The contribution of emotional partners to sexual risk taking and violence among female sex workers in Mombasa, Kenya: a cohort study

Relationships Between Stigma and Intimate Partner Violence Among Female Sex Workers Living With HIV: Social and Economic Exclusion

Violence against female sex workers (FSWs) perpetrated by their intimate (i.e., non-commercial) partners, particularly against FSWs living with HIV, is understudied. Stigma can deplete the economic resources, social relationships, and mental well-being of stigmatized people, which may increase their intimate partner violence (IPV) risk. We quantitatively assessed relationships between HIV stigma and sex work stigma and IPV victimization among FSWs living with HIV in the Dominican Republic (n = 266). Enacted HIV stigma, in the form of job loss, and anticipated HIV stigma, in the form of fear of exclusion by family, were associated with increased IPV risk. Potential association mechanisms, including increased economic vulnerability and social isolation, and programmatic responses are discussed.

Using social practice theory in measuring perceived stigma among female sex workers in Mombasa, Kenya

BACKGROUND

Perceived stigma is a complex societal phenomenon that is harboured especially by female sex workers because of the interplay of a myriad of factors. As such, a precise measure of the contribution of different social practices and characteristics is necessary for both understanding and intervening in matters related to perceived stigma. We developed a Perceived Stigma Index that measures the factors that greatly contribute to the stigma among sex workers in Kenya, and thereby inform a framework for future interventions.

METHODS

Social Practice Theory was adopted in the development of the Perceived Stigma Index in which three social domains were extracted from data collected in the WHISPER or SHOUT study conducted among female sex workers (FSW), aged 16-35 years in Mombasa, Kenya. The three domains included: Social demographics, Relationship Control and Sexual and Gender-based Violence, and Society awareness of sexual and reproductive history. The factor assessment entailed Exploratory Factor Analysis (EFA), Confirmatory Factor Analysis (CFA), and the internal consistency of the index was measured using Cronbach's alpha coefficient.

RESULTS

We developed a perceived stigma index to measure perceived stigma among 882 FSWs with a median age of 26 years. A Cronbach's alpha coefficient of 0.86 (95% confidence interval (CI) 0.85-0.88) was obtained as a measure of the internal consistency of our index using the Social Practice Theory. In regression analysis, we identified three major factors that contribute to the perceived stigma and consists of : (i) income and family support (β = 1.69; 95% CI); (ii) society's awareness of the sex workers' sexual and reproductive history (β = 3.54; 95% CI); and (iii) different forms of relationship control e.g. physical abuse (β = 1.48; 95%CI that propagate the perceived stigma among the FSWs.

CONCLUSION

Social practice theory has solid properties that support and capture the multi-dimensional nature of perceived stigma. The findings support the fact that social practices contribute or provoke this fear of being discriminated against. Thus, in offering interventions to curb perceived stigma, focus should fall on the education of the society on the importance of acceptance and integration of the FSWs as part of the society and the eradication of sexual and gender based violence meted out on them.

TRIAL REGISTRATION

The trial was registered in the Australian New Zealand Clinical Trials Registry, ACTRN12616000852459.

Awareness, Willingness and Use of HIV Pre-Exposure Prophylaxis Among Female Sex Workers Living in Dar-es-Salaam, Tanzania

Tanzania is in the final stages to roll out pre-exposure prophylaxis (PrEP) to Female Sex Workers (FSWs) so as to reduce new infections. PrEP demonstration projects support programming through gaining first experiences.We analyzed data from a cohort of 700 HIV negative FSWs in Dar-es-Salaam to determine proportions of FSWs who were aware, willing and used PrEP. We compared proportions at cohort enrolment and after 12 months. Logistic regression was used to determine factors associated with PrEP use. PrEP awareness increased from 67% to 97% after 12 months. Willingness was high at both time points (98% versus 96%). Only 8% (57/700) had used PrEP. Being married/cohabiting or separated/divorced/widowed and having sex with a HIV infected partner were independently associated with PrEP use. The PrEP program should focus on scaling up access as willingness to use PrEP is high.

Intentional abortion and its associated factors among female sex workers in Iran: Results from national bio-behavioral surveillance-2020

Purpose

In addition to estimating the prevalence of intentional abortion in Iranian female sex workers (FSWs), this study identified related factors using the data of a national study.

Methods

This cross-sectional study utilizes the third round of integrated bio-behavioral surveillance-III data in Iranian FSWs in December 2019 and August 2020, and 1515 Participants were selected in 8 geographically diverse cities in Iran. Logistic regression was performed using unweighted analysis to identify factors associated with intentional abortion. Stata software (version 14), respondent-driven sampling analyses, and R (version 4.1.2) was used for data analysis.

Results

From 1390 participants with valid responses to the abortion question, 598 (37.3%; 95% CI: 32.43, 42.11%) reported intentional abortion during their life. According to the age groups, the highest prevalence of abortion was in the age group of 31 to 40 years (42.60%). In the multivariate logistic regression model, the marital status (divorced women (AOR = 2.05, 95% CI: 1.29, 3.27), concubines (AOR = 1.78, 95% CI: 1.02, 3.11)), work experience in brothels (AOR = 1.39, 95% CI: 1.04, 1.84), the type of sex (AOR = 2.75, 95% CI: 1.35, 5.58), the history of sexual violence (AOR = 1.54, 95% CI: 1.19, 2.01), and alcohol consumption (AOR = 1.53, 95% CI: 1.18, 2.01) were significantly associated with a history of intentional abortion.

Conclusion

Intentional abortion’s prevalence among Iranian FSWs has been much higher than that of the general female population in Iran, which is an alarming issue in the public health of this group and needs more effective interventions. In addition, alcohol consumption, working in a brothel, and being divorced are essential factors in increasing abortions among sex workers.

Challenges and Benefits of Disclosure of Sex Work to Intimate Partners

Sex workers' noncommercial intimate partnerships are marginalized on two counts - they are non-monogamous and at least one partner is in sex work, an occupation with much stigma. We asked a heterogeneous sample of Canadian sex workers (N = 218) about their decisions to reveal/not reveal their sex work to intimate partners, and the resulting challenges and benefits. A minority (58/183) of participants who had been or were currently involved in an intimate relationship kept their work secret from at least one partner or disclosed limited information, shielding them from stigma but resulting in a burden of secrecy. The majority of participants (151/183) who had been/were currently involved in an intimate relationship chose to disclose their sex work to at least one partner, which for most, had one or more negative consequences. A small group of participants related that disclosure resulted in acceptance, support, and understanding from their intimate partner. Some participants avoided the disclosure dilemma by forming intimate relationships from social connections where sex work status was already known. These relationships were generally supportive. We conclude that intimate relationships provide positive experiences for many people who sell sexual services and that these relationships could be stronger if societal stigma was reduced.

HIV prevalence and risk behaviors among female sex workers in Togo in 2017: a cross-sectional national study

BACKGROUND

The HIV epidemic remains an important public health challenge for the sub-Saharan region. Female Sex Workers (FSW) in this region are among the most vulnerable of the key population groups with HIV prevalence as high as twice that of the general population. The aim of this study was to estimate HIV prevalence and explore sexual risk behaviors among FSW in Togo.

METHODS

A cross-sectional study using a Respondent Driven Sampling method was conducted across the six regions of country among FSW in 2017. A comprehensive questionnaire was used to explore socio-demographic characteristics, sexual history, HIV knowledge, and sexual behaviors. HIV rapid tests were used to assess HIV infection.

