Unmet need for contraception among sex workers in Madagascar

Global epidemiology of abortion among female sex workers: a systematic review, meta-analysis, and meta-regression

PURPOSE

Despite the evidence of a high rate of unintended pregnancy, there remains limited information about the prevalence and experiences of abortion among female sex workers (FSWs). In response, we aimed to summarize the available evidence on abortion among FSWs.

METHODS

We searched Medline, Embase, PsycINFO, CINAHL, Scopus, and Web of Science from inception to January 29, 2023 . We pooled data from the included studies using random-effects meta-analyses. We also grouped countries for the legality of elective abortion stratified by the United Nations database on abortion laws and policies.

RESULTS

We identified 60 eligible studies from 2031 potentially eligible records. The pooled lifetime prevalence of at least one and multiple induced abortions was 37.7% (95% confidence interval, 31.8-43.7) and 21.7% (14.9-29.2), respectively. Among FSWs recruited in countries where elective abortion is illegal, at least one induced abortion prevalence was 35.1% (28.1-42.4), and multiple induced abortion prevalence was 23.1% (12.4-35.9). In countries where elective abortion is legal, at least one induced abortion prevalence was 44.6% (34.8-54.6), and multiple induced abortion prevalence was 19.9% (11.9-29.3). Among FSWs experiencing abortion, self-managed abortion prevalence was estimated at 32.8% (23.6-42.7) overall, 42.8% (37.2-48.5) for countries where elective abortion is illegal, and 15.6% (3.9-32.7) for countries that legally allow elective abortion.

CONCLUSIONS

Induced abortion is prevalent among FSWs, highlighting the need for interventions to increase access to effective contraception and safe abortion care. While induced abortion prevalence did not significantly differ across the legal grounds for abortion, self-managed abortion prevalence was higher in countries where elective abortion was illegal, highlighting the urgent need for accessible abortion services for FSWs in criminalized settings. Moving forward necessitates implementing and evaluating culturally acceptable models of safe abortion and post-abortion care for FSWs to increase access to the full spectrum of sexual and reproductive health services.

Longitudinal study of pregnancy intention and its association with pregnancy occurrence among female sex workers in Benin and Mali

BACKGROUND

The intention of becoming pregnant has an evident impact on the prenatal and postnatal period. For female sex workers (FSWs) in West Africa, among whom pregnancies are frequent as are HIV and sexually transmitted infections, a better understanding of their pregnancy intention and its influence on pregnancy occurrence could help prevent unwanted pregnancies and adverse effects on wanted pregnancies.

METHODS

We recruited 330 FSWs in Benin and 322 in Mali and followed them for 12 months. We evaluated their pregnancy intention at recruitment and 6-month follow-up, using a multidimensional prospective measure that we developed. We assessed pregnancy occurrence with a pregnancy test and a retrospective questionnaire at 6 and 12 months. A Cox proportional hazard model was used to estimate the association between intention and pregnancy. We carried out an analysis to take losses to follow-up into account using the inverse of probability of censoring weights and a cluster analysis to corroborate that the multidimensional measure of pregnancy intention fitted the data.

RESULTS

407 FSWs were included in the first 6-month analysis and 284 at 12 months. Mean age was 30.9 years. The pregnancy intention distribution was similar between the two periods: 15.2% in the first period and 16.3% in the second had a positive intention. One out of four were ambivalent and almost 60% (57.7% and 56.3%) had a negative intention. For 38.2% of the FSWs, the intention changed between the two periods. The global incidence rate (to first event) was 19.1 pregnancies per 100 person-years. There was a borderline significant trend (p = 0.0529) of decreased pregnancy incidence with decreasing intention. Compared to positive intention, the adjusted hazard ratio (aHR) for ambivalent and negative intentions were 0.71 [95% confidence interval (95% CI) 0.32-1.60] and 0.46 (95% CI 0.21-1.01), respectively.

CONCLUSION

The level of pregnancy intention influences its occurrence among FSWs and nearly one out of six wants a baby despite working in the sex trade. Programmatically, early identification of these women could facilitate provision of quality antenatal and postnatal care. Given other health risks associated with sex work this care may decrease potential risks of adverse maternal, fetal and neonatal outcomes.

Effectiveness of mHealth intervention on safe abortion knowledge and perceived barriers to safe abortion services among female sex workers in Vietnam

BACKGROUND

Mobile health (mHealth) has been used to promote sexual and reproductive health (SRH) education and services; however, little is known about the use of mHealth to improve safe abortion knowledge and access to safe abortion services among female sex workers (FSWs). This study evaluated the feasibility and effectiveness of iConnect intervention through changes in knowledge on safe abortion and changes in perceived barriers to safe abortion services among FSWs in Vietnam.

METHODS

iConnect mobile app was developed as an interactive platform to deliver safe abortion education and referral to safe abortion services through short messaging services (SMS) enhanced by tele-counseling for 512 FSWs in Hanoi, Vietnam. A pretest-posttest evaluation was conducted using questionnaire-based phone interviews administered to 251 participants at baseline and 3 months following the intervention. Non-parametric tests evaluated the change in abortion knowledge, behaviors, and perceived barriers to safe abortion.

RESULTS

There were significant improvements in the knowledge on safe abortion among the study participants. Specifically, FSWs' knowledge of correct gestational ages (≤22 weeks) for medical abortion increased from 78.9% at baseline to 96.8% (P=0.001). Knowledge of correct gestational ages for medical abortion at the private clinic increased from 45.3% to 63.1% (P=0.001). Knowledge on the consequences of unsafe abortion increased from 75.2% to 92.1% (P=0.001). In addition, perceived stigma and discrimination when seeking safe abortion decreased from 36.5% to 27.8% (P=0.036) and worry about the lack of confidentiality decreased from 23.3% to 15.5% (P=0.035).

CONCLUSIONS

The evaluation results showed the initial effectiveness of a mobile app-based intervention in improving access to safe abortion information and services among FSWs. A future study is needed to establish the efficacy of the intervention for scaling up in Vietnam and elsewhere.

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.

