Uptake of antiretrovirals in a cohort of women involved in high risk sexual behaviour in Kampala, Uganda J.Bukenya, M. Kwikiriza, O. Musana, J. Ssensamba, J. Bwana, H. Grosskurth, J. Vandepitte UVRI/MOH UGANDA

2 Background Access to ART has been increasing in Uganda –39 % in 2006 –53.5% in 2009 Female sex workers identified high risk group –HIV prevalence 37.2% vs 6.4% national average Limited data on access to ART in female sex workers –For their own health –Prevention of transmission benefit

3 KAMPALA Lake Victoria Good Health for Women Project Kampala MRC/UVRI Uganda Research Unit on AIDS

GHWP Cohort of 1027 women who report involvement in sex work enrolled Apr 08 – May 09 Aim – study epidemiology of HIV & STIs – conduct HIV prevention interventions Women attend clinic 3 monthly – social demographic data – data on sexual behaviour – blood & genital samples 4

GHWP clinic services General medical care – participants & children <5 yrs HIV Counselling & Testing Health education Free condoms Contraception Screening & treatment STIs Antenatal care Referral for ART 5

HIV Status - findings at screening 6 % Only one woman did not consent to having an HIV test

Objective To describe access to and uptake of ART among eligible HIV positive women who engage in high risk sexual behaviour in Kampala, Uganda 7

CD4-counts CD4 ≤ 250/ μl CD4 > 250 / μl Liver and renal function tests Full blood counts Pre-ART counselling Accompanied Referral for ART initiation Reassess: : 3 monthly > 400: 6 monthly All women receive CTX prophylaxis and ongoing counselling Management of HIV-positive study participants 8

Clients eligible for ART 9 HIV-positives at enrolment n= 382 (Prevalence: 37.2%) HIV-sero converters during follow- up (April 08 – June10) n= 34 (Incidence: 5.0 / 100 py) Returned for CD4-counts 411 / 416 (98.8%) * CD4 ≤ 250/μl n=177 CD4 > 250/μl n=234 * 2 women waiting for CD4-testing, 3 women did not return for CD4 assessment

Uptake of ART 10 Not on ART yet n= 142 (80%) Already on ART at enrolment n= 35 (20%) Eligible for n=177 Referred to ART providing centre n= 130 (92%) * Started ART n= 89 (69%) Missing at ART centre n= 23 (17%) * 8 women awaiting referral, 1 died and 3 missing for > 2 months On ART pathway n= 13 (10%) Died n= 5 (4%)

Discussion High acceptability of HCT services High HIV prevalence (37.2%) High HIV incidence (5.0%) 11

Discussion Low uptake of ART before enrolment – Only 20% of eligible women had accessed ART GHWP Project : increased uptake – Pre-assessment for ART – Baseline monitoring test – Pre-ART counselling – Continuing medical care in a trusted environment – Accompanied referral to ART provision centres – Regular follow up and defaulter tracing 12

Barriers to ART uptake Access to ART centres Stigma, fear, denial Alcohol & substance use 13 Lack of family support [drug companion / disclosure]

Recommendations Vulnerable high risk populations such as female sex workers require tailored interventions for sustained access to HIV testing and treatment Further research is needed to understand and overcome barriers to effective control and treatment of HIV infection in this population 14

Acknowledgements Good Health for Women Project Kampala staff and study participants Women at Work International (WAWI) Collaborating ART providing centres in Kampala, in particular Nsambya Hospital Medical Research Council, UK EDCTP 15