Presentation by Tshepo Molapo, at the National Sex Work Symposium, in the session 'What we know: evidence-based peer reviewed knowledge on sex work' (Boksburg, 22 August 2012).

1. SEX WORK AND HIV INCIDENCE IN
SOUTH AFRICA: WHAT DO WE
KNOW?
Mr Tshepo Molapo
Sex workers symposium
22-24 September 2012
Birchwood, Johannesburg

2. WHAT WILL BE PRESENTED?
 Introduction
 Background
 New HIV infections and sex work in South Africa
 How does incidence TRANSLATE when it come
to HIV prevalence among sex workers in South
Africa
 Implications for programmes

3. INTRODUCTION
 Globally, sex workers (SW), have been shown to be at
disproportionate risk for HIV infection.
 Sex workers (Female) are a population who are at
heightened risk of HIV infection secondary to biological,
behavioural, and structural risk factors.
 Multiple and concurrent partners, casual encounters
 Because they are often marginalized by society and
greatly affected by discrimination and stigma, these
groups have become some of the most at-risk
populations for HIV infection.
 SWs form part of “key populations”.

4. BACKGROUND
 High levels of prejudice and moral loading has been
shown to create barriers to accessing prevention,
treatment, care and support – increasing vulnerability
to HIV.
 Insufficient consensus around HIV incidence and
prevalence in this key population have led to
uncertainty around the perception of risk of HIV
acquisition

5. WHAT ARE THE ESTIMATES WHEN IT COMES
TO HIV INCIDENCE AND SEX WORK IN SOUTH
AFRICA?
 As part of the Know you epidemic/Know your
response (KYE/KYR), SACEMA was tasked with
running a model for South Africa in 2009.

6. THE MODES OF TRANSMISSION
(MOT) MODEL
The MoT model is static, and provides a short-term projection
based on current HIV prevalence levels and behaviours. The
adult population is segmented into six closed
subpopulations, namely
 Injecting drug users (IDU’s) and their partners
 Sex workers (SW’s), the clients of SW’s and the
clients’ partners
 Men who have sex with men (MSM) and their females
partners
 Individuals engaging in casual heterosexual sex (CHS) and
their partners
 Individuals engaging in low-risk heterosexual sex
 Individuals at no risk

7. MODEL INPUTS (SOURCES)
Estimates from national South African surveys were used where possible. The three main
surveys that provided data for model inputs are:
 The National HIV and Syphilis Prevalence Survey: by the National Department of
Health and involves the surveillance of women attending antenatal clinics.
 The Demographic and Health Survey (DHS): conducted in 1998 and 2003.
 The National HIV Prevalence, Incidence, Behaviour and Communication Survey:
by the Human Sciences Research Council (HSRC); the Medical Research Council (MRC);
the Centre for AIDS Development, Research and Evaluation (CADRE) and the South
African National Institute for Communicable Diseases (NICD).
 Estimates from smaller studies in South Africa and studies in other regions, as
found in published literature, were also used as model inputs. Such estimates were
particularly useful for describing the characteristics of the smaller, high-risk groups such
as SW’s or MSM.

8. MODEL OUTPUT: NEW HIV
INFECTIONS ESTIMATED DATA
 19.8% of all new HIV infections in South Africa are
related sex work (SACEMA)
 Percent of new HIV infections, group only (5.5 %)
 Percent of new infections, group and their
partners/clients (19.8 %)

9. HOW DOES THIS TRANSLATE IN TERMS
OF DISEASE BURDEN – HIV
PREVALENCE AS A START
 Meta-analyses of aggregate country data comparing
HIV prevalence among female sex workers and women
of reproductive age in low-income and middle-income
countries, 2007–11. (Lancet Infect Dis 2012;12: 538–
49)
 Method: Systematic review of 434 articles and
surveillance reports representing 99 878 female sex
workers in 50 middle income countries.

10. STUDY FINDINGS
HIV 95% CI HIV % HIV
prevalence prevalence infections
among among among
female sex female female
workers population sex
workers
59·6% 56.2–63.1 25.32% 5.7%

11. IMPLICATIONS FOR PROGRAMMES
 Results indicate the urgency of establishing a national
programme for sex workers that includes HIV prevention
interventions
 Further studies of South Africa’s high risk populations,
including sex workers and their clients, to obtain estimates
of the sizes of these groups and HIV incidence and
prevalence among them.
 “In South Africa, the HIV epidemic is truly generalized
with HIV transmitted mainly heterosexually, and high
levels of infection by no means restricted to the high-risk
groups”.

12. ACKNOWLEDGEMENTS
 The SACEMA team
• Reshma Kassanjee and Alex Welte
• Tyrone Lapidos
• Eleanor Gouws (UNAIDS)
 Dr John Mkandawire (WRHI)

13. Ke a leboga