Values and preferences of contraceptive methods: a mixed-methods study among sex workers from diverse settings

There is limited information on contraceptive values and preferences of sex workers. We conducted a mixed-method study to explore contraceptive values and preferences among sex workers. We conducted an online survey with individuals from 38 countries (n = 239), 6 focus group discussions (FGD, n = 68) in Zimbabwe, and 12 in-depth phone interviews (IDI) across 4 world regions, in June and July of 2019. Participants were asked about awareness of contraceptives, methods they had used in the past, and the determinants of their choices. Differences between respondents from high-, low- and middle- income countries were examined. Qualitative data were analysed thematically. Survey participants reported an awareness of modern contraceptive methods. FGDs found that younger women had lower awareness. Reports of condomless sex were common and modern contraceptive use was inconsistent. Determinants of contraceptive choices differed by setting according to results of the survey, FGD, and IDI. Regardless of country income level, determinants of contraceptive choices included ease of use, ease of access to a contraceptive method, and fewer side effects. Healthcare provider attitudes, availability of methods, and clinic schedules were important considerations. Most sex workers are aware of contraceptives, but barriers include male partners/clients, side effects, and health system factors such as access and clinic attitudes towards sex workers.

Usual source of healthcare and use of sexual and reproductive health services by female sex workers in Brazil

The fact of having a usual source of care can improve access to health services and preventive activities. The article aimed to estimate the proportion of factors associated with usual source of care among female sex workers. This was a socio-behavioral survey with 4,328 female sex workers, ≥ 18 years, in 12 Brazilian cities. Female sex workers were recruited by the respondent-driven sampling method (RDS). A descriptive profile was performed of the female sex workers who had usual source of care and the association was analyzed between usual source of care and indicators of access to HIV prevention and reproductive health. As effect measure, the study used adjusted odds ratio (OR) in a logistic regression model. The data were weighted by the RDS-II estimator. 71.5% of the female sex workers reported having a usual source of care, and of these, 54.3% cited primary healthcare (PHC) as their main usual source of care. Among female sex workers 18-24 years of age, there was an association between usual source of care and having a Pap smear test (OR = 2.27; 95%CI: 1.66-3.12), seven or more prenatal visits (OR = 2.56; 95%CI: 1.30-5.03), and the use of a contraceptive method (OR = 1.64; 95%CI: 1.09-2.46). Among female sex workers ≥ 25 years, there was an association between usual source of care and attending talks on sexually transmitted infections (STIs) (OR = 1.45; 95%CI: 1.12-1.89), prior knowledge of post-exposure prophylaxis (OR = 1.32; 95%CI: 1.02-1.71), and history of Pap smear test (OR = 1.92; 95%CI: 1.54-2.40). The study's results showed that female sex workers have PHC as their main usual source of care. usual source of care can also positively impact care and activities in reproductive health and prevention of HIV and STIs in this population group.

Integrating Sexual and Reproductive Health Services Within HIV Services: WHO Guidance

Among the 1.9 billion women of reproductive age worldwide in 2019, 1.1 billion need family planning and 270 million have an unmet need for contraception. For women and adolescent girls living with human immunodeficiency virus (HIV), using effective contraception reduces the mother-to-child transmission of HIV by preventing unintended pregnancies and enabling the planning and safer conception of desired pregnancies with optimal maternal and child health outcomes. The World Health Organization (WHO) recommends that sexual and reproductive health services, including contraception, may be integrated within HIV services. Integration is associated with increased offers and uptake of sexual and reproductive health services, including contraception, which is likely to result in improved downstream clinical outcomes. Integrating HIV and sexual and reproductive health services has been found to improve access, the quality of antenatal care and nurse productivity while reducing stigma and without compromising uptake of care. Research is encouraged to identify approaches to integration that lead to better uptake of sexual and reproductive health services, including contraception. Implementation research is encouraged to evaluate different strategies of integration in different health systems and social contexts; such research should include providing contraception, including long-acting contraception, in the context of less frequent clinical and ART refill visits.

Future directions for HIV service delivery research: Research gaps identified through WHO guideline development

Nathan Ford and co-authors discuss the systematic identification of research gaps in improving HIV service delivery.

"A condom is compulsory": A qualitative study of condom use and negotiation strategies among female sex workers in Nepal

The objective of this qualitative study was to understand Nepali female sex workers' (FSWs) condom negotiation strategies. In 2016, we conducted 30 semi-structured, in-depth interviews with street- and brothel-based FSWs residing in Kathmandu, Nepal. Participants reported that their first entry into sex work typically occurred between the ages of 17-32, and the average duration of women's involvement with sex work was 8 years. FSWs reported high knowledge and awareness of condoms, and many women had used various sexual and reproductive health services. FSWs used three types of negotiation strategies: withholding or refusing sex, providing risk information, and direct request. While some FSWs believed that these strategies were useful and successful, we found that, for some women, condom negotiation strategies were difficult to implement due to fear of abuse and threats of violence by clients. Condom negotiation was further complicated by poverty and substance abuse, and several narratives revealed the influence of gender and social norms on safe sexual practices. The findings highlight the need for improved sexual health interventions that incorporate a range of negotiation strategies and techniques (e.g., nonverbal communication and reward strategies) and aim to mitigate harm and violence against FSWs.

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.

Effect of a mobile phone intervention for female sex workers on unintended pregnancy in Kenya (WHISPER or SHOUT): a cluster-randomised controlled trial

BACKGROUND

Female sex workers in low-income and middle-income countries face high risks of unintended pregnancy. We developed a 12-month, multifaceted short messaging service intervention (WHISPER) for female sex workers in Kenya who had the potential to become pregnant, to improve their contraceptive knowledge and behaviours. The aim of this study was to assess the effectiveness of the intervention to reduce the incidence of unintended pregnancy among sex workers in Kenya compared with an equal-attention control group receiving nutrition-focused messages (SHOUT).

METHODS

Our two-arm, cluster-randomised controlled trial was done in sex-work venues in two subcounties of Mombasa, Kenya (Kisauni and Changamwe). Participants, aged 16-34 years, not pregnant or planning pregnancy, able to read text messages in English, residing in the study area, and who had a personal mobile phone with one of two phone networks, were recruited from 93 randomly selected sex-work venues (clusters). Random cluster allocation (1:1) to the intervention or control group was concealed from participants and researchers until the intervention started. Both groups received text messages in English delivered two to three times per week for 12 months (137 messages in total), as well as additional on-demand messages. Message content in the intervention group focused on promotion of contraception, particularly long-acting reversible contraception and dual method contraceptive use; message content in the control group focused on promotion of nutritional knowledge and practices, including food safety, preparation, and purchasing. The primary endpoint, analysed in all participants who were randomly assigned and attended at least one follow-up visit, compared unintended pregnancy incidence between groups using discrete-time survival analysis at 6 and 12 months. This trial is registered with Australian New Zealand Clinical Trials Registry, ACTRN12616000852459, and is closed to new participants.