RESULTS

A total of 1,036 FSW, with a median age of 26 years old [interquartile range (IQR): 22-33], participated in the study, with 49.2% (n = 510) of them having reached secondary school. Median age at first sexual intercourse was 20 years old [IQR: 17-25] and estimated number of clients per week was of 5 [IQR: 3-10]. A total of 936 (95.6%) reported the use of a condom during last sexual intercourse with a client and 493 (47.6%) reported the use of a condom during their last sexual intercourse with a partner or husband. HIV prevalence was 13.2% [95% CI: 11.2 - 15.4], and was associated with age (being between 26 and 32 years old; aOR = 4.5; 95% CI: [2.4 - 9.1], p < 0.0001) and ≥ 33 years old; aOR = 6.4; 95% CI [3.5 - 12.7], p < 0.0001), education level (being in primary school or less; aOR = 1.7; 95% CI: [1.1-2.6]; p = 0.012) and the number of partners per week (more than 2 and 3 partners; aOR = 2.5; 95% CI [1.2-5.2]; p = 0.014).

CONCLUSIONS

HIV prevalence and sexual risk behaviors remain high among FSW in Togo, despite prevention efforts aimed at curbing this trend. Other factors, such as access and availability of condoms, the social and legal environment in which FSW operate, should be considered for HIV prevention strategies in this population.

Derivation of an HIV Risk Score for African Women Who Engage in Sex Work

No tool exists to stratify HIV risk in contemporary African female sex worker (FSW) populations. Data from a cohort of HIV-negative FSWs in Mombasa, Kenya from 2010 to 2017 were used to conduct a survival analysis assessing predictors of HIV infection. Stepwise regression was used to construct a multivariable model that formed the basis for the score. Seventeen HIV infections occurred over 1247 person-years of follow-up contributed by 670 women. Using depot medroxyprogesterone acetate (DMPA), having a curable sexually transmitted infection (STI), and being married contributed points to the score. HIV incidence was 0.85/100 person-years in a lower-risk group and 3.10/100 person-years in a higher-risk group. In a cohort with overall HIV incidence < 1.50/100 person-years, this risk score identified a subgroup of FSWs with HIV incidence > 3.00/100 person-years, which is the threshold used by the World Health Organization for initiating pre-exposure prophylaxis (PrEP). If validated in an external population, this tool could be useful for targeted PrEP promotion among higher-risk FSWs.

Intimate partner and client-perpetrated violence are associated with reduced HIV pre-exposure prophylaxis (PrEP) uptake, depression and generalized anxiety in a cross-sectional study of female sex workers from Nairobi, Kenya

INTRODUCTION

UNAIDS has identified female sex workers (FSW) as a key HIV at-risk population. FSW disproportionately experience gender-based violence, which compounds their risk of HIV acquisition and may contribute to adverse mental health outcomes. Pre-exposure prophylaxis (PrEP) is a powerful but underused HIV prevention tool for these women. This study explored the associations between intimate partner violence (IPV) and client-perpetrated violence against FSW, mental health outcomes and PrEP use.

METHODS

An anonymous questionnaire was administered to a convenience sample of 220 Nairobi FSW attending dedicated clinics from June to July 2019, where PrEP was available free of charge. A modified version of the WHO Violence Against Women Instrument assessed IPV and client-perpetrated violence, and the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) assessed depressive and anxiety symptoms respectively. Multivariable logistic regressions evaluated predictors of depression, generalized anxiety and PrEP use.

RESULTS

Of the total 220 women (median [IQR] age 32 [27-39]), 56.8% (125/220) reported depression (PHQ-9 ≥ 10) and 39.1% (86/220) reported anxiety (GAD-7 ≥ 10). Only 41.4% (91/220) reported optimal use of PrEP (taken correctly six to seven days/week) despite the cohort pursuing sex work for a median of 7 (4 to 12) years. Most women reported experiencing any violence in the past 12 months (90%, 198/220). Any recent IPV was frequent (78.7%, 129/164), particularly emotional IPV (66.5%, 109/164), as was any client-perpetrated violence in the past 12 months (80.9%, 178/220). Regression analyses found that violence was independently associated with depression (adjusted OR [aOR] 9.39, 95% CI 2.90 to 30.42, p = 0.0002) and generalized anxiety (aOR 3.47, 95% CI 1.10 to 10.88, p = 0.03), with the strongest associations between emotional IPV and both depression and anxiety. Recent client-perpetrated emotional violence (aOR 0.23, 95% CI 0.07 to 0.71, p = 0.01) was associated with decreased PrEP use, whereas client-perpetrated physical violence was associated with increased PrEP use (aOR 3.01, 95% CI 1.16 to 7.81, p = 0.02).

CONCLUSIONS

There was a high prevalence of recent violence by different perpetrators as well as depression and anxiety among FSW from Nairobi. PrEP use was relatively infrequent, and recent client-perpetrated emotional violence was associated with PrEP non-use. Interventions to reduce gender-based violence may independently enhance HIV prevention and reduce the mental health burden in this community.

Unmet contraceptive needs among female sex workers (FSWs) in semi urban Blantyre, Malawi

Background

Research has paid limited attention to understanding factors that are associated with unmet contraceptive needs among female sex workers. In order to fill this knowledge gap, we estimated the prevalence of unmet contraceptive needs and examined associated factors among FSWs in semi urban Blantyre, Malawi.

Methods

We used systematic sampling to recruit 290 female sex workers in semi urban Blantyre between February and March 2019. In this cross sectional study, we used questionnaire interviews to collect quantitative data. We calculated the mean and standard deviation for continuous variables and proportions for categorical variables to describe the data. Logistic regression analysis was used to investigate the association between unmet needs (the outcome variable) and explanatory variables such as: having a steady partner, fear of contraceptives’ side effects and having a history of sexually transmitted infections.

Results

Out of the 290 study participants 102 (35.2%) reported unmet contraceptive needs. The following factors were significantly associated with unmet contraceptive needs in multivariate analysis: female sex workers’ history of physical and sexual violence by clients [OR 3.38, 95% CI (1.10, 10.43)], p < 0.03, participants with a steady partner [OR 3.28, 95% CI (1.89, 5.68)], p < 0.001, and participants who feared side effects of contraceptives [OR 2.99, 95% CI (1.73, 5.20)], p < 0.001.

Conclusion

Reproductive Health services should address barriers to contraceptives use for instance: violence by female sex workers’ clients, fear and misinformation on contraceptives. There is need to improve awareness of contraceptives. Specific health promotion interventions on female sex workers engaged in a steady partnership are recommended. It is important to enhance the knowledge, attitudes, and counseling skills of health care providers in order to address unmet contraceptive needs among female sex workers in semi-urban Blantyre.

Plain English summary

Unmet contraceptive needs are defined as lack of contraceptives use in heterosexually active women of childbearing age who do not wish to become pregnant. Unmet contraceptive needs are the main cause of short inter-pregnancy intervals, early childbearing, physical abuse, unintended pregnancy, poor maternal and child health outcomes. Several studies have documented low contraceptives use among female sex workers (FSWs), but research has paid limited attention to understanding factors associated with unmet contraceptive needs among this population in semi urban Blantyre Malawi.

In order to fill this knowledge gap, we estimated the prevalence of unmet contraceptive needs and examined factors that were associated with unmet contraceptive needs among FSWs in semi urban Blantyre, Malawi. We recruited 290 FSWs and collected quantitative data. These data were analyzed to obtain descriptive statistics. Logistic regression analysis was used to investigate the association between unmet contraceptive needs (the outcome variable) and explanatory variables such as: FSWs with history of physical and sexual violence by clients, having a steady partner, fear of contraceptives’ side effects and having a history of sexually transmitted infections.

Out of the 290 FSWs, 35% reported unmet contraceptive needs. The following factors were significantly associated with unmet contraceptive needs in multivariate analysis: FSWs’ history of physical and sexual violence by clients, participants with a steady partner and participants who feared contraceptive side effects.

