HIV awareness and condom use among female sex workers in Afghanistan: implications for intervention

HIV Knowledge and Its Associated Sociodemographic Factors among Female Sex Workers in Malaysia

Background

Female sex workers (FSWs) have a high risk of human immunodeficiency virus (HIV) infection. In spite of the alarming fact that a large proportion of FSWs does not have adequate HIV knowledge, the association between sociodemographic factors and HIV knowledge among FSWs have yet to be thoroughly explored in the context of Malaysia. The aims of this study are the following: i) to determine HIV knowledge and ii) to examine the associated factors of HIV knowledge.

Methods

An observational cross-sectional study was conducted. Data from the Integrated Biological and Behavioral Surveillance Survey (IBBS) 2017 (n = 630) were used. The survey was carried out in all states in Malaysia and its duration was 4 months (from March 2017 to June 2017). Ordered probit regressions were utilised to shed light on the association between sociodemographic variables and levels of HIV knowledge.

Results

A large proportion of FSWs had middle-level HIV knowledge (44.1%). FSWs with tertiary-level education were 19.5% more likely to have high-level HIV knowledge compared to those without formal education. The probability of having low-level HIV knowledge was 6.8% lower among FSWs with monthly incomes of RM1,500-RM1,999 than those having incomes of ≤ RM499. Being single instead of married was associated with 7.6%-8% lower probabilities of having low- and middle-level HIV knowledge.

Conclusion

Public health interventions to improve FSWs' HIV knowledge need to take into consideration the role of sociodemographic factors.

Correlates of pregnancy among Female Sex Workers (FSWs) in semi urban Blantyre, Malawi

Background

Little is known about female sex workers’ (FSWs) reproductive health apart from their being at higher than usual risk of sexually transmitted infections (STIs), including HIV. The aim of this study was therefore to investigate the correlates of pregnancy among FSWs in semi – urban Blantyre in Malawi.

Methods

We used systematic sampling to recruit a total of 200 FSWs in four different study sites in Blantyre. Data were collected through questionnaire interviews. We calculated the mean and standard deviation for continuous covariates and proportions for categorical variables to describe the data. Logistic regression analysis was used to examine the correlates between the outcome variable (pregnancy) and independent variables.

Results

Ninety one (45, 5%) FSWs were between 18 and 24 years. The prevalence of pregnancy was 61% for FSWs born in rural place as compared to 37% for those who were born in town. In multivariate analysis FSWs who reported to value being respected as mothers had 12 times the risk of pregnancy comparing to the ones who did not (AOR: 11.8, 95% CI: [4.56, 30.72] p-value < 0.001). FSWs who reported using condoms inconsistently had five times the risk of pregnancy compared to the ones who did not, (AOR: 5.26, 95% CI: [2.29, 12.08], p-value < 0.001). FSWs who had a request to bear children from steady partners had 5 times the risk of pregnancy comparing to the ones who did not (AOR: 5.07, 95% CI: [2.14, 11.99]). FSWs who reported forgetfulness of contraceptives’ use had 3 times more risk of pregnancy comparing to the ones who did not (AOR: 3.49 CI: [1.29, 9.37], p-value < 0.013).

Conclusion

The study documents a wide range of correlates of pregnancies among FSWs in the study sites. It is important to recognize the child bearing desires and circumstances of FSWs in order to inform health programs responsive to their needs.

Characterising HIV/AIDS knowledge and attitudes in the Middle East and North Africa: Systematic review and data synthesis

This article reviews HIV/AIDS knowledge and attitudes in various population groups in the Middle East and North Africa (MENA), and highlights their relevance to HIV epidemiology and the design and implementation of preventions and treatment efforts. PubMed and the MENA HIV/AIDS Epidemiology Synthesis Project database of grey/unpublished literature were searched. Levels of knowledge were categorised based on presence of basic knowledge, comprehensive knowledge, and misconceptions and misinformation. Attitudes towards people living with HIV/AIDS (PLHIV) were classified into positive or negative. Basic knowledge was overall high among key populations at higher risk of infection (KPAR), and bridging and general population groups, but still a few population pockets had low basic knowledge. Level of comprehensive knowledge was overall low, and misinformation and misconceptions were prevalent. Some KPAR, including people who inject drugs, men who have sex with men, and female sex workers, were unaware of some modes of HIV transmission. Perception of risk of infection was low even among KPAR. We found differentials in knowledge putting women, rural populations, refugees, and other marginalised minorities at a disadvantage. Attitudes towards PLHIV tended to be negative. These findings are of concern, particularly for KPAR currently experiencing emerging HIV epidemics.

