# Deaths of Female Sex Workers from HIV/AIDS in Kenya, Nigeria, and the Democratic Republic of the Congo 2019–2023 and Barriers to Antiretroviral Therapy Adherence

## TL;DR

This study finds that most female sex workers who died from HIV/AIDS in Kenya, Nigeria, and the DRC stopped taking antiretroviral therapy due to food insecurity, mental health issues, and stigma.

## Contribution

The study identifies specific barriers to ART adherence among FSWs who died from HIV/AIDS in sub-Saharan Africa using a community knowledge approach.

## Key findings

- 95.1% of FSWs who died from HIV/AIDS were not on ART at the time of death.
- Food insecurity was the leading barrier to ART adherence, cited by 22.9% of cases.
- Improving ART access alone is insufficient to reduce mortality among FSWs.

## Abstract

Public health relevance—How does this work relate to a public health issue?
This study uses a community knowledge approach to identify 445 female sex workers (FSWs) who died from HIV/AIDS deaths across Kenya, Nigeria, and the DRC from 2019 to 2023.This study examines barriers to antiretroviral therapy (ART) adherence among FSWs and investigates relationships between death from HIV/AIDS and food insecurity, behavioral health, and stigma.

This study uses a community knowledge approach to identify 445 female sex workers (FSWs) who died from HIV/AIDS deaths across Kenya, Nigeria, and the DRC from 2019 to 2023.

This study examines barriers to antiretroviral therapy (ART) adherence among FSWs and investigates relationships between death from HIV/AIDS and food insecurity, behavioral health, and stigma.

Public health significance—Why is this work of significance to public health?
A total of 95.1% of FSWs who died of HIV/AIDS were not taking ART at the time of their death, and 89.5% had stopped taking ART rather than never initiating, indicating sustained adherence, rather than initial availability, as being the dominant gap.The leading barriers to non-adherence were food insecurity (22.9%), depression (13.5%), alcohol or drug use (10.4%), and stigma (5.7%).

A total of 95.1% of FSWs who died of HIV/AIDS were not taking ART at the time of their death, and 89.5% had stopped taking ART rather than never initiating, indicating sustained adherence, rather than initial availability, as being the dominant gap.

The leading barriers to non-adherence were food insecurity (22.9%), depression (13.5%), alcohol or drug use (10.4%), and stigma (5.7%).

Public health implications—What are the key implications or messages for practitioners, policy makers and/or researchers in public health?
Programs seeking to reduce mortality from HIV/AIDS in FSWs should address food insecurity, mental health care, substance use treatment, and stigma reduction, as improving ART access alone is unlikely to reduce mortality.

Programs seeking to reduce mortality from HIV/AIDS in FSWs should address food insecurity, mental health care, substance use treatment, and stigma reduction, as improving ART access alone is unlikely to reduce mortality.

Introduction: Female sex workers (FSWs) face heightened health risks, particularly from HIV, which accounts for 8% of FSW deaths in low- and middle-income countries. Adherence to antiretroviral therapy (ART) remains suboptimal and few studies have explored drivers of ART non-adherence among FSWs who died from HIV in sub-Saharan Africa. Methods: Using a community knowledge approach methodology, data on HIV-related deaths among FSWs were collected from a convenience sample across Kenya, Nigeria, and the Democratic Republic of the Congo between 1 February 2022, and 28 February 2023. Participants were recruited through local sex worker organizations and non-governmental organizations. A structured questionnaire was used to collect demographic data, HIV treatment history, and reasons for ART non-adherence from participants about the deaths of FSWs they knew of personally. A qualitative descriptive analysis was used to code the interviews for reasons for ART non-adherence. Results: A total of 853 FSWs reported the deaths of 445 peers who had died from HIV/AIDS. The mean age at death was 27 years; 70.6% were mothers. Among the deceased, 95.1% were not taking antiretrovirals at the time of their death, and 90% had stopped using ART, rather than never initiating treatment. The most cited reasons for ART non-adherence were food insecurity (97; 22.9%), alcohol and drug use (44; 10.4%), depression (57; 13.5%), and stigma (24; 5.7%). Conclusion: HIV-related deaths among FSWs in these three sub-Saharan African countries are associated with food insecurity, mental health issues, substance use, and stigma. Improving access to ART alone is insufficient to reduce mortality.