Background Condom use remains the cornerstone of HIV prevention in sub-Saharan Africa where HIV transmission is predominantly heterosexual. The aim of this study conducted in Cotonou, Benin, was to determine factors associated with unprotected sex among female sex workers (FSW), an important core group for the transmission of HIV and sexually transmitted infections (STI).
Methods We have recruited and followed 396 FSW in a reference center for STI treatment. Condom use was assessed at enrolment and 6 months thereafter. FSW were asked how often they have used condoms with their clients during the last 7 days of work. During the study, FSW were encouraged to always use condoms with their clients. A generalised estimating equation model for binomial distribution with repeated measures was used to isolate factors independently associated with failure to use condoms during any sexual act.
Results The cohort comprised 1) 149 HIV-positive FSW, of which 52 were treated with antiretroviral therapy (ART) and 97 were not yet eligible for ART and 2) 247 HIV-negative subjects. Mean age (standard deviation; sd) and mean number of clients (sd) during the last 7 days of work were, respectively, 33.8 (9.3) years and 28.4 (26.1) clients. The majority of the FSW (55.3%) did not practice in brothels or equivalent set ups. At enrolment, 5.6% of the FSW reported that they have never used condoms during the last week of work. The proportion of FSW with full use of condoms during the last 7 days of work increased from 77.8% at enrolment to 90.6% 6 months after. First assessment of condom use (enrolment into the study) [RR 2.17; 95% CI 1.44% to 3.26%], not working in a brothel (RR 2.22; 95% CI 1.39% to 3.54%), having a relatively low monthly income (RR 1.63; 95% CI 1.04% to 2.57%) and older age (RR 1.50; 95% CI 1.03 to 2.21%) were independently associated with failure to always use condoms with the clients. Being HIV-infected or being treated with ART was not associated with the issue of interest. The reasons reported by the FSW for not using condoms during the last sexual act were dominated by the refusal of the client (46.0%).
Conclusion As suggested by our results, interventions promoting condom use during any commercial sexual act are fruitful and need to target women outside brothels, economically more vulnerable and older FSW as well as their clients.