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The burden of an HIV epidemic in Kosovo lies among the key populations (KPs) of female sex workers (FSWs), men who have sex with men (MSM), and people who inject drugs (PWIDs). The available interventions for KPs are fragmented and lack sufficient and appropriate granularity of information needed to develop large-scale outreach programs.
The aim of this study was to estimate the size and distribution of these populations to create evidence for developing action plans for HIV prevention.
The programmatic mapping approach was used to collect systematic information from key informants, including geographic and virtual locations in 26 municipalities of Kosovo between February to April 2016. In level 1, information was gathered about KPs’ numbers and locations through 1537 key informant interviews within each municipality. Level 2 involved validating these spots by conducting another 976 interviews with KPs congregating at those spots. Population size estimates were calculated for each spot, and finally a national-level estimate was developed, which was corrected for duplication and overlaps.
Of the estimated 6814 MSM (range: 6445 to 7117), nearly 4940 operate through the internet owing to the large stigma and discrimination against same-sex relationships. Geo-based MSM (who operate through physical spots) congregate at a few spots with large spot sizes (13.3 MSM/spot). Three-fourths of the MSM are distributed in 5 major municipalities. Fridays and Saturdays are the peak days of operation; however, the number only increases by 5%. A significant number are involved in sex work, that is, provide sex to other men for money. PWIDs are largely geo-based; 4973 (range: 3932 to 6015) PWIDs of the total number of 5819 (range: 4777 to 6860) visit geographical spots, with an average spot size of 7.1. In smaller municipalities, they mostly inject in residential locations. The numbers stay stable during the entire week, and there are no peak days. Of the 5037 (range: 4213 to 5860) FSWs, 20% use cell phones, whereas 10% use websites to connect with clients. The number increases by 25% on weekends, especially in larger municipalities where sex work is mostly concentrated. Other than a few street-based spots, most spots are establishments run by pimps, which is reflective of the highly institutionalized, structured, and organized FSW network.
This study provides valuable information about the population size estimates as well as dynamics of each KP, which is the key to developing effective HIV prevention strategies. The information should be utilized to develop microplans and effectively provide HIV prevention services to various KPs.
Kosovo is the smallest country in the Balkans region of Europe and, in terms of registered HIV cases, has the smallest HIV epidemic in the World Health Organization (WHO) Regional Office for Europe (WHO/Europe) [
Despite the small epidemic size, it is likely that the highest burden of HIV lies among various key populations (KPs), especially in men who have sex with men (MSM) and people who inject drugs (PWIDs), as seen in many neighboring countries [
To date, the HIV epidemic in Kosovo has remained insignificant, yet there is a strong potential for its growth, particularly among MSM and PWIDs [
On the basis of these principles, this study aimed to develop size estimates of KPs in Kosovo and provide the HIV prevention program with grassroot-level information to improve program design and coverage. The key objectives were to quantify the size of KPs, understand their subtypes, and identify locations where they can be found. Data from this study generated evidence for developing action plans for HIV prevention interventions tailored to KPs’ needs to scale up the HIV response.
In epidemiological terms, the mapping methodology employed within this study resembled a cross-sectional survey to identify KPs in the epidemiological context of person, place, and time. The study was conducted in 26 of the 38 municipalities in Kosovo. The remaining municipalities were excluded because of security issues or political unrest. Data were collected from February to April 2016. During the preparation phase, KP communities and networks were engaged to discuss and develop procedures that ensured no harm was caused to the KP. This engagement with KPs was critical and consistent, with the approach of
The broad methodological approach included 2 sequential phases. Level 1 (L1) was a systemic process of gathering information from secondary key informants on geo-locations where KPs congregate to meet sexual partners or inject drugs. Secondary key informants are people who are not KPs themselves but are knowledgeable of the presence and operations of KPs, for example, bar tenders, cab drivers, pimps, and massage parlor workers etc. A total of 1537 interviews were conducted in L1. The entire study area was divided geographically into smaller data collection units referred to as
Geographic mapping captures only the visible segment of KPs who operate at publicly accessible venues. Consultations with the MSM community revealed that it was important to account for the less visible/frequently active MSM who meet their clients/partners exclusively by other means (eg, through internet websites and mobile phone–based geo-social networking apps (GNA) [
The process involved working closely with the MSM community and making a list of all such MSM dating websites and mobile phone–based GNAs as the first step. These sites included global sites, county-specific sites, as well as Facebook and WhatsApp groups specific to the country. A total of 2 virtual mappers (VMs) who were knowledgeable about the use of such websites and apps were hired from the MSM community. A user profile was created at all active sites to be able to browse the websites/apps regularly. VMs logged in at each active internet site/GNA site 3 times a day for a period of 2 weeks to gather information about the total number of registered users, the number online at the particular time of visit, and the number of new registrations each day. To further understand these Web operations, the VMs contacted various virtual users randomly, introducing the research and encouraging them to participate in the study. Those who agreed to participate were invited for a face-to-face interview at a time and place of their convenience. During the interview, information was gathered on all websites/apps the MSM are registered with, multiple registrations with different identity documents at each site, the number of contacts made at each website, as well as use of geo-locations to look at overlap between virtual and geo-spaces. Although a high nonresponse was noticed (nearly one-thirds of the MSM contacted refused to participate), a sample of 84 MSM who operate through these sites were interviewed.
All data collected in the field were entered in a database developed in Microsoft Excel. The team leaders, along with the data manger, were responsible for all aspects of data quality and consistency. All spots were provided a unique code, and data were checked for consistency (eg, missing information, spelling mistakes, and outliers etc) by the field supervisors before forms were submitted to the data management team. Data entry was done at the project office in Pristina, under the supervision of a database supervisor.
KP size estimates were calculated for each spot. As a first step, all reported minimum and maximum KP estimates were summed up to get a range of estimate for each spot, which were rolled up into municipality estimates, while adjusting for duplication, that is, multiple spots visited by the same KP and also for invisible KPs who do not come to spots, using the following formula, where
Ei= si(1 – pi) +
The municipality estimates were aggregated into national-level estimates after adjusting for invisibility factor. Finally, average spot sizes (number of KPs per spot) were determined as well as the density of each KP per 1000 adult men or women was also calculated. The adult male and female population of Kosovo was used as a denominator [
This appraisal was designed to meet international ethical protocols by taking effective measures to avoid risk, protect individuals’ rights, and ensure safety of all study participants. Ethical approval for the study was taken from the Ethical Review Board at the Ministry of Health, Kosovo. In addition, specific measures were taken to ensure the safety of the field teams and KPs. Data were collected only in municipalities which were deemed safe and received support from the local police. The KP community was given the power to make decisions on how this project was implemented, and all their concerns and suggestions were duly incorporated in the research protocol. Recruitment of participants was conducted only after describing the study procedures and obtaining informed consent. A nonidentifying coding system was used to track study data while assuring nondisclosure of participants’ identities. All participants were provided information on existing services and were linked to the health and social services that are available for this community.
A total number of 17,670 KP members were identified in Kosovo. The largest KP found within the country was MSM, followed by PWIDs and FSWs. Aside from a difference in size estimation, stark differences were found surrounding the operational dynamics of each population, the type and location of spots frequented, and the alternative methods for seeking partners and/or engaging in risk activity.
This study estimated a total of 5037 (range: 4213 to 5860) FSWs in Kosovo (
Estimated number of female sex workers (FSWs), people who inject drugs (PWIDs), and men who have sex with men (MSM) in Kosovo in 2016.
Characteristics | FSWsa | PWIDsb | MSMc |
Estimated numberd | 5037 (4213-5860) | 5819 (4777-6860) | 6814 (6445-7117) |
Estimated number at geo-spots | 4163 (3482-4843) | 4974 (3932-6015) | 1874 (1570-2177) |
Estimated number of nongeo-spot/Web-based | 1058 | 845 | 4940 |
Estimated number of male sex workers | —e | — | 731 (595-865) |
Number of geo-spots | 790 | 847 | 141 |
Adult population | 566560f | 568903g | 568903g |
Number of KPsh per 1000 adults | 8.9 per adult females | 10.2 per adult males | 12.0 per adult males |
aFWSs: female sex workers.
bPWIDs: people who inject drugs.
cMSM: men who have sex with men.
dThe sum of geo-spot–based and nongeo-spot–based estimates might not add up to the total estimated number because of adjustments made in the final estimate to account for duplication.
eNot applicable.
fAdult female population.
gAdult male population.
hKPs: key populations.
Distribution of female sex workers (FSWs), men who have sex with men (MSM), and people who inject drugs (PWIDs) by municipalities in Kosovo in 2016.
Spot typologies and operational dynamics for various key populations in Kosovo in 2016.
