Characterizing the HIV Prevention and Treatment Needs among Key Populations, including Men who Have Sex with Men and Female Sex Workers in Swaziland:

Transcription

1 Characterizing the HIV Prevention and Treatment Needs among Key Populations, including Men who Have Sex with Men and Female Sex Workers in Swaziland: From Evidence to Action June 2015

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3 TABLE OF CONTENTS ACKNOWLEDGEMENTS...2 ACRONYMS...3 EXECUTIVE SUMMARY...4 Introduction...4 Methods...4 Results...5 Discussion...6 Conclusion...6 INTRODUCTION...7 HIV in Swaziland...7 HIV in Key Populations...7 Existing Data and Framework on Key Populations in Swaziland...7 Theoretical Framework...8 Engagement in the Continuum of HIV Care...9 Service Delivery Models...10 Aim and Objectives...11 Purpose...11 METHODS...12 The Priority Locations for AIDS Control Efforts...12 Study Sites...12 Inclusion Criteria and Ethical Considerations...12 Quantitative...13 Analysis...15 Qualitative...15 Analysis...16 Data Collection...16 RESULTS...18 Men who Have Sex with Men...18 Female Sex Workers...12 Health Service Assessment...24 Venue Verification Results...25 DISCUSSION...27 LIMITATIONS...30 CONCLUSIONS...31 PROGRAMMATIC RECOMMENDATIONS...32 RESEARCH RECOMMENDATIONS...35 REFERENCES...36 APPENDICES...38 Appendix 1. Towns included in Study Sites...38 Appendix 2. MSM Tables...39 Appendix 3. FSW Tables...48 Appendix 4. Health Service Assessment Tables...58 Appendix 5. Venue Verification Tables

4 ACKNOWLEDGEMENTS To be completed 2

5 ACRONYMS AIDS Acquired Immune Deficiency Syndrome ANC Antenatal Care ART Antiretroviral Therapy BSS Behavioural Surveillance Survey CBO Community-Based Organization CCP Johns Hopkins Center for Communication Programs CD4 Cluster of Differentiation 4 CI Confidence Interval CPHHR Center for Public Health and Human Rights ensf Extended National Multi-Sectoral HIV and AIDS Framework FLAS Family Life Association of Swaziland FSW Female Sex Worker HCT HIV Counselling and Testing HC3 Health Communication Capacity Collaborative HIV Human Immunodeficiency Virus KI Key Informant KP Key Population LGBT Lesbian, Gay, Bisexual and Transgender MSEM Modified Social Ecological Model MSM Men who Have Sex with Men NGO Non-Governmental Organisation NSUM Network Scale-Up Method OR Odds Ratio PEPFAR President s Emergency Plan for AIDS Relief PLACE Priorities Locations for AIDS Control Efforts study PMTCT Prevention of mother-to-child transmission PSI Population Services International RSP Royal Swaziland Police SNAP Swaziland National AIDS Program STI Sexually Transmitted Infection UNAIDS United Nations Programme on HIV/AIDS U.S. United States USAID United States Agency for International Development USD United States Dollar 3

6 EXECUTIVE SUMMARY Introduction Swaziland bears the burden of one of the world s most broadly generalized HIV epidemics. The prevalence of HIV among adults aged is currently estimated at 31 percent (1). UNAIDS estimates the country has about 12,000 incident cases of HIV per year and 5,500 AIDS-related deaths (2). Although the HIV epidemic in Swaziland is classified as a generalized epidemic (populationwide HIV prevalence of greater than one percent (2)), HIV risk is not evenly distributed throughout the population. In order to create an effective, targeted and financially viable national HIV response, it is critical to evaluate the context for HIV prevention, treatment and care among different population groups even in generalized epidemic settings (3). Key populations (KP), including female sex workers (FSW) and men who have sex with men (MSM), represent important groups for access and uptake of HIV prevention, treatment and care programmes, particularly due to the increased risk of HIV acquisition and transmission (4). The National Multi-Sectoral Strategic Framework for HIV and AIDS identified MSM and FSW as KP for HIV intervention (5). This research was designed to evaluate the social- and communitylevel determinants of HIV through interviews with MSM and FSW populations, as well as evaluating health services and social meeting places frequently accessed by these groups. The study was designed to provide further information to characterize the HIV risks of MSM and FSW in Swaziland, and assess their access to and uptake of HIV health services Aim and Objectives The primary aim of the Characterizing the HIV Prevention and Treatment Needs Among Key Populations in Swaziland study was to generate data for evidence-based programming, planning and delivery of cost-effective quality HIV prevention, care and support services for KP in Swaziland. The objectives of the study are: 1. To estimate the population size of FSW and MSM in Swaziland. 2. To locate, characterize and assess venues and HIV prevention, testing, care and treatment services and programmes utilized by FSW and MSM in Swaziland. 3. To triangulate HIV data for effective HIV prevention, treatment and care services for FSW and MSM in Swaziland. Methods This study used a modified Priorities Locations for AIDS Control Efforts (PLACE) methodology (6). The PLACE method is a location-based sampling method that uses the venues in which individuals are likely to meet new sexual partners to identify those individuals at high risk of HIV infection. The PLACE method has also characterized individuals and venues of higher risk to determine priority areas for HIV prevention, treatment and care (7, 8). In this study, the PLACE method was used to characterize venues where MSM and FSW meet new potential sexual partners, recruit MSM and FSW into the quantitative survey, assess the health services accessed by MSM and FSW through quantitative surveys with health providers, and conduct size estimation of the MSM and FSW population. Qualitative data collection employed focus groups, key informant (KI) interviews, and indepth interviews among MSM and FSW to obtain contextual and individual level data in each city of implementation. Interviewees were recruited through the study staff and KIs, and trained qualitative interviewers led all interviews and focus group discussions. 4

7 Results Population Size Estimates among MSM* Proportion of the Population that is MSM Aged [95%CI] MSM Population Size Estimate Aged [95%CI] Mbabane/Manzini Corridor 1.92% [ ] 1,709 [1,245-2,173] Piggs Peak 1.95% 341 Nhlangano 2.53% 363 *Size estimates include the study site and surrounding areas Results among MSM A total of 532 MSM participated in the study across Mbabane/Ezulwini, Manzini/Matsapha, Piggs Peak, Lavumisa and Nhlangano. Overall, the majority of MSM who reported ever having been tested for HIV ranged from 68.9 percent in Mbabane to 86.5 percent in Manzini. The majority of MSM across all sites reported that they had not been tested for other STIs in the 12 months that preceded the study. The highest proportion not tested for sexually transmitted infections (STIs) was found in Nhlangano (81.4 percent) and the lowest in Manzini (54.9 percent). MSM were subject to stigma and human rights abuses: 6.4 percent of MSM were forced to have sex against their will at least once. A large number reported being verbally harassed (43.7 percent), blackmailed (22.0 percent) or scared to walk in public places (37.7 percent). They also reported being afraid to access healthcare because of their sexual behaviour and/or identity (36.3 percent) and avoiding accessing health services for fear that someone may learn that they are MSM (34.8 percent). Population Size Estimation among FSW* Proportion of the population that is FSW Aged [95%CI] FSW Population Size Estimate Aged [95%CI] Mbabane/Manzini Corridor 2.38% [ ] 2,562 [731-4,393] Lavumisa 6.52% 186 Piggs Peak 3.89% 796 Nhlangano 2.68% 498 *Size estimates include the study site and surrounding areas Results among FSW A total of 781 FSW participated in the study across Mbabane/Ezulwini, Manzini/Matsapha, Piggs Peak, Lavumisa and Nhlangano. Overall, the majority of FSW had ever been tested for HIV ranged from 81.5 percent in Mbabane to 96.0 percent in Manzini. Fewer FSW reported STI testing than HIV testing, with about half (51.6 percent) of FSW across all sites reporting that they had been tested for other STIs in the 12 months that preceded the study. FSW were subject to stigma and human rights abuses: 27.9 percent of FSW were forced to have sex against their will at least once. A large number reported being verbally harassed (45.9 percent), blackmailed (23.5 percent) or physically aggressed (32.6 percent). They also reported being afraid to access healthcare because of their sexual behaviour (23.7 percent) and avoiding accessing health services for fear that someone may learn they sell sex (20.5 percent). Health Service Assessment Results In total, 54 health facilities were assessed across the five study sites and their surrounding areas. More health facilities were identified in Mbabane 5