FINDINGS

Between Sept 14, 2016, and May 16, 2017, 1728 individuals were approached to take part in the study. Of these, 1155 were eligible for full screening, 1035 were screened, and 882 were eligible, enrolled, and randomly assigned (451 participants from 47 venues in the intervention group; 431 participants from 46 venues in the control group). 401 participants from the intervention group and 385 participants from the control group were included in the primary analysis. Incidence of unintended pregnancy was 15·5 per 100 person-years in the intervention group and 14·7 per 100 person-years in the control group (hazard ratio 0·98, 95% CI 0·69-1·39).

INTERPRETATION

The intervention had no measurable effect on unintended pregnancy incidence. Mobile health interventions, even when acceptable and rigorously designed, are unlikely to have a sufficient effect on behaviour among female sex workers to change pregnancy incidence when used in isolation.

FUNDING

National Health and Medical Research Council of Australia.

"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.

Overview and factors associated with pregnancies and abortions occurring in sex workers in Benin

Background

Behavioural and structural factors related to sex work, place female sex workers (FSWs) at high risk of maternal mortality and morbidity (MMM), with a large portion due to unintended pregnancies and abortions. In the African context where MMM is the highest in the world, understanding the frequency and determinants of pregnancy and abortion among FSWs is important in order to meet their sexual and reproductive health needs.

Methods

Data from two Beninese cross-sectional surveys among FSWs aged 18+ (2013, N = 450; 2016, N = 504) were merged. We first performed exploratory univariate analyses to identify factors associated with pregnancy and abortion (p < 0.20) using Generalized Estimating Equations with Poisson regression and robust variance. Multivariate analyses first included all variables identified in the univariate models and backward selection (p ≤ 0.05) was used to generate the final models.

Results

Median age was 39 years (N = 866). The proportion of FSWs reporting at least one pregnancy during sex work practice was 16.4%, of whom 42.3% had more than one. Most pregnancies ended with an abortion (67.6%). In multivariate analyses, younger age, longer duration in sex work, previous HIV testing, having a boyfriend and not using condoms with him were significantly (p < 0.05) associated with more pregnancies.

Conclusion

One FSW out of five had at least one pregnancy during her sex work practice. Most of those pregnancies, regardless of their origin, ended with an abortion. Improving access to various forms of contraception and safe abortion is the key to reducing unintended pregnancies and consequently, MMM among FSWs in Benin.

Pragmatic women: negotiating sex work, pregnancy, and parenting in Mysore, South India

Persisting inequities in maternal health pose a particular burden for marginalised populations such as sex workers. However, current literature on pregnancy and sex work is limited to mostly quantitative studies focusing on contraception use, unplanned and/or undesired pregnancies and unsafe abortions. Additionally, emphasis has been placed on the prevention, treatment and care of STIs and HIV with less attention accorded to women's pregnancy desires and implications to work. In this paper, we explore sex workers' conflicted experiences surrounding pregnancy, parenthood, and work. Forty-six women participated in in-depth interviews as part of a qualitative exploratory study conducted in close collaboration with a sex worker collective in the city of Mysore (South India). Our analysis focuses on women's pragmatic responses to pregnancy desires, workplace challenges during and after pregnancy, strategies for managing risk and approaches to managing work and childcare. We show that women confront various intersecting challenges with respect to pregnancy and sex work. Women's complex decision-making balances multiple considerations while highlighting the temporal dimension of pragmatism as women respond not only to the immediacy of an encounter but also in anticipation of a better future.

A Mobile Phone-Based Sexual and Reproductive Health Intervention for Female Sex Workers in Kenya: Development and Qualitative Study

BACKGROUND

Female sex workers (FSWs) have high rates of both unintended pregnancy and HIV, but few health promotion interventions address their contraceptive needs or other sexual and reproductive health and rights (SRHR) concerns. A broader approach integrates contraceptive promotion with HIV and sexually transmitted infection (STI) prevention and management, alcohol awareness, gender-based violence and rights, and health care utilization. The Women's Health Intervention using SMS for Preventing Pregnancy (WHISPER) mobile phone intervention uses a participatory development approach and behavior change theory to address these high-priority concerns of FSWs in Mombasa, Kenya.

OBJECTIVE

This paper aimed to (1) describe the process of development of the WHISPER intervention, its theoretical framework, key content domains and strategies and (2) explore workshop participants' responses to the proposed intervention, particularly with regard to message content, behavior change constructs, and feasibility and acceptability.

METHODS

The research team worked closely with FSWs in two phases of intervention development. First, we drafted content for three different types of messages based on a review of the literature and behavior change theories. Second, we piloted the intervention by conducting six workshops with 42 FSWs to test and refine message content and 12 interviews to assess the technical performance of the intervention. Workshop data were thematically analyzed using a mixed deductive and inductive approach.

RESULTS

The intervention framework specified six SRHR domains that were viewed as highly relevant by FSWs. Reactions to intervention content revealed that social cognitive strategies to improve knowledge, outcome expectations, skills, and self-efficacy resonated well with workshop participants. Participants found the content empowering, and most said they would share the messages with others. The refined intervention was a 12-month SMS program consisting of informational and motivational messages, role model stories portraying behavior change among FSWs, and on-demand contraceptive information.

CONCLUSIONS

Our results highlight the need for health promotion interventions that incorporate broader components of SRHR, not only HIV prevention. Using a theory-based, participatory approach, we developed a digital health intervention that reflects the complex reality of FSWs' lives and provides a feasible, acceptable approach for addressing SRHR concerns and needs. FSWs may benefit from health promotion interventions that provide relevant, actionable, and engaging content to support behavior change.

Addressing broader reproductive health needs of female sex workers through integrated family planning/ HIV prevention services: A non-randomized trial of a health-services intervention designed to improve uptake of family planning services in Kenya

BACKGROUND

Despite considerable efforts to prevent HIV and other sexually transmitted infections (STI) among female sex workers (FSW), other sexual and reproductive health (SRH) needs, such preventing unintended pregnancies, among FSW have received far less attention. Programs targeting FSW with comprehensive, accessible services are needed to address their broader SRH needs. This study tested the effectiveness of an intervention to increase dual contraceptive method use to prevent STIs, HIV and unintended pregnancy among FSW attending services in drop-in centers (DIC) in two cities in Kenya. The intervention included enhanced peer education, and routine screening for family planning (FP) needs plus expanded non-condom FP method availability in the DIC.

METHODS

We conducted a two-group, pre-/posttest, quasi-experimental study with 719 FSW (360 intervention group, 359 comparison group). Participants were interviewed at baseline and 6 months later to examine changes in condom and non-condom FP method use.

