Try out PMC Labs and tell us what you think. Learn More. Female sex workers FSWs experience overlapping burdens of HIV, sexually transmitted infections and unintended pregnancy. It represents a promising strategy to reduce HIV acquisition risks among FSWs specifically given complex social and structural factors that challenge consistent condom use.
However, the potential impact on unintended pregnancy has garnered little attention. Synergies between PrEP and family planning could promote uptake and maintenance for both interventions. However, barriers to integration, such as provider skills and training and funding mechanisms, need to be addressed.
Despite these coexisting reproductive health needs, in many settings family planning is poorly integrated into sexual and reproductive health and rights SRHR services for FSWs, which often maintain a Women seeking sex Bourne focus on HIV and STI prevention and treatment 345. Although the potential benefits and acceptability of PrEP among FSWs have been ly established 91011121314specific consideration Women seeking sex Bourne the implications of PrEP for family planning in this population is lacking.
Drawing from our experience in working with national PrEP implementation programmes, the purpose of this commentary is to elaborate on the context in which PrEP is being implemented with FSWs and the potential concerns and opportunities for PrEP to impact unintended pregnancy and other aspects of SRHR.
There is strong evidence that PrEP is efficacious in preventing HIV infection among women when used consistently and as directed Additional barriers to access and uptake of contraception among FSWs include stigma or refusal of service due to sex work, young age or marital status, limited availability or choice of contraceptive methods, lack of health workers trained in LARC provision and limited knowledge of contraceptive methods 53132 The potential for individuals on PrEP to reduce their use of condoms due to negation of HIV risk is a commonly voiced concern While there is no current evidence among FSWs of decreasing condom use or other behaviours increasing vulnerability to STIs and unintended pregnancy 444546implementation data are too limited to discount this possibility.
It is possible that risk compensation will increase over time as PrEP Women seeking sex Bourne more normalized Importantly, price premiums for condomless sex are already reported by FSWs in many settings 474849and as community knowledge of PrEP increases, so too may client demand and pressure for condomless sex 1050 While undocumented, it is also possible that individuals in a position of disparate power or economic control over FSWs may coerce FSWs to use PrEP whether or not they consider it as the most suitable HIV prevention option for their circumstances.
Most concerns raised around the potential implications of condomless sex focus on STIs — perhaps given the predominance of PrEP studies involving MSM in the literature. Although less frequently considered, mistimed or unwanted pregnancies are a potential adverse outcome of PrEP use that may have enduring social and health consequences.
Among FSWs, unintended pregnancy is commonplace and is often followed by unsafe abortion In addition to the immediate health risks of unintended pregnancy due to unsafe abortion and high maternal mortality in areas most affected by HIV 56pregnancy and caring for children has major economic implications for FSWs that can Women seeking sex Bourne to subsequent risk.
Association of sex with the global burden of cataract
While motivations for selling sex are complex and multifactorial 57one reason often reported is the need for financial independence among women with children who are not financially supported by a partner 5758 Unintended motherhood may increase economic dependency on sex work and pressure women to take more clients, accept condomless sex for Women seeking sex Bourne money, or serve as a barrier to leaving sex work, thus increasing or prolonging risk for HIV and other STIs 5960Women seeking sex Bourne A study in India found that FSWs with more children were more likely to report inconsistent condom use and accept more money for condomless sex Pregnancy and childcare may also lead to women taking unplanned or unwanted breaks from sex work, thus adding to household insecurity Conversely, for some FSWs, responsibility to care for children may be a motivator to use PrEP in order to stay healthy and maintain their earning potential 1235 Evidence of the impact of PrEP on pregnancy rates among all women is scant.
High rates of unintended pregnancies have also been reported in older PrEP trials 22 and trials of other HIV prevention technologies 7273often in the context of free provision of contraceptives 69 Importantly, many PrEP trials provided oral and injectable contraceptives onsite but referral for LARCs 6574which may have been a deterrent to accessing more effective contraception. Trials have also indicated higher pregnancy incidence among new versus established contraceptive users, especially among oral contraceptive users, emphasizing the need for counselling support for new users 65 There are opportunities to meet the HIV prevention needs of many FSWs while minimizing additional unintended pregnancy risk through the integration of PrEP and family planning services.
Such service integration would also enhance opportunities for STI prevention and treatment and could promote more efficacious approaches such as LARCs and multipurpose prevention technologies for combined HIV prevention and contraception. Integration of family planning may also facilitate PrEP uptake and continuation, as women seeking contraception or wanting to conceive may be ideal PrEP candidates.
Regular monitoring of individuals on PrEP also provides opportunities for contraception renewal and vice versa. Shared social, economic and structural factors underlying vulnerability to both unintended pregnancy and HIV acquisition, such as violence, substance use and financial insecurity, may also affect uptake of PrEP and family planning 81 Programmes which address these factors may support uptake and adherence to PrEP, contraception and condoms alike Acceptability studies indicate that these focused services are often the preferred way for FSWs to access healthcare due to staff friendliness, lower cost, Women seeking sex Bourne waiting times, privacy, proximity to places of work and greater quality of care 88185 There are several advantages of building upon this model for integrated PrEP and family planning delivery.