8 (17) and Manzini (16), compared to Lavumisa (7), Nhlangano (8) and Piggs Peak (6). More than half (59.3 percent) of the 54 facilities were government public health facilities, while privately owned health facilities comprised 13.0 percent of the facilities. Nongovernmental and other types of facilities comprised 27.9 percent of the assessed health facilities. The facilities reported that 40.8 percent of their workers who work with MSM and FSW have never received any special training for working with MSM and FSW and 14.3 percent of the facilities reported that more than half of their workers were trained in MSM or FSW care. In terms of services offered at the facilities in the four weeks preceding the study, a large proportion (92.6 percent) of the facilities offered HIV testing and counselling. A much lower proportion (38.9 percent) reported that they provided HIV testing and counselling with an MSM or FSW specialist. Similarly, 70.4 percent of the facilities reported providing antiretroviral therapy (ART) medication for people living with HIV in the past four weeks. However, less than half of the facilities (22/54, 41.5 percent) reporting providing ART for either MSM or FSW in the past four weeks. Venue Verification Results A total of 56 venues were assessed across the study sites. The venues included bars or clubs (91.1 percent, n=51), hotels or guesthouses (7.1 percent, n=4), and a brothel (1.8 percent, n=1). More than half (59.6 percent) of the venues were frequented by both MSM and FSW, while about 40.0 percent were exclusive to FSW. FSW solicit clients in 22.0 percent of the venues. Thirty-eight of the 56 venue owners responded to the question whether FSW have sex with clients at the venue, and out of these, 52.6 percent reported that FSW have sex with clients at the venue. Venues where MSM socialize reported 56.3 percent of MSM meeting new male sexual partners at the venue. Fewer venues reported that MSM have sex with male partners at the venue (15.4 percent) than among FSW. Discussion Engagement in the continuum of HIV care from diagnosing unknown HIV infections to sustained viral suppression has been demonstrated to improve health outcomes for individuals living with HIV, as well as to decrease transmission of HIV within the population (9-12). This study identified gaps in the continuum of HIV care among KPs at many levels from undiagnosed HIV to inadequate uptake and utilization of prevention information, and STI testing, care and treatment. Additionally, the health facilities assessed in the study demonstrated limited provision of specialized services for KP across the study sites, such as knowledge about the management of anal STIs. Consequently, these limitations in cultural competency highlighted a lack of provider training to improve the capacity for quality KP service delivery. The study also highlighted differences in service provision and outreach for KP at health facilities in the different models of service delivery. These results underscore the importance of ensuring that available clinical care services are able to competently address KP health needs, as well as prevention programmes specifically tailored to the existing risk factors among both FSW and MSM. Furthermore, population size estimation and service provision data can be used together to calculate the coverage of HIV prevention, treatment and care among KPs (13). Conclusion This study found that MSM and FSW in Swaziland require greater access to and uptake of HIV prevention, treatment and care programming than they are currently receiving given their increased burden of HIV. Prevention programmes should model strategies on the continuum of care and evaluate programmes to increase uptake of services among KP, address the barriers to healthcare that exist in highly stigmatized settings, and ultimately reduce community viral loads and transmission. Ensuring effective and continued engagement in the continuum of HIV care is essential for KP, given their increased burden of disease and risk of HIV infection. Comprehensive HIV prevention, treatment and care programming specifically targeted for MSM and FSW populations is therefore needed across the country. Access to and creation and maintenance of environments which promote uptake of HIV services that effectively address the needs of KP, from HIV testing to sustained ART medication, is critical for decreasing new HIV infections in Swaziland and to improving the health profile of the country. 6

9 INTRODUCTION HIV in Swaziland Swaziland bears the burden of one of the world s most broadly generalized HIV epidemics. The prevalence of HIV among adults aged is currently estimated at 31 percent (1). UNAIDS estimates the country has about 12,000 incident cases of HIV per year and 5,500 AIDS-related deaths (2). However, there is evidence that the epidemic in Swaziland is stabilizing. From 2009 to 2015, the HIV incidence rate is projected to decline from 2.9 percent to 2.4 percent (14). Additionally, in 2011 ART was provided to 80 percent of individuals with a cluster of differentiation 4 (CD4) cell count of less than 350/mm3, which was the national guideline at that time (14). Although the HIV epidemic in Swaziland is classified as a generalized epidemic [population-wide HIV prevalence of greater than one percent (2)], HIV risk is not evenly distributed throughout the population. For example, antenatal care (ANC) surveillance indicated that in 2010, HIV prevalence among pregnant women was higher than the national average at about 42 percent (14). The prevalence among pregnant women has declined in recent years and was estimated at 35.0 percent in 2014 (15). In order to create an effective, targeted and financially viable national HIV response, it is critical to evaluate the context for HIV prevention, treatment and care among different population groups, even in generalized epidemic settings (3). HIV in Key Populations KPs, including FSW and MSM, represent important groups for evaluating and optimizing the access and uptake of HIV prevention, treatment and care programmes given the often increased risks of HIV acquisition and transmission (4). Globally, a significantly higher burden of HIV infection has been documented among KPs compared to other population groups (16, 17). MSM and FSW face behavioural and biological risks of HIV infection, as well as structural and social barriers to health services. MSM are at an increased risk of HIV due to the higher probability of HIV transmission during anal intercourse compared to vaginal intercourse (18). Additionally, behavioural studies of MSM in Sub-Saharan Africa consistently report that condomless anal sex in the absence of condom-compatible lubricants is common, and knowledge and access to appropriate risk prevention measures are inadequate (19, 20). For FSW, the biological risk associated with being the receptive partners during compensated sexual activity, consistently low reported usage of condoms with regular or non-paying partners, and the high periodicity of sexual exchanges and sexual partners increase individual risk for acquiring HIV and other STIs (16). At the structural and social level, stigma, discrimination and inadequate protective legal policies contribute to the risk of HIV infection among KPs (21, 22). Existing Data and Framework on Key Populations in Swaziland The National Multi-Sectoral Strategic Framework for HIV and AIDS identified MSM and FSW as KP for HIV interventions (5). A behavioural surveillance survey (BSS) among MSM and FSW was conducted in 2011 by the Ministry of Health and the Johns Hopkins Bloomberg School of Public Health under the U.S. President s Emergency Plan for AIDS Relief (PEPFAR)-funded R2P project. The purpose of the BSS was to focus on the individual-level risk behaviours of these KPs, examine the relationship between social and structural factors and HIV-related behaviours, and characterize the HIV epidemic stage in these groups through seroprevalence testing (23) and a positive health, dignity and prevention needs assessment (24). The BSS estimated a prevalence of HIV among MSM at 17.1 percent and among FSW, 69.7 percent. Condom use differed among the two study populations, with 82.3 percent of FSW reporting to have used a condom at last sex with their regular client and 70.7 percent of MSM reporting to have used a condom at last sex with a regular male partner. Additionally, 74.6 percent of FSW reported having received an HIV test in the past 12 months, but only 30.4 percent of MSM reported having been 7

10 tested for HIV in the same time period. The BSS also found that 81.0 percent of FSW reported they received information on HIV in the last 12 months, while only 27.1 percent of MSM reported they received HIV information in the same period of time. Barriers to receiving HIV information among MSM may be partly due to fear, as 55.5 percent of MSM reported fear of seeking healthcare. Furthermore, MSM who experienced legal discrimination as a result of their sexual orientation were almost twice as likely to report being afraid to seek healthcare services (25) and perceived and experienced stigma from healthcare settings also contributed to inadequate utilization of healthcare (26). FSW also reported high levels of experienced and perceived stigma, including refusal of police protection, being verbally or physically harassed, and being afraid to seek health services (27). Given the limited uptake of HIV prevention, testing and treatment services among KPs in Swaziland, the government s extended National Multi-Sectoral HIV and AIDS Framework (ensf) designates specific HIV programmes and targets around MSM and FSW populations (28). The ensf lists as a programme objective to improve the availability, access and utilization of HIV prevention and treatment services by KP at higher risk of HIV infections, including FSW and MSM. Specific targets include increasing the percent of FSW reporting use of a condom with their most recent client to 95 percent in 2018 and increasing the percent of MSM reporting the use of a condom the last time they had anal sex to 80 percent in However, the ability of the government to achieve these objectives is hindered by the legal and social environment toward KPs in Swaziland, including, as noted in the ensf, the criminalization of both FSW and MSM and pervasive stigma and discrimination toward KPs. As a result, the ensf notes that future policy strategies should address barriers to providing HIV services to KPs and address the gaps in the evidence base for KPs, building targeted HIV prevention programming for KPs, and increasing access to and utilization of HIV services among KP (19, 28). Theoretical Framework The Characterizing HIV Prevention and Treatment Needs among Key Populations study used the Modified Social Ecological Model (MSEM) as a theoretical framework for assessing HIV risk. The MSEM depicts the five layers of risk for HIV infection: individual, social, community, public policy and the HIV epidemic stage (29). The MSEM is modified from the original Social Ecological Model (30) to account for HIV-specific risk domains. The MSEM recognizes the importance of higher-level determinants of HIV risk and accounts for influences outside of individual biological or behavioural risks (31). 8