RESULTS

The intervention had a significant positive effect on non-condom, FP method use (OR = 1.38, 95%CI (1.04, 1.83)), but no effect on dual method use. Consistent condom use was reported to be high; however, many women also reported negotiating condom use with both paying and non-paying partners as difficult or very difficult. The strongest predictor of consistent condom use was partner type (paying versus non-paying/emotional); FSW reported both paying and non-paying partners also influence non-condom contraceptive use. Substantial numbers of FSW also reported experiencing sexual violence by both paying and non-paying partners.

CONCLUSIONS

Self-reported difficulties with consistent condom use and the sometimes dangerous conditions under which they work leave FSW vulnerable to unintended pregnancy STIs/HIV. Adding non-barrier FP methods to condoms is crucial to curb unintended pregnancies and their potential adverse health, social and economic consequences. Findings also highlight the need for additional strategies beyond condoms to reduce HIV and STI risk among FSW.

TRIAL REGISTRATION

Clinicaltrials.gov NCT01957813.

Prevalence and predictors of unmet contraceptive need in HIV-positive female sex workers in Mombasa, Kenya

OBJECTIVES

Female sex workers (FSWs) in sub-Saharan Africa are a key population for HIV prevention and treatment interventions, but less attention is given to their family planning needs. We evaluated the prevalence and predictors of unmet contraceptive need in HIV-positive FSWs.

STUDY DESIGN

This cross-sectional analysis used data from an existing longitudinal study of FSWs in Mombasa, Kenya. This analysis included women who were HIV positive, age ≥18 years, pre-menopausal, not currently pregnant or desiring pregnancy, and reported exchanging sex for cash or in-kind payment at the time of enrollment. Unmet contraceptive need was defined as non-use of modern non-barrier contraceptives and not currently trying to become pregnant. Poisson regression was used to identify factors independently associated with unmet contraceptive need.

RESULTS

Among 346 HIV-positive FSWs, 125 (36.1%) reported modern non-barrier contraceptive use, leaving 221 (63.9%, 95%CI 58.8-68.9%) with unmet contraceptive need. Condom use was the only form of contraception for 129 (37.3%) participants. In unadjusted analyses, unmet contraceptive need was associated with physical abuse in the past year by someone other than a regular partner (PR 1.2, 95%CI 1.0-1.5), desire for (more) children (PR 1.3, 95%CI 1.1-1.5), and having 2-3 previous pregnancies compared to 0-1 prior pregnancies (PR 0.8, 95%CI 0.6-0.9). In adjusted analyses, lower number of previous pregnancies and having desire for future children remained significantly associated with a higher prevalence of unmet contraceptive need.

CONCLUSIONS

Unmet need for modern non-barrier contraception was found in two-thirds of HIV-positive FSWs who reported that they were not currently trying to become pregnant, and was higher in women with the lowest number of prior pregnancies (0-1 prior pregnancies) and in those reporting desire for (more) children in the future. These findings highlight the need for concerted efforts to identify and eliminate barriers to contraceptive use in FSWs living with HIV.

Incidence of unintended pregnancy among female sex workers in low-income and middle-income countries: a systematic review and meta-analysis

OBJECTIVES

To determine the incidence of unintended pregnancy among female sex workers (FSWs) in low-income and middle-income countries (LMICs).

DESIGN

We searched MEDLINE, PsychInfo, Embase and Popline for papers published in English between January 2000 and January 2016, and Web of Science and Proquest for conference abstracts. Meta-analysis was performed on the primary outcomes using random effects models, with subgroup analysis used to explore heterogeneity.

PARTICIPANTS

Eligible studies targeted FSWs aged 15-49 years living or working in an LMIC.

OUTCOME MEASURES

Studies were eligible if they provided data on one of two primary outcomes: incidence of unintended pregnancy and incidence of pregnancy where intention is undefined. Secondary outcomes were also extracted when they were reported in included studies: incidence of induced abortion; incidence of birth; and correlates/predictors of pregnancy or unintended pregnancy.

RESULTS

Twenty-five eligible studies were identified from 3866 articles. Methodological quality was low overall. Unintended pregnancy incidence showed high heterogeneity (I²>95%), ranging from 7.2 to 59.6 per 100 person-years across 10 studies. Study design and duration were found to account for heterogeneity. On subgroup analysis, the three cohort studies in which no intervention was introduced had a pooled incidence of 27.1 per 100 person-years (95% CI 24.4 to 29.8; I²=0%). Incidence of pregnancy (intention undefined) was also highly heterogeneous, ranging from 2.0 to 23.4 per 100 person-years (15 studies).

CONCLUSIONS

Of the many studies examining FSWs' sexual and reproductive health in LMICs, very few measured pregnancy and fewer assessed pregnancy intention. Incidence varied widely, likely due to differences in study design, duration and baseline population risk, but was high in most studies, representing a considerable concern for this key population. Evidence-based approaches that place greater importance on unintended pregnancy prevention need to be incorporated into existing sexual and reproductive health programmes for FSWs.

PROSPERO REGISTRATION NUMBER

CRD42016029185.

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.

Barriers to sexual and reproductive healthcare services as experienced by female sex workers and service providers in Dhaka city, Bangladesh

OBJECTIVES

This study aimed to identify the barriers female sex workers (FSWs) in Bangladesh face with regard to accessing sexual and reproductive health (SRH) care, and assess the satisfaction with the healthcare received.

METHODS

Data were collected from coverage areas of four community-based drop-in-centers (DICs) in Dhaka where sexually transmitted infection (STI) and human immunovirus (HIV) prevention interventions have been implemented for FSWs. A total of 731 FSWs aged 15-49 years were surveyed. In addition, in-depth interviews (IDIs) were conducted with 14 FSWs and 9 service providers. Respondent satisfaction was measured based on recorded scores on dignity, privacy, autonomy, confidentiality, prompt attention, access to social support networks during care, basic amenities, and choice of institution/care provider.

RESULTS

Of 731 FSWs, 353 (51%) reported facing barriers when seeking sexual and reproductive healthcare. Financial problems (72%), shame about receiving care (52.3%), unwillingness of service providers to provide care (39.9%), unfriendly behavior of the provider (24.4%), and distance to care (16.9%) were mentioned as barriers. Only one-third of the respondents reported an overall satisfaction score of more than fifty percent (a score of between 9 and16) with formal healthcare. Inadequacy or lack of SRH services and referral problems (e.g., financial charge at referral centers, unsustainable referral provision, or unknown location of referral) were reported by the qualitative FSWs as the major barriers to accessing and utilizing SRH care.

CONCLUSIONS

These findings are useful for program implementers and policy makers to take the necessary steps to reduce or remove the barriers in the health system that are preventing FSWs from accessing SRH care, and ultimately meet the unmet healthcare needs of FSWs.

