HIV incidence estimation among female sex workers in South Africa: a multiple methods analysis of cross-sectional survey data

BACKGROUND: Although numerous studies have investigated HIV risk factors and shown high HIV prevalence among female sex workers in South Africa, no national HIV incidence estimate exists for this potentially important group for HIV transmission. We aimed to estimate HIV incidence among female sex workers in South Africa who could be accessed through sex worker programmes, and to refine and describe the methods that enabled analysis. METHODS: This study was embedded in a cross-sectional national survey of female sex workers who were linked to sex worker programmes. We aimed to enrol 3000 female sex workers aged at least 18 years who had sold or transacted in sex in the preceding 6 months in 12 randomly selected districts of the 22 districts with sex worker programmes, ensuring coverage of all provinces of South Africa. Women who self-reported as current victims of human trafficking were excluded from enrolment. We used a multistep process to sample districts and then hotspots, and a chain referral method to recruit participants. We collected cross-sectional data for self-reported HIV status, demographic characteristics, and exposure to violence. Two rapid tests were used to ascertain diagnostic markers, a viral load assay was used to ascertain clinical markers, and the Maxim Limiting Antigen Avidity EIA was used to ascertain infection-staging HIV markers. Given the challenges of estimating HIV incidence, especially cross-sectionally, multiple methods of estimation were adapted to our setting, leveraging the age structure of HIV prevalence, recency-of -infection biomarker results (ie, where recent infection is classified as ≤1·5 normalised optical density [ODn] on the avidity assay and viral load of ≥1000 copies per mL), and reported testing histories. FINDINGS: Of 3005 female sex workers who were enrolled and interviewed between Feb 4 and June 26, 2019, 2999 who had HIV test results were included in this analysis. The median age of participants was 32 years (IQR 27–38). 1714 (57·2%) of 2999 participants self-reported as being HIV positive, and 1447 (48·3%) of 2993 participants reported client sexual violence in the past year. The measured HIV prevalence was 62·1% (95% CI 60·3–65·7) and peaked at approximately age 40 years. Using recency-of-infection biomarker results, we obtained a base case estimate of HIV incidence of 4·60 cases per 100 person-years (95% CI 1·53–8·45) for the population. Estimates were generally consistent by method, and outlying incidence estimates calculated by self-reported testing histories were considered unreliable. Various sensitivity analyses produced estimates up to 11 cases per 100 person-years, and we did not detect differences by age and region. INTERPRETATION: We found that female sex workers have extraordinarily high HIV incidence of approximately 5 cases per 100 person-years, emphasising the need to sustain and strengthen efforts to mitigate risk and provide adequate care. The notable role that sex work has in HIV transmission demands substantial investment in ongoing epidemiological monitoring. FUNDING: South African Medical Research Council, South African National Treasury, Global Fund, South African Department of Science and Innovation, Wellcome Trust.