# Implementing PrEP among Female Sex Workers in Côte d'Ivoire: new challenges for models of care (PrEP-CI ANRS 12361)

Valentine Becquet, Jean-Marie Masumbuko, Marcellin N Nouaman, Mélanie

Plazy, Christine Danel, Serge Eholié, Joseph Larmarange

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► To cite this version:

Valentine Becquet, Jean-Marie Masumbuko, Marcellin N Nouaman, Mélanie Plazy, Christine Danel, et al. Implementing PrEP among Female Sex Workers in Côte d'Ivoire: new challenges for models of care (PrEP-CI ANRS 12361). 28th International Population Conference, International Union for the Scientific Study of Population, Nov 2017, Cape Town, South Africa. ird-03911133

HAL Id: ird-03911133

https://ird.hal.science/ird-03911133

Submitted on 13 Jun 2023

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PRINCESSE

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PRep · INfections sexuellement transmissibles
Contraception · hEpatite b · Santé SExuelle

Implementing PrEP among
female sex workers in Côte d'Ivoire:
New challenges for models of care

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Valentine Becquet (Ceped/IRD), Jean-Marie Masumbuko (PAC-CI), Marcellin Nouaman (PAC-CI), Mélanie Plazy (ISPED/Inserm), Christine Danel (PAC-CI), Joseph Larmarange (Ceped/IRD)

International Population Conference, Cape Town, 2 November 2017
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WHEN TAKEN DAILY AS PRESCRIBED, PRE-EXPOSURE PROPHYLAXIS (PrEP) HAS BEEN SHOWN TO BE UP TO 96-99% EFFECTIVE IN PREVENTING HIV INFECTION.
» Since 2015, oral PrEP is recommended by WHO for populations at substantial risk

» However, WHO points out the need for additional research on PrEP in “real life”

> demand creation for oral PrEP

> best delivery models in different contexts / for different populations

> social and behavioural impact of PrEP

> integration of PrEP services with other services

» In Cote d'Ivoire, PrEP is not yet implemented and willingness of the national programme for operational research before scaling-up
» Main objective

› evaluate **relevance** and **feasibility** of implementing a PrEP among female sex workers (FSW) in Cote d'Ivoire

» In collaboration with 2 community-based NGOs

› Aprosam (San Pedro)

› Espace Confiance (Abidjan)

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APROSAM

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» Conducted activities (September 2016 – March 2017)

i. **Standardized questionnaires** among 1000 FSW, never tested or previously tested HIV-, reached on prostitution sites (median age: 25 years-old; mostly Ivorian: 69%)

ii. **Qualitative survey:** 66 FSW interviewed (22 in-depth interviews, 8 focus groups)

iii. **Workshop** with 6 community NGOs and national program
# FINDINGS

## 1. HIV exposure despite condoms

## High HIV exposure despite the use of condom

» **87%** use condoms regularly

» However, they have still some unprotected sexual intercourses
> **59%** had at least one condomless intercourse over the last week

» **23%** would accept condomless sex for a large sum on money

"Et quand regardes dans ta semaine, tu n'as même pas attrapé 2000 F.
Tu tournes dans ta pensée. Ah ! Moi franchement moi j'accepte !"

(focus group, Bardot slum, San Pedro)

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# FINDINGS

## 1. HIV exposure despite condoms

## High HIV exposure despite the use of condom

» **87%** use condoms regularly

» However, they have still some unprotected sexual intercourses

» **59%** had at least one condomless intercourse over the last week

» **23%** would accept condomless sex for a large sum on money

» **88%** do not use systematically condom with their regular partner, even when they perceive a risk

"L'amour est la seule arme où on dort avec son ennemi. (rires)
C'est-à-dire c'est ton ennemi proche, c'est lui qui peut te tuer
parce qu'il n'est pas avec toi seule. Mais tu dis, c'est mon titulaire."

"Or avec lui là, il te dit non, je suis fidèle à toi. Je veux qu'on sorte sans préservatif pour montrer une confiance. Donc moi je pense que la personne qui fait peur même, c'est ton petit ami. Ce n'est pas le client."