Contraceptive use and unplanned pregnancy among female sex workers in Zambia

Objectives

Access to reproductive healthcare, including contraceptive services, is an essential component of comprehensive healthcare for female sex workers (FSW). Here, we evaluated the prevalence of and factors associated with contraceptive use, unplanned pregnancy, and pregnancy termination among FSW in three transit towns in Zambia.

Study design

Data arose from the baseline quantitative survey from a randomized controlled trial of HIV self-testing among FSW. Eligible participants were 18 years of age or older, exchanged sex for money or goods at least once in the past month, and were HIV-uninfected or status unknown without recent HIV testing (<3 months). Logistic regression models were used to assess factors associated with contraceptive use and unplanned pregnancy.

Results

Of 946 women eligible for this analysis, 84.1% had been pregnant at least once, and among those 61.6% had an unplanned pregnancy, and 47.7% had a terminated pregnancy. Incarceration was associated with decreased odds of dual contraception use (aOR=0.46, 95% CI 0.32–0.67) and increased odds of unplanned pregnancy (aOR=1.75, 95% CI 1.56–1.97). Condom availability at work was associated with increased odds of using condoms only for contraception (aOR=1.74, 95% CI 1.21–2.51) and decreased odds of unplanned pregnancy (aOR=0.63, 95% CI 0.61–0.64).

Conclusions

FSW in this setting have large unmet reproductive health needs. Structural interventions, such as increasing condom availability in workplaces, may be useful for reducing the burden of unplanned pregnancy.

Meeting the Reproductive Health Needs of Female Key Populations Affected by HIV in Low- and Middle-Income Countries: A Review of the Evidence

Female sex workers and other women at high risk of acquiring HIV have the right to sexual and reproductive health, including the right to determine the number and timing of pregnancies. We conducted a literature review to examine the data that exist regarding the family planning and reproductive health needs of female key populations, the underlying determinants of these populations' vulnerability to poor reproductive health outcomes, and the obstacles they face in accessing high-quality reproductive health services. Findings indicate that female key populations experience high rates of unmet need for family planning and safer conception services, unintended pregnancies, sexual violence, and abortion, and that they practice inconsistent condom use. Restrictive policy environments, stigma and discrimination in health care settings, gender inequality, and economic marginalization restrict access to services and undermine the ability to safely achieve reproductive intentions. We offer recommendations for structural, health system, community, and individual-level interventions that can mitigate the effects of these barriers and improve reproductive health outcomes.

Sexual and reproductive health services utilization by female sex workers is context-specific: results from a cross-sectional survey in India, Kenya, Mozambique and South Africa

BACKGROUND

Female sex workers (FSWs) are extremely vulnerable to adverse sexual and reproductive health (SRH) outcomes. To mitigate these risks, they require access to services covering not only HIV prevention but also contraception, cervical cancer screening and sexual violence. To develop context-specific intervention packages to improve uptake, we identified gaps in service utilization in four different cities.

METHODS

A cross-sectional survey was conducted, as part of the baseline assessment of an implementation research project. FWSs were recruited in Durban, South Africa (n = 400), Mombasa, Kenya (n = 400), Mysore, India (n = 458) and Tete, Mozambique (n = 308), using respondent-driven sampling (RDS) and starting with 8-16 'seeds' identified by the peer educators. FSWs responded to a standardised interviewer-administered questionnaire about the use of contraceptive methods and services for cervical cancer screening, sexual violence and unwanted pregnancies. RDS-adjusted proportions and surrounding 95% confidence intervals were estimated by non-parametric bootstrapping, and compared across cities using post-hoc pairwise comparison tests with Dunn-Šidák correction.

RESULTS

Current use of any modern contraception ranged from 86.2% in Tete to 98.4% in Mombasa (p = 0.001), while non-barrier contraception (hormonal, IUD or sterilisation) varied from 33.4% in Durban to 85.1% in Mysore (p < 0.001). Ever having used emergency contraception ranged from 2.4% in Mysore to 38.1% in Mombasa (p < 0.001), ever having been screened for cervical cancer from 0.0% in Tete to 29.0% in Durban (p < 0.001), and having gone to a health facility for a termination of an unwanted pregnancy from 15.0% in Durban to 93.7% in Mysore (p < 0.001). Having sought medical care after forced sex varied from 34.4% in Mombasa to 51.9% in Mysore (p = 0.860). Many of the differences between cities remained statistically significant after adjusting for variations in FSWs' sociodemographic characteristics.

CONCLUSION

The use of SRH commodities and services by FSWs is often low and is highly context-specific. Reasons for variation across cities need to be further explored. The differences are unlikely caused by differences in socio-demographic characteristics and more probably stem from differences in the availability and accessibility of SRH services. Intervention packages to improve use of contraceptives and SRH services should be tailored to the particular gaps in each city.

WOMEN'S EMPOWERMENT AND FAMILY PLANNING: A REVIEW OF THE LITERATURE

This paper reviews the literature examining the relationship between women's empowerment and contraceptive use, unmet need for contraception and related family planning topics in developing countries. Searches were conducted using PubMed, Popline and Web of Science search engines in May 2013 to examine literature published between January 1990 and December 2012. Among the 46 articles included in the review, the majority were conducted in South Asia (n=24). Household decision-making (n=21) and mobility (n=17) were the most commonly examined domains of women's empowerment. Findings show that the relationship between empowerment and family planning is complex, with mixed positive and null associations. Consistently positive associations between empowerment and family planning outcomes were found for most family planning outcomes but those investigations represented fewer than two-fifths of the analyses. Current use of contraception was the most commonly studied family planning outcome, examined in more than half the analyses, but reviewed articles showed inconsistent findings. This review provides the first critical synthesis of the literature and assesses existing evidence between women's empowerment and family planning use.

Non-barrier contraceptive use and relation to condom use behaviour by partner type among female sex workers in Andhra Pradesh, India

OBJECTIVE

The study assessed non-barrier contraceptive use among female sex workers (FSW) in Andhra Pradesh, India and relation to inconsistent condom use among commercial and non-commercial male sexual partners.

METHODS

FSW at least 18 years of age (n=2338) were recruited through respondent-driven sampling for an HIV risk survey. Analysis was restricted to women of childbearing age (n=2197). Crude and adjusted logistic regression models were used to assess non-barrier contraceptive use and relation to inconsistent condom use with husbands or regular male partners (i.e. non-clients), regular clients and occasional clients.

