HIV Pre-Exposure Prophylaxis (PrEP) Online Course at Coursera Review. Day 17 of 42.

We start the 17th lesson of the PrEParing MOOC on the topic “PrEP among women in sex work exposed to violence or coercion”. The lecture was read by Michele R. Decker, ScD, MPH, an Associate Professor in the Department of Population, Family and Reproductive Health at the Johns Hopkins Bloomberg School of Public Health.

Dr. Decker directs the Women’s Health & Rights Program at the Center for Public Health & Human Rights. A social epidemiologist by training, her research focuses on gender-based violence (e.g., sexual assault, intimate partner violence, sex trafficking), its prevention, and its implications for sexual and reproductive health (e.g., STI/HIV, unintended pregnancy). Much of this work involves marginalized populations including urban women, adolescents and those involved in transactional sex or sex work. Her work includes clinic-based intervention efforts to mitigate the health consequences of violence, as well as primary research to understand the mechanisms by which violence influences sexual health and HIV risk. She blends large-scale quantitative investigations with qualitative methods. She works domestically as well as in South and Southeast Asia, and Eastern Europe/Central Asia.

“One of the three women who have ever been in a partnership has experienced physical or sexual violence throughout life,” Dr. Decker begins the lecture. Physical and sexual abuse is still prevalent even in developed countries, we often hear reports of coercive involvement of women in commercial sex, violence in families towards women partners and children. Close partners commit violence towards women. Husbands, cohabitants, boyfriends, clients of commercial sex services or partners for transactional “sex in exchange for a gift,” even partners in martial arts.

Fear accompanies violence, in such cases, the woman is simply afraid to offer an aggressive partner a condom, so violence is very consistently associated with HIV risk behavior. Often, it is not possible to offer a condom to a partner, and even if used, an aggressive partner can insistently propose to continue sex without a condom. Such circumstances lead to an increased risk of HIV transmission to a woman.

Women who experience physical or sexual violence do not always ask for a medical consultation. They may fear being blamed or stigmatized. They may not see violence as being connected with their health. So the recommendation to a PrEP provider is to listen very carefully to what might be going on in HIV risk behavior, to be ready to offer referrals for violence-related care if PrEP consultant suspect or are concerned that someone might be experiencing violence in their relationship.

Further, Michelle moves to female sex workers, the risk of getting HIV among them is 11 times higher than among the average global female population of reproductive age.

Most women who practice commercial sex are aware of the need to use a condom, but it often happens that the condom is not used. For example, in countries where commercial sex is prosecuted, the police often arrange raids in places where such women gather seizing condoms as evidence of sex work.

Clients do not seek to disclose their HIV-positive status to sex workers, and often do not know themselves about the positive status, and if they know, they can often be afraid of conviction or stigma from a sex worker.

Such women often seek to silence facts in dialogue with a doctor or a PrEP consultant, they afraid of consequences or blame, especially in countries where the law prohibits such business. Dr. Decker recommends for the PrEP consultant to listen, be attentive to details and demonstrate a lack of any prejudice, blame, astonishment, condemnation. It is worth letting the client know that HIV prevention services and PrEP are provided for everyone, without exception.

Women who engage in commercial sex, always depend on the will of the client and they constantly have to monitor this will, ensuring that the condom is used correctly.

PrEP is a woman-controlled method of risk reduction; this is an effective strategy for harm and risk reduction. A woman can keep calm for her health if she takes PrEP even if unsafe exposure to HIV happens.

The role of the PrEP consultant or sexual health physician who contacts sex workers is to convey to women the idea of taking control of HIV prevention in their own hands in a soft and unobtrusive manner. That PrEP is not an indicator of impairment; it is a simple and understandable practice of reducing the risk for all . In case the woman shows interest, a consultant should prescribe PrEP as soon as possible, according to the FDA’s clinical guidelines for prescribing PrEP.

Adherence to PrEP is important among sex workers. Truvada, a drug included in the current scheme of PrEP, reaches the significant concentrations in the vagina mucosal tissues much later than in rectum, not earlier than after 21 days of a regular drug intake. Therefore PrEP consultant needs to find a way to convey information that the first month of taking PrEP does not protect a woman from HIV, but she still needs to take the pills every day without missing any dose. It is recommended to exclude sex in the first month.

Women who experience violence from a partner of during sex trade could have issues with adherence to ART. Often they are choosing to hide PrEP intake; this leads to missing doses sometimes causing PrEP to become ineffective.

How can a PrEP consultant help a woman? It is worth trying to ask her about the time of the day she takes the pill, perhaps it is difficult for her to look at the situation from the other point of view and the solution becomes apparent to the doctor. Or maybe she does not want to make noise handling packing with pills? Then consultant could offer her to use a keychain, where two tablets of Truvada could be placed.

At the end of the lecture, Dr. Michele Decker states that it is important to educate sex about PrEP, inspiring them to spread information about PrEP among women in their community. The network effect works well and can significantly reduce the risks of HIV transmission among women at risk.

For today, the review is completed, if the information you read in the article seems to be important — please, share it on a social network or send it to friends by email or via Whatsapp, Viber, Telegram or another messenger.

Tomorrow we are waiting for the 4th day of the third module. If you have not already signed up for the PrEParing course on the Coursera platform, it’s never too late to do it, just follow the link https://www.coursera.org/learn/prep.

Stay with us and stay healthy!