11 Figure 1. Modified Social Ecological Model for HIV risk in vulnerable populations (Baral et al., 2013). HIV Epidemic Stage Prevent transmission of HIV in the population. Public Policy Content and implementation of policies serve to promote or hinder ability to decrease HIV risk. Community Determines access to safe and competent prevention, treatment and care services. Can promote health and well-being, or reinforce stigma and discrimination. Social/Sexual Networks Group of people who are predisposed to risk based on sexual or parenteral exposures. Family and social networks can provide social support or reinforce protective social norms. Individual Biological or behavioural factors associated with acquisition or transmission tasks. Building on the knowledge from the BSS completed in 2011, this study focused on the community- and social/sexual network-level risks of HIV among KPs. This second phase of research was designed to evaluate the social- and community-level determinants of HIV through interviews with MSM and FSW populations, as well as evaluating health services and social meeting places frequently accessed by these groups. The study was designed to provide further information to characterize the HIV risks of MSM and FSW in Swaziland, and assess their access to and uptake of HIV health services. Engagement in the Continuum of HIV Care A growing body of evidence has demonstrated the importance of entry and retention in the continuum of HIV care, to improve the health outcomes of individuals living with HIV and prevent onward transmission among the population (10, 32). The continuum of HIV care (Figure 2) begins with detecting undiagnosed HIV, connecting those individuals living with HIV to ART, and achieving viral suppression through adherence to ART and retention in treatment. High levels of engagement in the continuum of HIV care at the population level, resulting in viral suppression among those living with HIV, have been shown to lower the community viral load decreasing the risk of HIV-related morbidity, as well as transmission and acquisition of HIV (11). Connection to and retention in the continuum of care is essential for KPs due to their increased risks of HIV infection (16). 9

12 Figure 2.Continuum of Care (after Gardner, 2011) It is critical for individuals to remain in care at each step of the continuum and each step represents a potential for loss to follow-up (33). Furthermore, specific barriers to engagement in the continuum of care exist among KPs. These barriers include stigma and discrimination, both perceived and experienced, at the health service level (34). For effective retention in the continuum, these individual and structural barriers must be addressed (10). This study aims to evaluate access to and uptake of services at each level of the continuum of HIV care through individual interviews with MSM and FSW and health service assessments. Service Delivery Models Engagement in the continuum of care can be influenced by the quality of provision of services and treatment experienced at health facilities. MSM and FSW communities may prefer to access certain health facilities due to various factors, including a welcoming and friendly reception by staff. Additionally, stigma, discrimination and inadequate confidentiality at health facilities and among healthcare providers can decrease care-seeking among KPs (35). To account for differing needs of KP in diverse contexts, three models of health service delivery have been proposed: fully integrated, standalone and hybrid (34). The fully integrated model for HIV services proposes that KP services are integrated into general HIV programmes without creating separate, targeted KP HIV programmes. This model can eliminate stigma toward the health facilities, but some KPs may be uncomfortable disclosing their identity and will not receive appropriate care. A stand-alone model provides services specifically and exclusively to KP at separate health facilities. A stand-alone clinic can deliver non-discriminatory services designed for MSM and FSW communities; however, in some environments stand-alone services could also be potential targets for antihomosexual or sex work campaigns at the structural or community level (34). Hybrid services combine targeted outreach and prevention messaging for MSM and FSW with trained KP providers at general population HIV services. This model attempts to incorporate the strengths from the integrated and stand-alone models to provide safe and de-stigmatized HIV services to KPs (34). Hybrid services require collaboration between community-based outreach and HIV service providers. The various proposed models of service delivery and coverage of HIV services for KPs have been evaluated 10

13 across settings using population size estimates of MSM and FSW as a denominator (13). It is important to evaluate these models of care to create contextspecific and effective KP services. This study aims to evaluate the health services accessed by MSM and FSW in Swaziland to determine appropriate models of care for these communities. Aim and Objectives The primary aim of the Characterizing the HIV Prevention and Treatment Needs among Key Populations in Swaziland study was to generate data for evidence-based programming, planning and delivery of cost-effective quality HIV prevention, care and support services for KPs in Swaziland. The objectives of the study are: 1. To estimate the population size of FSW and MSM in Swaziland. 2. To locate, characterize and assess venues and HIV prevention, testing, care and treatment services and programmes utilized by FSW and MSM in Swaziland. 3. To triangulate HIV data for effective HIV prevention, treatment and care services for FSW and MSM in Swaziland. Purpose Through venue and health service assessment and mapping and size estimation, this study intended to assist the Government of Swaziland to fill the gaps in HIV prevention programming for KP and HIV service uptake by KPs by providing a stronger evidence base from which informed HIV programming and policies for KPs can be developed and implemented. This study was led by a Task Force comprised of the Swaziland National AIDS Programme (SNAP) in the Ministry of Health, in collaboration with Health Communication Capacity Collaborative (HC3) Swaziland, and supported through community mobilisation by KP organisations and individuals. HC3 Swaziland is a four-year project funded by PEPFAR through the United States Agency for International Development (USAID) Swaziland. The project is led by Johns Hopkins Center for Communication Programs (CCP). Technical assistance for the study was provided by the Johns Hopkins University Department of Epidemiology and the Center for Public Health and Human Rights (CPHHR). 11

14 METHODS The Priority Locations for AIDS Control Efforts This study used a modified PLACE methodology (6), which is a location-based sampling method that uses the venues in which individuals are likely to meet new sexual partners to identify those individuals at a high risk of HIV infection. The PLACE method has also characterized individuals and venues of higher risk to determine priority areas for HIV prevention, treatment and care (7, 8). The PLACE method has been shown to reach individuals at a higher risk than other population survey methods. For example, a study in Zambia found that survey participants in the PLACE method reported higher levels of HIV sexual risk behaviours than individuals surveyed in a household survey (36). As the PLACE method provides a link to high risk individuals, it has also been used to sample high risk KP, such as MSM, FSW and people who inject drugs (13, 37). In this study, the PLACE method was used to characterize venues where MSM and FSW meet new potential sexual partners, recruit MSM and FSW into the quantitative survey, assess the health services accessed by MSM and FSW through quantitative surveys with health providers, and conduct size estimation of the MSM and FSW population. The modified PLACE method included the following types of data collection: Quantitative Venue and service identification with KIs Venue verification surveys Health service assessments MSM and FSW quantitative interviews MSM and FSW size estimation Qualitative MSM and FSW in-depth interviews MSM and FSW focus group discussions KI in-depth interviews Study Sites The study took place in five towns: Mbabane, Manzini, Piggs Peak, Lavumisa and Nhlangano. Due to movement of people among populated areas of Swaziland, the study sites included the surrounding geographic areas. The Mbabane study site also included the towns of Ngwenya and Ezulwini, and the Manzini site included the town of Matsapha. Therefore, the sample sizes, population size estimates and quantitative results are representative of the study sites and neighboring areas. For a complete list of areas included in each study site, see Appendix 1. The Task Force selected the sites based on the following factors: region, population size, presence of local partner organisations, existence of KP programming, health services, proximity to the border and other KP hot spots. Although site selection was conducted primarily through Task Force meetings, the KP Technical Working Group had the opportunity to provide input on what sites would be best for implementation. Inclusion Criteria and Ethical Considerations To be eligible to participate in the quantitative and qualitative components of the study, potential participants had to be at least 18 years old, be mentally sound and provide informed consent in SiSwati or English. FSW were eligible if they were assigned female sex at birth and reported having exchanged or sold sex for money, favors or goods in the last 12 months. MSM were eligible if they were assigned male sex at birth and reported to have engaged in anal sex with another man at least once in the past 12 months. KIs were eligible if they had knowledge of the MSM or FSW population through occupation or social interaction. This includes, but is not limited to individuals who serve FSW and MSM through HIV prevention programmes, work for organisations or businesses that affect FSW and MSM, such as sex work hotspots, or those who interact socially with FSW or MSM. 12