RESULTS

Non-barrier methods of contraception included contraceptive pills (3.8%) and sterilisation (68.4%). In logistic regression models adjusted for relevant demographics, FSW using contraceptive pills were more likely to report inconsistent condom use with a regular client (past week) [adjusted odds ratio (AOR) 2.2, 95% confidence interval (CI) 1.2-4.0] and with an occasional client (past week) (AOR 2.6, 95% CI 1.6-5.3), as well as accepting more money for sex without a condom (past 30 days) (AOR 2.5, 95% CI 1.5-4.3). No significant associations were found between pill use and inconsistent condom use among women's non-client partners, potentially related to small sample sizes within these subgroups. Reporting sterilisation, which was more common among FSW who were older in age, was not associated with inconsistent condom use with client or non-client sexual partners.

CONCLUSIONS

Findings document potential unmet need for modern, spacing contraceptives (i.e. pill, intrauterine device), but also indicate the importance for family planning services, particularly those promoting modern contraceptive methods to be provided alongside HIV prevention among FSW in Andhra Pradesh, India.

Lifetime Abortion of Female Sex Workers in Iran: Findings of a National Bio-Behavioural Survey In 2010

Introduction

Unintended pregnancies and abortion may be considered as occupational hazards for female sex workers (FSWs). As our understanding of contraceptive and abortion practices of Iranian FSWs is very limited, this study tries to assess the dynamics of contraception and abortion among this sub-population.

Methods

This survey was conducted in 2010, by recruiting 872 FSWs through facility-based sampling from 21 sites in 14 cities in Iran. Data were collected through face-to-face interviews using a pilot-tested standardized risk assessment questionnaire. We applied the logistic regression model to investigate the correlates of induced abortion among FSWs.

Results

Of the 863 participants with valid responses to the abortion variable, 35.3% (95% CI: 32.1–38.6) acknowledged ever induced abortion and the annual rate of abortion was estimated at 20.7 per 1000 women. Around 31.2% of FSWs reported no usual contraceptive use, 32.6% barrier method, 23.6% non-barrier modern contraception methods, and 12.5% dual protection. In our multivariable model, older age (Adjusted Odds Ratio (AOR) = 1.74, 95% Confidence Interval (CI): 1.02, 2.96), group sex (AOR = 1.92, 95% CI: 1.10, 3.35), history of travel for sex work (AOR = 1.55, 95% CI: 1.09, 2.20), sexual violence (AOR = 1.77, 95% CI: 1.25, 2.50), STIs in last year (AOR = 1.53, 95% CI: 1.09, 2.14), and accessing family planning services (AOR = 1.76, 95% CI: 1.24, 2.49) were significant predictors of lifetime abortion.

Conclusions

The reproductive health needs of Iranian FSWs are unmet and around one-third of FSWs reported induced abortion. Scaling-up comprehensive family planning services and empowering FSWs to have safer sex practices may help them to prevent unintended pregnancies and further risk of HIV transmission.

"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.

'I won't be able to go home being pregnant': sex work and pregnancy in Dhaka, Bangladesh

Sex workers report high rates of unintended pregnancy that are inconsistent with widespread reports of condom use. Greater understanding of the implications of an unintended pregnancy and barriers to contraceptive use is needed to better meet the broader sexual and reproductive health needs of this population. We conducted in-depth interviews with 20 women sex workers in Dhaka, Bangladesh. Findings reveal that most women are trying to conform to societal norms and protect their reputations. They fear pregnancy would reveal that they are having unsanctioned sex and that they are sex workers. This could lead to ostracism from families and society, resulting in homelessness and abandonment by partners. Pregnancy may affect a sex worker's ability to work and leave her unable to meet financial obligations. All study participants were using condoms but most acknowledged they could not use them consistently. They had all tried other contraceptive methods, notably injectables and the pill, but some noted experience of side-effects, difficulties in adherence and the desire to use other methods. Understanding the context of sex workers' lives is an important step in informing stakeholders about the range of services needed to improve their sexual and reproductive health.

Contraceptive use among female sex workers in three Russian cities

OBJECTIVE

To determine the prevalence of, and factors associated with, use of non-barrier contraception (intrauterine device, hormonal contraceptives, and female sterilization) among female sex workers (FSWs) in three Russian cities.

METHODS

A secondary analysis of data from a cross-sectional survey of FSWs aged 18 years and older from Kazan, Krasnoyarsk, and Tomsk was undertaken. Participants had completed a one-time computer-based survey in 2011. Among the 708 with a current contraceptive need, logistic regression was used to evaluate factors associated with use of non-barrier contraceptives.

RESULTS

Use of non-barrier contraceptives was reported by 237 (33.5%) FSWs. Use of non-barrier contraceptives was associated with being in sex work longer (≥ 4 years vs < 1 year: adjusted odds ratio [AOR] 4.70; 95% confidence interval [CI] 1.51-14.66) and having a non-paying partner (AOR 2.02; 95% CI 1.32-3.11). Odds of non-barrier contraception were reduced among FSWs who had ever worked with a pimp/momka (AOR 0.46; 95% CI 0.24-0.87), who had experienced recent client-perpetrated violence (AOR 0.19; 95% CI 0.07-0.52), or reporting consistent condom use (AOR 0.30; 95% CI 0.16-0.54). Only 13 (5.5%) of the 237 FSWs using non-barrier contraception reported consistent condom use.

CONCLUSION

Only one-third reported use of non-barrier contraception, suggesting substantial unmet contraceptive needs. FSWs are an important target population for family planning, reproductive health counseling, and care.

Structural determinants of dual contraceptive use among female sex workers in Gulu, northern Uganda

OBJECTIVE

To describe the characteristics of female sex workers (FSWs) who do and do not use dual contraceptives (i.e. male condoms plus a non-barrier method) in Gulu, northern Uganda.

METHODS

The present analysis was based on data gathered as part of a questionnaire-based, cross-sectional study conducted between May 2011 and January 2012. FSWs aged 14 years or older were recruited through peer-led or sex worker-led outreach and community-based services. Logistic regression was used to identify correlates of dual contraceptive use.

RESULTS

Among the 400 FSWs who participated, 180 (45.0%) had ever used dual contraceptives. In the multivariate model, dual contraceptive use was positively associated with older age (adjusted odds ratio [AOR] 1.09, 95% confidence interval [CI] 1.04-1.15; P=0.001), prior unintended pregnancy (AOR 1.53, 95% CI 1.01-2.34; P=0.046), and HIV testing (AOR 5.22, 95% CI 1.75-15.57; P=0.003). Having to rush sexual negotiations owing to police presence was negatively associated with dual contraceptive use (AOR 0.65, 95% CI 0.42-1.00; P=0.050).