Sexual and Reproductive Health services should address barriers to contraceptives use, female sex workers exposure to violence, having a steady partners and concerns about side effects. There is also a need to improve the knowledge, attitudes, and counseling skills of health providers in order to address unmet contraceptive needs among FSWs.

Actions taken by female sex workers (FSWs) after condom failure in semi urban Blantyre, Malawi

Background

Little is known about actions taken by female sex workers (FSWs) after male condom failure during male–female sexual intercourse. The objective of this study was to investigate the actions taken by FSWs after condom failure among FSWs in semi-urban, Blantyre in Malawi.

Methods

A cross sectional, qualitative study was conducted among FSWs in Blantyre, Malawi between May and July 2019. Snowballing technique was used to recruit study participants in four purposively selected study sites. Focus group discussions and in-depth interviews were conducted by trained research assistants among 40 FSWs. Data were analyzed using thematic content analysis.

Results

Study participants reported having taken different actions after condom failure. Out of 18 FSWs who experienced condom failure, 10 reported to have stopped sex immediately and changed the condom and then resumed afterwards. They reported to have douched, urinated, and/or squatted to prevent pregnancy, sexually transmitted infections (STIs) and HIV acquisition. Five study participants reported to have asked for extra pay from the client; 10 FSWs didn’t seek medical care. They thought the actions taken were enough for HIV and pregnancy prevention. Out of the 18 FSWs, only 3 stopped sexual intercourse completely and sought medical care which included post-exposure prophylaxis for HIV, STI treatment, and emergency contraceptives. Another 3 reported that they did not stop the sexual intercourse but only squatted and/or douched after sexual intercourse. The remaining 2 FSWs reported not to have stopped sexual intercourse and no any other actions were taken after the condom failure.

Conclusion

We report some inadequate behaviors among FSWs after condom failure. Health programs should develop interventions and support the performance of safer sex and actions after condom failure among FSWs to prevent STIs including HIV, and unplanned pregnancies. Interpersonal, structural and policy factors hindering FSWs’ access to perform effective interventions need to be addressed.

"I did not plan to have a baby. This is the outcome of our work": a qualitative study exploring unintended pregnancy among female sex workers

BACKGROUND

High number of unintended pregnancies-often leading to induced abortions-are reported among female sex workers (FSWs), highlighting a major unmet need for contraception. To better understand barriers to contraceptive use, we explored FSW's pregnancy perceptions and experiences of unintended pregnancy. We hypothesized that sex work exacerbates barriers to contraceptive use and that FSW's pregnancy perceptions and experiences of unintended pregnancy influence future commitment to contraceptive use.

METHODS

We conducted in-depth interviews with 11 FSWs (January-June 2019) in Dar es Salaam, Tanzania. We purposively sampled FSWs with a positive pregnancy test from those participating in a HIV vaccine preparedness cohort. We used open ended questions to explore how FSWs make decisions when facing barriers to contraceptive use, dealing with unintended pregnancy and adhering to contraceptive use after experiencing unintended pregnancy. All interviews were conducted in Kiswahili, audio-recorded, transcribed and translated into English. Grounded theory approach was used to analyse transcripts. Open and selective coding was performed using Nvivo software.

RESULTS

FSWs reported that sex work impedes good contraceptive behaviour because sex workers felt unable to negotiate consistent condom use, avoided health services due to stigma, missed monthly contraceptive supplies because of inconvenient clinic operating hours or skipped contraceptive pills when intoxicated after taking alcohol. FSWs who perceived pregnancy to be a burden terminated the pregnancy because of fear of loss of income during pregnancy or child rearing expenses in case child support was not assured by their partners. FSWs who perceived pregnancy to be a blessing decided to keep the pregnancy because they desired motherhood and hoped that children would bring prosperity. Family planning counselling and availability of contraceptives during postpartum care influenced the initiation of contraception among FSWs. Financial hardships related to childrearing or painful abortion experiences influenced FSWs' commitment to good contraceptive practices.

CONCLUSION

Our results demonstrate that FSWs face barriers to initiating and adhering to contraceptive use because of sex work stigma, inability to negotiate condoms and failure to access medical services at their convenience. Our findings underscore the need to integrate contraceptive services with HIV programs serving FSWs in their areas of work.

Pathways from Police, Intimate Partner, and Client Violence to Condom Use Outcomes among Sex Workers in Jamaica

BACKGROUND

Violence reduces sex workers' ability to enforce consistent condom use. Less is known of violence and condom use among gender diverse sex workers in Jamaica, where both sex work and same-sex practices are criminalized. We examined pathways from violence to consistent condom use among sex workers in Jamaica.

METHODS

We conducted a cross-sectional survey with a peer-driven sample of sex workers (n = 340: n = 124 cisgender men, n = 115 cisgender women, n = 101 transgender women) in Kingston, Ocho Rios, and Montego Bay, Jamaica. We conducted structural equation modeling using weighted least square estimation methods to test the direct effects of police harassment (ever), intimate partner violence (IPV) (ever), and recent (past 6-month) client violence on consistent condom use, and indirect effects via condom use self-efficacy, adjusting for socio-demographic factors. Moderation analysis was conducted to estimate the effect of binge drinking on condom use self-efficacy. We conducted a second SEM taking into consideration measurement invariance to test gender differences.

RESULTS

Over half of participants reported police harassment, half intimate partner violence, and one-third client violence. Overall, the direct path from police harassment to consistent condom use was significant. Condom use self-efficacy mediated associations between client violence and IPV with consistent condom use. Binge drinking moderated the association between client violence and condom use self-efficacy. There were gender differences in these pathways.

CONCLUSIONS

Violence has direct and indirect effects on condom use outcomes among sex workers in Jamaica. Multilevel, gender-tailored interventions at policy, police, and community levels can promote sex workers' health and human rights.

HIV infections among female sex workers in Mombasa, Kenya: current prevalence and trends over 25 years

Over 20 years, interventions have targeted HIV among female sex workers (FSWs) in Kenya given their central role in new infections. To determine the effects of these interventions, we assessed the prevalence and correlates of HIV among a random sample of FSWs and modelled prevalence estimates from studies since 1993. FSWs aged 16-34 years were enrolled through multi-stage sampling. Regression models identified correlates of HIV infection. Generalised linear mixed modelling estimated temporal changes in prevalence between 1993 and 2016. 882 FSWs were enrolled. Prevalence rose from 3.6% among 16-20-year-olds to 31.6% among 31-34-year-old FSWs. Those aged 31 to 34 years had greater odds of HIV compared to those 16 to 20 years (AOR 14.2, 95% CI, 5.5-36.8). Infection was less prevalent among FSWs with tertiary education compared to those with primary or no education (AOR 0.23, 95% CI, 0.07-0.78). There was an overall 30% reduction in prevalence from 1993 to 2016 with an average annual decline of 3%. About one in ten FSWs in Mombasa are currently infected with HIV. Considering FSWs' central role in sustaining population-level infections, these initiatives require continued support, focusing on reducing transmission from older FSWs and those with less education.