15 Participants gave written informed consent at the study sites and to maintain confidentiality. Due to the sensitive and criminalized status of MSM and FSW, written consent was provided using initials so that no names were collected as part of the study. Consent forms were also signed by the interviewer who obtained consent. No names were linked with quantitative questionnaire responses or qualitative data. If the participant traveled for the interview, upon completion of the quantitative questionnaire or qualitative interview each participant was given a 50 Emalangeni [approximately 5 U.S. dollars (USD)] reimbursement for transport and offered condoms and condom compatible lubricants. The study received ethical approval from the Science and Ethics Committee of Swaziland and the Johns Hopkins Bloomberg School of Public Health Institutional Review Board. Procedures were put in place to protect participants against risks. Questionnaires and in-depth interviews were conducted in a private setting. Psychological risks were minimized by providing research ethics training and sensitivity training for all staff on the specific needs of MSM and FSW. Additionally, a referral system for psychological care was also in place in cases of trauma exposure or other psychological needs. Confidentiality was maintained by using a unique study identifier rather than real names on questionnaires, audio files and other study documents, protecting all electronic data with passwords, and storing hard copies of data in locked cabinets. An adverse events reporting mechanism, in compliance with the Institutional Review Board and the Science and Ethics Committee was also in place. Quantitative Identification of FSW and MSM Venues and Services For venue identification, KIs with knowledge of FSW and MSM populations and services for these populations were surveyed. Local study staff conducted a single questionnaire with each KI to determine the location of venues and services for FSWs and MSM. Participants were asked to list all venues where MSM and FSWs socialize and meet new potential sexual partners. Venue Verification Survey and Mapping of Identified Sites Each venue identified by KIs was visited by the study staff and a questionnaire was administered to the venue manager or owner. The venue managers/ owners were asked about the type of venue, the patrons of the venue, MSM and FSWs at the venue, and HIV prevention available. The location of the venues was also collected for programmatic mapping purposes. Health Service Assessment and Mapping of Identified Sites Health services identified by KIs and MSM and FSWs participants were visited, and a questionnaire was administered to the health worker in charge. Participants were asked about the type of services, funding and management of services, the type of patients served, the staffing, and HIV prevention, testing, care and treatment services available. The location of the services was also collected for programmatic mapping purposes. Individual Quantitative Surveys with FSW and MSM FSWs and MSM participants completed interviewadministered face-to-face questionnaires in a private room. Topics included in the questionnaires were designed to explore the multiple dimensions of the MSEM theoretical framework described above and focus on social- and community-level factors. Participants were first asked about their sociodemographics, followed by questions related to stigma and human rights violations, behavioural HIV risk factors, mental health, social cohesion, health service access and population size estimation. Recruitment for the quantitative survey was also conducted through community led mobilisation. The community mobilizers were representatives of the local community-based organisations (CBOs) and MSM and FSW leaders. The community mobilizers led outreach and helped connect wider networks of MSM and FSW participants to the study. They also provided feedback from participants and ensured the participants felt safe and that their confidentiality was being protected. If any participants did not want to come to the study site due to concerns about disclosure as an MSM or FSW, community mobilizers organized an interview location with the participant. 13

16 Population Size Estimates This study estimated the number of MSM and FSWs in each of the study sites. Multiple population size estimation methods were implemented for both MSM and FSWs. The methods conducted for MSM and FSWs were wisdom of the masses, unique object method, service multiplier methods and network scale-up method. Wisdom of the Masses To calculate population size using wisdom of the masses method, MSM and FSW participants were asked in the questionnaire How many MSM/FSW would you guess live in this town? The resulting estimate is the median response to that question. The median was used to reduce the possibility of skewing from outlier responses. Wisdom of the masses estimates were excluded from the analysis when the resulting estimate was lower than the sample size reached in that town. Unique Object Method In each city, the study s community mobilizers distributed up to 400 unique objects per population approximately two weeks before the study start date. For the unique object method, a specially designed deck of cards was distributed to members of the MSM and FSW populations in the two weeks before the start of data collection. During the questionnaire that was administered in the quantitative part of the study, participants were asked if they had received the unique identifier cards, and, if so, where and from whom they received it. The estimation of population size using the unique object method is done by using the following formula: 1 p = * n m 1 ( n 2 ) Where p is the population estimate, n 1 is the number of objects distributed; n 2 is the total number of participants in the study and m is the number of participants who received the object. This method was excluded from the final analysis if more than 90 percent of the distributed objects were received by the study sample, as this violates the assumption of the method that the two samples should be independent. Service Multiplier Method The service multiplier method was implemented through the quantitative questionnaire, and using existing service and event records in the country. The proportion of participants who reported they were members of a local FSW or MSM service or reported attending a specific event was determined using a question in the individual quantitative survey. The method also required registration records from local FSW and MSM organisations and events to obtain the accurate number of individuals who were members of each service or attended each event. For the service multiplier methods, data were gathered from existing KP service organisations, PSI and Family Life Association of Swaziland (FLAS), about their service numbers in the month preceding data collection. In the questionnaire, each participant in the quantitative phase was asked: Did you participate in [specific MSM or FSW service] in September? The service multiplier population size estimates were calculated in the same way as with the unique object estimates, with the reception of the object being replaced by participation in the local service or organisation, or attendance at the social event. Service multiplier methods were excluded when assumptions of the method were violated or the service records were inaccurate. Network Scale-Up Method The Network Scale-Up Method (NSUM) is a population estimation method using each participant s individual social network to estimate the composition of the total population. The method uses the principle that individuals social networks are representative of the population they live in (38). In order to calculate the NSUM estimates, each participant is asked a series of questions to determine their active social network. The method used to determine social network in this case was the summation method, in which each participant is asked about how many people they know in various subgroups and their network is the total of all people they know (39). The summation questions were adapted from previous literature using UNAIDS guidelines (39) and pretested during a similar study in Cameroon. The questions were then adapted by the task force, community-based MSM and FSW organisations, and the data collectors. Participants were also asked how many people they know in 14

17 the target population to calculate the proportion of their social network that is made up by either MSM or FSW. MSM and FSW participants were asked about each member of the opposite KP they know to reduce the impact of barrier bias, in which individuals are more likely to know others like them (40). Additionally, we asked each of the KI and the venue owners/managers about the number of MSM and FSW they know. The final NSUM analysis was conducted excluding MSM participants from the MSM estimate and excluding FSW participants from the FSW estimate. Using all the responses, we calculated the proportion of the average Swazi s social network that was MSM or FSW. This proportion is then applied to the total general population to produce size estimates of the target group (41). The estimate is strengthened by a larger sample size of participants. The resulting formula used for the estimate is: ê = i m i.n i c i Where ê is the population size estimate, m is the number of people in the target population known by the participant, c is the estimated network size of each participant and N is the general population (38). Data Triangulation Existing published and unpublished data sources were used to assess population size by providing population census information for population adjustment and projection. Analysis Quantitative Quantitative analysis was conducted using Stata 13 and SPSS Quantitative data were tabulated by town creating descriptive statistics for each population in each study location. Population Size Estimates We conducted analysis of each method and obtained varying size estimates. We validated each method with the task team for inclusion in a final combined estimate. Unique object method exclusion criteria state that the method will be excluded if over 90 percent of the objects were received by the study sample. The special event multiplier method was excluded if the assumption that each sample must be independent was not met. We standardized the age ranges that are included in the estimate for each method by dividing each estimate by the population who match the sample by gender and age in each site. The denominator for the unique object and service multiplier methods was calculated using the age range of 90 percent of the MSM and FSW sample in each study site. The denominator for the NSUM method was calculated using reproductive age adults (15-49). The denominators were calculated using Swaziland population data from the 2007 census and Swaziland Population Projections. The geographic areas included in the denominator were determined by the task team and data collectors as the areas where the sample was recruited from in each site. Then we calculated the average proportion of the female population that is FSW. Assuming that the proportion of FSW is the same for women who are 15-49, we re-estimated the population size in this age group using the average proportion. The same procedure was used to estimate the MSM population. We included the population in our final estimate as this age range represents reproductive age adults and is programmatically relevant. The population size estimates, as all results presented in this document, are not only for the town limits, but inclusive of neighboring areas represented in the study sample. This is in recognition of the fact that the networks of MSM and FSWs are not limited to town limits and MSM and FSWs in surrounding areas also access services in these towns. There was insufficient information to estimate a 95 percent confidence interval (CI) around population size estimates for Lavumisa, Piggs Peak and Nhlangano because only two methods provided sufficient data for the calculation of the population sizes in those other areas. Qualitative Key Informant Interviews Semi-structured interviews were conducted with a variety of KIs who had in-depth knowledge regarding the FSW and MSM communities. These included individuals who serve FSWs or MSM through HIV prevention programmes, those who 15

