Systematic review of facility-based sexual and reproductive health services for female sex workers in Africa

For the review, a FSW was defined as women who exchanges sex for money or other gifts and commodities. We included any study in Africa (either in sub-Saharan Africa or any other part of the continent) that described facility-based SRH prevention and care services for FSWs. Studies of services solely for other groups at high-risk, such as female bar workers, were excluded, as were studies of services for clients or other partners of FSWs. The review does, however, include studies reporting on services provided for FSWs in addition to other groups, as well as services constructed either within general population services or as targeted stand-alone services only addressing the needs of sex workers and other at-risk populations. Both public- and private-sector services were included. The review aimed to be as inclusive as possible and thus encompassed projects established solely for FSW service provision and sites set up primarily for research purposes, but which nonetheless had extended clinical services to their participants. If non-clinical services were mentioned, data were extracted on these studies, provided they included at least some facility-based SRH services, such as condom provision. We excluded articles that only described population characteristics or needs of FSWs and did not describe interventions for this population. Studies in languages other than English were excluded, as were studies based solely on mathematical modelling of interventions.

A single reviewer extracted data from included articles using standardised tools. Variables extracted encompassed general characteristics of the services provided (year started, country, and part of city where services are provided) and service settings (facility and its setting, types of buildings, or use of mobile clinics). Service delivery models were classified as stand-alone services, or whether all or any components were integrated with general population services. Data were extracted on the clinical and social services provided in each project. Finally, we extracted – from the main article as well as its acknowledgments section and footnotes – any mention of support or involvement of government, organizations, or other donors in each project.Key themes across the studies are summed along with novel service delivery examples that illustrate exceptions to common themes. Analysis was mostly qualitative, though the proportions of projects with specific characteristics are also presented. Where possible, lessons are then drawn for future design of FSW interventions in these settings. Finally, we collated all information to form a conceptual framework depicting the interacting factors which likely determine the service delivery models and their coverage (Figure 1).

Of the 47 projects that document the year in which services began, 19 began in the period after 2000, while 15 began between 1990 and 1999, and 13 in the 1980s (Additional file 1: Table S1). We located services specifically for FSWs (either targeted services for sex workers and other at-risk groups, or those integrated within general services) in only 28 of the 58 countries located in Africa. Much of the data we identified reported on sites that provided services as part of research projects among this population, rather than on sites that focused exclusively on service delivery.

Services were commonly situated in sex work hot spots within national or regional capital cities of a country. Other settings included truck stops, borders, ports, and mining areas. Of note, two sites in Zimbabwe reported specifically providing rural-based services, either on farms or near mines [12, 13]. Of the 54 projects, 15 involved some form of outreach, either to streets, bars or other places of entertainment, and rarely to brothels [14]. Outreach was provided either through the use of mobile clinics, or through peer workers or counsellors. Visits to FSWs’ homes were also reported in Benin and Kenya [15, 16].

Most projects were localised and small-scale and were often confined to a single sex work hot spot; only about two thirds provided services at more than one point or city in a country, and few projects extended over large geographical areas and populations. On the whole, explicit networking or cross-learning between FSW projects was uncommon. A noteworthy exception was the establishment of services in Kisumu Kenya in 2006, which were modelled on the Abidjan Cote d’Ivoire project, operational since 1992 [17, 18]. In general, most services developed from the ground up and not as part of a national coordinated approach. In Kenya and Ghana, however, there were examples of services that began as single clinical sites and then expanded to other areas [19‐23].

We did, however, find some initiatives to provide regional coordination of projects. The West African Project to Combat AIDS and STIs provided preventive and curative care to FSWs and their clients in nine West African countries, with funding from the Canadian International Development Agency [24]. Coordination of services along several major transport routes was also noted [25‐29]. In the West Africa Highways Project, over 36 public, private and community health facilities were upgraded, equipped, and provided with an adequate supply of drugs in five countries. One national level project was also attempted in Malawi, but appears to have reached low coverage overall [19].

Most sites specifically targeted FSWs, but a few also offered services to key client groups such as truckers, miners and even military personnel. Services for client groups, however, were mostly provided through outreach, rather than by specialised clinics. Of note, two sites in Namibia and Kenya also offered services for other high-risk groups such as men who have sex with men (MSM) [30, 31]. Most FSW services along major highways were integrated with services for other high-risk groups.

Night-time or after-hours services were mentioned in only four reports. No clinic offered 24 hour services, but one clinic in Benin was open up to 01:00am [16]. Frequency of contact was variable, ranging from weekly to every four months, but most projects aimed to have contact with FSWs either monthly or two-monthly.

