High Drop-off Along the HIV Care Continuum and ART Interruption Among Female Sex Workers in the Dominican Republic

Background: Engagement in HIV care offers clear individual and societal benefits, but little evidence exists on the care experiences of key populations. Methods: A cross-sectional survey was conducted with 268 female sex workers (FSWs) living with HIV in Santo Domingo, Dominican Republic, to describe the HIV care continuum and to determine factors associated with antiretroviral therapy (ART) interruption. Results: FSWs disengaged throughout the care continuum with the highest drop-off after ART initiation. Most participants were linked to care (92%), retained in care (85%), and initiated onto ART (78%), but ART discontinuation and irregular adherence were frequent. Only 48% of participants had an undetectable HIV viral load. Overall, 36% of participants ever initiated onto ART reported lifetime experience with ART interruption. The odds of ART interruption were 3.24 times higher among women who experienced FSW-related discrimination [95% confidence interval (CI): 1.28 to 8.20], 2.41 times higher among women who used any drug (95% CI: 1.09 to 5.34), and 2.35 times higher among women who worked in an FSW establishment (95% CI: 1.20 to 4.60). Internalized stigma related to FSW was associated with higher odds of interruption (adjusted odds ratio: 1.09; 95% CI: 1.02 to 1.16), and positive perceptions of HIV providers were protective (adjusted odds ratio: 0.91; 95% CI: 0.85 to 0.98). Conclusions: FSWs living with HIV confront multiple barriers throughout the HIV care continuum, many of which are related to the social context and stigmatization of sex work. Given the clear importance of maximizing the potential benefits of engagement in HIV care, there is an urgent need for interventions to support FSWs throughout the HIV care continuum.

[1]  David R. Holtgrave,et al.  Retention in HIV Care Among Female Sex Workers in the Dominican Republic: Implications for Research, Policy and Programming , 2015, AIDS and Behavior.

[2]  C. Beyrer,et al.  Enhancing Benefits or Increasing Harms: Community Responses for HIV Among Men Who Have Sex With Men, Transgender Women, Female Sex Workers, and People Who Inject Drugs , 2014, Journal of acquired immune deficiency syndromes.

[3]  M. Gill,et al.  The Cost of Antiretroviral Drug Resistance in HIV-Positive Patients , 2014, Antiviral therapy.

[4]  H. Raymond,et al.  HIV treatment cascade among transgender women in a San Francisco respondent driven sampling study , 2014, Sexually Transmitted Infections.

[5]  Brian C. Zanoni,et al.  The adolescent and young adult HIV cascade of care in the United States: exaggerated health disparities. , 2014, AIDS patient care and STDs.

[6]  D. Kerrigan,et al.  Abriendo Puertas: Baseline Findings from an Integrated Intervention to Promote Prevention, Treatment and Care among FSW Living with HIV in the Dominican Republic , 2014, PloS one.

[7]  Maria H. Kim,et al.  Linkage, initiation and retention of children in the antiretroviral therapy cascade: an overview , 2013, AIDS.

[8]  J. Hargreaves,et al.  Engagement with HIV Prevention Treatment and Care among Female Sex Workers in Zimbabwe: a Respondent Driven Sampling Survey , 2013, PloS one.

[9]  M. Mugavero,et al.  The state of engagement in HIV care in the United States: from cascade to continuum to control. , 2013, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[10]  J. Busza,et al.  “You are wasting our drugs”: health service barriers to HIV treatment for sex workers in Zimbabwe , 2013, BMC Public Health.

[11]  J. Baeten,et al.  HIV-1 prevention with ART and PrEP: mathematical modeling insights into resistance, effectiveness, and public health impact. , 2013, The Journal of infectious diseases.

[12]  G. Alvarez-Uria,et al.  Entry, Retention, and Virological Suppression in an HIV Cohort Study in India: Description of the Cascade of Care and Implications for Reducing HIV-Related Mortality in Low- and Middle-Income Countries , 2013, Interdisciplinary perspectives on infectious diseases.

[13]  Richard D Moore,et al.  Higher Quality Communication and Relationships Are Associated With Improved Patient Engagement in HIV Care , 2013, Journal of acquired immune deficiency syndromes.

[14]  J. Bowling,et al.  The Influence of Stigma and Discrimination on Female Sex Workers’ Access to HIV Services in St. Petersburg, Russia , 2013, AIDS and Behavior.

[15]  M. Chersich,et al.  ‘We are despised in the hospitals’: sex workers' experiences of accessing health care in four African countries , 2013, Culture, health & sexuality.

[16]  P. Kilmarx,et al.  Patching a leaky pipe: the cascade of HIV care , 2012, Current opinion in HIV and AIDS.

[17]  Bereket Yakob,et al.  Barriers to Retention in Care as Perceived by Persons Living with HIV in Rural Ethiopia , 2012, Journal of the International Association of Providers of AIDS Care.

[18]  C. Beyrer,et al.  Burden of HIV among female sex workers in low-income and middle-income countries: a systematic review and meta-analysis. , 2012, The Lancet. Infectious diseases.

