EXPERIENCES OF FEMALE SEX WORKERS ALONG THE HIV CARE CONTINUUM IN SANTO DOMINGO, DOMINICAN REPUBLIC
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Introduction Approximately 12% of all female sex workers (FSWs) around the world are living with HIV. FSWs confront heightened vulnerability not only to HIV infection, but also to social, economic and systemic barriers throughout the HIV care continuum and have sub-optimal engagement in HIV care. Despite this large burden of disease, there is very limited evidence on the HIV care experiences of FSWs living with HIV. Methods This study utilized a mixed methods approach to investigate FSWs’ experiences along the HIV care continuum. The first manuscript explored the experiences of 44 FSWs living with HIV throughout the HIV care continuum through in-depth interviews and focus group discussions in Santo Domingo, Dominican Republic. Informed by the findings from this thematic and narrative analysis, the second manuscript analyzed a quantitative, cross-sectional survey to describe the baseline HIV care continuum among 268 FSWs living with HIV in Santo Domingo. The manuscript then specifically examined factors associated with experience of antiretroviral therapy (ART) interruption using multiple logistic regression. The final manuscript determined the factors associated with retention in HIV care in the same study population using multiple measure of retention. Results FSWs living with HIV disengaged at each step of the HIV care continuum. Engagement in HIV care was not a static construct as participants continually negotiated engagement within a broader context of structural constraints and social conditions. FSWs described critical influences across multiple levels that either facilitated (re)engagement in HIV care or led to disengagement. Key individual-level factors identified in the qualitative analysis were physical and mental health as post-diagnosis depression was often followed by disengagement in HIV care until declines in physical health were noted. Interpersonal factors centered on disclosure of HIV or FSW status and existent support. At the environmental level, participants frequently described systemic delays and the high costs of care, but good relationships with HIV care providers. Some experiences of discrimination within the clinic environment were, however, described. Lack of economic resources and pervasive HIV stigma and discrimination also complicated adherence to clinical appointments and ART. Within the quantitative sample, most participants linked to HIV care (92%), attended HIV services in the past six months (85%) and were initiated onto ART (78%), but discontinuation of treatment and irregular adherence to clinical appointments were frequent. A total of 36% of the participants ever initiated onto ART reported lifetime experience with an interruption of ART. The odds of ART interruption were 3.24 times higher among women who experienced sex work (SW)-related discrimination (95% confidence interval [CI]: 1.28, 8.20), 2.41 times higher among women who reported ever using any drug (95% CI: 1.09, 5.34) and 2.35 times higher among women who worked in a SW establishment (95% CI: 1.20, 4.60). Self-stigmatizing beliefs related to SW were associated with higher odds of interruption as each additional point on the SW self-stigma scale was associated with a 9% increase in the odds of ART interruption (95% CI: 1.02, 1.16). Positive perceptions of HIV providers were protective with each additional point on the perception of HIV provider scale associated with a 9% reduction in the odds of treatment interruption (95% CI: 0.85, 0.98). The final manuscript determined that a retention measure which included both attended and missed visits was the most appropriate measure of retention in this study population. A total of 37% of the women who attended HIV services in the past six months had missed at least one clinical appointment. The odds of being retained in HIV care were higher among participants with more positive perceptions of HIV service providers (adjusted relative odds [ARO]: 1.17; 95% confidence interval [CI]: 01.09, 1.25). The odds of retention were lower among women who reported recent alcohol consumption (ARO: 0.50; 95% CI: 0.28, 0.92) and among women with self-stigmatizing beliefs related to SW (ARO: 0.93; 95% CI: 0.88, 0.98). Conclusions Individual, interpersonal, environmental and structural factors were important influences on engagement in HIV care among FSWs throughout the HIV care continuum. In addition to challenges faced by the general population living with HIV, FSWs confronted additional economic instability and the compounded stigma of being both HIV-infected and a FSW. Given the clear importance of improving engagement in HIV care to maximize individual and public health, there is an urgent need for multi-level interventions to help support FSWs throughout the HIV care continuum.