18 work for other organisations or businesses that work with FSWs or MSM, such as bars or hotels, and those who interact socially with FSWs or MSM. KIs were identified through FSW and MSM community partner organisations. The team of investigators made contact with the identified KI and presented the purpose of the study to them. If KI were interested in participating in the study, the investigators set up an interview appointment. Semi-structured interviews were conducted at a location agreed upon by the interviewer and the interviewee, taking into account the privacy and security of both. Before the start of the interview, the interviewer explained the objectives of the study and obtained the participant s written informed consent. Each participant was interviewed once. All interviews were conducted in the language spoken by the participant (English or siswati) and lasted approximately one hour. Interview guides directed research question-inspired discussion and stimulated conversation. KIs were asked to describe the situation for the relevant KPs in their communities, their knowledge of existing HIV care services available, as well as services specifically targeting MSM and FSWs, and their views on how these services could be improved to better meet the needs of these populations. In-depth Interviews with Female Sex Workers and Men who Have Sex with Men In addition to KI interviews, MSM and FSWs were interviewed. These participants were recruited at the time they participated in the quantitative component of the study. Eligible individuals were invited to participate in a semi-structured interview at the study site. Before the start of the interview, the interviewer explained the objectives of the study and obtained written informed consent. Each participant was interviewed once, and no personally identifying information was stored with the audio file or transcript. All interviews were conducted in the language spoken by the participant (English or siswati) and lasted approximately 90 minutes. Interview guides directed the discussion and stimulated conversation on topics of interest. The guides covered the general experiences and practices of FSW and MSM, the organisation and networks of these populations, their knowledge and practices regarding HIV and STI prevention and treatment, their experiences with stigmatization and discrimination, and their experiences and interactions with HIV and reproductive health services. Focus Groups with Female Sex Workers and Men who have Sex with Men Focus groups were conducted separately with FSWs and MSM. These participants were identified in the same manner as the participants in the in-depth interviews. Eligible individuals were invited to participate in a focus group discussion at the study site. Each focus group had six to eight MSM or FSW participants. Before the start of the focus group, a staff member explained the objectives of the study and obtained written informed consent from each participant individually. Focus groups were conducted in the language spoken by the participants in that group (English or SiSwati) and lasted approximately 90 minutes. Discussion guides directed the focus group and stimulated conversation on topics of interest. The guides covered similar topics as the in-depth interview guides. Analysis With the consent of the participants, interviews and focus groups were audio recorded. SiSwati recordings were transcribed into siswati and then translated into English. Data categorization and coding for analysis was done by hand. Within each population, individual themes emerged from the transcription texts and were summarized into narrative text, as well as highlighted using exemplar quotes per theme. Data Collection Training of the field research team occurred from September 16-26, Data collection commenced in Mbabane and Manzini on September 29, 2014, and in Piggs Peak, Lavumisa and Nhlangano on November 24,

19 Data collection was conducted in the language of choice of the participant (English or siswati) and collected on paper forms and through audio recordings. Data collection was completed successfully on January 31, Table 1. Data Collection Activities by Study Site Venue and Service Identification Survey Venue and Service Characterization Survey Venue Verification Survey FSW Quantitative Survey Mbabane Manzini Lavumisa Piggs Peak Nhlangano TOTAL Service Assessment MSM Quantitative Survey KI In-Depth Interviews FSW In-Depth Interviews MSM In-Depth Interviews FSW Focus Group Discussions MSM Focus Group Discussion In total, 781 FSWs and 532 MSM were recruited for quantitative questionnaires. The team surveyed 56 venue managers/owners and 54 health service providers across the five sites. Twenty-five KI in-depth interviews were conducted, along with 86 in-depth interviews with FSWs and 61 in-depth interviews with MSM. In total, 18 focus group discussions were conducted with FSW and 10 were conducted with MSM. The majority of the data collection occurred in the Mbabane and Manzini study sites, together known as the corridor. Results are reported by site in all cases except for MSM in Lavumisa, due to the small sample size. Additionally, results are presented for the respondents who answered each question so differences in the denominator are created by missing data or refusal. 17

20 RESULTS Men who Have Sex with Men Population Size Estimation Definition of the population: The MSM population is defined by the eligibility criteria for this study: being assigned male sex at birth and having insertive and/ or receptive anal sex with another man in the last 12 months. Validation of methods: The methods included in the final MSM estimation after validation were unique object method, service multiplier using data from subsidized HIV services and the network scale-up method. The wisdom of the masses, the social event multiplier and service multiplier using the 2011 BSS study data were excluded from the analysis. Table 2. Men who Have Sex with Men Population Size Estimates in Swaziland* Proportion of the Population that is MSM Aged [95%CI] MSM Population Size Estimate Aged [95%CI] Mbabane/Manzini Corridor 1.92% [ ] 1,709 [1,245-2,173] Piggs Peak 1.95% 341 Nhlangano 2.53% 363 *Size estimates include the study site and surrounding areas Table 3. Male Population-based on 2014 Central Statistics Office Projections Males Aged Projected Corridor Population 89, Projected Piggs Peak Population 17, Projected Nhlangano Population 14,349 The population proportions found in the study areas can be used to estimate the MSM population in other similar urban areas. The proportions can be applied to the male population aged in a specific geographic area of interest to estimate the MSM population in that location. Socio-demographic Profile In total, 532 MSM were recruited to participate in the quantitative part of the study from the five selected study sites. The distribution per study site was as follows: Mbabane (N=229), Manzini (N=174), Nhlangano (N=70), Piggs Peak (N=54) and Lavumisa (N=5). Due to the small sample size in Lavumisa, data from Lavumisa are not reported separately, but participants are included in the total sample percentages. The majority of the MSM who participated in the survey were young men. Close to two-thirds of the participants in Nhlangano (64.3 percent), over half in Mbabane (53.5 percent), half in Manzini (50.0 percent) and 43.9 percent in Piggs Peak were below 24 years of age. The mean age of the participants was 25.4 years (SD 5.1), with Nhlangano having a lower mean age of 23.7 years and Piggs Peak having a higher mean age of 26.2 years. With regards to identified gender, the majority of the MSM identified themselves as males, with proportions that ranged from 75.6 percent in Nhlangano to 91.2 percent in Piggs Peak. More intersex MSM were found in Mbabane (12.0 percent) compared to the other sites that reported proportions less than 7.0 percent at each site. When asked about their sexual orientation, high proportions of the MSM in Mbabane (81.2 percent), 80 percent in Nhlangano, 62.8 percent in Manzini and 54.4 percent in Piggs Peak reported their sexual orientation as gay or homosexual. The highest 18

21 proportion of MSM who reported being bisexual were found in Piggs Peak (45.6 percent) and Manzini (33.7 percent) compared to the other cities. Education levels among the MSM were high across the study sites. The majority of MSM in Piggs Peak (66.7 percent), Nhlangano (60.0 percent) and Mbabane (52.2 percent) completed high school. In Manzini, 44.8 percent of MSM completed tertiary education. High unemployment rates were reported in all the study sites, with 59.3 percent of the MSM in Piggs Peak, 47.6 percent in Mbabane, 36.2 percent in Manzini and 35.7 percent in Nhlangano reporting being unemployed. Students consisted of 20.0 percent of the MSM in Nhlangano and 16.1 percent in Manzini. Prevalence of Human Rights Violations About 7.0 percent of the MSM reported that someone has ever forced them into sex. Forced sex was defined as being physically forced, or coerced to have sex, or penetrated with an object without their consent. Across the study sites, forced sex was higher in Mbabane and Piggs Peak, with proportions of 27.3 percent and 20.4 percent respectively. Similarly, reports of torture due to having sex with men were recorded with higher proportions in Mbabane (27.1 percent) and Piggs Peak (21.1 percent). Torture was left to be defined by the participant. Verbal harassment was reported by the majority of MSM in Manzini (53.9 percent), while this was reported by half of the MSM in Nhlangano and 42.7 percent in Mbabane. Also, high proportions of being afraid to walk in public because of sexual orientation were reported in Nhlangano (68.6 percent), Mbabane (41.8 percent) and Manzini (30.5 percent). Small proportions of MSM reported being blackmailed because they have sex with men, with proportions that ranged from 8.8 percent in Piggs Peak to 28.2 percent in Manzini. Community-level stigma toward MSM was also a theme found in the qualitative results. One MSM in Mbabane explained community attitudes in the next column: The community is against homosexuality and the situation is tough such that even if you have friends, once they know that you are gay they distance themselves from you. Others even claim that they don t want to be your victims, things like that you know. They don t even take a moment to try and understand what s happening in your life instead they just jump into calling you a Satanist and all sorts of names (MSM, Mbabane). Stigma and discrimination were also reported at the health service level. Over half (54.2 percent) of the MSM in Mbabane were afraid to access healthcare services, and a further 50.7 percent reported they deliberately avoided accessing healthcare services for fear that a healthcare worker might learn that they have sex with men. The same trend was reported in Manzini where 24.7 percent and 26.4 percent of the MSM expressed fear and deliberate avoidance respectively to accessing healthcare services. In Nhlangano close to a quarter (24.3 percent) of MSM reported ever feeling afraid and ever deliberately avoiding accessing healthcare services because of their sexual orientation. Being denied healthcare services as a result of having sex with men was reported by a minority of MSM across all sites. In the overall sample, this was reported by 8.7 percent of the MSM, with higher proportions reported in Mbabane (15.1 percent) compared to the other sites. Close to a third (32.6 percent) of MSM in the overall sample experienced some form of discriminatory comments from family as a result of being MSM, with highest proportions reported in Manzini (41.4 percent) and lowest in Piggs Peak (5.6 percent). Additionally, close to a quarter (22.1 percent) of MSM reported being rejected by their friends, proportions that ranged from 1.9 percent in Piggs Peak to 26.4 percent in Manzini. Fear of getting in trouble with the police resulted in close to 70.0 percent of MSM in Nhlangano reporting that they were scared to walk in public places. In the qualitative interviews, MSM also reported limited access to health programmes and services for MSM. Below an MSM participant from Mbabane describes the limited access to MSM-specific nongovernmental organisations (NGOs) due to the official standing of the organisations (on the next page): 19

