Contextualising the lived experience of sex workers living with HIV in South Africa: a call for a human-centred response to sexual and reproductive health and rights

Heterogeneity exists in every population for all health outcomes, including HIV acquisition and transmission among female sex workers (FSW) in South Africa. An estimated 58% of FSW in South Africa are living with HIV.1 While antiretroviral therapy (ART) is free at primary health clinics, ART coverage among FSW is estimated to be 24% and viral suppression rates, when available, are poor.1,2 These data highlight the current gaps in sexual and reproductive health and rights (SRHR) services for FSW in South Africa, which stem from multi-level barriers to SRHR service access, sustained engagement, and overall health and wellbeing.3 Creating programmes that assume homogeneity of needs for FSW living with HIV are unlikely to be successful. Even interventions designed to address complex barriers to SRHR services will fall short, and treatment outcomes will remain suboptimal, if we do not recognise that the context of women’s lives matters. The Siyaphambili study, launched in June 2018, addresses multi-level barriers to ART.4 Siyaphambili builds on the understanding that risk is heterogeneously distributed across FSW, and aims to identify the minimum cost-effective package and duration of additional services needed by different FSW in Durban, South Africa, beyond the standard of care, to promote retention and viral suppression.4 As of 7 June 2019, 769 FSW have been enrolled, with 40% virally suppressed (50 copies/mL) and a mean CD4 count of 551 mm3 (SD ± 317) at baseline. Siyaphambili data reinforce the layered complexity of women’s lives; even when viral suppression has been achieved, young women particularly remain at high risk of dying. The objective here is to describe lived experiences of South African FSW, using preliminary data and illustrative vignettes from Siyaphambili which highlight the need for tailored, comprehensive and adaptive SRHR services applied within the current policy- and community-level environments. Policy, violence and sex work SRHR care, including HIV care and treatment, can be intrinsically shaped by structural barriers (such as criminalisation and corruption), national policy around sex work and experiences of PERSPECTIVE 316 © 2019 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (