Age Matters: Determinants of sexual and reproductive health vulnerabilities amongst young women who sell sex (16-24 years) in Zimbabwe

Stigmatizing and inaccessible: The perspectives of female sex workers on barriers to reproductive healthcare utilization - A scoping review

AIM

To systematically map the extent, range and nature of qualitative studies that explored female sex workers' own perspectives on barriers to accessing reproductive healthcare services.

DESIGN

A scoping review of the literature utilizing Arksey and O'Malley's method.

DATA SOURCES/REVIEW METHODS

A search of the electronic databases MEDLINE/ PubMed, PsycNET, Sociological Abstracts, ProQuest, ScienceDirect, HeinOnline, Scopus, Web of Science and Google Scholar was conducted for items published in English between 2001 and 2021.

RESULTS

Twenty-one studies were included in the review, the majority of which were conducted in lower-middle-income countries. RHC themes studied were diverse, with a few more studies focusing on STI/HIV, contraceptive use and pregnancy than those focusing on childbirth and postnatal care. The findings indicate barriers in four main domains: socio-legal barriers, health services-related barriers, interpersonal barriers and personal history-related barriers. Stigma was a major multifaceted barrier.

CONCLUSION

Female sex workers experience exclusion in utilizing reproductive healthcare services globally. As such, healthcare services are advised to adopt a nonjudgemental approach, to enhance physical accessibility and to train nurses and other healthcare professionals on reproductive health needs of female sex workers. Finally, knowledge production processes on the RHC of FSW should adopt a holistic view of FSW, by exploring their needs and barriers related to childbirth and maternity care and by including the perspectives of FSW in high-income countries.

IMPACT

The review offered an in-depth understanding of female sex workers' own perspectives regarding needs and barriers in utilizing reproductive healthcare services. Findings indicated socio-legal barriers, health services-related barriers, interpersonal barriers and personal history-related barriers. The review could inform the training of nurses and other healthcare professionals in reproductive healthcare services globally. Researchers should adopt a holistic view of female sex workers, by exploring their family planning needs, including barriers related to childbirth, maternity and postpartum care.

REPORTING METHOD

We adhered to the EQUATOR guidelines PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation.

Differential Burden of HIV Among Adolescent Girls and Young Women by Places Associated With Sex Work: An Observational Study in Mombasa, Kenya

BACKGROUND

The design of HIV prevention programs for adolescent girls and young women (AGYW) are informed by data on who is at highest risk and where they can be reached. Places (hotspots) associated with selling sex are an established outreach strategy for sex work (SW) programs but could be used to reach other AGYW at high risk.

SETTING

This study took place in Mombasa, Kenya.

METHODS

We conducted a cross-sectional, bio-behavioural survey among (N = 1193) sexually active AGYW aged 14-24 years recruited at hotspots. We compared HIV prevalence by subgroup (SW; transactional sex, TS; and non-transactional sex), stratified by hotspot type (venues and nonvenues). We examined whether associations between HIV prevalence and hotspot/subgroup remained after adjustment for individual-level risk factors, and estimated HIV prevalence ratio with and without adjustment for these individual-level factors.

RESULTS

Overall HIV prevalence was 5.6%, 5.3% in venues and 7.3% in nonvenues. Overall SW HIV prevalence was 2-fold higher than among participants engaged in nontransactional sex. After adjusting for age and individual-level risk factors, HIV prevalence was 2.72 times higher among venue-based SWs (95% confidence interval: 1.56 to 4.85) and 2.11 times higher among nonvenue AGYW not engaged in SW (95% confidence interval: 0.97 to 4.30) compared with venue-based AGYW not engaged in SW.

CONCLUSION

AGYW who sell sex remain at high risk of HIV across types of hotspots. The residual pattern of elevated HIV burden by AGWY subgroup and hotspot type suggests that unmeasured, network-level factors underscore differential risks. As such, hotspots constitute a "place" to reach AGYW at high risk of HIV.