[19]  S. Hammer,et al.  Transmitted drug resistance among antiretroviral-naive patients with established HIV type 1 infection in Santo Domingo, Dominican Republic and review of the Latin American and Caribbean literature. , 2012, AIDS research and human retroviruses.

[20]  David R. Holtgrave,et al.  Behavioral Factors in Assessing Impact of HIV Treatment as Prevention , 2012, AIDS and Behavior.

[21]  N. Ford,et al.  Quantifying and addressing losses along the continuum of care for people living with HIV infection in sub-Saharan Africa: a systematic review , 2012, Journal of the International AIDS Society.

[22]  J. Pape,et al.  Long-Term Antiretroviral Treatment Outcomes in Seven Countries in the Caribbean , 2012, Journal of acquired immune deficiency syndromes.

[23]  R. Valdiserri,et al.  Reaping the prevention benefits of highly active antiretroviral treatment: policy implications of HIV Prevention Trials Network 052. , 2012, Current opinion in HIV and AIDS.

[24]  Satyanarayana,et al.  Rates and determinants of HIV-attributable mortality among rural female sex workers in Northern Karnataka, India , 2012, International journal of STD & AIDS.

[25]  M. Loutfy,et al.  HIV, Gender, Race, Sexual Orientation, and Sex Work: A Qualitative Study of Intersectional Stigma Experienced by HIV-Positive Women in Ontario, Canada , 2011, PLoS medicine.

[26]  A. Ouedraogo,et al.  Long term virological, immunological and mortality outcomes in a cohort of HIV-infected female sex workers treated with highly active antiretroviral therapy in Africa , 2011, BMC public health.

[27]  S. Swindells,et al.  Prevention of HIV-1 infection with early antiretroviral therapy , 2011, Journal of Family Planning and Reproductive Health Care.

[28]  C. Beyrer,et al.  Expanding the Space: Inclusion of Most-at-Risk Populations in HIV Prevention, Treatment, and Care Services , 2011, Journal of acquired immune deficiency syndromes.

[29]  J. Steiner,et al.  The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. , 2011, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[30]  C. Beyrer,et al.  A cross-sectional assessment of population demographics, HIV risks and human rights contexts among men who have sex with men in Lesotho , 2011, Journal of the International AIDS Society.

[31]  R. Wood,et al.  Initiating patients on antiretroviral therapy at CD4 cell counts above 200 cells/μl is associated with improved treatment outcomes in South Africa , 2010, AIDS.

[32]  Venkatesan Chakrapani,et al.  Barriers to free antiretroviral treatment access for female sex workers in Chennai, India. , 2009, AIDS patient care and STDs.

[33]  Matthias Egger,et al.  Sexual transmission of HIV according to viral load and antiretroviral therapy: systematic review and meta-analysis , 2009, AIDS.

[34]  D. Celentano,et al.  HIV/AIDS Stigma: Reliability and Validity of a New Measurement Instrument in Chennai, India , 2008, AIDS and Behavior.

[35]  A. Walker,et al.  Fixed duration interruptions are inferior to continuous treatment in African adults starting therapy with CD4 cell counts < 200 cells/microl. , 2008, AIDS.

[36]  Dart Trial Team.  Fixed duration interruptions are inferior to continuous treatment in African adults starting therapy with CD4 cell counts < 200 cells/μl , 2008 .

[37]  Gregory M. Herek,et al.  Confronting Sexual Stigma and Prejudice: Theory and Practice , 2007 .

[38]  C. Rebholz,et al.  "Getting me back on track": the role of outreach interventions in engaging and retaining people living with HIV/AIDS in medical care. , 2007, AIDS patient care and STDs.

[39]  J. Bradford.  The promise of outreach for engaging and retaining out-of-care persons in HIV medical care. , 2007, AIDS patient care and STDs.

[40]  S. Naar-King,et al.  Social support and disclosure as predictors of mental health in HIV-positive youth. , 2007, AIDS patient care and STDs.

[41]  D. Reidpath,et al.  A method for the quantitative analysis of the layering of HIV-related stigma , 2005, AIDS care.

[42]  C. Ferrans,et al.  Measuring stigma in people with HIV: psychometric assessment of the HIV stigma scale. , 2001, Research in nursing & health.

[43]  M. Chesney,et al.  Factors affecting adherence to antiretroviral therapy. , 2000, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[44]  J. Galassi,et al.  The Patient Reactions Assessment : a brief measure of the quality of the patient-provider medical relationship , 1992 .

[45]  E. Gardner,et al.  The HIV care cascade through time. , 2014, The Lancet. Infectious diseases.

[46]  B. Yip,et al.  The cascade of HIV care in British Columbia, Canada, 1996-2011: a population-based retrospective cohort study. , 2014, The Lancet. Infectious diseases.

[47]  P. Aggleton,et al.  HIV/AIDS-related stigma and discrimination: a conceptual framework and implications for action , 2002 .

[48]  J. Nachega,et al.  HIV treatment adherence, drug resistance, virologic failure: Evolving concepts , 2022 .