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Potential reduction in female sex workers’ risk of contracting HIV during coronavirus disease 2019

Female sex workers’ livelihoods in Zimbabwe have been severely impacted by the coronavirus disease 2019 pandemic due to closure of entertainment venues. Competition over fewer clients has reduced ability to negotiate condom use. At the same time as partner numbers have decreased, frequency of reported condomless sex has not increased, suggesting potential reduction in overall HIV and sexually transmitted infection risk and an opportunity for programmes to reach sex workers with holistic social and economic support and prevention services.

Female sex workers' livelihoods in Zimbabwe have been severely impacted by the coronavirus disease 2019 pandemic due to closure of entertainment venues. Competition over fewer clients has reduced ability to negotiate condom use. At the same time as partner numbers have decreased, frequency of reported condomless sex has not increased, suggesting potential reduction in overall HIV and sexually transmitted infection risk and an opportunity for programmes to reach sex workers with holistic social and economic support and prevention services.
The global coronavirus disease 2019  pandemic has disrupted economies across the world, disproportionately threatening the livelihoods of people working in the informal sector with low-wage jobs [1]. These include sex workers, who are further marginalized due to the criminalization of sex work [2]. Reports from diverse regions suggest sex workers continue to work despite restrictions to survive, but struggle to find clients and experience increased vulnerability to stigma, violence and police harassment [3].
In Zimbabwe, Sisters with a Voice is a nationally scaled HIV prevention and treatment programme for sex workers that reaches over 26 000 female sex workers (FSW) annually with social and clinical services [4]. During Zimbabwe's national lockdown (April-October 2020), we collected data from FSW visiting our two largest clinics in Harare and Bulawayo on their client numbers, earned income, work conditions and condomless sex, which we compared with our most recent representative data from Respondent Driven Surveys (RDS) conducted in these sites in 2017.
We found 90% FSW attending these clinics reported reduced client numbers. In 2017 RDS, weekly client numbers averaged 14 in Harare and eight in Bulawayo but since lockdown, FSW reported mean monthly client numbers of nine and three, respectively. Of these, FSW reported condomless sex with two of nine clients (Harare) and one of three (Bulawayo) following lockdown compared with 2 of 52 and 1 of 32 in 2017, but absolute numbers of condomless partners did not increase. Anecdotally, sex workers report that closure of entertainment venues, restrictions on mobility, and male clients' fear of contracting COVID-19 have significantly reduced earnings. When FSW do procure a client, they are less likely to negotiate condom use or high fees, and are more willing to accept condomless sex and exchange sex for food.
Restrictions in Zimbabwe have constrained FSW ability to work, negotiate condom use or refuse clients, increasing their social and economic marginalization. However, it is possible that a reduction in overall client numbers without an accompanying increase in condomless sex has not increased their risk of HIV and STI, and possibly decreased it. The Sisters programme has addressed FSW precarious survival at this time by offering psychosocial support and livelihood assistance; for example, by facilitating self-help groups to set up shared savings and income support schemes, including making facemasks to sell. It is imperative to address FSWs' needs holistically as well as reinforce HIV prevention messages to take advantage of a possible reduction in HIV risk by ensuring its sustainability. In this study of 12 people with HIV (PWH) who received the first dose of SARS-CoV-2 mRNA vaccination, anti-SARS-CoV-2 receptor-binding domain antibodies were detectable in all participants; lower antibody levels were seen in those with lower CD4 R counts, and vaccine reactions were generally mild.
People with HIV (PWH) were included in the original severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) mRNA vaccine trials in small numbers [0.6% for mRNA-1273 (Moderna) and 0.5% for BNT162b2 (Pfizer/BioNTech)], yet the immunogenicity and safety of the vaccines has not been reported in this subgroup [1,2]. Vaccination is currently recommended for all PWH; however, some have expressed vaccine hesitancy for fear of harmful side effects and unknown effectiveness [3,4]. We, therefore, studied the antibody response and reactogenicity to the first dose of SARS-CoV-2 mRNA vaccination in PWH.