Act now to stop HIV progressing among Sri Lankan women who sell sex, researchers warn
Sex worker study in three cities reports low HIV prevalence – but knowledge on HIV prevention and condom use is falling
Research involving around 1,200 women who sell sex in Sri Lanka has found a relatively low HIV prevalence. But worrying declines in condom use and HIV prevention knowledge suggest the window to stop HIV from getting worse could be closing.
Sri Lanka has a low-level HIV epidemic, with prevalence lower than most South Asian countries at below 0.1%, according to UNAIDS data. In 2018, 350 people acquired HIV. Although this is low, it is still the highest number of new infections since 1987, when the first case was identified and is 23% higher than in 2017.
To examine whether HIV is beginning to increase among people at higher risk of infection between 2017 and 2018 researchers conduced an integrated bio-behavioural survey (IBBS) among around 460 women who sell sex in Colombo, 360 in Galle and 360 in Kandy. This is the second IBBS to be carried out among women who sell sex in the country. Its results suggest some worsening and some improvement since 2015 when the first survey happened.
The 2018 survey found no sex workers in Galle and Kandy were living with HIV or hepatitis B. This is an improvement on the 2015 situation in Galle and no change in Kandy.
But in Colombo, 0.4% of participants were found to be living with HIV, four times the prevalence found in 2015, and 0.6% had hepatitis B.
Around 8.5% in Colombo, 2.5% in Kandy and 2% in Galle tested positive for syphilis antibodies. These levels are all higher than in 2015.
Overall, two-thirds of participants had heard of HIV, but knowledge on how to prevent HIV varied. Only 15% in Colombo could correctly answer five questions on HIV transmission, with levels higher in Kandy at 28% and in Galle at 41%. This was worse in Colombo and Kandy than in 2015 and better in Galle. Participants with a worse understanding of HIV were less likely to test.
Although Sri Lanka has scaled up HIV prevention services for people most at risk of infection between 2015 and 2018, condom use was found to be declining in some circumstances.
Around 80% used a condom the last time they had sex with a regular partner in Colombo, 36% in Galle, and 17% in Kandy. These levels are all lower than in 2015.
Condom use with clients in Colombo and Galle remains stable, and relatively high, at around 90%. But in Kandy, condom use at last sex with a client is lower at 57% and is worse than in 2015.
In 2018, around half of participants in Colombo and Galle and around 40% in Kandy had ever taken an HIV test. This is a slight improvement from 2015 in Galle and Kandy but a decline in Colombo where HIV is more prevalent.
In Colombo, just under 5% of participants reported injecting drugs, as did 0.9% in Kandy and none in Galle. Around 15% of participants in Kandy had been sexually assaulted or raped, 11% in Colombo and 1% in Galle.
The findings make it clear that women in Sri Lanka who sell sex are vulnerable to sexually transmitted infections, despite relatively low prevalence levels. To help protect sex workers from HIV and STIs, mobile testing services, self-testing and partner testing should be introduced. Tailored, peer-led interventions that increase condom negotiation skills across all types of partnerships should also be provided.