HIV prevalence, sexual risk behaviours and HIV testing among female sex workers in three cities in Sri Lanka: Findings from respondent-driven sampling surveys

Sri Lanka has a low-level HIV epidemic. This study aims to provide evidence on HIV, syphilis and hepatitis B (HBV) prevalence, sexual risk behaviours and utilisation of HIV prevention interventions among female sex workers (FSW) in the cities Colombo, Galle, and Kandy. Using respondent-driven sampling (RDS), we recruited a total of 458 FSW in Colombo, 360 in Galle and 362 in Kandy from November 2017 to March 2018. Participants provided biological specimens for testing for infections and completed a behavioural questionnaire. We found no HIV nor HBV infections in Galle and Kandy, and low HIV (0.4%) and HBV surface antigen (0.6%) prevalence in Colombo. FSW in Colombo had higher positivity on Treponema pallidum-particle agglutination test (8.4%) compared to Galle (2.0%) and Kandy (2.5%). About two thirds of FSW heard of HIV in each of the cities. Around 90% of FSW used condom at last sex with a client in both Colombo and Galle, but considerably less in Kandy (57.1%). However, lower proportion of FSW used condoms every time during sex with clients in the past 30 day: 22.9% of FSW in Colombo, 26.6% in Kandy and 68.4% in Galle. Across cities, 17.5%-39.5% of FSW reported being tested for HIV in the past 12 months or knowing HIV positive status. The commonest reasons for never testing for HIV was not knowing where to test (54.2% in Colombo, 41.8% in Galle, 48.1% in Kandy) followed by inconvenient testing location (23.7% in Colombo and 31.1% in Kandy). HIV has not yet been firmly established among FSW in three cities in Sri Lanka, but the vulnerability towards HIV and STIs is substantial. HIV interventions should be intensified by expanding community-based HIV testing approaches, increasingawareness of HIV risks and addressing socio-structural vulnerabilities of FSW to HIV.

Sexual and reproductive health correlates of polysubstance use among female adolescents who sell sex in the southwest of China

Background

Substance use and adverse sexual and reproductive health (SRH) outcomes continue to be significant threats to female adolescents’ health and wellbeing, particularly to these marginalized subpopulations. Our research aimed to tackle knowledge gaps regarding the prevalence of concurrent substance use including alcohol, tobacco, illicit drug among Chinese adolescent female sex workers (AFSWs), while to assess the correlates between substance use and SRH risks; the needs for comprehensive SRH services were also examined in this study.

Methods

A cross-sectional study enrolled 310 AFSWs aged 15–19 years by using cluster sampling method in Kunming, China. Descriptive analysis was employed to characterize the participants who were regular-alcohol users, regular-tobacco users, illicit drug users and polysubstance users. Multivariable logistic regression analysis was performed to detect the SRH correlates of regular-alcohol use, regular-tobacco use, illicit drugs and polysubstance use respectively.

Results

There is a high prevalence of regular-alcohol drinking (83%, 257/310) among AFSWs, with 44% (136/310) smoking cigarettes regularly and 9% using illicit drug (27/310) in the past year. In multivariate analysis, AFSWs who had middle and high school education, had higher monthly income, experienced of sexual and gender based violence (SGBV) and prior abortion, and regular-tobacco smoking were associated with increased odds of regular-alcohol drinking; engaging in unprotected sex while drunk, having STIs symptoms and using illicit drugs were significantly associated with regular-tobacco smoking; while AFSWs who had an illicit drug using- intimate partner, experienced forced sexual initiation, accessed unsafe medical providers for STIs treatment were associate with increased odds of illicit drug use. Moreover, 35% (105/298) AFSWs sought unsafe medical care for STIs treatment, or no treatment at all, among them, majority were using polysubstance (87%; 91/105).

Conclusions

Our findings reveal combined threats of substance use to AFSWs’ SRH and wellbeing in China, this study emphasises that the coordinated efforts are needed to integrate SRH promotion and harm reduction service across sectors, and not only fragmented measures. An effective response should include an agreed framework, indicators and targets supported by political will, solid leadership and policy reform to deal with AFSWs’ overlapping vulnerabilities in a systematic way.

Unmet Need for Family Planning and Experience of Unintended Pregnancy Among Female Sex Workers in Urban Cameroon: Results From a National Cross-Sectional Study

Female sex workers (FSWs) in Cameroon have unmet need for effective contraception, and experience of unintended pregnancy and pregnancy termination is common. Reducing barriers to accessing high-quality, voluntary family planning services in FSW-focused community services is a key strategy to promote client-centered care, promote informed choice, reduce unintended pregnancies, and improve quality of life for FSWs.

Background:

Female sex workers (FSWs) in Cameroon commonly have unmet need for contraception posing a high risk of unintended pregnancy. Unintended pregnancy leads to a range of outcomes, and due to legal restrictions, FSWs often seek unsafe abortions. Aside from the high burden of HIV, little is known about the broader sexual and reproductive health of FSWs in Cameroon.

Methods:

From December 2015 to October 2016, we recruited FSWs aged ≥18 years through respondent-driven sampling across 5 Cameroonian cities. Cross-sectional data were collected through a behavioral questionnaire. Modified-robust Poisson regression was used to approximate adjusted prevalence ratios (aPR) for TOP and current use of effective nonbarrier contraception.

Results:

Among 2,255 FSWs (median age 28 years), 57.6% reported history of unintended pregnancy and 40.0% reported prior TOP. In multivariable analysis, TOP history was associated with current nonbarrier contraceptive use (aPR=1.23, 95% confidence interval [CI]=1.07, 1.42); ever using emergency contraception (aPR=1.34, 95% CI=1.17, 1.55); >60 clients in the past month (aPR=1.29, 95% CI= 1.07, 1.54) compared to ≤30; inconsistent condom use with clients (aPR=1.17, 95% CI=1.00, 1.37); ever experiencing physical violence (aPR=1.24, 95% CI=1.09, 1.42); and older age. Most (76.5%) women used male condoms for contraception, but only 33.2% reported consistent condom use with all partners. Overall, 26.4% of women reported currently using a nonbarrier contraceptive method, and 6.2% reported using a long-acting method. Previous TOP (aPR=1.41, 95%CI=1.16, 1.72) and ever using emergency contraception (aPR=2.70, 95% CI=2.23, 3.26) were associated with higher nonbarrier contraceptive use. Recent receipt of HIV information (aPR=0.72, 95% CI=0.59, 0.89) and membership in an FSW community-based organization (aPR=0.73, 95% CI=0.57, 0.92) were associated with lower use nonbarrier contraceptive use.

Conclusions:

Experience of unintended pregnancies and TOP is common among FSWs in Cameroon. Given the low use of nonbarrier contraceptive methods and inconsistent condom use, FSWs are at risk of repeat unintended pregnancies. Improved integration of client-centered, voluntary family planning within community-led HIV services may better support the sexual and reproductive health and human rights of FSWs consistent with the United Nations Declaration of Human Rights.

Contraceptive use, prevalence and predictors of pregnancy planning among female sex workers in Uganda: a cross sectional study

BACKGROUND

Unintended pregnancies are associated with negative consequences to both mother and baby. Female Sex Workers (FSWs) are at high risk of unintended/unplanned pregnancies. However, prevalence of pregnancy planning and its predictors among FSWs has not been comprehensively investigated. This study was designed to determine contraceptive use, the prevalence, and predictors of pregnancy planning among FSWs in Uganda.

METHODS

In this cross-sectional study, 819 FSWs attending most at risk populations initiative (MARPI) clinics were recruited using systematic sampling and interviewed with a pretested questionnaire that included collection of data on pregnancy intention using the London Measure of Unplanned Pregnancy (LMUP). Data were analysed using STATA version 14.0. Multinomial logistic regression model was used to identify predictors of pregnancy planning, RESULTS: Of the 819 study participants, only 90 (11.0%) had planned pregnancies. Overall, 462 (56.4%) were hazardous alcohol users and 335 (40.9%) abused drugs; 172 (21.0%) had been raped in the last 2 years and 70 (40.7%) of these accessed emergency contraception post-rape. Dual contraception use (condom and other modern method) was 58.0%. Having a non-emotional partner as a man who impregnated the FSW compared to emotional partner was significantly associated with less planned relative to unplanned pregnancy, (aRR = 0.15 95%Cl =0.08, 0.30), so was lack of reported social support compared to support from friends, (aRR = 0.44; 95% CI = 0.22-0.87), keeping all factors constant in the model. Being raped (aRR = 0.51; 95% CI = 0.31-0.84) or abuse of substances (aRR = 0.65; 95% CI = 0.45-0.93) were significantly associated with lower ambivalence relative to unplanned pregnancy but not with planned relative to unplanned pregnancy.