Violence Against Women Who Sell Sex in Eastern and Southern Africa: A Scoping Review

Women who sell sex (WSS) are vulnerable to violence. We present a scoping review of the last decade of research on the prevalence and incidence of, factors associated with, and services regarding violence against WSS in Eastern and Southern African (ESA). A systematic search of various databases resulted in 20 papers being reviewed. Inclusion criteria, applied by the first two authors, were as follows: empirical papers, key research problem is violence against WSS, and conducted in ESA countries. The lifetime prevalence of violence revealed in the studies ranged from 21% to 82%. A pattern of generalized violence against WSS from paying clients, male partners, strangers, family members, friends/acquaintances, and the authorities emerged. Factors associated with violence included the context within which the sex work occurs, alcohol use, type of sex exchange interactions, and personal factors (low education, low income, marriage, youth, high client volume, time in sex work, forced sexual debut, and internalized sex work stigma). WSS seldom access services after violence. Evaluations of two programs, a woman-focused HIV intervention, and the Diagonal Interventions to Fast-Forward Reproductive Health project, showed improvements in gender-based violence services. Findings suggest that targeted programmes should be paired with improving general health services and focus on promoting collective agency among WSS.

HIV prevention in individuals engaged in sex work

PURPOSE OF REVIEW

People who sell sex remain at disproportionate risk of acquiring HIV and should be prioritized for evidence-based HIV prevention programmes delivered at sufficient scale and intensity for effectiveness. Although new biomedical tools are becoming available, many basic lessons learned early in the HIV pandemic remain salient today and need renewed attention.

RECENT FINDINGS

New preexposure prophylaxis formulations, distribution systems, and delivery mechanisms are being successfully trialled and implemented, adding to well established prevention tools such as male and female condoms and lubricants. The importance of social support networks and community ownership of programmes has been consistently reaffirmed. Serious challenges remain in optimizing HIV prevention for sex workers, including providing services at the scale and intensity necessary for population level impact, addressing culturally sensitive issues of gender identity and sexual orientation, and protecting adolescents and young people who may sell sex. Pervasive social stigma, often reinforced by criminalization and police harassment, further constrain sex workers' access to available services and prevention tools.

SUMMARY

Meaningful community engagement and addressing the multiple social determinants of vulnerability at individual, community, and structural levels remain at the core of preventing HIV among people involved in selling sex.

"It was protected, except, it wasn't [with] a condom": a mixed-methods study of BBVs/STIs protective practices among International University Students in Sydney, Australia

BACKGROUND

A number of previous sex-related studies among international students in Australia and other Western societies may be limited by conflating students from conservative and non-conservative sexual backgrounds. Such conflation leads to situations where nuances and complexities around sex-related experiences are lost or, at most, tangentially investigated. To address this research problem, this study used a mixed-methods design to examine protective practices against blood-borne viruses and sexually transmissible infections (BBVs/STIs) among Sydney-based East Asian and sub-Saharan African international students.

METHODS

This mixed-methods study generated quantitative data using anonymous online survey (n = 149), and qualitative data through in-depth interviews (n = 20). The main recruitment strategy involved advertising the study through paper and electronic flyers. Quantitative data were analysed using logistic regression, while interviews data were analysed using reflexive thematic analysis.

