Patterns of inconsistent condom use and risky sexual behaviors among female sex workers in Mozambique

Temporal trends in HIV prevention service access and use among female sex workers (FSW) in Mozambique: a comparative analysis 2011-2019

BACKGROUND

Female sex workers (FSWs) remain disproportionately affected by HIV due to a combination of structural, social, and behavioral factors, including stigma, limited access to health services, gender-based violence, and legal barriers. In Mozambique, where sex work is informal and highly marginalized, monitoring trends in service uptake is essential to guide responsive and equitable HIV interventions. This study analyzes changes in access to and use of HIV prevention services among FSWs between 2011 and 2019.

METHODS

We conducted a secondary analysis of cross-sectional bio-behavioral survey (BBS) data collected among FSWs in 2011 and 2019 in three Mozambican urban centers. Standardized questionnaires were used to collect behavioral and biological data, including indicators of HIV prevention service access. Participants were recruited using Respondent-Driven Sampling (RDS). Logistic regression was applied to assess time trends and identify factors associated with service uptake.

RESULTS

A total of 1,240 FSWs participants were recruited in 2011 and 1,530 in 2019. Between 2011 and 2019, there was a significant increase in HIV prevalence (from 11.9 to 24.5%). The proportion of participants accessing HIV prevention services more than doubled (from 21.4 to 52.3%), alongside marked improvements in HIV testing uptake (68.0-83.1%) and consistent condom use with clients (74.1-86.3%). Multivariate analysis showed that age ≥ 25, moderate HIV risk perception, and experiences of sexual violence were positively associated with access to prevention services in 2019. In contrast, alcohol use and physical assault were negatively associated with service use. Determinants of access shifted over time; for example, while secondary education was positively associated with service access in 2011, it was negatively associated in 2019.

CONCLUSION

There has been substantial progress in access to and use of HIV prevention services among FSWs in Mozambique over the past decade. Nonetheless, the rising HIV prevalence and persistent disparities related to age, education, economic vulnerability, and exposure to violence signal the need for more comprehensive, context-specific, and equity-focused strategies. Reinforcing peer-led outreach, integrating gender-based violence response, and addressing risk misperception are critical to strengthening Mozambique's HIV prevention continuum for this key population.

Condomless sexual encounters among female sex workers included in a longitudinal coital diary study in Zimbabwe

BACKGROUND

Compared with the general female population, female sex workers (FSWs) experience a greater burden of STIs, including HIV. Consistent condom use reduces HIV risk; however, while many FSWs are aware of condom efficacy, this knowledge does not consistently translate into use. We aimed to estimate the prevalence and patterns of condomless sex by partner type at the sexual encounter level, as well as identify factors associated with condomless sex among FSWs recruited into a diary study in Zimbabwe.

METHODS

We conducted a longitudinal coital diary study in site A and site B between 25 November 2020 and 30 December 2021. Pictorial diaries were developed in collaboration with FSWs. We recruited participants using snowball sampling and asked them to complete a daily diary of their sexual encounters with each partner for one month, repeated over three non-consecutive months within 12 months. The following FSW characteristics were recorded: FSW age, Key Populations (KP) Programme contact, partner type and age, condom use categorized as none, partial, or full, types of sexual activity, and violence experiences. To identify factors associated with condomless sex, we used hierarchical Poisson regression modelling.

RESULTS

404 FSWs documented 62,559 sex encounters, with 17,325 (27.7%) reported as condomless. Our adjusted analysis showed that encounters with permanent partners had the highest likelihood of being condomless (59.5%; adjusted relative risk [aRR] 3.83, 95% CI: 3.38-4.35), followed by regular partners (25.6%; aRR 1.63, 95% CI: 1.50-1.78), compared to new partners (15.0%). Compared with FSWs aged < 25 years (29.7%), those aged ≥ 35 years were less likely to have condomless sex (22.1%; aRR 0.79, 95% CI: 0.66-0.94), while sex without violence was less likely (24.1%) to be condomless than sex with violence (57.7%; aRR 2.32, 95% CI: 2.00-2.70). FSWs with the KP programme contact reported fewer condomless encounters (25.9%; aRR 0.81, 95% CI: 0.90-0.94) than those without (32.9%).

CONCLUSION

Condomless sex was common and varied based on FSW age, partner type, experiencing violence during sex, and KP programme contact. These findings emphasize the need for continued condom promotion, counseling, violence mitigation, and training in condom negotiation skills especially given the heightened risk of HIV transmission among FSWs.