CONCLUSION

Compared to women in the general population, pregnancy planning was low among FSWs amidst modest use of dual contraceptive. There is an urgent need to promote dual contraception among FSWs to prevent unplanned pregnancies especially with non-emotional partners, drug users, and post-rape.

Recruitment of Female Sex Workers in HIV Prevention Trials: Can Efficacy Endpoints Be Reached More Efficiently?

BACKGROUND/SETTING

Randomized controlled trials (RCTs) of HIV biomedical prevention interventions often enroll participants with varying levels of HIV exposure, including people never exposed to HIV. We assessed whether enrolling larger proportion of participants with consistently high exposure to HIV, such as female sex workers (FSWs), might reduce trial duration and improve the accuracy of product efficacy estimates in future HIV prevention trials.

METHODS

We used an individual-based stochastic model to simulate event-driven RCTs of an HIV prevention intervention providing 80% reduction in susceptibility per act under different proportions of FSW enrolled. A 5% annual dropout rate was assumed for both FSW and non-FSW in our main scenario, but rates of up to 50% for FSW were also explored.

RESULTS

Enrolling 20% and 50% FSW reduced the median-simulated trial duration from 30 months with 0% FSW enrolled to 22 months and 17 months, respectively. Estimated efficacy increased from 71% for RCTs without FSW to 74% and 76% for RCTs with 20% and 50% FSW enrolled, respectively. Increasing the FSW dropout rate to 50% increased the duration of RCTs by 1-2 months on average and preserved the gain in estimated efficacy.

CONCLUSIONS

Despite the potential logistical challenges of recruiting and retaining FSW, trialists should revisit the idea of enrolling FSW in settings where HIV incidence among FSW is higher than among non-FSW. Our analysis suggests that enrolling FSW would increase HIV incidence, reduce trial duration, and improve efficacy estimates, even if the annual dropout rate among FSW participants is high.

Love, power, resilience and vulnerability: relationship dynamics between female sex workers in Ghana and their intimate partners

Little is known about female sex workers' daily lives or emotional relationships. Using relational-cultural theory, this study explored the relationship dynamics between sex workers and their intimate partners in Kumasi, Ghana. We collected qualitative data from 37 male intimate partners through 24 in-depth interviews and two focus group discussions (FGDs) with 13 male partners. We also conducted three FGDs with 20 women involved in sex work. Relationships between sex workers and their intimate partners were mutual, reciprocal and transactional. Male partners provided protection for financial support, a place to sleep and intimacy. Both men and women described their relationships in terms of friendship, love and a hopeful future. Women were reluctant to quit sex work because they depended on it for income. Most respondents did not use condoms in these romantic relationships, citing trust, love, faithfulness and commitment. Both men and women described high levels of violence in their relationships. The context of sex work heightens vulnerability but also appears to facilitate resilience and creative coping strategies. The relational dynamics between sex workers and their intimate partners in Ghana merit further exploration to examine the extent to which women involved in sex work hold and exert power within these relationships.

Patterns of Gender-Based Violence and Associations with Mental Health and HIV Risk Behavior Among Female Sex Workers in Mombasa, Kenya: A Latent Class Analysis

Gender-based violence (GBV) is common among female sex workers (FSWs) and is associated with multiple HIV risk factors, including poor mental health, high-risk sexual behavior, and sexually transmitted infections (STIs). Prior studies have focused on GBV of one type (e.g. physical or sexual) or from one kind of perpetrator (e.g., clients or regular partners), but many FSWs experience overlapping types of violence from multiple perpetrators, with varying frequency and severity. We examined the association between lifetime patterns of GBV and HIV risk factors in 283 FSWs in Mombasa, Kenya. Patterns of GBV were identified with latent class analysis based on physical, sexual, or emotional violence from multiple perpetrators. Cross-sectional outcomes included depressive symptoms, post-traumatic stress disorder (PTSD) symptoms, disordered alcohol and other drug use, number of sex partners, self-reported unprotected sex, prostate-specific antigen (PSA) in vaginal secretions, and a combined unprotected sex indicator based on self-report or PSA detection. We also measured HIV/STI incidence over 12 months following GBV assessment. Associations between GBV patterns and each outcome were modeled separately using linear regression for mental health outcomes and Poisson regression for sexual risk outcomes. Lifetime prevalence of GBV was 87%. We identified 4 GBV patterns, labeled Low (21% prevalence), Sexual (23%), Physical/Moderate Emotional (18%), and Severe (39%). Compared to women with Low GBV, those with Severe GBV had higher scores for depressive symptoms, PTSD symptoms, and disordered alcohol use, and had more sex partners. Women with Sexual GBV had higher scores for disordered alcohol use than women with Low GBV, but similar sexual risk behavior. Women with Physical/Moderate Emotional GBV had more sex partners and a higher prevalence of unprotected sex than women with Low GBV, but no differences in mental health. HIV/STI incidence did not differ significantly by GBV pattern. The prevalence of GBV was extremely high in this sample of Kenyan FSWs, and different GBV patterns were associated with distinct mental health and sexual risk outcomes. Increased understanding of how health consequences vary by GBV type and severity could lead to more effective programs to reduce HIV risk in this vulnerable population.

Love moderates the relationship between partner type and condom use among women engaging in transactional vaginal sex

Background Relationship characteristics and day-to-day variation in affective state have been associated with HIV risk behaviour. However, no research has assessed the impact of these factors on event-level condom use among women engaging in transactional sex.

METHODS

Twenty-six women engaging in transactional sex were enrolled in a prospective study of their sexual health. They completed diaries about multi-level predictors of condom use during vaginal sex twice, daily.

RESULTS

Over 4 weeks, 18 participants reported 87 paid/traded vaginal intercourse events. Of these, 51.7% were condom protected. The majority of paid/traded events (81.5%) occurred with a non-romantic partner. After controlling for partner type, feeling in love on a given day was associated with higher odds of condom use during paid/traded sexual events, while having sex on the weekend and at night were associated with lower odds of condom use (all P≤0.05). There was a significant interaction between being in love and using condoms during transactional sex (P<0.01). In paid/traded sexual events with romantic partners, the frequency of condom use was 71.4% (5/7) when women did not report love and 40% (4/10) when love was reported. In sexual events with non-romantic partners, the frequency of condom use was 43.8% (14/32) when women did not report love and 59.5% (22/37) when love was reported.

CONCLUSIONS

Women were less likely to report protected sex with romantic partners and more likely to report protected sex with non-romantic partners when they are in love. Interventions focusing on the link between day-to-day variation in affective state on condom use may help women with risk management across partner types.