Mapping | FSWsa | PWIDsb | MSMsc | ||||
Number of spots | Estimates | Number of spots | Estimates | Number of spots | Estimates | ||
Estimated number | 790 | 4163 | 847 | 4974 | 141 | 1874 | |
Spot size | 5.3 | 5.3 | 5.9 | 5.9 | 13.3 | 13.3 | |
Abandoned buildings | 0 | 0 | 240 | 1567 | 0 | 0 | |
Hotel/motel/guest house | 38 | 238 | 155 | 804 | 3 | 22 | |
Public transport stop | 13 | 62 | 42 | 261 | 63 | 709 | |
Residential place | 4 | 16 | 63 | 298 | 11 | 95 | |
Restaurant with live music | 225 | 1326 | 0 | 0 | 0 | 0 | |
Restaurant/coffee shop | 330 | 1584 | 0 | 0 | 18 | 348 | |
Salons/casino/shops | 66 | 273 | 0 | 0 | 20 | 318 | |
Streets/open spaces/park | 114 | 664 | 347 | 2044 | 26 | 382 | |
Peak day of operation | Friday, Saturday | All week | Friday, Saturday | ||||
Morning (before 12 noon) | 11.4 (29/481) | 71.0 (431/607) | 12.1 (16/132) | ||||
Afternoon (12-5 PM) | 41.2 (105/481) | 87.2 (529/607) | 44.7 (59/132) | ||||
Evening (5-9 PM) | 51.8 (132/481) | 57.8 (351/607) | 59.8 (79/132) | ||||
Night (9 PM onward) | 78.0 (199/481) | 20.9 (127/607) | 39.4 (52/132) |
aFWSs: female sex workers.
bPWIDs: people who inject drugs.
cMSM: men who have sex with men.
Although there have been some efforts in Kosovo in the past to estimate KP size and understand their operational dynamics [
Our study followed a simple community-led approach, ensuring active leadership and involvement of the KPs themselves in validating estimates. A total number of 6814 MSM, 5819 PWIDs, and 5037 FSWs were identified in Kosovo. Other than FSW estimates, the estimated numbers for both MSM and PWIDs are much lower than what have been calculated through previous research [
This research revealed in-depth information on the structure, subculture, and operational dynamics of each KP and found striking differences between them. This study identified 7 different types of geographic spots where FSWs in Kosovo congregate, find sexual partners, or engage in sexual activities. FSWs in Kosovo are centered around restaurants/coffee shops with live music and hotels/motels etc with a number of typologies involved; each having its own operational dynamics and prevention needs. Nearly all FSWs are a part of a wider but hidden network that functions undercover and are largely managed by network operators and pimps. Although sex workers are visible at a few spots, the network that operates them is extremely organized and well-connected and mostly keeps the sex work clandestine. This nature of sex work in Kosovo is reflective of the illegality of sex work and high prevalence of sex trafficking into and through the country [
PWIDs represent a small proportion of an overall large population of drug users in Kosovo [
Overall, this study has provided valuable information about the operational typologies and dynamics of these populations, which is the key to developing effective HIV prevention strategies. As part of utilization of the results, the knowledge gained from this study could be used to strategize target regions and towns where provision of services would be most effective and cost beneficial [
There were few limitations the study encountered regarding the geographic-spot validation process. Security issues and prohibited entry surrounding PWIDs and FSW spots inhibited the validation of various spots. Moreover, misclassification of exposures may also have occurred leading to an over or under representation of the study population. This could have resulted in an over classification of drug users as PWIDs or under classification of MSM who only engage in sexual activity with men occasionally or experimentally; thus, various drug users who share the same spots as PWIDs could have been included in the estimated PWIDs numbers, and MSM who do not engage regularly in MSM activities might have been missed in the overall estimates of MSM.
Overall, this study has shown that a substantial number of KPs are present in Kosovo, comprising of MSM, PWIDs, and FSWs. Each KP has a unique geographic distribution and operational dynamics by which they seek partners and/or engage in risk activity. Despite all limitations, this study’s findings can guide program planners to develop appropriate HIV program implementation strategies and enhance coverage. Knowledge gained can be used to develop macroplans to strategically target regions/town and microplans to strategically deliver services, as well as to develop and strengthen the structural components of the HIV prevention programs within Kosovo.
female sex worker
geo-social networking apps
integrated biological and behavioral survey
key population
Level 1
Level 2
male sex worker
men who have sex with men
nongovernmental organization
people who inject drugs
virtual mapper
World Health Organization
The authors would like to thank members of KPs, NGOs, and data collection staff for their engagement and commitment. They would also like to thank The Global Fund and Community Development Fund for financial support, and also Muhammad Zubair for developing ArcGIS maps and formatting of this manuscript.
None declared.