Developing a data system to inform real-time public health action among female sex workers in Zimbabwe

HIV and AIDS remain a global infectious disease priority, which disproportionally affects marginalised populations. Female sex workers (FSW) in sub-Saharan Africa are one such population at high risk of HIV infection. In the region, FSW are estimated to be 12 times more likely to have HIV than women of the same age who are not engaged in sex work. Just under half of all FSW in sub-Saharan Africa are thought to be living with HIV, with an estimated 12.5 new infections per 100 person-years of follow up. Despite the high burden of HIV among FSW, current research into the rate of new HIV infections and engagement of FSW throughout HIV care is limited. In population surveys and routine surveillance, FSW are typically under-represented due to high mobility, stigma and the criminalisation of sex work in many settings. To get a more accurate understanding of HIV among FSW in sub-Saharan Africa, different approaches including surveys using respondent driven and venue based snowball sampling have been used, yet there is much debate on how best to obtain representative data for this population. To monitor HIV infections and use of HIV services among the general population, data routinely collected from public health programmes and services are widely used. For FSW these data often don't exist, or where they do, are generally underused. These type of data are collected over long periods of time and at relatively low cost, they exist in large quantities providing a potentially valuable source of information. This project will use quantitative methods to analyse routinely collected programme data from Zimbabwe's National Sex Work programme, "Sisters with a Voice". The project aims to address current knowledge gaps on HIV among FSW in Zimbabwe and contribute to current research on methods for analysing and using routinely collected health service data for harder to reach populations. The Sisters programme provides HIV prevention and sexual and reproductive health services for FSW across Zimbabwe, including free access to HIV testing, diagnosis and treatment for sexually transmitted infection (STIs), family planning, HIV prevention education, condoms and legal support. Services are provided from fixed clinic sites and through mobile teams. Data on more than 30,000 FSW collected over approximately 10 years from 36 sites will be available for analysis. Every time a woman receives services from the programme, details of STIs, HIV testing and treatment history, along with socio-demographic information are recorded. Individual client data will be used to obtain estimates such as the number of new HIV infections and HIV prevalence and look at how this varies by socio-demographic factors including age and geographic location. These estimates will be compared to those obtained through cross-sectional surveys to validate findings. Measures of how women living with HIV engage with services provided by the programme will be used to look at bottlenecks throughout the course of care. Beyond the statistical methods applied to obtain estimates from this data, health informatics approaches, considering the management and use of client health care information, will be applied to develop systems of real-time data use to improve service delivery. With the global reduction in funding for HIV programming and research, and the high cost of population surveys, better use of routine data sources will facilitate increased understanding of HIV among population groups that are at increased risk of HIV infection, including FSW. Understanding the strengths and limitations of this data and being able to interpret and establish systems for real-time use is vital for improving service delivery and strengthening public heath responses to HIV.