The Prevalence and Correlates of Physical and Sexual Violence Affecting Female Sex Workers in Swaziland

Female sex workers (FSW) have a heightened vulnerability to violence and negative sexual/reproductive health outcomes. Limited research has examined how experiencing physical and sexual violence (PSV) mediates risk for poor health outcomes among FSW in Swaziland. The present analyses aim to contribute to literature linking violence with poor health outcomes, high-risk behaviors, and reduced health service-seeking among FSW. Data were analyzed from a cross-sectional study conducted in Swaziland between July and September 2011 with 325 adult women who reported exchanging sex for money, goods, or favors in the last 12 months, recruited through respondent-driven sampling (RDS). Logistic regression was used to assess the relationship between PSV and ancillary violence/abuse exposures, risk behaviors, and sexual/reproductive and mental health outcomes. PSV was conceptualized as either ever having been beaten up as a result of selling sex or ever being forced to have sex since the age of 18, or both. Prevalence of PSV in this sample was 59.0% in crude estimation, and 48.4% (95% confidence interval [CI]:[39.2,57.6]) with RDS weighting. Separate RDS-weighted estimates of being beaten up as a result of sex work and ever being forced to have sex were 32.4% (95%CI=[24.4,40.4]) and 33.1% (95%CI =[25.0,41.2%]), respectively. Experiencing PSV was associated with being blackmailed (adjusted odds ratio [aOR]= 1.93, 95%CI= [1.07,3.52]), non-injection drug use in the last 12 months (aOR= 1.84, 95%CI= [1.02,3.33]), and feeling afraid to seek health services as a result of selling sex (aOR = 1.74, 95%CI= [1.01,2.99]). Given these findings, violence prevention strategies should be prioritized in programs that address Swazi FSW health, empowerment, and safety.

Female sex workers experiences of using contraceptive methods: a qualitative study in Kenya

Background

Female Sex Workers (FSWs) are predisposed to a broad range of social, sexual and reproductive health problems such as sexually transmitted infections (STIs)/HIV, unintended pregnancy, violence, sexual exploitation, stigma and discrimination. Female sex workers have unmet need for contraceptives and require comprehensive Sexual and Reproductive Health (SRH) prevention interventions. Existing programs pay little attention to the broad sexual and reproductive health and rights of these women and often focus on HIV and other STIs prevention, care and treatment while neglecting their reproductive health needs, including access to family planning methods. The aim of this study is, therefore, to explore the experiences of female sex workers with using existing contraceptive methods, assess individual and health facility-level barriers and document inter-partner relationship in the use of contraceptives.

Methods

We focus on women aged 15–49, who reported current sex work, defined as ‘providing sexual services in exchange for money or other material compensation as part of an individual’s livelihood.’

Results

Findings reveal that while some FSWs know about modern contraceptives, others have limited knowledge or out rightly refuse to use contraceptives for fear of losing clients. The interaction with different client types act as a barrier but also provide an opportunity for contraceptive use among FSWs. Most FSWs recognize the importance of dual protection for HIV/STI and pregnancy prevention. However, myths and misconceptions, fear of being tested for HIV at the family planning clinic, wait time, and long queues at the clinics all act in combination to hinder uptake of contraceptives.

Conclusions

We recommend a targeted approach to address the contraceptive needs of FSWs to help remove barriers to contraceptive uptake. We also support the introduction of counseling services to provide information on the benefits of non-barrier contraceptive methods and thereby enhance dual use for both pregnancy and STI/HIV prevention.

WHISPER or SHOUT study: protocol of a cluster-randomised controlled trial assessing mHealth sexual reproductive health and nutrition interventions among female sex workers in Mombasa, Kenya

INTRODUCTION

New interventions are required to reduce unintended pregnancies among female sex workers (FSWs) in low- and middle-income countries and to improve their nutritional health. Given sex workers' high mobile phone usage, repeated exposure to short messaging service (SMS) messages could address individual and interpersonal barriers to contraceptive uptake and better nutrition.

METHODS

In this two-arm cluster randomised trial, each arm constitutes an equal-attention control group for the other. SMS messages were developed systematically, participatory and theory-driven and cover either sexual and reproductive health (WHISPER) or nutrition (SHOUT). Messages are sent to participants 2-3 times/week for 12 months and include fact-based and motivational content as well as role model stories. Participants can send reply texts to obtain additional information. Sex work venues (clusters) in Mombasa, Kenya, were randomly sampled with a probability proportionate to venue size. Up to 10 women were recruited from each venue to enrol 860 women. FSWs aged 16-35 years, who owned a mobile phone and were not pregnant at enrolment were eligible. Structured questionnaires, pregnancy tests, HIV and syphilis rapid tests and full blood counts were performed at enrolment, with subsequent visits at 6 and 12 months.

ANALYSIS

The primary outcomes of WHISPER and SHOUT are unintended pregnancy incidence and prevalence of anaemia at 12 months, respectively. Each will be compared between study groups using discrete-time survival analysis.

POTENTIAL LIMITATIONS

Contamination may occur if participants discuss their intervention with those in the other trial arm. This is mitigated by cluster recruitment and only sampling a small proportion of sex work venues from the sampling frame.

CONCLUSIONS

The design allows for the simultaneous testing of two independent mHealth interventions for which messaging frequency and study procedures are identical. This trial may guide future mHealth initiatives and provide methodological insights into use of reciprocal control groups.

TRIAL REGISTRATION NUMBER

ACTRN12616000852459; Pre-results.

Risky Business: condom failures as experienced by female sex workers in Mombasa, Kenya

Limited research exists about condom failure as experienced by female sex workers. We conducted a qualitative study to examine how female sex workers in Mombasa, Kenya contextualise and explain the occurrence of condom failure. In-depth, semi-structured interviews were conducted with thirty female sex workers to ascertain their condom failure experiences. We qualitatively analysed interview transcripts to determine how the women mitigate risk and cope with condom failure. Condom failure was not uncommon, but women mitigated the risk by learning about correct use, and by supplying and applying condoms themselves. Many female sex workers felt that men intentionally rupture condoms. Few women were aware of or felt empowered to prevent HIV, STIs, and pregnancy after condom failure. Interventions to equip female sex workers with strategies for minimising the risk of HIV, STIs, and pregnancy in the aftermath of a condom failure should be investigated.

Sex with sweethearts: Exploring factors associated with inconsistent condom use among unmarried female entertainment workers in Cambodia

BACKGROUND

Despite the success in promoting condom use in commercial relationships, condom use with regular, noncommercial partners remains low among key populations in Cambodia. This study explores factors associated inconsistent condom use with sweethearts among unmarried sexually active female entertainment workers (FEWs).

METHODS

In 2014, the probability proportional to size sampling method was used to randomly select 204 FEWs from entertainment venues in Phnom Penh and Siem Reap for face-to-face interviews. Multivariate logistic regression analysis was conducted to examine independent determinants of inconsistent condom use.

RESULTS

Of total, 31.4% of the respondents reported consistent condom use with sweethearts in the past three months. After adjustment, respondents who reported inconsistent condom use with sweethearts remained significantly less likely to report having received any form of sexual and reproductive health education (AOR = 0.49, 95% CI = 0.22-0.99), but more likely to report having been tested for HIV in the past six months (AOR = 2.19, 95% CI = 1.03-4.65). They were significantly more likely to report having used higher amount of alcohol in the past three months (AOR = 1.29, 95% CI = 1.01-1.99) and currently using a contraceptive method other than condoms such as pills (AOR = 4.46, 95% CI = 1.34-10.52) or other methods (AOR = 9.75, 95% CI = 2.07-9.86).

CONCLUSIONS

The rate of consistent condom use in romantic relationships among unmarried FEWs in this study is considerably low. The importance of consistent condom use with regular, non-commercial partners should be emphasized in the education sessions and materials, particularly for FEWs who use non-barrier contraceptive methods.

Prevalence and correlates of sexual and gender-based violence against Chinese adolescent women who are involved in commercial sex: a cross-sectional study

OBJECTIVES

Despite the vast quantity of research among Chinese female sex workers (FSWs) to address concerns regarding HIV/sexually transmitted infection (STI) risk, there is a paucity of research on issues of sexual and gender-based violence (SGBV) and the missed opportunity for sexual and reproductive health (SRH) promotion among young FSWs. Our research aimed to assess the prevalence and correlates of SGBV among Chinese adolescent FSWs, and to explore SRH service utilisation.

