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Engagement in the HIV care cascade and barriers to antiretroviral therapy uptake among female sex workers in Port Elizabeth, South Africa: findings from a respondent-driven sampling study
  1. Sheree Schwartz1,
  2. Andrew Lambert2,
  3. Nancy Phaswana-Mafuya3,4,
  4. Zamakayise Kose3,
  5. Mfezi Mcingana5,
  6. Claire Holland1,
  7. Sosthenes Ketende1,
  8. Clarence Yah3,
  9. Stephanie Sweitzer1,
  10. Harry Hausler2,
  11. Stefan Baral1
  1. 1Department of Epidemiology, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
  2. 2The TB/HIV Care Association, Cape Town, South Africa
  3. 3The Human Sciences Research Council, Port Elizabeth, South Africa
  4. 4Nelson Mandela Metropolitan University, Port Elizabeth, South Africa
  5. 5The TB/HIV Care Association, Port Elizabeth, South Africa
  1. Correspondence to Dr Sheree Schwartz, Department of Epidemiology, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, E7139, Baltimore, MD 21205, USA; sschwartz{at}


Background Female sex workers (FSWs) are disproportionately affected by HIV, even in the context of broadly generalised HIV epidemics such as South Africa. This has been observed in spite of the individual and population-level benefits of HIV treatment. We characterise the HIV care cascade among FSWs and relationships with antiretroviral therapy (ART) use.

Methods FSWs ≥18 years were recruited through respondent-driven sampling into a cross-sectional study in Port Elizabeth, South Africa. Participants completed questionnaires and received HIV and syphilis testing; CD4 counts were assessed among women living with HIV. Engagement in the HIV care cascade is described, and correlates of self-reported ART use among treatment-eligible previously diagnosed FSWs were estimated using robust Poisson regression.

Results Between October 2014 and April 2015, 410 FSWs participated in study activities. Overall, 261/410 were living with HIV (respondent-driven sampling-weighted prevalence 61.5% (95% bootstrapped CI 54.1% to 68.0%)). Prior diagnosis of HIV was relatively high (214/261, 82%); however, ART coverage among FSWs living with HIV was 39% (102/261). In multivariate analyses, FSWs were less likely to be on ART if they had not disclosed their HIV status to non-paying partners (adjusted prevalence ratio (aPR) 0.43, 95% CI 0.22 to 0.86, where the reference is FSWs without non-paying partners), and also if they engaged in mobile healthcare services (aPR 0.71, 95% CI 0.57 to 0.89).

Conclusions HIV testing and awareness of HIV status were high, but substantial losses in the cascade occur at treatment initiation. Given that FSWs engaged in mobile HIV testing and peer education programmes have unmet HIV treatment needs, models of decentralised treatment provision such as mobile-based ART care should be evaluated.


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  • Handling editor Jackie A Cassell

  • Contributors ShS, SB, NP-M, ZK, AL and MM conceptualised the study; ZK, MM, ShS, AL, NP-M, CH, SK, CY, StS, HH and SB all supported implementation of the study; ShS and SK conducted the analyses; ShS and SB drafted the manuscript and all authors read through and contributed to the content of the manuscript.

  • Funding This work was funded by the MAC AIDS Foundation and conducted by the Human Sciences Research Council (HSRC) and the TB/HIV Care Association (THCA) in collaboration with the Johns Hopkins University.

  • Competing interests None.

  • Ethics approval Johns Hopkins Bloomberg School of Public Health Institutional Review Board and the Human Sciences Research Council's Human Research Ethics Committee.

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

  • Data sharing statement The data are jointly owned by the partner institutions. Requests for collaboration or utilisation of the data should be sent to ShS at