A comprehensive review of HIV/STI prevention and sexual and reproductive health services among sex Workers in Conflict-Affected Settings: call for an evidence- and rights-based approach in the humanitarian response

Background

While the conditions in emergency humanitarian and conflict-affected settings often result in significant sex work economies, there is limited information on the social and structural conditions of sex work in these settings, and the impacts on HIV/STI prevention and access to sexual and reproductive health (SRH) services for sex workers. Our objective was to comprehensively review existing evidence on HIV/STI prevention and access to SRH services for sex workers in conflict-affected settings globally.

Methods

We conducted a comprehensive review of all peer review (both epidemiological and qualitative) and grey literature published in the last 15 years (2000–2015), focusing on 1) HIV/STI vulnerability or prevention, and/or 2) access to SRH services for sex workers in conflict-affected settings. Five databases were searched, using combinations of sex work, conflict/mobility, HIV/STI, and SRH service terms. Relevant peer-reviewed and grey literature were also hand-searched, and key papers were cross-referenced for additional material.

Results

Five hundred fifty one records were screened and 416 records reviewed. Of 33 records describing HIV/STI prevention and/or access to SRH services among sex workers in conflict-affected settings, 24 were from sub-Saharan Africa; 18 studies described the results of primary research (13 quantitative, 3 qualitative, 2 mixed-methods) and 15 were non-primary research (e.g., commentaries, policy reports, programmatic manuals). Available evidence indicated that within conflict-affected settings, SWs’ capacity to engage in HIV/STI prevention and access SRH services is severely undermined by social and structural determinants including widespread violence and human rights violations, the collapse of livelihoods and traditional social structures, high levels of displacement, and difficulties accessing already scant health services due to stigma, discrimination and criminalization.

Discussion/Conclusions

This review identified significant gaps in HIV/STI and SRH research, policy, and programming for conflict-affected sex workers, highlighting a critical gap in the humanitarian response. Sex worker-informed policies and interventions to promote HIV/STI prevention and access to HIV and SRH services using a rights-based approach are recommended, and further research on the degree to which conflict-affected sex workers are accessing HIV/STI and SRH services is recommended.

A paradigm shift from the behavioural and biomedical approach to a human rights-based approach to HIV/STI prevention and SRH is strongly recommended.

War-Related Abduction and History of Incarceration Linked to High Burden of HIV Among Female Sex Workers in Conflict-Affected Northern Uganda

OBJECTIVE

Sex workers (SWs) in sub-Saharan Africa face a disproportionate HIV burden and growing concerns of severe human rights violations. Given the dearth of evidence on the burden and correlates of HIV among SWs in sub-Saharan Africa, particularly within conflict-affected settings, we examined the relationship between structural determinants (eg, war-related abduction, incarceration) and HIV infection among conflict-affected SWs in Northern Uganda.

DESIGN

Cross-sectional community-based research study among female SWs in conflict-affected Gulu, Northern Uganda.

METHODS

Interview questionnaires and voluntary HIV testing were conducted with participants recruited through SW/peer-led outreach and time-location sampling from 2011 to 2012. HIV prevalence was calculated, and bivariable and multivariable logistic regression was used to identify independent associations with HIV seroprevalence.

RESULTS

Of 400 SWs, 135 (33.75%) were HIV seropositive; of whom one-third were new/previously undiagnosed HIV infections. In multivariable analysis, after adjusting for age of sex work entry and education, lifetime incarceration (adjusted odds ratio: 1.93, 95% confidence interval: 1.17 to -3.20) was independently associated with HIV seroprevalence, and history of wartime abduction (adjusted odds ratio: 1.62, 95% confidence interval: 1.00 to 2.63) was marginally associated (P = 0.051).

CONCLUSIONS

This study documented a high rate of undiagnosed HIV infections and associations between war-related human rights violations, incarceration, and a heavy HIV burden among SWs in conflict-affected Northern Uganda. These findings highlight the serious harms of conflict and criminalization of marginalized women in sub-Saharan African contexts. SW-led interventions that address conflict experiences and policy shifts to promote a rights-based approach to HIV prevention and care remain critically needed.

Prevalence of drug and alcohol use in urban Afghanistan: epidemiological data from the Afghanistan National Urban Drug Use Study (ANUDUS)

BACKGROUND

Previous attempts to assess the prevalence of drug use in Afghanistan have focused on subgroups that are not generalisable. In the Afghanistan National Urban Drug Use Study, we assessed risk factors and drug use in Afghanistan through self-report questionnaires that we validated with laboratory test confirmation using analysis of hair, urine, and saliva.

METHODS

The study took place between July 13, 2010, to April 25, 2012, in 11 Afghan provinces. 2187 randomly selected households completed a survey, representing 19 025 household members. We completed surveys with the female head of the household about past and current drug use among members of their household. We also obtained hair, urine, and saliva samples from 5236 people in these households and tested them for metabolites of 13 drugs.