DESIGN AND METHODS

A cross-sectional study using a one-stage cluster sampling method was employed. A semistructured questionnaire was administered by trained peer educators or health workers. Multivariable logistic regression was conducted to determine individual and structural correlates of SGBV.

SETTING AND PARTICIPANTS

Between July and September 2012, 310 adolescent women aged 15-20 years, and who self-reported having received money or gifts in exchange for sex in the past 6 months were recruited and completed their interview in Kunming, Yunnan Province, China.

RESULTS

Findings confirm the high prevalence of SGBV against adolescent FSWs in China, with 38% (118/310) of participants affected in the past year. Moreover, our study demonstrated the low uptake of public health services and high rates of prior unwanted pregnancy (52%; 61/118), abortion (53%; 63/118) and self-reported STI symptoms (84%; 99/118) in participants who were exposed to SGBV. Forced sexual debut was reported by nearly a quarter of FSWs (23%; 70/310) and was independently associated with having had a drug-using intimate partner and younger age (<17 years old) at first abortion. When controlling for potential confounders, having experienced SGBV was associated with frequent alcohol use, having self-reported symptoms of STI, having an intimate partner and having an intimate partner with illicit drug use.

CONCLUSIONS

This study calls for effective and integrated interventions addressing adolescent FSWs' vulnerability to SGBV and broader SRH consequences.

"A Baby Was an Added Burden": Predictors and Consequences of Unintended Pregnancies for Female Sex Workers in Mombasa, Kenya: A Mixed-Methods Study

INTRODUCTION

Female sex workers (FSW) have high rates of unintended pregnancy, sexually transmitted infections including HIV, and other adverse sexual and reproductive health outcomes. Few services for FSWs include contraception. This mixed-methods study aimed to determine the rate, predictors and consequences of unintended pregnancy among FSWs in Mombasa, Kenya.

METHODS

A prospective cohort study of non-pregnant FSWs was conducted. Quantitative data were collected quarterly, including a structured questionnaire and testing for pregnancy and HIV. Predictors of unintended pregnancy were investigated using multivariate logistic regression. Qualitative data were gathered through focus group discussions and in-depth interviews with FSWs who became pregnant during the study, and interviews with five key informants. These data were transcribed, translated and analysed thematically.

RESULTS

Four hundred women were enrolled, with 92% remaining in the cohort after one year. Fifty-seven percent reported using a modern contraceptive method (including condoms when used consistently). Over one-third (36%) of women were using condoms inconsistently without another method. Twenty-four percent had an unintended pregnancy during the study. Younger age, having an emotional partner and using traditional or no contraception, or condoms only, were independent predictors of unintended pregnancy. Women attributed pregnancy to forgetting to use contraception and being pressured not to by clients and emotional partners, as well as "bad luck". They described numerous negative consequences of unintended pregnancy.

CONCLUSION

Modern contraceptive uptake is surprisingly low in this at-risk population, which in turn has a high rate of unintended pregnancy. The latter may result in financial hardship, social stigma, risk of abandonment, or dangerous abortion practices. FSWs face considerable barriers to the adoption of dual method contraceptive use, including low levels of control in their emotional and commercial relationships. Reproductive health services need to be incorporated into programs for sexually transmitted infections and HIV, which address the socially-determined barriers to contraceptive use.

A Prospective Cohort Study of Intimate Partner Violence and Unprotected Sex in HIV-Positive Female Sex Workers in Mombasa, Kenya

We conducted a prospective cohort study to test the hypothesis that intimate partner violence (IPV) is associated with unprotected sex in HIV-positive female sex workers in Mombasa, Kenya. Women completed monthly visits and quarterly examinations. Any IPV in the past year was defined as ≥1 act of physical, sexual, or emotional violence by the current or most recent emotional partner ('index partner'). Unprotected sex with any partner was measured by self-report and prostate specific antigen (PSA) test. Recent IPV was associated with significantly higher risk of unprotected sex (adjusted relative risk [aRR] 1.91, 95 % CI 1.32, 2.78, p = 0.001) and PSA (aRR 1.54, 95 % CI 1.17, 2.04, p = 0.002) after adjusting for age, alcohol use, and sexual violence by someone besides the index partner. Addressing IPV in comprehensive HIV programs for HIV-positive women in this key population is important to improve wellbeing and reduce risk of sexual transmission of HIV.

HIV prevention and care-seeking behaviour among female sex workers in four cities in India, Kenya, Mozambique and South Africa

OBJECTIVE

To identify gaps in the use of HIV prevention and care services and commodities for female sex workers, we conducted a baseline cross-sectional survey in four cities, in the context of an implementation research project aiming to improve use of sexual and reproductive health services.

METHODS

Using respondent-driven sampling, 400 sex workers were recruited in Durban, 308 in Tete, 400 in Mombasa and 458 in Mysore and interviewed face-to-face. RDS-adjusted proportions were estimated by nonparametric bootstrapping and compared across cities using post hoc pairwise comparison.

RESULTS

Condom use with last client ranged from 88.3% to 96.8%, ever female condom use from 1.6% to 37.9%, HIV testing within the past 6 months from 40.5% to 70.9%, receiving HIV treatment and care from 35.5% to 92.7%, care seeking for last STI from 74.4% to 87.6% and having had at least 10 contacts with a peer educator in the past year from 5.7% to 98.1%. Many of the differences between cities remained statistically significant (P < 0.05) after adjusting for differences in FSWs' socio-demographic characteristics.

CONCLUSION

The use of HIV prevention and care by FSWs is often insufficient and differed greatly between cities. Differences could not be explained by variations in socio-demographic sex worker characteristics. Models to improve use of condoms and HIV prevention and care services should be tailored to the specific context of each site. Programmes at each site must focus on improving availability and uptake of those services that are currently least used.

Changes in Condom Use Over Time Among Female Sex Workers and Their Male Noncommercial Partners and Clients

Female sex workers (FSWs) often report inconsistent condom use with clients and noncommercial male partners, yet changes in condom use with various partner types during participation in observation studies remains underexplored. This longitudinal study of 214 FSWs and their male, noncommercial partners in the Mexico-U.S. border region, where HIV prevalence among FSWs continues to be high, utilized negative binomial regressions to examine changes in condom use with intimate partners and clients (regular and nonregular) over 24 months. Condom use decreased over time among couples in Ciudad Juarez, but there was no change in condom use among couples in Tijuana. FSWs' condom use with regular and nonregular clients significantly increased over time, which is consistent with previous research finding behavioral changes when participating in observational studies. Findings suggest the need for continued efforts to promote condom use among FSWs and their noncommercial male partners in addition to clients.

Reducing violence and increasing condom use in the intimate partnerships of female sex workers: study protocol for Samvedana Plus, a cluster randomised controlled trial in Karnataka state, south India

BACKGROUND

Female sex workers (FSWs) are at increased risk of HIV and STIs compared to women in the general population, and frequently experience violence in their working and domestic lives from a variety of perpetrators, which can enhance this risk. While progress has been made in addressing violence by police and clients, little work has been done to understand and prevent violence by intimate partners (IPs) among FSW populations.

