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Occupational barriers to accessing and adhering to antiretroviral therapy for female sex workers living with HIV in South Africa
  1. Lauren E Parmley1,2,
  2. Carly A Comins2,
  3. Katherine Young3,
  4. Mfezi Mcingana3,
  5. Deliwe Rene Phetlhu4,
  6. Vijay Guddera5,
  7. Happiness Mkhize5,
  8. Harry Hausler3,
  9. Stefan Baral2,
  10. Sheree Schwartz2
  1. 1 ICAP, Columbia University, New York City, New York, USA
  2. 2 Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
  3. 3 TB HIV Care, Cape Town, South Africa
  4. 4 School of Nursing, University of the Western Cape, Cape Town, South Africa
  5. 5 Key Populations Programme, TB HIV Care, Durban, South Africa
  1. Correspondence to Lauren E Parmley, Columbia University, New York, NY 10027-6902, USA; lp2786{at}


Objectives While female sex workers (FSW) are nearly 14 times more likely to be living with HIV than non-FSW, less than 40% of FSW living with HIV are on antiretroviral therapy (ART). We sought to understand how the work environment influences ART access and adherence for FSW in preparation for the Siyaphambili trial.

Methods FSW living with HIV (n=24) and key informants (n=15) were recruited to participate in semistructured in-depth interviews using maximum variation and snowball sampling, respectively. FSW were recruited on key variants including type of sex work venue, primary work time and history of ART use. Data were collected between September and November 2017 in Durban, South Africa. Interviews were audio-recorded, transcribed and translated. Data were then coded applying grounded theory in Atlas.ti.

Results FSW experienced occupational barriers to adherence including work-related migration, substance use and theft of ART on the job. Fear of wage loss due to HIV disclosure to clients and brothel managers prevented some FSW from accessing ART at their clinic and taking medications while working. FSW employed coping strategies to overcome barriers including sharing ART with colleagues, carrying small supplies of ART and visiting the clinic prior to appointments for ART refills. Further, some FSW received adherence support from colleagues who were also living with HIV.

Conclusions Considering these occupational pressures on FSW and supporting positive coping strategies are important when designing and implementing HIV treatment programmes. Findings suggest strengthening social cohesion and supporting differentiated care efforts to improve HIV outcomes among FSW living with HIV.

  • female sex workers
  • HIV
  • adherence
  • antiretroviral therapy
  • sex work

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  • Presented at Presented at the 22nd International AIDS Conference. 23-27 July 2018.

  • Contributors LEP, CAC, KY, DRP, VG, HH, SB, SS and MM designed the study. LEP, VG and HM supported data collection. LEP, CAC and HM conducted data analysis. LEP drafted the manuscript. All authors reviewed and approved the final manuscript.

  • Funding This research was supported by the National Institute of Nursing Research of the National Institutes of Health (NIH) under Award Number R01NR016650 as well as through support from the Johns Hopkins University Center for AIDS Research (CFAR) through the National Institutes of Health (award P30AI094189).

  • Disclaimer The contents expressed here are the sole responsibility of the authors and may not represent the views of the NIH and/or the CFAR.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available on reasonable request. Given that transcripts may have elements of personal identification and highly sensitive information given the criminalised nature of sex work in South Africa, requests for access to data should be sent for review to Dr Sheree Schwartz or Dr Stefan Baral

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