Characterizing Multi-level Determinants of HIV Prevalence Among Female Sex Workers in Maseru and Maputsoe, Lesotho

Lesotho has a broadly generalized HIV epidemic with nearly one in three reproductive-aged women living with HIV. Given this context, there has been limited research on specific HIV risks. In response, this study aimed to characterize the burden of HIV and multi-level correlates of HIV infection amongst female sex workers (FSW) in Lesotho. Respondent driven sampling was used to recruit 744 FSW from February to September 2014 in Maseru and Maputsoe, Lesotho. Robust Poisson regression was used to model weighted prevalence ratios (PR) for HIV, leveraging a modified social ecological model. The HIV prevalence among participants was 71.9% (534/743), with a mean age of 26.8 (SD 7.2). Both individual and structural determinants involving stigma were significantly associated with HIV. Women with the highest enacted stigma score (≥ 5) had a 26% higher prevalence of HIV than individuals that did not experience any stigma (PR 1.26, 95% CI 1.01, 1.57). These data reinforce the extraordinarily high burden of HIV borne by FSW even in the context of the generalized HIV epidemic observed in Lesotho and across southern Africa. Moreover, stigma represents a structural determinant that is fundamental to an effective HIV response for FSW in Lesotho.