FINDINGS

Of 2170 households with biological samples tested, 247 (11·4%) tested positive for any drug. Overall, opioids were the most prevalent drug in the biological samples (5·6%), although prescription drugs (prescription pain pills, sedatives, and tranquilliser) were the most commonly reported in the past 30 days in the questionnaires (7·6%). Of individuals testing positive for at least one substance, opioids accounted for more than 50% of substance use in women and children, but only a third of substances in men, who predominantly tested positive for cannabinoids. After controlling for age with direct standardisation, individual prevalence of substance use (from laboratory tests) was 7·2% (95% CI 6·1-8·3) in men and 3·1% (2·5-3·7) in women-with a national prevalence of 5·1% (4·4-5·8) and a prevalence of 5·0% (4·1-5·8) in Kabul. Concordance between laboratory test results and self-reports was high.

INTERPRETATION

These data suggest the female head of household to be a knowledgeable informant for household substance use. They also might provide insight into new avenues for targeted behavioural interventions and prevention messages.

Policing the epidemic: High burden of workplace violence among female sex workers in conflict-affected northern Uganda

Sex workers in sub-Saharan Africa experience a high burden of HIV with a paucity of data on violence and links to HIV risk among sex workers, and even less within conflict-affected environments. Data are from a cross-sectional survey of female sex workers in Gulu, northern Uganda (n = 400). Logistic regression was used to determine the specific association between policing and recent physical/sexual violence from clients. A total of 196 (49.0%) sex workers experienced physical/sexual violence by a client. From those who experienced client violence the most common forms included physical assault (58.7%), rape (38.3%), and gang rape (15.8%) Police harassment was very common, a total of 149 (37.3%) reported rushing negotiations with clients because of police presence, a practice that was significantly associated with increased odds of client violence (adjusted odds ratio: 1.61, 95% confidence intervals: 1.03-2.52). Inconsistent condom use with clients, servicing clients in a bar, and working for a manager/pimp were also independently associated with recent client violence. Structural and community-led responses, including decriminalisation, and engagement with police and policy stakeholders, remain critical to addressing violence, both a human rights and public health imperative.

Determinants of consistent condom use among female sex workers in Savannakhet, Lao PDR

Background

Female sex workers (FSWs) are a high-risk population for HIV. Correct and consistent use of condoms is the most effective measure for reducing transmission of HIV. Lao PDR is a low HIV-prevalence country, but FSWs have a relatively high HIV prevalence. To be able to make recommendations for condom promotion interventions in Lao PDR it is important to know more about the context specific situation. This study looked at reasons for and associated factors of consistent condom use among FSWs.

Methods

A cross-sectional survey among 258 FSWs in Kaysone Phomvihan district in Savannakhet province was performed.

Results

Almost all FSWs had enough condoms (94 %), condoms always available (100 %) and could always afford condoms (92 %). Consistent condom use was 97% with non-regular partners and 60% with regular partners. Almost all respondents (95 %) had received information about condoms from the drop-in centre. Stated reasons for consistent condom use were prevention of HIV (94 %), STIs (88 %) and pregnancy (87 %). Most reasons for inconsistent condom use were related to partners not wanting to use condoms because of reduced sexual pleasure. Some FSWs reported that they were physically abused and forced not to use condoms. Shorter time in sex work, higher education and FSW not having regular partners were significantly associated with consistent condom use.

Conclusions

Consistent condom use was very high with non-regular partners, but less frequent with regular partners. The main reason for inconsistent condom use was that the partner did not want to use a condom. Associated factors for consistent condom use were not having regular partners, higher education and shorter time in sex work. Condom promotion programs should include both FSWs and their partners and female condoms should be included in condom intervention efforts. Future studies should investigate the validity of self-reported sexual practices, partners’ reasons for inconsistent condom use, risk of violence in sex work and why shorter time in sex work is associated with consistent condom use.

Mothers who sell sex: a potential paradigm for integrated HIV, sexual, and reproductive health interventions among women at high risk of HIV in Burkina Faso

BACKGROUND

Antenatal care is a point of entry into the health system for women across Africa and may facilitate the uptake of HIV services among female sex workers (FSWs). This study aimed to evaluate the determinants of motherhood among FSWs, their sexual risks, and their engagement in health care.

METHODS

A cross-sectional study was conducted from January to July 2013 among FSWs in Ouagadougou and Bobo-Dioulasso, Burkina Faso. The study used respondent-driven sampling for HIV testing and behavioral data collection. Predictors of motherhood and the association of motherhood and sex work dynamics were assessed separately using logistic regression.

