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HIV pre-exposure prophylaxis for female sex workers : ensuring women's family planning needs are not left behind

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Abstract
Introduction Female sex workers (FSWs) experience overlapping burdens of HIV, sexually transmitted infections and unintended pregnancy. Pre-exposure prophylaxis (PrEP) is highly efficacious for HIV prevention. It represents a promising strategy to reduce HIV acquisition risks among FSWs specifically given complex social and structural factors that challenge consistent condom use. However, the potential impact on unintended pregnancy has garnered little attention. We discuss the potential concerns and opportunities for PrEP to positively or negatively impact the sexual and reproductive health and rights (SRHR) of FSWs. Discussion FSWs have high unmet need for effective contraception and unintended pregnancy is common in low- and middle-income countries. Unintended pregnancy can have enduring health and social effects for FSWs, including consequences of unsafe abortion and financial impacts affecting subsequent risk-taking. It is possible that PrEP could negatively impact condom and other contraceptive use among FSWs due to condom substitution, normalization, external pressures or PrEP provision by single-focus services. There are limited empirical data available to assess the impact of PrEP on pregnancy rates in real-life settings. However, pregnancy rates are relatively high in PrEP trials and modelling suggests a potential two-fold increase in condomless sex among FSWs on PrEP, which, given low use of non-barrier contraceptive methods, would increase rates of unintended pregnancy. Opportunities for integrating family planning with PrEP and HIV services may circumvent these concerns and support improved SRHR. Synergies between PrEP and family planning could promote uptake and maintenance for both interventions. Integrating family planning into FSW-focused community-based HIV services is likely to be the most effective model for improving access to non-barrier contraception among FSWs. However, barriers to integration, such as provider skills and training and funding mechanisms, need to be addressed. Conclusions As PrEP is scaled up among FSWs, there is growing impetus to consider integrating family planning services with PrEP delivery in order to better meet the diverse SRHR needs of FSWs and to prevent unintended consequences. Programme monitoring combined with research can close data gaps and mobilize adequate resources to deliver comprehensive SRHR services respectful of all women's rights.
Keywords
sex workers, Pre-Exposure Prophylaxis (PrEP), contraception, unplanned pregnancy, HIV infections, REPRODUCTIVE HEALTH NEEDS, SUB-SAHARAN AFRICA, MIDDLE-INCOME COUNTRIES, CONTRACEPTIVE USE, SOUTH-AFRICA, HIGH-RISK, UNPLANNED PREGNANCY, HIGH BURDEN, CONDOM USE, PREVENTION

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MLA
Bowring, AL, et al. “HIV Pre-Exposure Prophylaxis for Female Sex Workers : Ensuring Women’s Family Planning Needs Are Not Left Behind.” JOURNAL OF THE INTERNATIONAL AIDS SOCIETY, vol. 23, no. 2, 2020, doi:10.1002/jia2.25442.
APA
Bowring, A., Ampt, F., Schwartz, S., Stoové, M., Lüchters, S., Baral, S., & Hellard, M. (2020). HIV pre-exposure prophylaxis for female sex workers : ensuring women’s family planning needs are not left behind. JOURNAL OF THE INTERNATIONAL AIDS SOCIETY, 23(2). https://doi.org/10.1002/jia2.25442
Chicago author-date
Bowring, AL, FH Ampt, S Schwartz, MA Stoové, Stanley Lüchters, S Baral, and M Hellard. 2020. “HIV Pre-Exposure Prophylaxis for Female Sex Workers : Ensuring Women’s Family Planning Needs Are Not Left Behind.” JOURNAL OF THE INTERNATIONAL AIDS SOCIETY 23 (2). https://doi.org/10.1002/jia2.25442.
Chicago author-date (all authors)
Bowring, AL, FH Ampt, S Schwartz, MA Stoové, Stanley Lüchters, S Baral, and M Hellard. 2020. “HIV Pre-Exposure Prophylaxis for Female Sex Workers : Ensuring Women’s Family Planning Needs Are Not Left Behind.” JOURNAL OF THE INTERNATIONAL AIDS SOCIETY 23 (2). doi:10.1002/jia2.25442.
Vancouver
1.
Bowring A, Ampt F, Schwartz S, Stoové M, Lüchters S, Baral S, et al. HIV pre-exposure prophylaxis for female sex workers : ensuring women’s family planning needs are not left behind. JOURNAL OF THE INTERNATIONAL AIDS SOCIETY. 2020;23(2).
IEEE
[1]
A. Bowring et al., “HIV pre-exposure prophylaxis for female sex workers : ensuring women’s family planning needs are not left behind,” JOURNAL OF THE INTERNATIONAL AIDS SOCIETY, vol. 23, no. 2, 2020.
@article{8656368,
  abstract     = {{Introduction Female sex workers (FSWs) experience overlapping burdens of HIV, sexually transmitted infections and unintended pregnancy. Pre-exposure prophylaxis (PrEP) is highly efficacious for HIV prevention. It represents a promising strategy to reduce HIV acquisition risks among FSWs specifically given complex social and structural factors that challenge consistent condom use. However, the potential impact on unintended pregnancy has garnered little attention. We discuss the potential concerns and opportunities for PrEP to positively or negatively impact the sexual and reproductive health and rights (SRHR) of FSWs.

