Modeling the impacts of a comprehensive community empowerment-based, HIV prevention intervention for female sex workers in generalized and concentrated epidemics: infections averted among sex workers and adults Andrea L. Wirtz Carel Pretorius Susan G. Sherman Stefan D. Baral Michele R. Decker Michael D. Sweat Chris Beyrer Deanna L. Kerrigan International AIDS Conference, Washington D.C. 26 July 2012 This work was supported by the International Bank for Reconstruction and Development, the World Bank, and UNFPA. The findings, interpretations and conclusions expressed in this publication do not necessarily reflect the views of the executive directors of the World Bank, UNFPA, or the governments they represent. Center for Public Health and Human Rights

Background Comprehensive report commissioned by the World Bank: global review of HIV epidemiology, interventions, human rights, impact and cost analysis of HIV prevention interventions for female sex workers Inform decisions and resource allocation in contexts of constrained funding and across epidemics (Kerrigan, World Bank 2012) Meta-analysis: persistent and high prevalence of HIV among sex workers in LMIC Evidence and human rights-based approaches and prioritization towards preventing infections sex workers are warranted (Baral, 2012) Mathematical modeling objective: to demonstrate possible impacts of scaling up HIV prevention interventions for sex workers Presentation focuses on the possible impacts of the community- empowerment, comprehensive HIV prevention intervention 2 © 2009, Johns Hopkins University. All rights reserved.

The community-empowerment comprehensive HIV prevention intervention Defined as: the collective process through which structural constraints to health, human rights, and well-being are jointly addressed by sex workers to create new possibilities for social and behavioral change and access to health services to reduce their risk for acquiring HIV (Kerrigan, 2006; Kerrigan, 2008) Emphasizes role of sex worker community to lead, mobilize around, and address priorities and needs RCT conducted in India based on the Sonagachi model demonstrated changes in condom use with clients and lower STI (Basu, 2004) Often begins with promoting social cohesion – and building on cohesion for collective action to overcome structural constraints 3

The community-empowerment comprehensive HIV prevention intervention Typically includes organizing and mobilization of sex workers plus… 1.Community education: communication between sex workers describing HIV transmission and risk factors and the importance of safer sexual behaviors 2.Sex worker led condom access and use programs: sex workers are involved in condom program design, education, influence distribution 3.Promotion of sex worker friendly clinical services for the screening and treatment of STIs and access to other sex worker-led services Systematic review found that community empowerment demonstrated 51% reduction in inconsistent condom use (RR:1.77; 95% CI ) comparing intervention exposed sex workers to unexposed (WHO, UNFPA 2012) 4

Methods The Goals model (Futures Institute), a deterministic model, projects the impacts of the intervention on new adult and female sex worker infections Modeled four low and middle income countries, to represent diverse epidemic, cultural, political contexts 5 Map adapted from Baral et al., Lancet Infectious Disease 2012 Map. Modeled countries and prevalence of HIV infection among female sex workers and female adult populations (Brazil, Kenya, Thailand, Ukraine)

Methods: Parameterized with epidemiology (HIV and STI) and behavioral data for risk groups Nine ‘risk groups’ based on gender and sexual or parenteral transmission risk Female sex workers included in female ‘high risk’ category Clients included as male ‘high risk’ category Husband/partners are included by ‘% married’ -medium risk Calibrated against historical adult and female sex worker HIV prevalence trends (UNAIDS) 6

Methods: Baseline coverage (2011) of the empowerment intervention was estimated by reported coverage prevention programs and expert opinion on coverage Modeled the impact of increasing coverage of empowerment intervention via the impact of the intervention on condom non-use among sex workers (- 51% reduction) Projections from , all other interventions held constant Second analysis with combination of empowerment + equal access to ART (planned coverage for adults; CD4 < 350) Results: annual new infections among female sex workers and adults 7

Results: Brazil 8 Increased coverage from baseline of 10% to 70% by 2016: 1,830 infections averted among sex workers in 5 yrs. (10% reduction) 4,740 infections averted among adults in 5 yrs. (3% reduction) Increasing coverage (to 70%) with expansion of ART and equal access for sex workers living with HIV yields: 7,120 infections averted among sex workers (40% reduction)

Results: Kenya 9 Increased coverage from baseline of 5% to 65% by 2016: 10,800 infections averted among sex workers in 5 yrs. (11.5% reduction) 20,680 infections averted among adults in 5 yrs. (4% reduction) Increasing coverage (to 65%) with expansion of ART and equal access for sex workers living with HIV yields: 31,160 infections averted among sex workers (33% reduction)

Results: Thailand 10 Increased coverage from baseline of 10% to 70% by 2016: 220 infections averted among sex workers in 5 yrs. (8% reduction) 730 infections averted among adults in 5 yrs. (1% reduction) Increasing coverage (to 70%) with expansion of ART and equal access for sex workers living with HIV yields: 1,970 infections averted among sex workers (28% reduction)

Results: Ukraine 11 Increased coverage from baseline of 5% to 65% by 2016: 2,220 infections averted among sex workers in 5 yrs. (12% reduction) 6,920 infections averted among adults in 5 yrs. (3% reduction) Increasing coverage (to 65%) with expansion of ART and equal access for sex workers living with HIV yields: 3,110 infections averted among sex workers (17% reduction)

Limitations: 12 Subject to reporting and publication biases: rely on published studies and expert input, more challenging where criminalized Little known about what interventions in each country are truly empowerment-based; baseline may be optimistic Sex workers and clients are heterogeneous Limitation of Goals model is the need to assess the sex workers as single population with a specific behavior & risk Though important populations, could not include male and transgendered sex workers who have different behavioral, transmission, and acquisition risks May not capture full effect of structural issues on access

Limitations For inclusion of impact of ART in analysis: Model does not link HCT associated with empowerment to ART (allocation based on CD4 count) CD4 count and the populations who are in need of/covered by ART are influenced by disease progression and duration in risk group  sex workers living with HIV may ‘move’ to medium risk group before progressing to stage when they require ART Effects of discrimination and criminalization on access to ART are not captured  estimates of sex work population receiving ART and impact of ART among sex workers may be optimistic, without equal access to testing and ART 13

Conclusions: Scale up of empowerment based, comprehensive HIV prevention intervention can positively impact HIV epidemics among female sex workers, averting 8-12% of new infections Positive impacts among adults Benefits in both concentrated and generalized epidemic Potential benefits of averting other morbidity associated with HIV and STI 14 Cumulative infections averted among FSWs and adults with scale-up of empowerment ( )

Conclusions: Combined expansion of ART and empowerment intervention may avert % of infections among sex workers across epidemics, assuming equal access to HIV testing and treatment May be synergistic: empowerment intervention could enable ART expansion among sex workers through a community-based outreach and mobilization approach 15 *ART expansion based on national plans

Sincere thanks to: Sex workers and sex work organizations worldwide The collaboration, support, and partnership with the World Bank and UNFPA, the leadership of Robert Oelrichs and Jenny Butler, and other staff members including Iris Semini, Anderson Stanciole, Ndella Nnjie, and Sutayut Osornprasop Consultants and student investigators at the Johns Hopkins School of Public Health: Laura Murray (Columbia University), Pamela S. Lilleston, Kate Muessig, Madeleine Schlefer, Dina Fine Meron, Shirin Kakayeva, and Sara Coleman Futures Institute, with leadership of John Stover & Lori Bollinger The International AIDS Society for their interest in this important field of research 16