Reducing HIV transmission among female sex workers in Mali: a retrospective evaluation of prevention interventions among female sex workers in Mali from 2000 to 2013
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Background Female Sex Workers (FSW) in Mali are highly vulnerable to HIV. Their prevalence in 2009 was nine times higher (24.2%) than that among pregnant women (2.7%). The aim of this study was to document the effectiveness of HIV prevention programming targeting FSW between 2000 and 2013 funded by the U.S. Government (USG) in Mali. Methods The content, scope and coverage of interventions were assessed through a document review and key informant interviews with FSW peer educators and program managers. Data from the Integrated Sexually Transmitted Infection (STI) Prevalence and Behavior Surveys (ISBS) conducted in 2000, 2003, 2006, and 2009 were analyzed to measure changes in outcomes over time. Multivariate logistic regression was used to control for changes in FSW demographics and to analyze sub-groups. Results From 2000 to 2013 the USG was the key partner to the government of Mali (GOM) for HIV testing, surveillance, STI treatment, and behavior change communication (BCC) targeting FSW. The USG spent over $42 million on HIV programming between 2003 and 2013. Since 2001, programming for FSW covered most urban areas and transport hubs in Mali. USG partners exceeded their goals, making over 1.3 million BCC contacts with FSW and their sexual partners. However, outcomes were negatively impacted by frequent stock-outs of medications to treat STIs between 2006 and 2011. Also, evidence suggests that interventions were of insufficient intensity and coverage. Finally, M&E system was rudimentary and inconsistent, which made it impossible to link outcomes with programming with confidence. Nevertheless, important positive changes in outcomes occurred. Between 2003 and 2009, HIV prevalence dropped from 44.14% to 28.49% (P <0.0001) among Malian FSW, from 21.33% to 12.71% (P =0.0082) among Nigerian FSW, and from 43.42% to 33.67% (P =0.0442) among FSW from other countries. Between 2000 and 2009 HIV testing increased (40% to 76% P <0.0001). Consistent condom use with clients improved for Malian FSW (72.3% to 81.5% P =0.0092). Consistent condom use with boyfriends was low and improved only for Nigerian FSW (9.8% to 28.4% P =0.0003). Factors associated with HIV prevalence in the multivariate model were older age, study year (2003 and 2006), nationality, lack of education, mobility, STI symptoms, gonorrhea prevalence, and younger age at first sex. Conclusions This study documents progress in the fight against HIV among FSW in Mali, but coverage and intensity must be increased and the quality and diversity of interventions must be expanded. The different vulnerabilities to HIV of different nationality FSW should be addressed in future programming and research. Program adoption of and adherence to Mali’s new M&E plan for key populations would do much to facilitate the necessary improvements.