22 Those that I know are those from NGOs like FLAS, New Start for now are the two ok and the very same one HC3 well there are also other MSM organisations but I don t know them because I am not even involved with them because there is no even that law that permit them to operate officially they are still underground most of them (MSM, Mbabane). In the overall sample, 14.7 percent of the MSM stated that they have ever felt that they were denied police protection a result of having sex with men. This was reported more in Mbabane (19.4 percent) and Manzini (16.8 percent) compared to the other sites. Similarly being arrested as a result of having sex with men was reported by a few (7.8 percent) of the MSM across all the sites. In Mbabane, 14.7 percent of the MSM and 4.0 percent in Manzini reported ever having been arrested due to having sex with men. Sexual Behaviours, Condom Use and Negotiation The mean age at first anal sex with another man was similar across the study sites with the lowest mean age found in Mbabane at 18.0 and the highest mean age reported in Piggs Peak and Manzini at MSM participating in the survey were asked about their sexual behavior including condom use. In the 12 months preceding the survey, 66.8 percent of MSM reported always using a condom during insertive anal sex with a man and 64.0 percent of MSM reported always using a condom during receptive anal sex with a man. The greatest proportion of MSM who reported never using a condom during anal sex with a man was reported in regards to receptive anal sex in Mbabane, 7.4 percent. The majority of MSM reported that they had very easy access to condoms, ranging from 100 percent of MSM in Piggs Peak to 75.6 percent in Mbabane. A large proportion of MSM reported that they never use lubricants during sex with 41.5 percent of the total sample reporting no lubricant use, and up to 59.6 percent of the sample reporting no lubricant use in Piggs Peak. Additionally, 60.4 percent of those who reported lubricant use indicated that it was somewhat or very difficult to access lubricants. HIV and STI Outcomes High rates of HIV testing were reported in the entire sample. The majority of MSM reported they had ever been tested for HIV, with highest proportion reported in Manzini (86.5 percent) and lowest in Mbabane (68.9 percent). HIV testing within the three months prior to the study was reported by less than half of the MSM in all the study sites, ranging from 33.1 percent in Mbabane to 49.3 percent in Manzini. In Mbabane 35.8 percent of the MSM reporting HIV test haven t had a repeated test in the 12 months preceding the study. All MSM who had been tested for HIV in Piggs Peak and Nhlangano reported that they received their test results, while 11 MSM in Mbabane and three in Manzini did not. The highest prevalence of self-reported HIV was found in Manzini with 7.6 percent of MSM reporting a diagnosis of HIV. The proportion of self-reported HIV diagnosis in the other sites ranged from 1.9 percent in Piggs Peak to 4.2 percent in Mbabane. The majority of MSM across all sites reported that they had not been tested for other STIs in the 12 months that preceded the study. The highest proportion was found in Nhlangano (81.4 percent) and lowest in Manzini (54.9 percent). Symptoms of STIs were reported by 16.9 percent in Manzini and Mbabane, 10.7 percent in Piggs Peak and 5.7 percent in Nhlangano. Knowledge of HIV Risks and Exposure to Prevention Efforts Knowledge that sharing a needle to inject drugs can transmit HIV was reported by a vast majority of MSM in all the sites, but levels of knowledge about the higher HIV transmission risk that anal sex carries was lower in each location. The proportions of MSM that did not know that anal sex carries higher HIV transmission risk were 77.2 percent in Piggs Peak, 66.8 percent in Mbabane, 62.8 percent in Nhlangano and 59.5 percent in Manzini. Similarly, higher proportions of MSM in all the sites did not know that receptive anal sex is riskier than insertive anal sex, with highest proportion reported in Piggs Peak (86.0 percent). Proportions in the other sites ranged from 62.2 percent in Mbabane to 69.9 percent in Manzini. 20

23 The majority of MSM in Manzini (69.4 percent), Nhlangano (57.4 percent) and Mbabane (56.1 percent) identified water-based lubricants as the safest to use when having anal sex with condoms. In Piggs Peak, fewer MSM (33.3 percent) reported having this type of knowledge. The proportion of MSM who reported receiving HIV prevention information about transmission risks between a man and a woman in the past 12 months (89.5 percent) was higher than the proportion who reported receiving HIV prevention information about transmission risks of sex between men in the past 12 months (75.0 percent). The largest gap in specialized prevention information was found in Nhlangano with 97.1 percent of MSM receiving prevention information about transmission risks between a man and a woman, and 64.3 percent receiving prevention information about transmission risk between two men. The most common place for MSM to report receiving HIV prevention information was at health facilities (40.2 percent), followed by NGOs (15.9 percent). Female Sex Workers Population Size Estimation Definition of the population: The FSW population is defined by the eligibility criteria for this study: being assigned female sex at birth and exchanging or selling sex for money, favors or goods in the last 12 months. Validation of methods: The methods included in the final FSW estimation after validation were unique object method, service multiplier using data from FLAS and the NSUM. The wisdom of the masses, service multiplier based on HIV service coupons and service multiplier using the 2011 BSS study data were excluded from the analysis. Table 4. Female Sex Work Population Size Estimates in Swaziland* Proportion of the population that is FSW Aged [95%CI] FSW Population Size Estimate Aged [95%CI] Mbabane/Manzini Corridor 2.38% [ ] 2,562 [731-4,393] Lavumisa 6.52% 186 Piggs Peak 3.89% 796 Nhlangano 2.68% 498 *Size estimates include the study site and surrounding areas Table 5. Female Population-based 2014 Central Statistics Office Projections Males Aged Projected Corridor Population 107, Projected Lavumisa Population 2, Projected Piggs Peak Population 20, Projected Nhlangano Population 18,584 The population proportions found in the study areas can be used to estimate the FSW population in other similar urban areas. The proportions can be applied to the female population aged in a specific geographic area of interest to estimate the FSW population in that location. Socio-demographic Profile The study recruited a total of 781 FSW from the five study sites, distributed as follows: Mbabane (N=262), Manzini (N=250), Piggs Peak (N=127), Lavumisa (N=95) and Nhlangano (N=47). 21