Overall, specialized facility-based services for FSWs were prominent, with few opting to integrate services within existing facilities. In a study of targeted services for FSWs and truck drivers in Tete, Mozambique, all the interviewed informants endorsed the notion of separate SRH clinics and the need to expand these services to other areas in the country. FSWs reported high satisfaction with the clinic, mentioning good reception by staff, prompt attendance, close proximity and free health services as measures of satisfaction. Women, however, wanted the range of services and opening times to be expanded [32].

Virtually all projects focused on HIV and STI interventions rather than on broader SRH services. Condoms were provided as part of almost all clinical services as well as within peer outreach or sex work settings (Additional 1: Table S2). In some instances bar owners assisted with condom distribution [33]. Provision of automated condom dispensers appeared rare. Free condom distribution was common, as was condom promotion and distribution within a social marketing or social campaign approach [28, 34‐40]. Female condoms were distributed by less than a tenth of all services. In Madagascar, staff advised FSWs to use female condoms only when male condoms could not be used [36]. One site in Zimbabwe provided instruction sheets on female condom use, and women practiced insertion in the presence of a trained project nurse [41]. Another site recruited FSWs to study the safety, acceptability and feasibility of female condom re-use and lubrication [42]. Overall, however, water-based lubricant, for use with either male or female condoms, was provided by only three projects [31, 39, 42, 43]. Condom promotion, often led by peer workers, included demonstrations and training on negotiation skills, as well as the correct storage, use, and disposal of condoms. While condom-use negotiation skills may have been a part of condom promotion activities, they were only explicitly mentioned in nine projects. Education on condom use was either clinic or community based. Notably, innovative approaches to education activities were employed by projects in Cote d’Ivoire and along the West African highways; these activities included promoting condom use through picture albums, videos, cue cards, drawings, billboards, radio, calendars, t-shirts, and commercials. Advertisements in these projects were localized to reduce project costs [24, 44]. In Malawi, nightclub disk jockeys promoted condom use and distributed safe sex messages [45]. Only a few sites encouraged an explicit, standardised “no condom no sex” approach [36, 46]. By contrast, a site in Pretoria, South Africa, used a personalised approach to assess each FSWs risks and goals for negotiating risk-reduction [47].

HIV testing and counselling (HCT) was common (35/54), including testing for HIV-2 in many West African sites. HCT was mostly done at clinical centres, but also through mobile clinics and peer outreach. Repeat HCT for HIV-negative women was less common and offered either monthly or 3-monthly, while a few sites tested 6 or 12 monthly. No site reported offering HCT to couples or partners. Provision of HIV care – CD4 cell count testing (7/54), cotrimoxazole prophylaxis (3/54), antiretroviral therapy (ART) (3/54), and prevention of mother-to-child transmission (PMTCT) (1/54) – was mentioned by few services, with the majority referring HIV-infected women to other centres for HIV care and treatment. In the West African Highways project, free ART was provided to over 500 people, but treatment was mainly offered to vehicle drivers who tested positive. A referral system was, however, established for those eligible for ART [24]. ART services in Burkina Faso did include adherence support and active tracing of women who defaulted follow-up [48]. In that country and in Kampala, Uganda, women received pre-ART counselling and, to reduce potential discrimination, a staff member would then physically accompany them to the local ART clinic [48, 49]. In Namibia, health workers underwent training and sensitization to reduce stigma and improve care and support for FSWs [37]. By contrast, concerns around confidentiality meant that some FSWs at a site in Rwanda elected to obtain ART at more distant sites. Oral pre-exposure prophylaxis against HIV was only offered in Kilifi, Kenya [31]. No site specifically mentioned providing post-exposure prophylaxis following either unprotected sex or sexual abuse. There was also no specific mention of care and treatment services for other HIV-related comorbidities such as tuberculosis.

Most STI interventions encompassed STI education, screening, and syndromic or aetiological management. History and pelvic examination – often with a speculum, and to a lesser extent, by colposcopy – was common, even for asymptomatic women. Screening tests often included visualization of the cervix; collection of vaginal and cervical samples; and other laboratory tests. Screening for syphilis, trichomoniasis (TV), gonorrhoea (NG) and chlamydial infection (CT) was common, though testing for candidiasis (CA) and bacterial vaginosis (BV) was less frequent. Testing for herpes simplex virus type 2 (HSV-2), M.genitalium and H.ducreyi was uncommon. At the Majengo clinic in Nairobi, expansion of existing infrastructure made polymerize chain reaction (PCR) testing for STIs possible [21]. Intervals between STI screening visits were mostly monthly or three monthly, and even weekly in one instance in Malawi [50]. Some sites in Madagascar offered different STI services at first visits compared to later visits, which were risk-score based [51, 52]. Similarly, women new to the clinic’s services initially had visits scheduled at closer intervals, but then over longer periods over time. A novel approach to providing STI care was offered in Malawi, where services were offered at places of entertainment [45]. Partner tracing and notification was rare and only mentioned by five sites. Peer-led education sessions on STIs, however, were common. Most sites reported using WHO or national STI screening and syndromic management algorithms. Use of risk assessments to guide STI treatment was used at two sites [28, 53]. Acyclovir treatment for HSV-2 may have been included in management guidelines, but was only specifically mentioned in a few instances. No services offered immunization or testing for hepatitis B. In contrast to frequent STI screening services, we located only 11 reports of periodic presumptive treatment (PPT), which consisted of azithromycin alone or in combination with ciprofloxacin, doxycycline, or metronidazole. Regimens aimed to cover CT and NG, though PPT for CA, TV and BV was also used. Treatment intervals varied, from single-dose therapy to once every one to three months.

