Article Text

Download PDFPDF

Do female sex workers have lower uptake of HIV treatment services than non-sex workers? A cross-sectional study from east Zimbabwe
  1. Rebecca Rhead1,
  2. Jocelyn Elmes1,
  3. Eloghene Otobo1,
  4. Kundai Nhongo2,
  5. Albert Takaruza2,
  6. Peter J White1,3,4,
  7. Constance Anesu Nyamukapa1,2,
  8. Simon Gregson1
  1. 1 Department of Infectious Disease Epidemiology, Imperial College London School of Public Health, London, UK
  2. 2 Biomedical Research and Training Institute, Harare, Zimbabwe
  3. 3 MRC Centre for Outbreak Analysis and Modelling and NIHR Health Protection Research Unit in Modelling Methodology, Imperial College London School of Public Health, London, UK
  4. 4 Modelling and Economics Unit, National Infection Service, Public Health England, London, UK
  1. Correspondence to Dr Rebecca Rhead; r.rhead{at}


Objective Globally, HIV disproportionately affects female sex workers (FSWs) yet HIV treatment coverage is suboptimal. To improve uptake of HIV services by FSWs, it is important to identify potential inequalities in access and use of care and their determinants. Our aim is to investigate HIV treatment cascades for FSWs and non-sex workers (NSWs) in Manicaland province, Zimbabwe, and to examine the socio-demographic characteristics and intermediate determinants that might explain differences in service uptake.

Methods Data from a household survey conducted in 2009–2011 and a parallel snowball sample survey of FSWs were matched using probability methods to reduce under-reporting of FSWs. HIV treatment cascades were constructed and compared for FSWs (n=174) and NSWs (n=2555). Determinants of service uptake were identified a priori in a theoretical framework and tested using logistic regression.

Results HIV prevalence was higher in FSWs than in NSWs (52.6% vs 19.8%; age-adjusted OR (AOR) 4.0; 95% CI 2.9 to 5.5). In HIV-positive women, FSWs were more likely to have been diagnosed (58.2% vs 42.6%; AOR 1.62; 1.02–2.59) and HIV-diagnosed FSWs were more likely to initiate ART (84.9% vs 64.0%; AOR 2.33; 1.03–5.28). No difference was found for antiretroviral treatment (ART) adherence (91.1% vs 90.5%; P=0.9). FSWs’ greater uptake of HIV treatment services became non-significant after adjusting for intermediate factors including HIV knowledge and risk perception, travel time to services, physical and mental health, and recent pregnancy.

Conclusion FSWs are more likely to take up testing and treatment services and were closer to achieving optimal outcomes along the cascade compared with NSWs. However, ART coverage was low in all women at the time of the survey. FSWs’ need for, knowledge of and proximity to HIV testing and treatment facilities appear to increase uptake.

  • epidemiology
  • public health

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See:

View Full Text

Statistics from


  • RR and JE contributed equally.

  • Contributors RR, JE, PJW, SG, CAN and KN were involved in study concept and design. CAN, JE, KN and AT acquired and curated the data. JE, RR, SG and EO were involved in the design of the analysis. RR conducted the statistical analysis supervised by SG and JE. RR, SG, JE and EO interpreted the results and drafted the article.

  • Funding SG thanks the Wellcome Trust for funding (grants: 084401/Z/07/B and 090285MA). JE thanks the Medical Research Council for her PhD funding (grant number and the Wellcome Trust for postdoctoral funding (grant number: 090285/Z/09/Z; PJW thanks the MRC for Centre funding (MR/K010174/1) and the UK NIHR Health Protection Research Unit in Modelling Methodology at Imperial College London in partnership with Public Health England for funding (HPRU-2012-10080).

  • Disclaimer The views expressed are those of the authors and not necessarily those of the Department of Health, MRC, NHS, NIHR, Public Health England or the Wellcome Trust.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Ethics approval Prior ethical approval for the Manicaland study (with the WR study included as a substudy) was obtained from the Medical Research Council of Zimbabwe (MRCZ/A/681) and the Imperial College Research Ethics Committee (ICREC_9_3_13).

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

  • Data sharing statement Data produced by the Manicaland Project can be obtained from the project website: Here we provide a core dataset which contains a sample of socio-demographic, sexual behaviour and HIV testing variables from all six rounds of the main survey, as well as data used in the production of recent academic publications. If further data are required, a data request form must be completed (available to download from our website) and submitted to If the proposal is approved, we will send a data sharing agreement which must be agreed upon before we release the requested data.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.