Community Engagement for HIV Prevention Among Sex Workers in The MIFI District: Experience of Horizons Femmes Bafoussam

Introduction: According to the study (CAMPHIA 2017), the HIV prevalence among adults in Cameroon is 3.7% (5.0% among women and 2.3% among men). The HIV prevalence among Female Sex Workers (FSW) in Cameroon was estimated at 24.3% according to the 2016 IBBS survey. We wanted to share the experience of Horizons Femmes Bafoussam in HIV prevention among FSWs in the MIFI district.

Methods: The activities took place from September 2023 to August 2024. Initially, these involved mobilizations and awareness-raising of SWs by peer leaders recruited for this purpose in the project. Awareness-raising was carried out in the WhatsApp/Facebook groups/pages of sex work and in the community in hot spots, accompanied by demonstrations of correct use and distribution of male and female condoms and lubricating gels, HIV screening by DETERMINE, support for linking to treatment, follow-up of people who tested positive and initiation of PrEP.

Results: A total of 2,005 women workers were sensitized during this period on HIV/AIDS. They all received prevention materials (female and male condoms and lubricating gels), 1,731 self-tests were distributed during the period, 246 women workers were initiated on PrEP. Screening was carried out on 527. The positivity rate was 9.3%, i.e., 49 women workers newly tested positive. Among these, 48 were put on ART for a link rate of 97.9%.

Conclusion: Many challenges were encountered, but we overcame them. We believe that by building on the trust already established with this population, becoming an OBC dispensing ARVs in the Western region would allow us to improve the quality of life of our key populations.

In Cameroon, despite considerable efforts in the fight against HIV/AIDS, the prevalence of the infection remains a major public health concern. According to data from the 2017 CAMPHIA study [1], the prevalence of HIV among adults aged 15 to 49 is estimated at 3.7%. However, these average masks significant disparities between the sexes, with a prevalence of 5.0% in women compared to 2.3% in men. This difference highlights the increased vulnerability of women to infection due to complex biological, socio-economic, and cultural factors [2]. Studies have notably highlighted the role of gender inequalities, lack of economic autonomy, and patriarchal social norms in increasing the risk of infection among women [3]. Among the key populations most affected by HIV in Cameroon, female sex workers (FSW) are distinguished by a particulierement high vulnerability. The IBBS (Integrated Biological and Behavioral Surveillance Survey) conducted in 2016 revealed an alarming HIV prevalence of 24.3% within this population. This figure, significantly higher than the national average, demonstrates the urgency of targeted interventions adapted to the specific needs of FSWs. Several factors contribute to this increased vulnerability, including precarious working conditions, exposure to violence, lack of access to health services, and stigmatization [4,5]. Furthermore, FSWs often face legal and social barriers that hinder their access to HIV prevention and treatment services [6]. In this context, community organizations play an essential role in implementing HIV prevention strategies adapted to the realities of FSWs. By establishing relationships of trust, offering local services, and advocating for their rights, these organizations contribute to reducing the transmission of the virus and improving the quality of life of this vulnerable population. This article aims to present the experience of the Horizons Femmes Bafoussam organization in HIV prevention among FSWs in the MIFI health district, over a period from September 2023 to August 2024. The objective is to highlight the strategies implemented on the ground within the framework of the CHILL project, the challenges encountered, and the results obtained, in order to share good practices and inform future interventions.

HIV Prevention Strategies Implemented by Horizons Femmes Bafoussam

Within the framework of the CHILL project (Community HIV/AIDS Investments for Longer and Healthier Lives), whose objective is to reduce HIV/STI infections as well as related morbidity and mortality, and to mitigate the impact of HIV on the socio-economic development of Cameroon, Horizons Femmes is a sub-recipient.

The activities of Horizons Femmes within the framework of this project are implemented in the cities of Douala, Yaoundé, and Bafoussam (MIFI health district). Within the framework of this HIV prevention program among female sex workers (FSW) in the MIFI district, the Horizons Femmes Bafoussam organization used a multi-dimensional approach combining several complementary strategies:

Awareness Campaigns and Distribution of Prevention Materials: Collective and individual information sessions were organized to raise awareness among FSWs about HIV transmission modes and prevention methods. These campaigns were coupled with the free distribution of prevention materials, including male and female condoms, lubricating gels, and HIV self-testing kits. Practical demonstrations of the correct use of condoms and self-tests were also offered.

Initiation to Pre-Exposure Prophylaxis (PrEP): Horizons Femmes, within the framework of this project, actively promoted PrEP among FSWs, providing comprehensive information on its effectiveness and how to use it. The organization facilitated access to PrEP by initiating eligible beneficiaries and offering them personalized support for treatment adherence.

HIV Testing: Regular testing sessions were organized within the FSW community, using rapid tests to facilitate access and obtain immediate results. The use of HIV self-tests was also encouraged to allow FSWs to test themselves autonomously and confidentially.