RESULTS

Self-reported BBVs/STIs protective practices in the last 12 months include abstinence (28.7%), consistent condom use (19.9%), occasional condom use (18.7%), single partner fidelity (25.1%), other strategies (1.8%), and nothing (5.8%). Further, findings from the bivariate analysis showed higher BBVs/STIs prevention knowledge, lower acculturation into Australian sexual culture, greater access to sexual health information, less conservative sexual norms, greater emotional social support and older age were significantly associated with increased protective practices. Variables significant at bivariate level were entered into a logistic regression. The model was statistically significant, (X²(6) = 31.33, p < 0.01) and explained 33.1% of the variance in BBVs/STIs protective practices. However, only acculturation to sexual norms in Australia (OR = 0.883, 95% CI = 0.820-0.952) was found to be independent predictor of BBVs/STIs protective practices. The results of the study based on the quantitative data, indicated condom use (consistent and occasional) was the most reported BBVs/STIs protective behaviour among sexually active participants. Therefore, interviews data was used to explore condom-use motives and practices. The interviews results showed participants primary concern as regards condom use was around pregnancy and not BBVs/STIs. Thus, some participants described safe sex largely as contraception, with BBVs/STIs constituting a secondary concern or no concern at all.

CONCLUSIONS

Based on the results of this study, tailored sexual health interventions for international students; which incorporate strategies for modifying perceived sexual norms in Australia, are advocated. In addition, this study recommends sexual health interventions that promote dual protection of condoms for both contraception and BBVs/STIs.

High burden of self-reported sexually transmitted infections among female sex workers in Togo in 2021

Background

Sexually Transmitted Infections (STI) remain a public health challenge, especially for Female Sex Workers (FSW) who are particularly vulnerable. In sub-Saharan Africa where the overlapping epidemics of STI and HIV are concentrated among key populations, epidemiological data are needed in order to better understand STI trends in this population. The aim of this study was to assess the prevalence of self-reported STI symptoms and their risk factors among FSW in Togo in 2021.

Methods

A cross-sectional study was completed in June and July 2021 among FSW in two cities of Togo: in Lomé (capital city, south of Togo) and in Kara (north of Togo). A snowball sampling method was used and after consent, a standardized questionnaire was administered by trained research staff to collect information on STI. A multivariate logistic regression model was used to identify factors associated with self-reported STI.

Results

A total of 447 FSW, 300 in Lomé and 147 in Kara participated in this study. Median age was 30 [IQR: 24–38] and STI symptoms in the previous 12 months were reported by 191 FSW [42.7%, 95% CI: (38.1–47.5)], among whom 116 (60.7%) sought medical care. The most common reported symptoms were abnormal vaginal discharge (n = 78; 67.2%) and vaginal itching (n = 68; 58.6%). Current STI symptoms (at the time of the survey) were reported by 88 FSW (19.7%). In multivariable logistic regression, self-reported STI symptoms in the previous 12 months was negatively associated with living in the Lomé and older age and positively associated with having more than 15 clients in the previous week and being victim of violence.

Conclusions

Findings from this study reveal that the self-reported STI burden is relatively high among FSW Togo. Additional strategies are needed at the structural, medical, political and social levels to curb this trend and effectively aim at the elimination of STI epidemics by the year 2030.

Intersectional vulnerabilities and differential impacts of COVID-19 responses on young people who sell sex in Zimbabwe

The varying impact of the COVID-19 pandemic on different populations has brought into focus the pre-existing inequalities which shape vulnerabilities amongst marginalised and key populations. More nuanced approaches which understand intersectional vulnerabilities and differential impacts of the pandemic on gender and sexuality diversity within these groups are required. We investigated the economic, social and health impacts of COVID-19 on young people of diverse genders and sexualities who sell sex (16-24 years) in Zimbabwe. We found that all groups had heightened vulnerability to economic and social hardship during the first two COVID waves in Zimbabwe. However, vulnerability was unequally distributed by geography and socio-economic position, as well as by gender and age, both within and between groups of participants. With limited funding resources for the promotion of sexual and reproductive health and rights in the push for universal health coverage, nuanced approaches which include analysis of multidimensional vulnerabilities between and within groups is required to develop the most cost effective and impactful policy and programme interventions.