CONCLUSION

Although a history of unintended pregnancy and accessing HIV testing might promote contraceptive use, criminalized work environments continue to pose barriers to uptake of sexual and reproductive health services among FSWs in post-conflict northern Uganda. Integrated links between HIV and sexual health programs could support contraceptive uptake among FSWs.

An urgent need for integration of family planning services into HIV care: the high burden of unplanned pregnancy, termination of pregnancy, and limited contraception use among female sex workers in Côte d'Ivoire

BACKGROUND

HIV infection and unintended pregnancy are occupational risks of commercial female sex work (FSW). The burden of unintended pregnancy among FSW including maternal and infant outcomes in the context of HIV is largely unknown.

METHODS

FSW ≥18 years were recruited through respondent driven sampling into a cross-sectional study in Abidjan, Côte d'Ivoire. Participants completed a sociobehavioral questionnaire and HIV counseling and testing. Pregnancy history by HIV status and contraceptive use were described, and Poisson regression used to estimate correlates of termination of pregnancy (TOP).

RESULTS

From March to July 2014, 466 FSW were enrolled. Unintended pregnancy was common, and 64% of participants had ≥1 TOP. Half of FSW experiencing TOPs did so without a medical professional, resulting in frequent complications. Contraceptive use was lowest among younger FSW, and 37% of 20-24 year olds reported multiple TOPs. FSW with a TOP history reported 19% less consistent condom use with clients than women who never had a TOP (adjusted-prevalence ratio, 0.81; 95% confidence interval: 0.74 to 0.88), whereas use of reliable nonbarrier contraceptive methods was comparable between the groups. Although FSW were engaged in HIV testing and prevention services, only 59% of FSW had received HIV testing before childbirth during their last pregnancy, and 30% of HIV-infected FSW had lost ≥1 children.

CONCLUSIONS

Low contraceptive use and high burden of unintended pregnancy result in poor reproductive outcomes for FSW and avoidable mother-to-child HIV transmission risks. Integration of family planning and antenatal services into HIV prevention and care programs accessed by FSW could enhance reproductive outcomes and HIV prevention goals.

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.

Sexual violence against female sex workers in The Gambia: a cross-sectional examination of the associations between victimization and reproductive, sexual and mental health

Background

Female sex workers (FSW) are a vulnerable population for sexual violence and poor sexual and reproductive health outcomes. Sexual violence against FSW has not been widely studied in The Gambia. This study will report the prevalence of and evaluate the health issues correlated with forced sex perpetrated by clients against FSW in The Gambia, and will secondly aim to inform future research and efforts to improve health outcomes for survivors of violence.

Methods

A cross-sectional survey was administered among 251 FSW accrued through a combination of chain referral and venue-based sampling in The Gambia. Eligibility criteria included being over 16 years old and having exchanged sex for money, goods, or favors in the past 12 months.

Results

There is a high prevalence of sexual violence against FSW in The Gambia, with 29% (n = 70) of participants reporting a client forced them to have sex in their lifetime. Women who reported forced sex by a client were more likely to report symptoms of depression (aOR 2.15, CI: 1.10 – 4.16 p < 0.05), unwanted pregnancy (aOR: 2.69, CI: 1.12 – 6.49 p < 0.05) and report “no”, “difficult” or “somewhat difficult” access to condoms (aOR: 3.31, CI: 1.76 – 6.26 p < .01) compared to women who did not report forced sex. Client-perpetrated forced sex was also negatively associated with receiving any sexually transmitted infection (STI) test in the past 12 months (aOR: 0.49, CI: .26 – .91 p < .05).

Conclusion

FSW who experience sexual violence by a client are more likely to experience poor sexual, reproductive and mental health outcomes. Responding to sexual violence among FSW, including providing survivors with access to post-exposure prophylaxis, emergency contraception, and mental health services, must be a priority given the prevalence of forced sex and links with poor health outcomes. Efforts to reduce sexual violence against FSW is a vital strategy to improve the health and safety of FSW as well as impact the spread of HIV/STIs in The Gambia.

Systematic review of facility-based sexual and reproductive health services for female sex workers in Africa

Background

Several biological, behavioural, and structural risk factors place female sex workers (FSWs) at heightened risk of HIV, sexually transmitted infections (STIs), and other adverse sexual and reproductive health (SRH) outcomes. FSW projects in many settings have demonstrated effective ways of altering this risk, improving the health and wellbeing of these women. Yet the optimum delivery model of FSW projects in Africa is unclear. This systematic review describes intervention packages, service-delivery models, and extent of government involvement in these services in Africa.

Methods

On 22 November 2012, we searched Web of Science and MEDLINE, without date restrictions, for studies describing clinical and non-clinical facility-based SRH prevention and care services for FSWs in low- and middle-income countries in Africa. We also identified articles in key non-indexed journals and on websites of international organizations. A single reviewer screened titles and abstracts, and extracted data from articles using standardised tools.

Results

We located 149 articles, which described 54 projects. Most were localised and small-scale; focused on research activities (rather than on large-scale service delivery); operated with little coordination, either nationally or regionally; and had scanty government support (instead a range of international donors generally funded services). Almost all sites only addressed HIV prevention and STIs. Most services distributed male condoms, but only 10% provided female condoms. HIV services mainly encompassed HIV counselling and testing; few offered HIV care and treatment such as CD4 testing or antiretroviral therapy (ART). While STI services were more comprehensive, periodic presumptive treatment was only provided in 11 instances. Services often ignored broader SRH needs such as family planning, cervical cancer screening, and gender-based violence services.

Conclusions

Sex work programmes in Africa have limited coverage and a narrow scope of services and are poorly coordinated with broader HIV and SRH services. To improve FSWs’ health and reduce onward HIV transmission, access to ART needs to be addressed urgently. Nevertheless, HIV prevention should remain the mainstay of services. Service delivery models that integrate broader SRH services and address structural risk factors are much needed. Government-led FSW services of high quality and scale would markedly reduce SRH vulnerabilities of FSWs in Africa.

Influence of integrated services on postpartum family planning use: a cross-sectional survey from urban Senegal

Background

Although the majority of postpartum women indicate a desire to delay a next birth, family planning (FP) methods are often not offered to, or taken up by, women in the first year postpartum. This study uses data from urban Senegal to examine exposure to FP information and services at the time of delivery and at child immunization appointments and to determine if these points of integration are associated with greater use of postpartum FP.

