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Original research
Prevalence and incidence of HIV among female sex workers and their clients: modelling the potential effects of intervention in Rwanda
  1. Sabin Nsanzimana1,2,
  2. Edward J Mills3,4,
  3. Ofir Harari4,
  4. Placidie Mugwaneza5,
  5. Etienne Karita6,
  6. Jean Paul Uwizihiwe7,8,
  7. Jay JH Park4,9,
  8. Louis Dron4,
  9. Jeanine Condo10,
  10. Heiner Bucher2,
  11. Kristian Thorlund3,4
  1. 1Rwanda Biomedical Center, Kigali, Rwanda
  2. 2Basel Institute for Clinical Epidemiology and Biostatistics, University of Basel, Basel, Switzerland
  3. 3Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada, McMaster University, Hamilton, Ontario, Canada
  4. 4Real World and Advanced Analytics, Cytel Inc, Vancouver, BC, Canada
  5. 5Institute for HIV, Diseases Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda
  6. 6School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, United States
  7. 7School of Medicine and Pharmacy, Department of Primary Health Care, University of Rwanda, Kigali, Rwanda
  8. 8Department of Public Health, Center for Global Health, Aarhus University, Aarhus University, Aarhus, Denmark
  9. 9Experimental Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
  10. 10School of Public Health, University of Rwanda, Kigali, Rwanda
  1. Correspondence to Dr Sabin Nsanzimana; nsabinco{at}gmail.com

Abstract

Background Rwanda has identified several targeted HIV prevention strategies, such as promotion of condom use and provision of antiretroviral therapy (ART) and pre-exposure prophylaxis (PrEP) for female sex workers (FSWs). Given this country’s limited resources, understanding how the HIV epidemic will be affected by these strategies is crucial.

Methods We developed a Markov model to estimate the effects of targeted strategies to FSWs on the HIV prevalence/incidence in Rwanda from 2017 to 2027. Our model consists of the six states: HIV-; HIV+ undiagnosed/diagnosed pre-ART; HIV+ diagnosed with/without ART; and death. We considered three populations: FSWs, sex clients and the general population. For the period 2017–2027, the HIV epidemic among each of these population was estimated using Rwanda’s demographic, sexual risk behaviour and HIV-associated morbidity and mortality data.

Results Between 2017 and 2027, with no changes in the current condom and ART use, the overall number of people living with HIV is expected to increase from 344,971 to 402,451. HIV incidence will also decrease from 1.36 to 1.20 100 person-years. By 2027, a 30% improvement in consistent condom use among FSWs will result in absolute reduction of HIV prevalence among FSWs, sex clients and the general population by 7.86%, 5.97% and 0.17%, respectively. While recurring HIV testing and improving the ART coverage mildly reduced the prevalence/incidence among FSWs and sex clients, worsening the two (shown by our worst-case scenario) will result in an increase in the HIV prevalence/incidence among FSWs and sex clients. Introduction of PrEP to FSWs in 2019 will reduce the HIV incidence among FSWs by 1.28%.

Conclusions Continued efforts toward improving condom and ART use will be critical for Rwanda to continue their HIV epidemic control. Implementing a targeted intervention strategy in PrEP for FSWs will reduce the HIV epidemic in this high-risk population.

  • epidemiology
  • health economics
  • HIV
http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjgh-2020-002300

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    Footnotes

    • Handling editor Lei Si

    • Contributors SN, EJM, OH, JJHP, LD, HCB and KT contributed to the conception and design of the work. SN, EJM, OH, JJHP and KT contributed to data analysis. SN, EJM, OH, PM, EK, JPU, JJHP, LD, JC, HCB and KT contributed to the data interpretation, drafting the article, critical revision of the article and final approval of the text.

    • Funding This study was funded by the Rwanda Biomedical CenterCentre (RBC).

    • Disclaimer The RBC did not have any role in the study design, collection, analysis and interpretation of the data.

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting or dissemination plans of this research.

    • Patient consent for publication Not required.

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

    • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.