RESULTS

Of the 696 women enrolled, the majority of participants (76.6%, n = 533) had at least 1 biological child. Mothers were more likely to have a nonpaying partner [adjusted odds ratio (aOR), 1.73; 95% confidence interval (CI): 1.20 to 2.49], and significantly less likely to currently desire to conceive (aOR, 0.21; 95% CI: 0.13 to 0.33). Motherhood was predictive of having reduced condomless vaginal or anal sex with a new client [age-adjusted odds ratio (aaOR), 0.80; 95% CI: 0.65 to 0.97] in the past 30 days, and increased condomless vaginal or anal sex with a nonpaying partner (aaOR, 1.49; 95% CI: 1.13 to 1.96). Motherhood was prognostic of a higher likelihood of ever being tested for HIV (aaOR, 1.89; 95% CI: 1.55 to 2.31). Motherhood was predictive of reporting limited difficulty when accessing health services (aaOR, 0.15; 95% CI: 0.67 to 0.34).

CONCLUSIONS

Motherhood is common among FSWs. The results indicate that FSWs who are mothers may have more exposure to health care because of seeking antenatal/perinatal services, presenting important opportunities for inclusion in the HIV continuum of care and to prevent vertical transmission.

Cross-sectional assessment of prevalence and correlates of blood-borne and sexually-transmitted infections among Afghan National Army recruits

BACKGROUND

Few data are available in Afghanistan to shape national military force health practices, particularly with regard to sexually-transmitted infections (STIs). We measured prevalence and correlates of HIV, syphilis, herpes simplex 2 virus (HSV-2), and hepatitis C virus (HCV) among Afghan National Army (ANA) recruits.

METHODS

A cross-sectional sample of male ANA recruits aged 18-35 years were randomly selected at the Kabul Military Training Center between February 2010 and January 2011. Participants completed an interviewer-administered questionnaire and serum-based rapid testing for syphilis and hepatitis C virus antibody on-site; HIV and HSV-2 screening, and confirmatory testing were performed off-site. Prevalence of each infection was calculated and logistic regression analysis performed to identify correlates.

RESULTS

Of 5313 recruits approached, 4750 consented to participation. Participants had a mean age of 21.8 years (SD±3.8), 65.5% had lived outside Afghanistan, and 44.3% had no formal education. Few reported prior marijuana (16.3%), alcohol (5.3%), or opiate (3.4%) use. Of sexually active recruits (58.7%, N = 2786), 21.3% reported paying women for sex and 21.3% reported sex with males. Prevalence of HIV (0.063%, 95% CI: 0.013- 0.19), syphilis (0.65%, 95% CI: 0.44 - 0.93), and HCV (0.82%, 95% CI: 0.58 - 1.12) were quite low. Prevalence of HSV-2 was 3.03% (95% CI: 2.56 - 3.57), which was independently associated with age (Adjusted Odds Ratio (AOR) = 1.04, 95% CI: 1.00 - 1.09) and having a television (socioeconomic marker) (AOR = 1.46, 95% CI: 1.03 - 2.05).

CONCLUSION

Though prevalence of HIV, HCV, syphilis, and HSV-2 was low, sexual risk behaviors and intoxicant use were present among a substantial minority, indicating need for prevention programming. Formative work is needed to determine a culturally appropriate approach for prevention programming to reduce STI risk among Afghan National Army troops.

Contraceptive utilization and pregnancy termination among female sex workers in Afghanistan

BACKGROUND

To determine the prevalence and correlates of prior pregnancy termination and unmet need for contraception among female sex workers (FSWs) in Afghanistan.

METHODS

FSWs in Jalalabad, Kabul, and Mazar-i-Sharif were recruited between June 2006 and December 2007 through outreach programs. Participants completed an interviewer-administered survey describing demographics, behaviors associated with risk of sexually transmitted infections (STIs) and unplanned pregnancy, and medical history. Correlates of prior pregnancy termination and current unmet need for contraception were assessed with logistic regression analysis, controlling for site.

RESULTS

Of 520 FSWs, most (82.3%) had been pregnant at least once (mean 4.9 ± 2.7, range 1-17), among whom unplanned pregnancy (36.9%) and termination (33.2%) were common. Jalalabad participants were more likely to report both prior unplanned pregnancy (60.6% vs. 48.3% in Kabul or 20.7% in Mazar, p < 0.001) and prior termination (54.9% vs. 31.8% in Kabul or 26.8% in Mazar, p < 0.001). Most FSWs (90.0%) stated pregnancy was not currently desirable, and 85.2% were using contraception. Unmet need for contraception (14.7% of participants) was positively associated with having sold sex outside their city of residence (adjusted odds ratio [AOR] 1.88, 95% confidence interval [CI] 1.28-2.77) and inversely associated with illicit drug use (AOR 0.41, 95% CI 0.31-0.53).

CONCLUSIONS

Although FSWs in Afghanistan report high rates of contraceptive use, unplanned pregnancy is common. Reproductive health services should be included in programming for FSWs to reduce unplanned pregnancies and to reduce HIV/STI risks.