Luc BÉHANZIN MD, MSc, PhD Afri -Can Forum, Entebbe, January 17-19, 2013

1. Decline in the prevalence of HIV and sexually transmitted infections among female sex workers in Benin over 15 years of targeted interventions Luc BÉHANZIN MD, MSc, PhD Afri-Can Forum, Entebbe, January 17-19, 2013 The GHRI-funded capacity building team of Benin

2. CO- AUTHORS • Dr. MICHEL ALARY (CHU de Québec) • Dr. SOULEYMANE DIABATÉ (CHU de Québec) • Dr. CATHERINE LOWNDES (Health Protection Agency, London, UK) • Dr. MARCEL ZANNOU (Faculté des Sciences de la Santé de Cotonou, Bénin) • Dr. ISAAC MINANI (DIST Cotonou, Bénin) • Dr. SEVERIN ANAGONOU (Faculté des Sciences de la Santé de Cotonou, Bénin) • Dr. CLÉMENT AHOUSSINOU (Programme national de lutte contre le SIDA et les IST) • Dr. Marie-Claude BOILY (Imperial College, London, UK) • Dr. ANNIE-CLAUDE LABBE (Hôpital Maisonneuve-Rosemont, Montréal, Canada) • Article accepted for publication in JAIDS. QAIB4115R1,December 21, 2012

3. Outline ofpresentation • Background • Objectives • Methodology • Results • Discussion • Conclusion

4. BENIN • Population ~ 10 millions • Life expectancy at birth 59.2 • Cotonou: economic capital (Benin’s largest city) • Population of Greater Cotonou ~1 million

5. Background (2) Benin:

6. Background(3) • Benin has benefitedfrom Canadian Project implemented : • 1992 to 2006 • funded by Canadian International Development Agency (CIDA) • Interventions of this preventive project targeted at FSW and their clients had fully integrated activities of the main components of the project: • Community (principally: promotion of Consistent condom use) • Clinical (principally: curable STI control among FSW and their clients) • Structural (principally: securing the working environment and conditions of FSW) • Initially implemented in Cotonou, the interventions had been extended in 2000 to FSW clients and to six other cities

7. Background(4) • In 2006, the closingyear of the project, therewas the transfer of the responsibility of implementing the intervention from CIDA to the national authorities • The project was scaled up to the whole country: • Abandonment of the structural interventions and strategies targeting clients of FSW • Reduction in the intensity of the BCC activities that were also managed separately from the clinical component

8. Objectives • Estimate the time trends in HIV/STI prevalence and associated sexual behaviour among FSW in Benin from 1993 to 2008 • Assess whether or not the modification of the intervention that occurred after the Canadian project had any impact on the trends

9. Methodology

10. Methods (1) • Integrated Biological and Behavioural Survey (IBBS) conductedexclusively in Cotonou in 1993 (N=374), 1996 (N=350), 1999 (N=593) • IBBS extended to outside Cotonou in 2002 (N=723), 2005 (N=1482) and 2008 (N=1082) Study sites and population

11. Methods (2) • Sampling and Recruitment • Cluster sampling: sex work sites (clusters) were sampled with a probability proportional to size • Sampled clusters were systematically visited and all the FSW aged 15 years or older were asked to participate in the study • Laboratoryprocedures • HIV testing was carried out at the reference laboratory of the Benin National AIDS Control Programme using the National algorithm • Neisseriagonorrhoeae (NG) and Chlamydia trachomatis (CT) were tested using nucleic acid amplification tests

12. StatisticalAnalyses • Chi-square (proportions) and F (means) tests were used to assess temporal variations in socio-demographic and sexual behaviour characteristics • Extension of the Mantel-Haenszel chi-square was used for univariate analyses of time trends in HIV/STI Prevalence • Log-binomial regression was used for adjusting the time trends for socio-demographic characteristics

13. Results

14. Temporal variations in country of origin among female sex workers in Benin

15. Temporal variations in age among female sex workers in Benin

16. Time trends in consistent condom use among female sex workers in Benin Extension in outside Cotonou

17. Time trends in HIV/gonorrhea/chlamydia prevalence among female sex workers in Benin Extension in outside Cotonou 34 – 51% (O/Cotonou: 93-99)

18. Comparison of HIV/STI prevalence between 2005 and 2008 among female sex workers, Benin * significative decrease in consistent condom use in outside Cotonou

19. Discussion • Plausible impact of Canadian project: • The Canadian project could be characterized as employing the principles of combination prevention (documented by UNAIDS as a best practice for HIV prevention) • The context of natural experiments confers a level of plausibility for attributing the strong declines in HIV/STI prevalence to the Canadian project • Previous studies have shown that specific targeted preventive interventions of this type, can be effective in reducing both sexual risk taking and HIV/STI acquisition and transmission

20. Conclusion • Our results suggest a plausible significant impact of the targeted preventive interventions • The increase in gonorrhea prevalence after the Canadian project could be related to the absence of structural interventions, the reduction in the intensity of the community activities and the lack of integration of the different intervention components • To be effective on HIV and STI risk reduction, all components of preventive interventions targeting the most vulnerable populations, such as FSW, should be integrated

21. ACKNOWLEDGEMENTS • CIHR for funding the study • CIDA for funding the FSW intervention • All the personnel of Projet Sida 1/2/3 • The personnel of NACP and the Ministry of Health involved in Projet Sida 1/2/3 • All the personnel of DIST-Cotonou • All the female sex workers who accepted to be enrolled in the IBBS

22. Thank you, Merci!Comments and questions