Background: Recently there has been interest in HIV prevention cascades. We applied a proposed prevention cascade framework (Garnett, 2016, Lancet) to data collected for a PLACE mapping and biobehavioral survey in 30 districts in Uganda.
Description: The client-centric and program centric cascades were measured for condom use among 9,207 HIV-negative female sex workers from 30 districts. The client centric cascade showed that over half of the female sex workers did not perceive themselves to be at risk for HIV acquisition. Most of those who perceived themselves at risk had ever used condoms but only 64 of the 9,207 female sex workers reported consistent use. The program centric prevention cascade found that only two-thirds of the female sex workers who are at risk have access to condoms. But of those who have ever used condoms, consistent use is very poor. Estimating the condom cascade led us to estimate the number of condoms that would be required per month in order to protect female sex workers. We estimated that 110,889 condoms would be required to for 10,417 female sex workers. We estimated that 1677 acts in the past 4 weeks were among HIV infected sex workers who did not use a condom. Anal sex was also often not protected.
Lessons learned: Both the program centric and the client centric cascades provided compelling evidence of the lack of availability of condoms, the poor uptake of condoms, and the almost negligible consistent use of condoms in this population. It is striking that 4,736 of 9207 female sex workers did not perceive they were at risk for HIV acquisition. It is also striking that 2853 female sex workers reported that condoms were not readily available to them. The cascade helped document the condom programming needs for this key population.
Conclusions/Next steps: These findings have already been used to advocate to increase cthe accessibility of condoms to those who most need it. Additionally, there is interest in developing HIV prevention cascades at the venue level to characterize venues that have been adequately reached by prevention programs and those where there remain gaps.