Discussion FSWs have high unmet need for effective contraception and unintended pregnancy is common in low- and middle-income countries. Unintended pregnancy can have enduring health and social effects for FSWs, including consequences of unsafe abortion and financial impacts affecting subsequent risk-taking. It is possible that PrEP could negatively impact condom and other contraceptive use among FSWs due to condom substitution, normalization, external pressures or PrEP provision by single-focus services. There are limited empirical data available to assess the impact of PrEP on pregnancy rates in real-life settings. However, pregnancy rates are relatively high in PrEP trials and modelling suggests a potential two-fold increase in condomless sex among FSWs on PrEP, which, given low use of non-barrier contraceptive methods, would increase rates of unintended pregnancy. Opportunities for integrating family planning with PrEP and HIV services may circumvent these concerns and support improved SRHR. Synergies between PrEP and family planning could promote uptake and maintenance for both interventions. Integrating family planning into FSW-focused community-based HIV services is likely to be the most effective model for improving access to non-barrier contraception among FSWs. However, barriers to integration, such as provider skills and training and funding mechanisms, need to be addressed.

Conclusions As PrEP is scaled up among FSWs, there is growing impetus to consider integrating family planning services with PrEP delivery in order to better meet the diverse SRHR needs of FSWs and to prevent unintended consequences. Programme monitoring combined with research can close data gaps and mobilize adequate resources to deliver comprehensive SRHR services respectful of all women's rights.}},
  articleno    = {{e25442}},
  author       = {{Bowring, AL and Ampt, FH and Schwartz, S and Stoové, MA and Lüchters, Stanley and Baral, S and Hellard, M}},
  issn         = {{1758-2652}},
  journal      = {{JOURNAL OF THE INTERNATIONAL AIDS SOCIETY}},
  keywords     = {{sex workers,Pre-Exposure Prophylaxis (PrEP),contraception,unplanned pregnancy,HIV infections,REPRODUCTIVE HEALTH NEEDS,SUB-SAHARAN AFRICA,MIDDLE-INCOME COUNTRIES,CONTRACEPTIVE USE,SOUTH-AFRICA,HIGH-RISK,UNPLANNED PREGNANCY,HIGH BURDEN,CONDOM USE,PREVENTION}},
  language     = {{eng}},
  number       = {{2}},
  pages        = {{8}},
  title        = {{HIV pre-exposure prophylaxis for female sex workers : ensuring women's family planning needs are not left behind}},
  url          = {{http://doi.org/10.1002/jia2.25442}},
  volume       = {{23}},
  year         = {{2020}},
}

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