Microsoft word - models of health service delivery for female sex workers_20130620(2)

Systematic review of 66 service delivery models for female sex workers (FSWs) in
Africa and India
Ashar Dhana1, Richard Steen2, Lizzie Moore3, Anuradha Roy4, Yves Lafort5, Fiona Scorgie3, 1. Center for Health Policy, University of the Witwatersrand, Johannesburg, South Africa 2. Department of Public Health, University Medical Center Rotterdam, Rotterdam, 3. MatCH, University of the Witwatersrand, Durban, South Africa 4. London School of Hygiene and Tropical Medicine, London, UK 5. International Centre for Reproductive Health, Ghent University, Ghent, Belgium Background: Several biological, behavioural, and structural risk factors place FSWs at
heightened risk of HIV and other sexually-transmitted infections (STI) transmission.
Interventions targeting these factors can reduce HIV incidence among FSWs and,
consequently, the general population. However, the optimum scale, intensity and delivery
model of these interventions needs to be determined. This systematic review of projects in
Africa and India evaluated service delivery settings, intervention packages provided and
extent of government involvement in these services.

Methods: We searched Web of Science, MEDLINE and reference lists for studies of FSWs in
low- and middle-income countries published from January 2000 to November 2012. Articles
in key non-indexed journals and on websites of international organizations were also
identified. All studies describing a set of clinical or non-clinical services for FSWs in India
and Africa were included. A single reviewer screened articles and extracted data into
predefined fields.

Results: A total of 181 articles were included, with 58 service delivery models in Africa and
8 in India. In Africa, most models were localised and small-scale; distinct from other
services; and centred around research activities or demonstration projects. Conversely,
Indian models covered large geographical areas and often extended beyond state lines.
However, there were few instances of services in Africa beginning as single clinical sites and
later expanding to other areas. Also, two initiatives to provide regional coordination of
projects in Africa were located, especially around services along major transport routes.
Although models in both settings were generally funded by international donors, the Indian
government recently took over its programme. In Africa and India, almost all models
provided integrated HIV and STI interventions. Most services distributed male condoms, but
only about 10% provided female condoms. While most HIV services encompassed HIV
counselling and testing, including mobile and peer outreach testing, few offered
antiretroviral therapy (ART) or CD4 testing. STI services were more comprehensive and
included screening and syndromic management, although periodic presumptive treatment
was only provided by 11 services and acyclovir treatment was rare. By contrast, few projects
in Africa or India included reproductive health services such as family planning and cervical
cancer screening. Unlike models in Africa, those in India placed much emphasis on gender-
based violence services and community engagement.

Conclusions and recommendations: We found marked weaknesses in delivery models in
Africa, compared with those in India. The coordinated large-scale programmes in India, and
their consequent economies of scale, contrast strongly with the multiple small projects in
Africa with low coverage. The India project was recently subsumed within government
services. A large-scale project in Africa, initially donor-led, could do likewise. While HIV
prevention remains the mainstay of services, access to ART should be enhanced both for
FSWs health and for reducing onward HIV transmission. Moreover, service delivery models
are needed which integrate reproductive health services and address structural risk factors,
such as gender-based violence. Much could be learnt from the India experience. By raising
the quality and scale of services for FSWs, Africa can reduce the considerable transmission
of HIV and STIs in these settings.

Key words: female sex workers, intervention packages, service delivery settings,
government involvement


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Manuscript of Review Article published in: MICROSCOPY RESEARCH and TECHNIQUE 2000; 48: 303-11 ROLE OF APOPTOSIS IN GASTRIC EPITHELIAL TURNOVER Axel von Herbay 1 , Jochen Rudi 2 1 Institute of Pathology, 2 Medizinische Klinik IV, University of Heidelberg, GermanyAddress for correspondance: Priv.-Doz. Dr. med. A. von Herbay, Pathologisches Institut,Universitätsklinikum, Im Neuenheimer F

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