METHODS

Samvedana Plus is a multi-level intervention programme that works with FSWs, their IPs, the sex worker community, and the general population, and aims to reduce violence and increase consistent condom use within these 'intimate' relationships. The programme involves shifting norms around the acceptability of beating as a form of discipline, challenging gender roles that give men authority over women, and working with men and women to encourage new relationship models based on gender equity and respect. The programme will aim to cover 800 FSWs and their IPs living in 47 villages in Bagalkot district, northern Karnataka. The study is designed to assess two primary outcomes: the proportion of FSWs who report: (i) physical or sexual partner violence; and (ii) consistent condom use in their intimate relationship, within the past 6 months. The evaluation will employ a cluster-randomised controlled trial design, with 50 % of the village clusters (n = 24) randomly selected to receive the intervention for the first 24 months and the remaining 50 % (n = 23) receiving the intervention thereafter. Statisticians will be blinded to treatment arm allocation. The evaluation will use an adjusted, cluster-level intention to treat analysis, comparing outcomes in intervention and control villages at midline (12 months) and endline (24 months). The evaluation design will involve quantitative and qualitative assessments with (i) all FSWs who report an IP (ii) IPs; and process/ implementation monitoring. Baseline data collection was completed in April 2015, and endline data collection is anticipated in May 2017.

CONCLUSIONS

This is an innovative intervention programme that aims to address violence by IPs as part of HIV prevention programming with FSWs. Reducing violence is expected to reduce vulnerability to HIV acquisition, and help women to work and live without fear of violence.

TRIAL REGISTRATION

Clinical Trials NCT02807259 Jun 24 2016 (retrospectively registered).

Prevalence and correlates of intimate partner violence in HIV-positive women engaged in transactional sex in Mombasa, Kenya

We evaluated the prevalence and correlates of intimate partner violence (IPV) in the past year by a regular male partner in HIV-positive female sex workers (FSWs) in Mombasa, Kenya. This cross-sectional study included HIV-positive women ≥18 years old who reported engagement in transactional sex at the time of enrolment in the parent cohort. We asked 13 questions adapted from the World Health Organization survey on violence against women about physical, sexual, or emotional violence in the past year by the current or most recent emotional partner (index partner). We used standardised instruments to assess socio-demographic and behavioural characteristics as possible correlates of IPV. Associations between IPV and these correlates were evaluated using univariate and multivariate logistic regression. Overall, 286/357 women (80.4%) had an index partner, and 52/357 (14.6%, 95% confidence interval 10.9%-18.2%) reported IPV by that partner in the past year. In multivariate analysis, women with severe alcohol problems (adjusted odds ratio 4.39, 1.16-16.61) and those experiencing controlling behaviours by the index partner (adjusted odds ratio 4.98, 2.31-10.74) were significantly more likely to report recent IPV. Recent IPV was common in HIV-positive FSWs. Interventions targeting risk factors for IPV, including alcohol problems and partner controlling behaviours, could help to reduce recurrent violence and negative health outcomes in this key population.

Sexual violence, condom negotiation, and condom use in the context of sex work: results from two West African countries

BACKGROUND

Female sex workers (FSWs) are vulnerable to violence within and beyond the workplace. Violence is associated with increased burden of HIV, possibly explained through physiologic or behavioral causal pathways. These analyses sought to determine the relationship between lifetime sexual violence with unprotected, condomless vaginal intercourse (UVI) among FSWs in West Africa.

METHODS

FSWs (aged ≥18 years) were recruited into a cross-sectional study through respondent-driven sampling in two West African countries, Togo and Burkina Faso. A total of 1380 participants were enrolled from January to July 2013, and completed a sociobehavioral questionnaire and HIV testing. Measures included sex work history, lifetime experiences of violence victimization, sexual practices, and UVI (past month). Crude and adjusted robust log binomial regression was conducted to estimate prevalence ratios (PrR) as a measure of association between UVI with clients and the primary exposure, forced sex.

RESULTS

Self-reported lifetime physical abuse (47.3%), forced sex (33.0%), and any violence (57.9%) were common. Almost one-quarter (23.9%) reported recent UVI with clients. History of forced sex was independently associated with recent UVI with clients [vs. none, adjusted PrR: 1.49; 95% confidence interval (CI): 1.18 to 1.88], with evidence of partial mediation by difficult condom negotiation with regular (aPrR: 1.83; 95% CI: 1.43 to 2.34) and new clients (aPrR: 1.60; 95% CI: 1.13 to 2.29).

DISCUSSION

These data demonstrate the significant relationship between sexual violence experienced by FSWs and unprotected sex with clients. Comprehensive interventions reducing vulnerabilities to violence combined with improved condom negotiation are needed to address the complex influences of condom use during sex work as a means of ultimately lowering HIV acquisition and transmission.

Risk behaviours among female sex workers in China: a systematic review and data synthesis

BACKGROUND

Commercial sex is one of the major modes of HIV transmission in China. Understanding HIV risk behaviours in female sex workers (FSW) is of great importance for prevention. This study aims to assess the magnitude and temporal changes of risk behaviours in Chinese FSW.

METHOD

Five electronic databases were searched to identify peer-reviewed English and Chinese language articles published between January 2000 and December 2012 that reported risk behaviours among FSW in China, including condom use, HIV testing, and drug use. Linear regression and Spearman's rank correlation were used to examine temporal trends in these risk factors. The study followed PRISMA guidelines for meta-analyses and was registered in the PROSPERO database for systematic reviews.

RESULTS

A total of 583 articles (44 English, 539 Chinese) investigating 594,583 Chinese FSW were included in this review. At last sex, condom use was highest with commercial partners (clients), increasing from 53.7% in 2000 to 84.9% in 2011. During this same time period, condom use increased with regular partners from 15.2% to 40.4% and with unspecified partners from 38.6% to 82.5%. Increasing trends were also found in the proportion of sampled FSW who reported testing for HIV in the past 12 months (from 3.2% in 2000 to 48.0% in 2011), while drug use behaviours decreased significantly from 10.9% to 2.6%.

CONCLUSION

During the first decade of 2000, Chinese FSWs' self-reported risk behaviours have decreased significantly while HIV testing has increased. Further outreach and intervention efforts are needed to encourage condom use with regular partners, continue promotion of HIV testing, and provide resources for the most vulnerable FSW, particularly low tier FSW, who may have limited access to sexual health and prevention programs.

Sexual and reproductive health knowledge, contraception uptake, and factors associated with unmet need for modern contraception among adolescent female sex workers in China

OBJECTIVE

In China, policy and social taboo prevent unmarried adolescents from accessing sexual and reproductive health (SRH) services. Research is needed to determine the SRH needs of highly disadvantaged groups, such as adolescent female sex workers (FSWs). This study describes SRH knowledge, contraception use, pregnancy, and factors associated with unmet need for modern contraception among adolescent FSWs in Kunming, China.

METHODS

A cross-sectional study using a one-stage cluster sampling method was employed to recruit adolescents aged 15 to 20 years, and who self-reported having received money or gifts in exchange for sex in the past 6 months. A semi-structured questionnaire was administered by trained peer educators or health workers. Multivariable logistic regression was conducted to determine correlates of low knowledge and unmet need for modern contraception.

RESULTS

SRH knowledge was poor among the 310 adolescents surveyed; only 39% had heard of any long-acting reversible contraception (implant, injection or IUD). Despite 98% reporting not wanting to get pregnant, just 43% reported consistent condom use and 28% currently used another form of modern contraception. Unmet need for modern contraception was found in 35% of adolescents, and was associated with having a current non-paying partner, regular alcohol use, and having poorer SRH knowledge. Past abortion was common (136, 44%). In the past year, 76% had reported a contraception consultation but only 27% reported ever receiving SRH information from a health service.

CONCLUSIONS

This study demonstrated a low level of SRH knowledge, a high unmet need for modern contraception and a high prevalence of unintended pregnancy among adolescent FSWs in Kunming. Most girls relied on condoms, emergency contraception, or traditional methods, putting them at risk of unwanted pregnancy. This study identifies an urgent need for Chinese adolescent FSWs to be able to access quality SRH information and effective modern contraception.