A population-based survey pooled analysis of women engaged in commercial sex in the HIV care cascade in sub-Saharan Africa, 2015–2017

Abstract Introduction Women who engage in commercial sex (WCS) have a higher prevalence of HIV in sub-Saharan Africa than other women of reproductive age. We aimed to describe the burden of HIV, testing, treatment, and viral load suppression (VLS) coverage among WCS and the correlates of not being engaged in each step of the HIV cascade across six countries between 2015 and 2017. Methods Using pooled data from six Population-based HIV Impact Assessment (PHIA) surveys from Eswatini, Lesotho, Malawi, Tanzania, Zambia, and Zimbabwe, socio-demographic, behavioral, and health-related indicators were assessed by commercial sex engagement and steps in the HIV cascade, using prevalence ratios with 95% confidence intervals and statistical significance of p < 0.05. All analyses were weighted, and variance was estimated using Taylor series. Results Among women aged 18 and older, 3.3% reported selling sex ever or in the last 12 months. HIV prevalence among WCS was 18.3%. HIV status awareness was 65.9% and among those aware of their status, only 57.0% were on treatment. Only half (51.9%) were virally suppressed. Women unmarried and with no reported history of pregnancy who engaged in commercial sex were less likely to be engaged in the HIV care cascade. Discussion Overall, women engaged in commercial sex have higher rates of non-engagement at each step in the HIV care cascade and have a higher prevalence of HIV than women in the general population in the countries surveyed. More efforts to engage young, unmarried women engaged in commercial sex who have never had a pregnancy in HIV testing and treatment are needed.