Support and Follow-Up for Initiation of Antiretroviral Therapy (ART): FSWs newly diagnosed with HIV benefited from personalized support to facilitate their initiation of ART and ensure good treatment adherence. This support included therapeutic education sessions, psychosocial support, and regular monitoring of viral load.

During the period studied (September 2023 - August 2024), the activities of Horizons Femmes achieved the following results:

Awareness of 2005 FSWs on HIV Transmission Modes and Prevention Methods

Raising awareness among female sex workers (FSWs) about HIV transmission and prevention is crucial for effective public health strategies. According to the World Health Organization (WHO) [7], education and awareness programs are fundamental components of effective HIV prevention efforts among key populations, including FSWs. Studies have shown that increased awareness correlates with higher uptake of preventive measures [8].

Distribution of 1731 HIV Self-Testing Kits

HIV self-testing (HIVST) has been recognized as an important tool in expanding access to HIV testing services. Research indicates that providing self-testing kits enables individuals to test for HIV in a private setting, thereby increasing testing rates, especially among hard-to-reach populations like FSWs [9,10]. The availability of these kits has been shown to facilitate earlier diagnosis and linkage to care.

Initiation of 256 FSWs to PrEP

Pre-exposure prophylaxis (PrEP) is a proven strategy for preventing HIV among high-risk populations. A meta-analysis highlighted that PrEP can reduce the risk of HIV infection by 86% among individuals at high risk, including FSWs [11,12]. The initiation of 256 FSWs to PrEP indicates a successful integration of this preventive measure into community health services.

HIV Testing of 527 FSWs with a Seropositivity Rate of 9.3% (49 New Infections)

The seropositivity rate of 9.3% among tested FSWs reflects ongoing transmission dynamics within this population. Studies have shown that FSWs often have higher rates of HIV prevalence compared to the general population due to various sociocultural and economic factors [13]. This finding underscores the need for targeted interventions tailored to their unique risks.

Initiation of ART for 97.9% of Newly Diagnosed HIV-Positive Individuals (48 out of 49 People)

The high rate of initiation of antiretroviral therapy (ART) among newly diagnosed individuals aligns with recommendations from public health agencies emphasizing the importance of immediate treatment initiation for improving health outcomes and reducing transmission [14,15]. Early ART initiation is critical for viral suppression, which is key to ending the HIV epidemic.

Challenges Encountered and Future Prospects

• Persistent Stigmatization Towards FSWs: Stigmatization remains a significant barrier to accessing health services among FSWs. Research indicates that stigma can lead to social isolation and decreased healthcare-seeking behavior, which increases vulnerability to HIV and other health issues [16]. Negative societal attitudes toward sex work can deter FSWs from utilizing health services due to fear of discrimination or harassment [17]. To combat stigma, community engagement and stigma-reduction initiatives are crucial. Studies have shown that targeted interventions aimed at reducing stigma within healthcare settings can improve health service uptake and overall health outcomes [18].
• Difficulties in Accessing Health Services: FSWs often encounter systemic barriers to accessing healthcare, including geographical constraints, cost, and lack of tailored services. According to a study by Chahom et al. [19], many FSWs report experiencing difficulties in obtaining essential health services, which is compounded by cultural and institutional barriers. Community-Based Organizations (CBOs) play a vital role in bridging these gaps by offering localized, stigma-free environments that facilitate easier access to health services [20].
• Supply Disruptions: Supply chain issues can significantly impede the distribution of essential healthcare services, including HIV testing and treatment. A study in sub-Saharan Africa highlighted that supply chain disruptions, often caused by logistic challenges and funding limitations, directly affect service delivery and patient outcomes [21]. Strengthening supply chain management and ensuring consistent availability of medical supplies are critical for maintaining treatment continuity for vulnerable populations.

Strategies for Sustaining Action

To address these challenges, Horizons Femmes aims to enhance its trust with the FSW community and expand its expertise in HIV care. Building trust is fundamental for effective intervention delivery in marginalized populations. According to a study by Rivas et al. [22], cultivating trust between healthcare providers and communities leads to improved healthcare engagement and program adherence.

Community-Based Organization (CBO) Model

The reference to the FHI 360 study [21] highlighting the satisfaction of CBO patients with HIV services underscores the potential effectiveness of this model. CBOs are often more attuned to the specific needs of their communities compared to traditional health facilities, leading to higher patient satisfaction [22]. By transitioning Horizons Femmes Bafoussam into a CBO focused on providing antiretroviral therapy (ART), the organization can enhance access to treatment and support the quality of life for key populations by creating a tailored, accessible health environment.

Many challenges were encountered, but we overcame them. We believe that by building on the trust already established with this population, becoming an OBC dispensing ARVs in the Western region would allow us to improve the quality of life of our key populations.

Acknowledgments

Our thanks go to Our beneficiaries for their participation in this study; MIFI Health District, GTR Ouest and DRSP O, for their constant support; Our technical and financial partners USAID/PEPFAR/CHP.

Competing Interest

The authors declare that they have no conflicts of interest.