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Part time female sex workers in a suburban community in Kenya: a vulnerable hidden population
1. M P Hawken1,3,
2. R D J Melis1,4,
3. D T Ngombo1,
4. K Mandaliya1,
5. L W Ng’ang’a3,
6. J Price2,
7. G Dallabetta2,
8. M Temmerman1
1. 1International Centre for Reproductive Health, Ghent University, Ghent, Belgium
2. 2Family Health International, Arlington, USA
3. 3Centre for Respiratory Diseases Research, Kenya Medical Research Institute, Kenya
4. 4Medicus Mundi, Belgium
1. Correspondence to:  Dr Mark Hawken, International Centre for Reproductive Health, PO Box 91109, Mombasa, Kenya;  icrh{at}ikenya.com

Abstract

Background: In sub-Saharan Africa, female sex workers (FSWs) are a vulnerable high risk group for the acquisition and transmission of sexually transmitted infections (STI) and HIV.

Objectives: To study parameters of sexual behaviour and knowledge of STI and HIV, to describe health seeking behaviour related to STI, and to measure the prevalence of gonorrhoea, chlamydia, syphilis, and HIV-1, to provide baseline data for targeted STI and HIV prevention interventions.

Methods: In a cross sectional survey with snowballing recruitment, between February and March 2000, 503 self identified FSWs in a suburb in Mombasa, Kenya, were interviewed with a structured questionnaire and screened for gonorrhoea, chlamydia, syphilis, and HIV-1.

Condom use

When asked about the frequency of condom use with a client generally, 145 (29%) used a condom always, 25 (5%) almost always, 187 (37%) sometimes, and 146 (29%) never used a condom with a client. Two hundred and thirty eight (47%) had used a condom with their most recent client. It was the sex worker who suggested condom use in 82% of interviewees and they provided it in 73%. The most common reason to always use a condom was prevention of STI and HIV (73%). The most common reason for not always using a condom was client refusal (50%). Two hundred and eight (41%) women said they had turned down a client because he refused to use a condom. Most condoms were obtained from a local shop in 50% of interviewees, a clinic in 20%, and a pharmacy in 10%. Only 8% of the interviewees thought that the influence of alcohol or drugs sometimes accounted for non-use. When asked about condom use with a regular non-paying partner, 66 (20%) used a condom always, 12 (4%) almost always, 102 (31%) sometimes, and 145 (45%) never. The most common reason for not using a condom with a regular non-paying partner was because of perceived trust (48%) or because the partner refused to use one (36%).

Sexually transmitted infections

Twenty one per cent reported having had a vaginal discharge and 11% a genital ulcer in the last 12 months. Twenty five per cent admitted to having sex while they had symptoms of an STI and of those only 11% used a condom to protect their partner. Of those with a vaginal discharge or genital ulcer in the last 12 months, 45% sought first line treatment at a government clinic or hospital and 31% at a private clinic; 14% did nothing. Eighty two per cent of interviewees were able to mention two correct symptoms of STI in women and 69% in men. Forty four per cent were able to cite two correct ways of preventing STI (abstinence, reduction in partners, staying with one faithful partner, and condom use), and 51% at least one correct way to prevent STI. Thirty six per cent were able to cite three or more correct ways to prevent HIV (abstinence, reduction in sexual partners, staying with one faithful (uninfected) partner, and condom use), 40% two correct ways, and 23% only one correct way. Only three women (0.6%) were unable to cite any correct preventive methods. The prevalence of gonorrhoea, chlamydia, and syphilis was 1.8%, 4.2%, and 2.0% respectively. Thirty seven of 503 (7%) had used antibiotics in the previous week. The overall HIV-1 seroprevalence was 30.6%. Table 1 shows the prevalence of HIV-1 and measured STI stratified by age group. HIV-1 seroprevalence in the 15–19 year age group was 14.8%. HIV-1 rates increased with age up to a peak in the 20–29 year age group and then declined with increasing age. In univariate analysis, age at the start of sex work was associated with being HIV-1 seropositive (p=0.08). In a logistic regression model, age (p=0.007), widowed status (p=0.03), and younger age at the start of sex work (p=0.0004) were associated with being HIV-1 positive (table 2). Number of partners and condom use were not significant risk factors in this study.

Table 1

HIV-1 and STI prevalence by age group in part time female sex workers in Mombasa, Kenya

Table 2

Correlates of HIV-1 positivity in part time female sex workers in Mombasa, Kenya (multiple logistic regression model)

DISCUSSION

This survey using a snowballing technique in a set geographic area, identified a group of women best described as part time sex workers. They are described as part time sex workers because the majority are self employed in some form of small business and sell sex to supplement their small income. Small businesses often include selling foodstuffs, vegetables, and in some areas local brew. The mean number of non-regular clients is less than two per week and a proportion have a regular non-paying partner. Most of these women are single or cohabiting and most have children and other dependants. The non-random nature of the population sampling is recognised but nevertheless it provides important information on a hidden population.

The HIV seroprevalence in this group was greater than in the general population but less than in many sex worker populations described to date. We were unable to demonstrate an association between the number of partners and HIV seroprevalence but the age of starting sex work (a surrogate marker of cumulative sex partners) was associated with HIV seroprevalence. STI prevalence within the last year was high and condom use was extremely low. Despite this, the prevalence of gonorrhoea and syphilis was low. We presume that this reflects reasonable access to medical care or frequent use of antibiotics in this group.

Despite a reasonable knowledge of symptoms of STI, knowledge of STI and HIV prevention was poor. Almost one third had never used a condom with a client and yet half of them perceived their chances of becoming infected with HIV as moderate or great. The most common reason not to use a condom was client refusal. In addition, condom use was even lower with non-paying partners of these women, placing them at increased risk of acquiring HIV, as reported elsewhere.9

There are interventions of proved efficacy in decreasing STI and HIV incidence in sex workers, such as peer education and condom promotion.6,7 In designing such interventions it is important to target part time sex workers, who because of the part time nature of their work, may otherwise be overlooked. The low use of condoms, incomplete knowledge of HIV and STI, the high number of reported STI, and the lower HIV-1 seroprevalence in the younger age group, emphasise a great need for intensive STI and HIV prevention programmes in this hidden population and particularly in those in the younger age group.

Key messages

• Part time FSWs are a hidden subgroup in a larger heterogeneous group of FSWs

• Part time FSWs may be overlooked and need to be specifically targeted in any FSW intervention

• The HIV seroprevalence in this group (30.6%) was greater than in the general population confirming that they are a vulnerable group

• There is a great need for intensive STI and HIV prevention programmes in this hidden population, particularly in those in the younger age groups

Acknowledgments

This work was supported by the United States Agency for International Development (USAID) as part of Family Health International’s (FHI) Implementing AIDS Prevention and Care (IMPACT) Project (Cooperative Agreement HRN-A-00-97-00017-00) and does not necessarily reflect the views of USAID or FHI. We would like to thank the interviewers and the women who participated in the study.

CONTRIBUTORS  MH was the study leader; RM, and DN were involved in the logistics of the study; LN performed the data analysis; and KM, JP, and GD contributed to study design and questionnaire development.

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