Unmet treatment needs of female sex workers may contribute to HIV transmission in South Africa

The unmet HIV prevention and treatment needs of female sex workers and especially their male clients could contribute substantially to ongoing HIV transmission in South Africa, according to a new study led by researchers at the University of Bristol, UK.

The researchers used mathematical modelling to look at the contribution of commercial sex, sex between men, and other heterosexual partnerships to HIV transmission in South Africa.

They found that, over a ten-year period (2010-19), sex between female sex workers and their paying clients contributed 6.9 per cent of new HIV infections, while sex between clients with their non-paying partners contributed 41.9 per cent.

Sex between men contributed 5.3 per cent and sex between men who have sex with men and their female partners contributed 3.7 per cent.

The study, published in Journal of the International AIDS Society, also looked at the potential impact and efficiency of increasing HIV treatment among each risk group. Increasing treatment among female sex workers, their paying clients and men who have sex with men would be up to five times more efficient for reducing HIV transmission than increasing treatment among the general population.

South Africa has made a considerable investment in scaling up interventions for preventing and treating HIV and are close to achieving the UNAIDS HIV treatment targets. However, the rate of new HIV infections remains over twice the UNAIDS 2020 target. To close this gap, and to regain momentum, the HIV response must adapt to focus on those communities where the risks and disease burden are greatest, which for South Africa are the paying clients of female sex workers."

Dr Jack Stone, Study Lead Author, Bristol Medical School,  University of Bristol

Professor Peter Vickerman, from the NIHR Health Protection Research Unit in Behavioural Science and Evaluation at the University of Bristol, who supervised the study, said:

"The HIV response in South Africa has traditionally focused on the general population. This is based on the assumption that key populations such as female sex workers and men who have sex with men play a small role in HIV transmission in countries where HIV is endemic. Our findings show this is not the case and suggest that South Africa, and indeed other countries, may not be focusing new initiatives on those who most need them, which, in South Africa, are the paying clients of female sex workers."

Dr Jenny Coetzee, CEO of the African Potential Foundation and Principal Researcher at the Perinatal HIV Research Unit, who contributed data from a study on male clients, commented that: "The response to HIV in South Africa places the burden of responsibility for prevention and behavioural change upon women. It is vital that we begin to draw men into the solution. This study highlights the importance of a criminalised and often marginalised group of men who have clearly been overlooked in our national response".