HIV seroprevalence, incidence, and viral suppression among Ugandan female bar workers: a population-based study

BackgroundPrior studies have linked female bar and sex work in Africa. However, population-level data on HIV burden among female bar workers (FBWs) in African settings are rare. MethodsWe used five survey rounds of data collected between 2011 and 2020 from the Rakai Community Cohort Study, a population-based HIV surveillance cohort in 36 inland agrarian and trading communities (HIV prevalence ~12%) and four Lake Victoria fishing communities (~36%) in southern Uganda. Women reporting bar work as a primary or secondary occupation were identified and compared to non-FBWs. Primary outcomes included laboratory-confirmed HIV seropositivity, incident infection, viral suppression (<200 copies/ml) among women with HIV, and population prevalence of viremia. Prevalence ratios (PRs) and incidence rate ratios (IRRs) were estimated using Poisson regression models with 95% confidence intervals (95%CI). FindingsA total of 23,556 female participants contributed 52,708 person visits. Overall, 1,205 (5.1%) women self-identified as FBWs. FBWs had significantly higher baseline HIV seroprevalence compared to non-FBWs (51.9% vs. 18.5%,PR=2.81, 95%CI=2.64-2.95). 356 HIV incident events occurred over 39,228 years of participant follow-up. Incidence among FBWs was 2.49/100 person-years versus 0.87/100 person-years among non-FBWs (age-adjusted IRR=3.64,95%CI=2.33-5.42). While HIV viral suppression was similar among participants living with HIV regardless of FBW status, the population prevalence of HIV viremia among FBWs was 1.69 times higher compared to non-FBWs, adjusting for age and community type (95%CI=1.38-2.08). Among 179 HIV seronegative FBWs surveyed in 2018-20, 79.9% (143/179) were aware of PrEP, while only 13.4% (24/179) had ever used it, and just 2.8% (5/179) were current users. InterpretationFBWs in Uganda experience substantially higher HIV burden and acquisition risk compared to the general population. Tailored prevention strategies like prioritizing their HIV service delivery may reduce HIV incidence among FBWs and their partners. FundingNational Institute of Allergy and Infectious Diseases, National Institutes of Health