain hidden and disconnected from services. Little is known about them, while their HIV risk is expected to be high. We determined HIV prevalence and risk among male and transgender sex workers in Zimbabwe.
By July 2018, the Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe has integrated an outreach intervention for male and transgender sex workers within the existing program for female sex workers. Participants were recruited through peer educator referral at multiple sex work hotspots throughout the country. From July 2018 to June 2019 in total 603 male and transgender sex workers enrolled the program. Trained staff administered a sociodemographic and behavioral survey and performed HIV voluntary counselling and testing. Determinants of HIV risk were analyzed through univariate and multivariate logistic regression analysis and compared to program data from 12,315 female sex workers.
In total 221 male sex workers (MSW), 233 transfemale sex workers (TFSW) and 149 transmale sex workers (TMSW) were included in the study. Crude HIV prevalence estimates were 28.2% in MSW, 37.6% in TFSW and 38.1% in TMSW, compared to 36.5% in FSW. Reported risk behavior appeared high in all groups, in particular high rates of condomless vaginal sex for all groups, and high rates of condomless anal sex amongst MSW and TFSW. High rates of female clients were reported by all groups. PrEP was significantly more commonly used amongst MSW and TFSW and appeared protective for HIV.
To our knowledge this is the first study conducted in sub-Saharan Africa specifically focused at male, transfemale and transmale sex workers. HIV prevalence among Zimbabwean male and transgender sex workers was as high as for female sex workers. High numbers of transmale sex workers and female clients give a new insight into the diversity of people participating in sex work. HIV research and interventions focused on sex work should be made inclusive for all genders.