Defining strata of women at risk for HIV in Sub-Saharan Africa: a pooled latent class analysis

Community-led programs have expanded sexual and reproductive health services for female sex workers (FSW) across sub-Saharan Africa. However, substantial heterogeneity in HIV risk and engagement with prevention services remains, underscoring the need for differentiated approaches to identify FSW who remain underserved by HIV programs.

We pooled 2013-2019 bio-behavioral survey data from nine countries in Sub-Sahara Africa. Latent class analysis defined underlying risk indicated by sexual behavior, client type, alcohol use, and violence. We profiled characteristics of classes and used mixture models to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) for associations of class membership with prior HIV testing and biologically-confirmed HIV status.

Among 5548 FSW (median age: 27, IQR 23-34), four classes were identified: Alcohol and Violence (16.8%), High Client Turnover (38.4%), Lower Client Volume (31.8%), and Limited Condoms and Lubricant Use (13.0%). Relative to other groups, FSW in Lower Client Volume were older and less likely to experience sex work interruptions or share earnings. Prior HIV testing was lower among the Limited Condoms and Lubricant Use class relative to others: Alcohol and Violence (aOR 4.99, 95%CI 3.44-7.24), High Client Turnover (aOR 4.09, 95%CI 3.19-5.24), and Lower Client Volume (aOR 3.58, 95%CI 2.80-4.59).

Pooled analyses demonstrated heterogeneous individual and structural influences on HIV prevention among FSW. Increased specificity in implementation of HIV services for FSW may increase efficiency to achieve more with less in the HIV response.