Methods

A representative, household sample of women, ages 15–49, was surveyed from six cities in Senegal in 2011. This study focuses on women who were within two years postpartum (n = 1879). We also include women who were surveyed through exit interviews after a visit to a high volume health facility in the same six cities; clients included were visiting the health facility for delivery, post-abortion care, postnatal care, and child immunization services (n = 794). Descriptive analyses are presented to examine exposure to FP services among postpartum women and women visiting the health facility. Logistic regression models are used to estimate the effect of integrated services on postpartum FP use in the household sample of women. Analyses were conducted using Stata version 12.

Results

Among exit interview clients, knowledge of integrated services is high but only a few reported receiving FP services. A majority of the women who did not receive FP services indicated an interest in receiving such information and services.

Among the household sample of women up to two-years postpartum, those who received FP information at the time of delivery are more likely to be using modern FP postpartum than their counterparts who also delivered in a facility but did not receive such information. Exposure to FP services at an immunization visit was not significantly related to postpartum FP use. Another key finding is that women with greater self-efficacy are more likely to use a modern FP method.

Conclusion

This study’s findings lend strong support for the need to improve integration of FP services into maternal, newborn, and child health services with the goal of increasing postpartum women’s use of FP methods in urban Senegal.

Contraception and condom use among Bolivian female sex workers: relationship-specific associations between disease prevention and family planning behaviors

We examined data from a clinic-based survey of 1,222 Bolivian female sex workers (FSWs) to assess whether use of nonbarrier modern contraception is associated with less consistent condom use with clients and noncommercial partners. Women who were using nonbarrier modern contraception were less likely than nonusers to consistently use condoms with noncommercial partners (AOR 0.393, 95% CI 0.203-0.759, p = .005). With clients, this inverse association did not hold. Public health professionals must consider both disease prevention and pregnancy prevention needs in this vulnerable population, and messages should be tailored to encourage dual method use with all partners.

'We are despised in the hospitals': sex workers' experiences of accessing health care in four African countries

Sex workers in east and southern Africa are exposed to multiple occupational health and safety risks. Detailed understanding of barriers to accessing care would optimise design of improved services for this population. In this study, trained sex workers conducted 55 in-depth interviews and 12 focus group discussions with 106 female, 26 male and 4 transgender sex workers across 6 urban sites in Kenya, Zimbabwe, Uganda and South Africa. Data were analysed thematically, following an interpretive framework. Participants cited numerous unmet health needs, including diagnosis and treatment for sexually transmitted infections and insufficient access to condoms and lubricant. Denial of treatment for injuries following physical assault or rape and general hostility from public-sector providers was common. Resources permitting, many sex workers attended private services, citing higher quality and respect for dignity and confidentiality. Sex workers in southern Africa accessed specialised sex worker clinics, reporting mostly positive experiences. Across sites, participants called for additional targeted services, but also sensitisation and training of public-sector providers. Criminalisation of sex workers and associated stigmatisation, particularly of transgender and male sex workers, hinder HIV-prevention efforts and render access to mainstream healthcare precarious. Alongside law reform, sex worker-led peer outreach work should be strengthened and calls by sex workers for additional targeted services heeded.

The Intersection between Sex Work and Reproductive Health in Northern Karnataka, India: Identifying Gaps and Opportunities in the Context of HIV Prevention

Objective. To examine the reproductive health practices of female sex workers (FSWs) in the context of an HIV prevention program in Karnataka, India. Methods. Data obtained from a survey of 1,011 FSWs registered with an HIV prevention program. We examined reproductive health indicators, and performed multivariate logistic regression among primiparous FSWs to assess sex work during pregnancy and antenatal HIV testing. Results. Among primiparous FSWs (N = 251), 92.0% continued sex work during pregnancy, and 55.4% received antenatal HIV testing. A longer duration in sex work (AOR 2.7, 95% CI: 1.0-7.5), rural residence (AOR 3.3, 95% CI: 1.2-8.9), and antenatal HIV testing (AOR 6.3, 95% CI: 2.0-20.1) were associated with continued sex work during pregnancy. Older FSWs (age >25 years, AOR 0.12, 95% CI: 0.05-0.33), who delivered at home (AOR 0.14, 95% CI: 0.09-0.34), were least likely to receive antenatal HIV testing. Antenatal HIV testing was associated with awareness of methods to prevent vertical HIV transmission (AOR 3.9, 95% CI: 1.9-14.1). Conclusions. Antenatal HIV testing remains low in the context of ongoing sex work during pregnancy. Existing HIV prevention programs are well positioned to immediately integrate reproductive health care with HIV interventions targeted to FSWs.

Induced abortion, contraceptive use, and dual protection among female sex workers in Moscow, Russia

OBJECTIVE

To describe abortion history and current contraceptive use among female sex workers (FSWs) in Moscow, Russia.

METHODS

A clinic-based survey was conducted among 147 FSWs in Moscow during an 8-month period in 2005.

RESULTS

In total, 83 of 143 (58.0%) FSWs reported a history of abortion, with 45 of 143 (31.5%) indicating multiple abortions. Condoms were the primary form of contraception (145/146 [99.3%]); just 17 of 142 (12.0%) FSWs reported using non-barrier modern contraception. All women who reported using a non-barrier modern method also indicated condom use (i.e. dual protection). Non-barrier contraceptive use was associated with inconsistent condom use (odds ratio [OR] 3.10; 95% confidence interval [CI], 1.07-9.02) and multiple abortions (OR 4.71; 95% CI, 1.19-18.62).

CONCLUSION

The results illustrate substantial risk for unintended pregnancy among FSWs. Further research is needed regarding the dynamics of non-barrier contraception and condom use. Efforts to improve the health and wellbeing of FSWs should include access to safe and effective contraception, in addition to HIV prevention.

Contraceptive needs of female sex workers in Kenya - a cross-sectional study

BACKGROUND AND OBJECTIVES

Female sex workers (FSWs) are thought to be at heightened risk for unintended pregnancy, although sexual and reproductive health interventions reaching these populations are typically focused on the increased risk of sexually transmitted infections. The objective of this study of FSWs in Kenya is to document patterns of contraceptive use and unmet need for contraception.

METHODS

This research surveys a large sample of female sex workers (N = 597) and also uses qualitative data from focus group discussions.

RESULTS

The reported level of modern contraceptives in our setting was very high. However, like in other studies, we found a great reliance on male condoms, coupled with inconsistent use at last sex, which resulted in a higher potential for unmet need for contraception than the elevated levels of modern contraceptives might suggest. Dual method use was also frequently encountered in this population and the benefits of this practice were clearly outlined by focus group participants.

CONCLUSION

These findings suggest that the promotion of dual methods among this population could help meet the broader reproductive health needs of FSWs. Furthermore, this research underscores the necessity of considering consistency of condom use when estimating the unmet or undermet contraceptive needs of this population.

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.