Women Who Sell Sex in Eastern and Southern Africa: A Scoping Review of Non-Barrier Contraception, Pregnancy and Abortion

Objectives: There is a need to hone reproductive health (RH) services for women who sell sex (WSS). The aim of this review was to collate findings on non-barrier contraception, pregnancies, and abortion amongst WSS in Eastern and Southern African (ESA). Methods: A scoping review methodology was employed. Inclusion criteria were: 1) empirical papers from 2) ESA, 3) published since 2010, and 4) addressing WSS in relation to 5) the identified RH issues. Results: Reports of rates of non-barrier contraceptive usage varied from 15% to 76%, of unintended pregnancy from 24% to 91%, and of abortion from 11% to 48%. Cross-cutting factors were alcohol use, violence, health systems problems, and socio-economic issues. Pregnancy desire was associated with having a non-paying partner. Barriers to accessing, and delaying, antenatal care were reported as common. Targeted programmes were reported as promoting RH amongst WSS. Conclusion: Programmes should be contextually relevant, based on local patterns, individual, interpersonal and systemic barriers. Targeted approaches should be implemented in conjunction with improvement of public health services. Linked HIV and RH services, and community empowerment approaches are recommended.

Human Papilloma Virus infection and cervical cancer among women who sell sex in Eastern and Southern Africa: A scoping review

OBJECTIVES

Women who sell sex have a high prevalence of human papilloma virus, which may cause cervical cancer. The objective of this review was to collate findings on prevalence, associated factors, screening, service provision and utilization of services in relation to human papilloma virus and cervical cancer among women who sell sex in Eastern and Southern Africa.

METHODS

A scoping review methodology was employed. Inclusion criteria were as follows: (1) empirical papers, (2) of studies conducted in Eastern and Southern Africa, (3) published in the last 10 years, and (4) addressing women who sell sex in relation to (5) human papilloma virus and cervical cancer. A thorough search of a range of databases surfaced 66 papers. Both authors applied inclusion and exclusion criteria, resulting in 14 papers being reviewed.

RESULTS

The reported prevalence of high-risk human papillomavirus virus varied between 23.6% and 70.5%. HIV sero-positivity, other sexually transmitted infections and Epstein-Barr virus were associated with human papilloma virus and high-grade cervical lesions. High-risk human papilloma virus was associated with women who reported younger age at first intercourse, non-barrier contraceptive use, and no history of condom use. For screening, there was overall agreement between physician- and self-collected samples. Contradictory results were found for visual inspection with acetic acid. Screening services utilization was associated with provider's recommendation, history of sexually transmitted infections, frequency of facility visit and history of vaginal examination. A diagonal programme led to an increase in screening, attributed to the targeted services.

CONCLUSIONS

Context is important in planning cervical cancer services. There is a need for enhanced sexually transmitted infections and viral management within cervical cancer prevention. Women who sell sex should be empowered in self-collection of stored-dry specimens, especially in resource-constrained regions. Cervical cancer screening services should be honed to the needs of women who sell sex.

Economic and social dimensions influencing safety of induced abortions amongst young women who sell sex in Zimbabwe

Globally, women, experience inequities in access to safe abortion services and this is most acutely felt in country contexts where legal abortions are highly restricted. Data around abortion amongst young women who sell sex (YWSS) in sub-Saharan Africa are very limited. We conducted 30 focus group discussions and 42 in-depth interviews (IDIs) amongst YWSS (16–24 years) in urban and peri-urban areas of Zimbabwe, as well as IDIs amongst 16 peer educators, five health care providers and four key informants. Our findings indicate that abortions occur amongst YWSS in Zimbabwe but there remain questions over the extent of safety of abortions. The restrictive legal context around abortion and illegality of sex work in the country are key determinants underlying the clandestine nature of abortions. Socioeconomic concerns are key in decision-making around abortions. Youth, cost and lack of referral networks contribute towards unsafe abortions, even when safe abortion services are available. Many YWSS are not aware of the availability of post abortion care (PAC) services and resort to self-administered PAC. Being young and selling sex combine and interact on the economic and social levels to produce vulnerabilities greater than their sum to experiencing unsafe abortion.