Characterising unmet HIV prevention and treatment needs among young female sex workers and young men who have sex with men in Cameroon: a cross-sectional analysis

Summary

Background

In Cameroon, female sex workers (FSWs) and men who have sex with men (MSM) carry disproportionately high burdens of HIV. Despite specific vulnerabilities and health needs, young key populations remain understudied and underserved in Cameroon owing to legal, ethical, and social challenges. We aimed to assess and compare HIV-related behavioural and structural risks and coverage of HIV prevention and treatment services between young and older key populations to inform implementation strategies.

Methods

FSWs and MSM aged 18 years or older were recruited through respondent-driven-sampling for a biobehavioural survey carried out in five Cameroonian cities. Prevalence of HIV, risk, stigma, and health service engagement were compared between young (18–24 years) and older (≥25 years) key populations. Multivariable Poisson regression models, disaggregated by key population, were constructed to estimate prevalence ratios (PR) by age group for HIV service engagement.

Findings

Participants were recruited between Nov 30, 2015, and Oct 12, 2016. Among FSWs, 724 (32%) of 2255 were aged 18–24 years, and median age of first transactional or compensated sex was 22 years (IQR 19–28). Among MSM, 840 (63%) of 1323 were aged 18–24 years, and median age of first anal sex was 18 years (IQR 17–21). RDS-adjusted HIV prevalence was 8·5% (95% CI 4·7–15·2) among young FSWs and 12·9% (9·5–18·2) among young MSM. HIV viral suppression (<1000 copies per mL) was evident in 24 (43%) of 56 young and 292 (61%) of 479 older FSWs (p=0·0091) and 40 (34%) of 119 of young and 64 (42%) of 153 older MSM (p=0·17). Young FSWs were less likely than older FSWs to report recent peer education (PR 0·65, 95% CI 0·48–0·88), or membership of an FSW community-based organisation (PR 0·69, 0·55–0·86) and were more likely to report untreated sexually transmitted infection symptoms in the past year (PR 1·29, 1·03–1·61). Young MSM were less likely than older MSM to report an HIV test in the past year (PR 0·88, 0·78–0·98), recent peer education (PR 0·77, 0·62–0·95) and receipt of free condoms (PR 0·77, 0·67–0·89). By key population, condom use and recent experiences of stigma and violence were similar between age groups (p>0·05).

Interpretation

Young key populations have similar behavioural and structural risks to older populations but have lower coverage of HIV preventive and treatment services. Achieving an AIDS-free generation in Cameroon and elsewhere in the region necessitates overcoming social and legal challenges and delivering innovative, evidence-based, and human rights-affirming HIV prevention and treatment interventions for young key populations.

Funding

PEPFAR, USAID.

Introduction

Globally, adolescents and young people aged 10–24 years are considered a priority for HIV prevention.¹ Most young people living with HIV reside across sub-Saharan Africa, where 15–24 year olds are estimated to account for 37% of all new HIV infections.² Importantly, reductions in new HIV infections achieved overall across sub-Saharan Africa have not been matched among young people.2, 3 Proximal factors such as biological risk factors, age-disparate relationships, early sexual debut, and risk-taking behaviours increase vulnerability to HIV among young people, especially among young women.1, 3 Structural issues, including poverty, low education, unemployment, housing instability, laws of consent, stigma, and discrimination, underlie some risks, delay diagnosis, and inhibit access to treatment among young men and women.⁴ Furthermore, social sanctions regarding premarital sex discourage discussion on sexual and reproductive health and health-care seeking.⁵ Although there is considerable documentation of the disproportionately high HIV prevalence and new infections among young women compared with young men in SSA,2, 3 WHO and others have recognised the gap in information, research and programmes targeting young people belonging to key populations (key populations).⁶

Research in context

Evidence before this study

There has been an increased focus on the HIV prevention needs of young people. Studies, reviews, and calls to action have highlighted the high incidence among young people, greater vulnerability to HIV, and lower coverage of HIV services compared with older adults. In higher income settings, the focus on young people has included young gay men and other men who have sex with men, whereas across sub-Saharan Africa, the focus has been on adolescent girls and young women aged 15–24 years. Notably, most young people living with HIV reside in countries across sub-Saharan Africa. Adult key populations—including gay, bisexual, and other men who have sex with men, and female sex workers—are also disproportionately burdened by high prevalence and HIV incidence throughout sub-Saharan Africa. The social and legal challenges in addressing the needs of adult key populations in rights-constrained environments have been well documented. Studying the intersections of vulnerability between youth and key populations is crucial to addressing potential unmet HIV prevention and treatment needs.