Community mobilization approaches promoting social cohesion, leadership and empowerment have been empirically associated with reductions in HIV and STI acquisition and increased treatment adherence 83Women seeking sex Bourne Providing options for PrEP and family planning through mobile service delivery may extend service access and acceptability among FSW 13 Alternative models for the integration of family planning and HIV services have focused on antenatal or family planning services 90 There are emerging data supporting the feasibility of integrating PrEP into family planning clinics targeting adolescent girls and young women 9293although these may have limited utility and acceptability for FSWs due to potential stigmatization.
FSWs and women who are pregnant outside of Women seeking sex Bourne are often stigmatized, shamed, denied care in public clinics, or are provided limited contraceptive choice based on assumptions about their needs and behaviours 5949596 However, this model of integration may still be valuable in contexts where FSWs are already accessing services in public or private antenatal or family planning facilities Lessons learned from these studies highlight that PrEP and family planning integration does not only confer synchronized commodity delivery in a common space; there is also a need to integrate tools for screening, monitoring and evaluation, coordinate demand generation activities and integrate training There are several barriers to realizing integrated PrEP and family planning services.
This is exacerbated by inadequate mobilization of domestic funding for HIV prevention programmes, particularly among key populations The management and procurement of PrEP and family planning commodities through different funding and sources may pose additional challenges to integrated delivery. Finally, there is currently a lack of policy guidance to support implementers to integrate family planning into their programmes, with most national PrEP policies and guidelines making fleeting references to including contraceptive counselling within a combination package of prevention services, Intersectional stigmas remain major barriers to PrEP uptake among key populations in many settings Combined delivery of PrEP and hormonal contraception could be a convenient and efficient means of simultaneously preventing HIV and unintended pregnancy.
Cite this item
Multipurpose prevention technologies for modern contraception and HIV are in early development stages, including intravaginal ring and gel preparations. However, this should still be considered in light of the limitations of oral contraceptives, in particular lower effectiveness compared to LARCs and pill burden Finally, despite synergies between HIV and unintended pregnancy risks, HIV risks and pregnancy intentions are each dynamic and temporal needs may not always synchronize.
Given the ificant social and health impacts of unintended pregnancy for FSWs, there is impetus to consider family planning as an integral component of PrEP programming. Systematic collection and reporting of implementation data pertaining to PrEP, family planning and related Women seeking sex Bourne will support the optimization of integration strategies to meet the multifaceted needs of FSWs. Furthermore, dedicated research is needed to test the hypotheses that integrating contraception with PrEP delivery improves PrEP continuation and decreases unintended pregnancy and to compare models of PrEP and family planning integration.
MH proposed the initial concept.
Hiv pre‐exposure prophylaxis for female sex workers: ensuring women’s family planning needs are not left behind
ALB took the lead role in writing the manuscript, reviewing the literature and developing the initial framework. All authors provided intellectual input on the contents and perspective of the commentary. The views expressed in this publication are solely the opinion of the authors and do not necessarily represent the official views of the NHMRC, the NINR or other sponsors.
Bowring, A. National Center for Biotechnology InformationU. Published online Feb Author information Article notes Copyright and information Disclaimer. Anna L Bowring, : ua. Corresponding author.
This article has been cited by other articles in PMC. Discussion 2. Risk compensation The potential for individuals on PrEP to reduce their use of condoms due to negation of HIV risk is a commonly voiced concern Impacts of unintended pregnancy Most Women seeking sex Bourne raised around the potential implications of condomless sex focus on STIs — perhaps given the predominance of PrEP studies involving MSM in the literature.
Opportunities and considerations for family planning and PrEP integration There are opportunities to meet the HIV prevention needs of many FSWs while minimizing additional unintended pregnancy risk through the integration of PrEP and family planning services. Barriers to integration There are several barriers to realizing integrated PrEP and family planning services. Multipurpose devices for prevention of HIV and pregnancy Combined delivery of PrEP and hormonal contraception could be a convenient and efficient means of simultaneously preventing HIV and unintended pregnancy.
Conclusions Given the ificant social and health impacts of unintended pregnancy for FSWs, there is impetus to consider family planning as an integral component of PrEP programming. Competing interest The authors have no competing interest to declare. Notes Bowring, A. References 1. Lancet Infect Dis. BMJ Open.
Glob Health. Community empowerment and involvement of female sex workers in targeted sexual and reproductive health interventions in Africa: a systematic review. Meeting the contraceptive needs of key populations affected by HIV in Asia: an unfinished agenda. Reprod Health.
Understanding the broader sexual and reproductive health needs of female sex workers in Dhaka, Bangladesh. Int Perspect Sex Reprod Health. Combination HIV prevention for female sex workers: what is the evidence? AIDS Behav. Exploring acceptability of oral PrEP prior to implementation among female sex workers in South Africa.
Global epidemiology of HIV among female sex workers: influence of structural determinants.