HIV risk segmentation in microplanning with female sex workers in Zimbabwe: an observational study

Abstract Introduction HIV acquisition and transmission risk among female sex workers (FSWs) is heterogeneous and shaped by overlapping behavioural, social and structural factors. Person-centred HIV programming requires tailoring support to FSWs’ needs. In the A dapted M icroplanning: E liminating T ransmissible HI V In S ex T ransactions (AMETHIST) cluster randomised trial, we implemented peer-led HIV risk assessments among FSWs in Zimbabwe enrolled in microplanning, a form of enhanced peer outreach. We examined how effectively HIV risk among FSWs was assessed. Methods At 11 sites, peer microplanners administered a risk assessment to FSWs based on six binary indicators, classifying them as at lower (score 0), moderate (score 1–2), or higher (score 3–6) risk. The risk assessment included information on both proximal ( condom use consistency, weekly client volume ) and distal ( young age, duration in sex work, substance and alcohol use, and violence ) factors. Risk was reassessed quarterly and FSWs were considered at higher risk until first assessment. Data from enrolment, quarterly assessments, and outreach data were analysed to assess: 1) risk assessment coverage, 2) risk heterogeneity between and within groups, 3) the association between factors included in the score, and 4) risk heterogeneity between sites. Results Among 7012 FSWs enrolled, 86.2% (n=6,045) completed ≥1 assessment, and 62% (29,163/47,101) of all expected assessments were completed. Exposure to violence and duration in sex work ≤6 months was far more likely in the higher risk group vs the moderate risk group. Risk factors were associated with each other as expected: for example, inconsistent condom use was associated with substance use (OR=3.05, 2.73–3.40), and violence (OR=2.16, CI 1.68–2.78). FSWs aged ≤24 years had higher odds of recent sex work entry (OR=3.91, 95% CI 3.48–4.38). Overall, 39.7% of FSWs were at higher risk with site level differences ranging from 22.8-74.9% across sites. Conclusion Peer microplanners effectively delivered risk assessments within microplanning with high coverage. The simple six factor tool captured both individual and contextual differences in risk. Risk segmentation by peer microplanners has the potential to enhance equity and efficiency in HIV services. Refinements including digital tools could further focus support. Trial registration : Pan African Clinical Trials Registry PACTR202007818077777. Registered on 2 July 2020.