HIV seroprevalence, incidence, and viral suppression among Ugandan female bar workers: a population-based study
Xinyi Feng, Gertrude Nakigozi, Eshan U. Patel, Caitlin E. Kennedy, Slisha Shrestha, Fred Nalugoda, Godfrey Kigozi, Robert Ssekubugu, Larry W Chang, Andrea L. Wirtz, Arthur G. Fitzmaurice, Hadijja Nakawooya, Grace Kigozi, Ronald M Galiwango, Steven J Reynolds, Joseph Kagaayi, Aaron A. R. Tobian, M. Kate GrabowskiIntroduction:
Prior studies showed that some female bar workers (FBWs) may engage in sex work in Africa. However, population-level data on HIV burden among FBWs in African settings are rare.
Methods:
We used five survey rounds of data (2011-2020) from the Rakai Community Cohort Study, a population-based HIV surveillance cohort in 36 inland agrarian/trading communities (HIV prevalence∼12%) and four Lake Victoria fishing communities(∼40%) in southern Uganda. Women reporting bar work as a primary or secondary occupation were identified and compared to non-FBWs. Primary outcomes included HIV seropositivity, incident infection, viral suppression (<200copies/ml) among women with HIV, and population prevalence of viremia. Prevalence ratios (PRs) and incidence rate ratios (IRRs) were estimated using Poisson regression with 95% confidence intervals (CIs).
Results:
Among 23,556 female participants contributing 52,708 person-visits, 1,205(5.1%) self-identified as FBWs, who had significantly higher baseline HIV seroprevalence than non-FBWs (51.9%vs.18.5%;PR=2.81,95%CI=2.64-2.95). There were 356 incident infections over 39,228 person-years. HIV incidence among FBWs was 2.49/100 person-years compared to 0.87 among non-FBWs (age-adjusted IRR=3.64,95%CI=2.33-5.42). While HIV viral suppression was similar among participants living with HIV regardless of FBW status, the population prevalence of HIV viremia was 1.69 times higher among FBWs (95%CI=1.38-2.08). Among 179 HIV-seronegative FBWs surveyed in 2018-2020, 79.9%(143/179) were aware of PrEP, while only 13.4%(24/179) had ever used it, with just 2.8%(5/179) current users.
Conclusions:
FBWs in Uganda experience substantially higher HIV burden and acquisition risk compared to the general population. Prevention strategies tailored to the occupational context of bar work, including prioritization of HIV service delivery and access to oral and long-acting injectable PrEP, may substantially reduce HIV incidence among FBWs and their sexual partners.