We searched PubMed for studies published until Nov 30, 2018, and used the MeSH terms (“hiv infections/prevention and control” OR “hiv infections/epidemiology” OR “risk factors” OR “risk taking” OR “health knowledge, attitudes, practice” OR “health care utilization” OR “health care accessibility”) AND (“sex workers” OR “sex work” OR “sexual and gender minorities” OR “homosexuality, male”) AND (“young adult” OR “adolescent”) AND (“Sub-Saharan Africa”). On the basis of abstract review, only three studies were identified which focused on comparisons between young and older key populations. One identified lower access to HIV care and prevention services among underage sex workers compared with adult sex workers in Mozambique, whereas the others reported contrary findings on age group and condom use among men who have sex with men. Numerous studies considered age as a determinant of HIV prevalence, but very few considered age as a determinant of HIV testing.

Data specifically focused on young key populations are scarce. In combination with biological factors, social and economic circumstances might make young women who sell or report transactional sex more vulnerable to power imbalances and violence. In turn, these experiences serve as barriers to condom use and heighten HIV risk. Some studies highlighted that adult sex workers who were sexually exploited through sex work as an adolescent had higher HIV risk than other sex workers. Several reviews were identified which highlighted the gap in data on young key populations, high vulnerability to HIV, and barriers to accessing HIV services in these populations globally. Finally, high HIV incidence has been recorded among young key populations in some settings.

Added value of this study

This is one of the first studies to specifically compare access to HIV services between young and older key populations in sub-Saharan Africa, and it is the first study to provide detailed information on HIV risk and service access among young key populations in Cameroon. Taken together, these data showed that key populations in Cameroonian cities already have a remarkably high HIV prevalence from a young age. Sexual risks, levels of stigma and violence were similar between younger and older key populations. However, there was far more sparse coverage of HIV prevention, testing and treatment services among younger as compared with older key populations. Given engagement in high-risk behaviours for transmission, high viral load among young key populations living with HIV poses a major barrier to HIV epidemic control.

Implications of all the available evidence

To end new HIV infections, it is essential to engage with key populations from a young age. In addition to criminalisation of sexual practices, intersecting risks, social and legal barriers related to youth limit the coverage of HIV services for young key populations compared with older key populations. To truly achieve a future AIDS-free generation in Cameroon and across sub-Saharan Africa, innovative, evidence-based, and human rights-affirming interventions are needed to specifically address the complex needs of young key populations, including non-HIV related needs. Interventions that leverage emerging technologies and that promote and reduce barriers to regular HIV testing appear most crucial in this setting.

Globally, key populations include female sex workers (FSWs) and men who have sex with men (MSM), and these groups are disproportionately affected by HIV across sub-Saharan Africa.7, 8 key populations encompass young people, and numerous studies based in sub-Saharan Africa indicate that upwards of 20% of adult FSWs first sold sex before age 18 years.9, 10 Early age of entry into sex work, which is recognised as sexual exploitation, has been associated with sustained higher risk of HIV in adult FSWs compared with FSWs with a later sex-work debut.⁹ Recent entry into sex work has also been associated with higher risk of HIV or sexually transmitted infection (STI).¹¹ Furthermore, several studies provide evidence of higher HIV or other STI incidence among young key populations than older key populations.12, 13, 14 The structural influences on HIV risk faced by young people might be compounded in young key populations, who are affected by additional legal and social challenges to effective service provision and uptake.15, 16 Supportive of this, several studies have empirically shown lower access to HIV testing and other services among younger compared with older key populations.17, 18 Finally, consent laws, which can serve as a barrier to young people participating in epidemiological and prevention research, might be augmented in young key populations owing to additional social and structural barriers to seeking parental consent,¹⁹ thus inhibiting data generation to inform services for young key populations.

There has been recognition of the delayed progress in HIV control across west and central Africa, reinforcing the importance of understanding the needs of young people at high risk of HIV acquisition.²⁰ In this region the burden of HIV is largely concentrated in key populations, and these populations substantially contribute to new HIV infections.7, 20, 21 25% of all new HIV infections among adolescents aged 15–19 years globally occur in west and central Africa alone, and this proportion is projected to increase, exceeding east and southern Africa by 2050.²² The present work focuses on Cameroon, in Central Africa, which has a relatively high HIV prevalence for the region—3·4% among adults aged 15–49 years in 2017—and a disproportionately high burden of HIV among key populations.7, 23, 24 Both sex work and same-sex practices are illegal in Cameroon, and previous work has shown the relevance of these and other social and structural influences to the elevated burden of HIV in key populations.¹⁶ Young people are also affected by HIV in Cameroon and sex disparities are most evident in this age group, with prevalence almost five-times higher in young women aged 20–24 years (2·9%) than young men (0·6%).²³ However data on the intersection between these priority populations for HIV prevention and control are scarce.

In response to a paucity of research on young key populations in Cameroon and throughout sub-Saharan Africa, we aimed to assess and compare HIV-related behavioural and structural risks, and coverage of HIV prevention and treatment services between younger and older key populations to inform implementation strategies for evidence-based and human-rights affirming HIV services.