(focus group, Bardot slum, San Pedro)
FINDINGS

1. HIV exposure despite condoms

2. Unmet needs in sexual health

Beyond HIV, many unmet sexual and reproductive health needs

» **43%** had at least one unwanted pregnancy

» **64%** had at least one abortion in their life time
(Schwartz et al. 2015)

» Although most of them do no want a child...

"Mon risque principal c'est pour ne pas tomber enceinte, parce que je suis encore élève. Je vais prendre ventre, qui va s'occuper ?"
(interview, 18 years old, Abidjan)

» ... only **39%** use a contraception other than condom ...

"Elles m'ont parlé mais je leur ai dit non comme je n'ai pas encore fait d'enfant là. Pour ne pas que demain ça puisse me créer des problems."

» ... because they fear to get sterile
# FINDINGS

1. HIV exposure despite condoms

2. Unmet needs in sexual health

## Beyond HIV, many unmet sexual and reproductive health needs

» **36%** continue to work during menstruation

» Using ice or tissue to stop bleeding (informal interviews)

» Source of bacterial infections

» **65%** had an STI over the past 12 months

» FSWs are more preoccupied by STIs than HIV

> "Sinon nous là, à chaque fois, quand on va en brousse là, ce n'est pas que le sida seulement qui tue. Il y a plusieurs maladies."

> (focus group, Bardot slum, San Pedro)
FINDINGS

1. HIV exposure despite condoms

2. Unmet needs in sexual health

3. Chronic follow-up for HIV-

(re)thinking chronic follow-up of HIV-negative FSWs

» The implementation of a PrEP program requires to (re)define a chronic follow-up for HIV uninfected women

» Current policies focus on HIV-infected women and testing “new FSWs”, few activities targeting repeat-testing and regular screening of HIV-negative

» Despite the work of peer educators on prostitution sites, few FSWs visit dedicated community clinics

» Only 68% consulted a health practitioner over the past year

» Some FSWs reported inconvenient opening times and/or location, or fear of being identified as FSW in the clinic area

"Et puis moi maintenant, je ne suis pas trop en place. Je vais à la maison, je viens. Soit je ne suis pas là. Donc je n'ai pas trop le temps comme cela."

(interview, 28 years old, Abidjan)
FINDINGS

1. HIV exposure despite condoms

2. Unmet needs in sexual health

3. Chronic follow-up for HIV-

(re)thinking chronic follow-up of HIV-negative FSWs

» In case of condom breakage, FSWs usually fall back on self-medication

"Je m'en vais acheter coca avec Nescafé.
C'est pour nettoyer tout ce qui descends."

(interview, 17 years old, Abidjan)

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## FINDINGS

1. HIV exposure despite condoms

2. Unmet needs in sexual health

3. Chronic follow-up for HIV-

4. Integration with HIV care

## Services for HIV+ and HIV- should not be separated

» To minimize stigma related to entry into care, services for HIV-positive and services for HIV-negative should not be dissociated
(informal interview, peer educators and physicians)

» Integrating services together also constitutes an opportunity for cost sharing and savings

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FINDINGS

1. HIV exposure despite condoms

2. Unmet needs in sexual health

3. Chronic follow-up for HIV-

4. Integration with HIV care

5. Management of hepatitis B

PrEP programmes should consider Hepatitis B

» High prevalence of HBV in Cote d'Ivoire (around 10-15%)

» Tenofovir, used for HIV prevention, is also recommended for hepatitis B treatment

» For HBV mono-infection, treatment is not free (while covered by national programme if co-infection with HIV)

It would be ethically unsustainable to implement PrEP without management of hepatitis B

» Most PrEP trials excluded AgHBs+ individuals

» Almost no clinical research on interactions between HIV PrEP and HBV treatment
## CONCLUSION AND PERSPECTIVES

Implementing PrEP among FSWs requires
to develop of global care package in
**sexual and reproductive health**, including:

» HIV prevention and care

» STIs screening and treatment

» Contraception

» Menstrual management counselling

» HBV screening, vaccination and treatment

delivered through **community clinics** and
on site activities (**mobile clinics**)

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PRINCESSE

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PRep · INfections sexuellement transmissibles
Contraception · hEpatite b · Santé SExuelle
THANK YOU

Photos credits: PRINCESSE team

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Centre Population
et Développement

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APROSAM

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Institut de Recherche
pour le Développement
FRANCE

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HARVARD
UNIVERSITY