24 The ages of the FSW sampled ranged from with an overall mean age of 27.5 (SD 5.5). The highest mean age was recorded in Manzini (28.2) and the lowest in Nhlangano (24.1). In Lavumisa, Manzini and Mbabane the highest proportions of FSW were in the age range 25-29, which were 38.9 percent, 37.6 percent and 34.4 percent, respectively. In Nhlangano and Piggs Peak, the highest proportions of FSW were observed in the age bracket recorded as 48.9 percent and 40.2 percent, respectively. Older women of 30 years and above comprised 36.0 percent of the FSW recruited in Manzini, 35.8 percent in Lavumisa and 30.5 percent in Mbabane, while young women less than 20 years formed 2.8 percent of the participating FSW in the overall sample. Regarding education levels among FSWs, the highest proportion (36.9 percent) had completed secondary school, followed by those who completed high school (32.4 percent). By study site, Lavumisa (9.6 percent) recorded a higher proportion of FSW who had not attended any school, while Mbabane (39.0 percent) and Piggs Peak (37.8 percent) had higher proportions of FSW who completed high school education. The majority of the FSWs were unemployed outside of sex work in the formal sector across all sites, with higher proportions observed in Piggs Peak (86.5 percent) and Lavumisa (85.1 percent) and a lower proportion observed in Manzini (48.2 percent). Prevalence of Human Rights Violations Human rights violations were assessed by questioning the respondents about the presence of sexual, physical, verbal and emotional abuse resulting from selling sex. Being forced to have sex was reported by 34.7 percent of FSWs in Mbabane and 30.0 percent in Manzini. The lowest proportion (14.9 percent) was reported in Nhlangano. Physical aggression, which included being pushed, hit or kicked, was reported more in Mbabane (42.9 percent) and Piggs Peak (33.1 percent) compared to the other sites. The other sites reported proportions lower than one-third. Similarly, the occurrence of torture followed the same trend as physical aggression where greater proportions of FSW reported ever been tortured in Mbabane (43.6 percent) and Piggs Peak (35.7 percent). The other sites reported proportions ranging from 4.3 percent in Nhlangano to 25.0 percent in Manzini. Verbal harassment appeared to be the most prevalent type of discrimination among FSW. In the overall sample, close to half (45.6 percent) of the FSW participating in the study reported ever been verbally harassed because they sell sex. Verbal harassment was reported by the majority of FSW in Mbabane (58.5 percent), Lavumisa (57.5 percent) and Nhlangano (51.1 percent). The proportion that reported blackmail from any source ranged from 11.0 percent in Piggs Peak to 30.7 percent in Mbabane. Discriminatory comments from family as a result of selling sex were reported by 27.4 percent of the sample. More discriminatory comments were reported in Mbabane (40.8 percent) compared to the other sites. Similarly, more FSWs in Mbabane (26.3 percent) than in the other sites reported rejection from friends as a result of selling sex. Avoiding carrying condoms due to fear of getting in trouble with the police was reported by in 37.5 percent of FSW in Mbabane and 25.2 percent in Manzini. With regards to accessing healthcare services, less than a quarter of the FSW (23.7 percent) across all the study sites reported having ever been afraid to go to a healthcare facility. Site disaggregation of data shows that Mbabane had the highest proportion of FSW who were afraid to go to a healthcare facility, reported by 43.9 percent. The other sites reported lower proportions ranging from 6.4 percent in Nhlangano to 16.5 percent in Piggs Peak. Similarly, avoiding going to a healthcare facility for fear that someone would learn that they sell sex was reported by higher proportions of FSW in Mbabane (38.5 percent). Denial of health services by a healthcare provider because of sex work was reported by 6.0 percent of the study population. Similarly, having not been treated well by a healthcare provider was reported by 9.6 percent of the FSW, with a higher proportion, of 16.8 percent, reported in Mbabane. However, 86.5 percent of FSW reported that no healthcare provider ever learned that they sell sex, ranging from 89.4 percent in Nhlangano to 84.2 percent in Mbabane, so the levels of stigma in a 22

25 healthcare setting may be influenced by a lack of disclosure to providers since only 13.5 percent of FSWs reported that health care providers knew that they were FSWs. One FSW in Manzini reported that sex workers would access health services more often if they had their own clinic: I wish we could just have our own clinic where we will be able to access all the health services and the clinic should be specifically for sex workers (FSW, Manzini). The greatest proportion of FSWs who reported that at some point, they felt they were denied police protection as a result of selling sex was found in Mbabane, reported by 48.3 percent of the participants. Few FSW reported denial of police protection in the other sites with 37.6 percent in Manzini, 11.6 percent in Lavumisa, 6.3 percent in Piggs Peak and 4.3 percent in Nhlangano. Having ever been arrested because of selling sex was reported by 6.4 percent in the overall sample. The highest proportions of arrests were reported in Manzini (14.4 percent) and Mbabane (13.0 percent). Examples of police refusing protection was also a theme reported by FSWs in the qualitative results: There is none [police protection] unless you go to the clinic but even before you get there you should be prepared to be mocked and laughed at by police officers they ll saying things like a prostitute can never be raped because she is always in a state of being raped? (FSW, Manzini). Sexual Behaviours, Condom Use and Negotiation The mean age FSWs reported exchanging sex for money the first time was similar across all study sites, a range of 20 to 21 years. The minimum age (11) was recorded in Piggs Peak. The predominant reason cited for starting selling sex was to feed oneself and/or family. This was reported more in Nhlangano (93.6 percent), followed by Mbabane (86.6 percent) and Piggs Peak (83.5 percent). The study found that FSWs have sex with their clients in several different places. Homes of clients and FSWs were the main place where sexual activities were reported, with over 90.0 percent of FSW reporting home-based sex work in Piggs Peak, Nhlangano and Mbabane. Hotels and guesthouses as a location for sex work were also reported in the study, with the highest prevalence in Lavumisa (84.2 percent), Mbabane (81.2 percent), Nhlangano (74.5 percent) and Manzini (69.9 percent). Sexual activities in bars or clubs were reported more in Lavumisa (63.2 percent) and Mbabane (60.2 percent), while streets or forests were reported more in Lavumisa (60.0 percent). FSW in a focus group discussion in Mbabane identified different categories of sex workers: P1: There are the roadside parking sex workers P2: There are those sex workers who operates in bars P3: There are those who operate from their houses who are called when their services are required (FSW, Mbabane). FSWs participating in the survey were asked about their sexual behaviour including condom use during their last sexual encounter. Generally, condom use was higher with new clients (88.4 percent) and regular paying clients (85.3 percent) compared with nonpaying partners (80.1 percent). In Manzini, Mbabane, Nhlangano and Piggs Peak, nine out of every 10 FSWs reported using a condom during their last vaginal sex with a new client. Lavumisa recorded the lowest condom use with a new client, at 54.9 percent. With regards to regular paying clients, a similar trend was observed where over 85.0 percent of FSWs overall reported condom use during their last vaginal sex. Condom use with a regular paying client was 47.9 percent in Lavumisa. Relatively lower proportions of those using condoms with non-paying partners were reported, ranging from 64.7 percent in Nhlangano to 89.6 percent in Piggs Peak. The majority of FSWs reported that they had never used lubricants during sex; Nhlangano (97.8 percent), Lavumisa (94.7 percent) and more than 70.0 percent in each of the other sites. Additionally, half of those who reported lubricant use indicated that it was somewhat or very difficult to access lubricants. 23

26 Knowledge of HIV Risks The majority of FSWs (95.0 percent) accurately indicated that one can get HIV from using a needle to inject a drug or substance after someone else has used the needle. Nearly half of the FSWs (47.9 percent) did not know the safest lubricant to use during vaginal sex with a condom. Out of 154 FSWs who correctly identified water-based lubricant as the safest lubricant to use, a greater proportion (27.1 percent) was recorded in Manzini followed by Mbabane (21.8 percent) and Piggs Peak (19.7 percent). Additionally, there were 7.2 percent participants who correctly identified anal sex as the highest risk for HIV acquisition. By study site, FSW from Lavumisa (38.9 percent) and Nhlangano (29.8 percent) recorded higher knowledge levels, while the other three sites had similar knowledge levels ranging from 24.4 percent in Nhlangano to 26.1 percent in Mbabane. Overall, the proportion of FSWs who reported receiving HIV prevention information in the past 12 months was 86.2 percent. This proportion varied by site, with the largest proportion of FSWs receiving HIV prevention information in Nhlangano (93.6 percent) to the smallest proportion (59.6 percent) in Lavumisa. The most common place for FSW to report receiving HIV prevention information was at health facilities (62.6 percent), followed by NGOs (12.5 percent). HIV, STI and Reproductive Health Outcomes Prevalence of HIV testing was high in all sites. Nearly all FSWs in Manzini (96.0 percent) reported they have ever had an HIV test. The percentages in the other four sites ranged between 81.5 percent in Mbabane and 89.4 percent in Nhlangano. However only 19.6 percent of the FSWs had the HIV test in the three months that preceded the study, with higher proportions reported in Mbabane (25.6 percent) and Manzini (23.4 percent), and lowest in Lavumisa (7.8 percent). Further, 29.2 percent of FSWs that had an HIV test did not have a repeat HIV test in the 12 months preceding the study, with Lavumisa reporting higher proportions (48.1 percent) than the other sites. Self-reported HIV positive diagnosis was high across all sites with the highest proportion reported in Lavumisa (67.1 percent) and lowest in Nhlangano (26.1 percent). The other sites reported prevalence between percent. Close to half (48.4 percent) of the FSWs in the entire sample stated that they were tested for STIs at least once in the 12 months prior to the study. More FSWs in Lavumisa (63.2 percent) and Manzini (58.5 percent) were tested than in the other sites. Symptoms of an STI in the past 12 months were reported more also in Lavumisa (37.2 percent) and Manzini (26.6 percent). The majority of FSWs reported giving birth to at least one child (64.7 percent), with the average number of births among the FSW sample at 1.3. High prevalence of unwanted or unplanned pregnancies was also recorded in the survey. Unwanted or unplanned pregnancies were reported by 71.4 percent of FSW in Mbabane, 62.1 percent in Manzini, 51.9 percent in Nhlangano, 46.4 percent in Piggs Peak and 41.5 percent in Lavumisa. However, close to all FSWs indicated it was important for them to avoid getting pregnant, with the highest proportion reported in Nhlangano (97.6 percent) and lowest in Manzini (85.2 percent). Health Service Assessment Health service assessments were conducted at each of the facilities cited by MSM and FSW participants as a location that provides HIV and AIDS treatment or prevention services. One health service worker was interviewed at each of the health facilities assessed. In total, 54 health facilities were assessed across the five study sites. More health facilities were identified in Mbabane (17) and Manzini (16), compared to Lavumisa (7), Nhlangano (8) and Piggs Peak (6). Due to the smaller number of identified health facilities in several sites, the health service results are aggregated across the study sites. More than two-thirds (69.6 percent) of the assessed facilities reported serving both MSM and FSW. Over a quarter (26.1 percent) reported serving FSW only, while two health facilities reported having served MSM but not FSW. More than half (59.3 percent) of the 54 facilities mentioned were government 24