In contrast to STI and HIV services, few sites reported providing general or primary health care services; even fewer offered broader SRH services. We located only six instances in which urine pregnancy testing was offered. Contraceptive services were similarly only available at seven sites: the East and Central African Highways project, Kenya, Madagascar, Malawi, Mozambique, South Africa, and Uganda. Few projects specifically promoted dual methods of contraception. Unlike at other sites, services in Madagascar covered a range of contraception methods, offering emergency contraception and the diaphragm [54]. The latter was also provided in a study in Mombasa, Kenya [55]. No programme mentioned termination of pregnancy services. Interestingly, a general care clinic in Uganda offered health services to children of FSWs [49]. Overall, access to cervical cancer screening and treatment (with cervical smear or colposcopy) was only reported in Senegal, South Africa, and Gambia [56‐58]. Two sites, in South Africa and in Kenya, tested for Human Papilloma Virus (HPV) subtypes [59, 60], but there were no instances in which services offered vaccination to prevent HPV.

Finally, few programmes provided structural interventions to address environmental sources of vulnerability and ill health. Gender-based violence services were only offered in Zambia and South Africa. In Zambia, legal protection was arranged through referrals from the local clinic, while FSWs were sent to government hospitals for violence-related health needs [61]. Only one project in Cape Town, South Africa, provided legal literacy for FSWs [62]. To reduce risk and achieve more independence, FSWs at another site in South Africa learnt violence prevention strategies and methods, such as developing concrete personal plans to reduce risk. In this programme, each woman’s drug and sexual risks were also assessed [47, 63]. No other sites were identified providing harm-reduction services for FSWs who inject drugs or consume alcohol. In Kenya, an income-generating project provided micro-enterprise services to FSWs [64], whereas a project in South Africa made an effort to improve literacy through educational programmes [56]. Another income-generating project that helped FSWs develop tailoring businesses was identified in Malawi, but reportedly only six FSWs were assisted [45].

We located no services for FSW that were fully government-funded; most were supported by a range of international donors. Although some involvement or approval from local authorities was reported by about a third of projects, direct government funding, or provision of FSW services within public-sector clinics, was largely absent.

Of 49 projects that documented either a funder or an organization responsible for the project, 31 (63%) had reported funding from at least one North American organization – Canada and/or United States of America (USA) - and 20 (41%) had at least one European donor. The President’s Emergency Plan for AIDS Relief (PEPFAR) or the United States Agency for International Development (13/49), as well as Family Health International (12/49), predominated among the USA funders, and many projects centred on research received funding from the USA Centre for Disease Control and Prevention (4/49) and the National Institutes of Health (4/49). European funders included the European Commission as well as individual European countries. Few private funding sources (commercial or donors) were acknowledged. We did, however, locate two instances of mining companies involved in sex work projects, both in Southern Africa [13, 65].

A sex worker clinic in Tete, Mozambique, reported novel arrangements between the government and external funders [32]. The government partly funded capital and operational costs, and provided health staff and medical supplies, while external funders contributed to other costs such as medical equipment and furniture, utilities, three security guards, over-time for nurses, training and educational materials, and peer educator costs.

User fees on the whole were uncommon. Some sites charged FSWs for commodities such as condoms or emergency contraception [22, 57, 66]. In some projects, only a pre-defined number of condoms were given to FSWs at no cost [16]. A site in Nigeria sold condoms at subsidized prices, while emphasising that they helped to save FSWs money on health services such as antibiotics for STI treatment. There were, however, two sites in Ghana and Guinea that employed a cost-recovery model for the management of health problems other than STIs [57]. In a few instances, the donor-funded model clearly limited sustainability, with interruptions in international funding leading to some services being discontinued. In projects in Ghana and Kenya, for example, condoms could no longer be provided for free, and other services such as STI diagnosis and treatment and HIV testing had ceased [67, 68]. FSWs in Madagascar were given sufficient condom supplies for only a few years of the project. For the years when funding was limited, women received some free condoms and were advised to purchase additional ones from either peer educators or social-marketing agents [69, 70].