27 public health facilities, while privately owned health facilities comprised 13.0 percent of the facilities. Nongovernmental and other types of facilities comprised 27.9 percent of the assessed health facilities. The majority (57.4 percent) of the facilities were primarily funded by the government of Swaziland, followed by those that were privately funded (18.5 percent). Over one-third (37.3 percent) of the facilities reported receiving funding from PEPFAR. With regards to numbers of paid staff at the facilities, there were on average 1.63 doctors, 7.77 nurses, 3.28 counsellors and 5.73 peer educators or social workers. The facilities reported that 40.8 percent of their workers who work with MSM and FSWs have never received any special training for working with MSM and FSWs. Only 14.3 percent of the facilities reported that almost all or all of their workers were trained in MSM or FSW care. Slightly over half (51.9 percent) of the facilities reported having outreach services. In terms of services offered at the facilities in the four weeks preceding the study, a large proportion (92.6 percent) of the facilities offered HIV testing and counselling. A much lower proportion (38.9 percent) reported that they provided HIV testing and counselling with an MSM or FSW specialist. Similarly, 70.4 percent of the facilities reported providing ART medication for people living with HIV in the past four weeks, but ART provision for MSM or FSWs was only reported in 22 of the 54 facilities assessed (41.5 percent). Over three-fourths (75.9 percent) of the facilities offered general health services. Customized general health services for MSM or FSWs were offered by 35.2 percent of the facilities. Availability of free male and free female condoms as reported by the interviewed health worker was high, with 92.6 percent and 87.0 percent respectively. Availability of free condom compatible lubricants were, however, reported by 31.5 percent of the facilities. Regarding the type of clients who access services at the facilities, over two-thirds (69.2 percent) of the facilities reported that less than half or none of their clients were FSW. Only 26.9 percent of the facilities reported that more than half of their clients were FSW. Close to nine facilities out of every 10 assessed (89.7 percent) reported that less than half or none of their clients were MSM, while only 10.3 percent reported that more than half of their clients were MSM. Over half (58.3 percent) of the health facilities reported that less than half or none of their clients were clients of sex workers, while a third reported that more than half of their clients were clients of sex workers. These data are limited to the knowledge of the health worker interviewed at each location and may be influenced by non-disclosure of MSM and FSW patients. The majority of the clients were reported to come from the same town where the facility was located, according to 72.2 percent of the facilities. A few facilities (18.5 percent) reported clients who came from elsewhere, but still within the region. The majority (80.0 percent) of the facilities who refer individuals who test positive for HIV to other health facilities for treatment reported that they use the government referral system. Additionally, 79.2 percent reported that they follow up with the referred patients to ensure they receive the care recommended by the referral. Regarding the user fees, over two-thirds (66.7 percent) of the facilities reported having user fees in place for at least one health service. The majority (63.9 percent) cited consultation fees, followed by medication charges (58.8 percent). Other costs included registration and laboratory, cited by 30.3 percent and 26.7 percent respectively. Over half (53.1 percent) of the facilities that have some user fees reported that they do have some discounts or exemptions from fees for some clients. Venue Verification Results A total of 56 venues were assessed across the study sites. These were venues mentioned by MSM or FSW during the quantitative questionnaires, as well as by KIs as places where FSWs and MSM frequent. At each venue, the venue owner or manager was interviewed using a structured questionnaire. By study site, 22 venues were in Mbabane, 20 in Manzini, seven in Nhlangano, four in Piggs Peak and one in Lavumisa. The venues included bars or clubs (91.1 percent, n=51), hotels or guesthouses (7.1 percent, n=4), and a brothel (1.8 percent, n=1). More than half (59.6 percent) of the venues were frequented by 25

28 both MSM and FSWs, while about 40.0 percent were exclusive to FSWs. Only one venue was exclusive to MSM. The venues reported that most of the people who come to socialize were from the same town where the venue was located (71.4 percent). Close to a quarter (23.2 percent) of the venues reported being patronised by clients from other regions within Swaziland and two of the venues (3.6 percent) reported serving individuals from outside the country. Forty-three venues out of 53 (81.1 percent) reported that they did not have someone within the site facilitating sexual exchanges. Despite this, the study found that FSWs solicit clients in only 78.0 percent of the assessed venues. Thirty-eight of the 56 venue owners responded to the question whether FSWs have sex with clients at the venue, and out of these, 52.6 percent reported that FSWs have sex with clients at the venue. Venues where MSM socialize reported 56.3 percent of MSM meeting new male sexual partners at the venue. Fewer venues reported that MSM have sex with male partners at the venue (15.4 percent) than among FSWs. Due to the sensitive nature of MSM and FSW populations, mapping data of venues and health services is not presented in this report to protect the safety of clients and staff of these locations. The mapping data will be used for programmatic planning and policy development by the Ministry of Health. 26

29 DISCUSSION In recent years, engagement in the continuum of HIV care, from diagnosing unknown HIV infections to sustained viral suppression, has been demonstrated to improve health outcomes for individuals living with HIV, as well as decrease transmission of HIV within the population (Figure 3) (9-12). Community viral suppression can be achieved through early diagnosis of HIV, adequate linkage to clinical care services, access to and uptake of antiretroviral medication, and adherence support for ART regimes (42). The impact of continued engagement in the continuum of care on HIV transmission in a population has been shown in low prevalence settings, such as the United States (33), as well as high prevalence settings, such as South Africa, where Tanser et al found that an individual who is not living with HIV was 38 percent less likely to become infected with HIV in a community with high ART coverage compared to a community with low ART coverage (11). Ensuring effective and continued engagement in the continuum of HIV care is essential for key populations, given their increased burden of disease and risk of HIV infection. Figure 3. Implementation Cascade for the Continuum of HIV Care. Image courtesy of Moupali Das, MD, MPH HIV Testing and Diagnosis A systematic review evaluating losses in the continuum of care in Sub-Saharan Africa determined that unknown HIV infection was one of the greatest gaps in engagement (43). This study identified that self-reported HIV prevalence was lower than seroprevalence of HIV among MSM and FSWs in the 2011 BSS in each of the study sites. Among MSM, self-reported prevalence ranged from 1.9 percent in Nhlangano to 7.6 percent in Manzini while seroprevalence among MSM from the BSS was 17.1 percent. Similarly, among FSWs, the selfreported prevalence was 37.8 percent, whereas the seroprevalence among FSWs from the BSS was 69.7 percent. These lower levels in reported HIV may be also influenced by non-disclosure, but it is likely that many of these individuals are unaware of their HIV status, especially given the rates of HIV testing in some of the sites. For example, 18.5 percent of FSWs sampled in the Mbabane area reported that they have never been tested for HIV and overall, 12.5 percent of FSWs in Swaziland reported never being tested for HIV. These numbers are even higher among MSM with 23.8 percent of the total sample never receiving an HIV test. Additionally, among FSWs, only 60.9 percent of the sample reported testing more than one time and given the high risk sex and inconsistent condom use among KPs, there 27