Objective To readjust HIV control programmes in Africa, we assessed the factors associated with high-risk behaviours and HIV infection among young female sex workers (FSW) in Burkina Faso.
Methods We carried out a cross-sectional study from September 2009 to September 2010 in Ouagadougou, the capital city. FSW were categorised as professionals and part-time sex workers (PTSW). After a face-to-face questionnaire, blood and urine samples were collected for HIV, HSV-2, genital infections and pregnancy. High-risk behaviour was defined as a recent unprotected sex with either casual clients, regular clients or regular partners.
Results We recruited 609 FSW including 188 (30.9%) professionals. Their median age was 21 years (IQR 19–23), and the prevalence of HIV was 10.3% among professionals and 6.5% among PTSW. Only 3 of 46 HIV-infected women were aware of their status. Overall, 277 (45.6%) women reported high-risk behaviours (41.2% among professionals and 47.5% among PTSW), which were driven mainly by non-systematic condom use with regular partners. In multivariable analysis, PTSW (adjusted OR (AOR)=1.89; 95% CI 1.27 to 2.82) and having a primary (AOR=1.75; 95% CI 1.15 to 2.67) or higher education level (AOR=1.80; 95% CI 1.13 to 2.89) remained associated with high-risk behaviours. HIV infection was associated with older age (AOR=1.44; 95% CI 1.22 to 1.71), with being married/cohabiting (AOR=2.70; 95% CI 1.21 to 6.04) and with Trichomonas vaginalis infection (AOR=9.63; 95% CI 2.93 to 31.59), while history of HIV testing was associated with a decreased risk (AOR=0.18; 95% CI 0.08 to 0.40).
Conclusions This study highlights the need for targeted interventions among young FSW focusing particularly on PTSW, sexual behaviours with regular partners and regular HIV testing.
- COMMERCIAL SEX
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The HIV epidemic in West Africa is highly concentrated in core groups such as female sex workers (FSW). The prevalence of HIV among FSW in the region is estimated to be higher than 20%, while it is <2% in the general population.1 In Burkina Faso, as in other parts of West Africa, sex work is an evolving milieu with an increasing involvement of part-time sex workers (PTSW) such as bar waitresses.2 Given the changing nature of both HIV epidemiology and sex work milieu,3 and the need to adjust HIV control programmes accordingly, it is crucial to regularly assess the levels of risk and behaviours among these women, and particularly among the younger ones.
As part of the recruitment process of an interventional cohort, this study aimed to estimate the prevalence and determinants of HIV and high-risk behaviours among young FSW in Burkina Faso. The intervention consisted of peer-led education sessions, free provision of STI syndromic management, condoms and hormonal contraceptives, psychological support and free general medical and HIV care (for those HIV infected at screening or seroconverting during the cohort follow-up).4
Between September 2009 and September 2010, we screened young FSW aged between 18 and 25 years in Ouagadougou, the capital city of Burkina Faso, for enrolment in a cohort aimed at evaluating the impact of a community-based intervention.
To identify the ‘hot spots’ where these women operate, we first conducted a geomapping of sex work venues throughout the city using a geographic information system. Then, on the mapped sex work venues, peers and social workers identified all women belonging to the established categories of FSW2 and invited them to attend a group information session at the study clinic. After this session, potentially eligible women interested in participating in the study took an appointment for the formal cohort screening visit. During this visit, women were asked to give informed written consent for screening and enrolment in the 12–24 months cohort study. All women who attended the group information session and the screening visit, who were aged between 18 and 25 years and who self-reported having at least one paying client over the last week, were included in the present work.
The procedures used during the screening visit were identical as those from the interventional cohort described and published elsewhere.4 In addition to HIV, HSV-2 serologies and detection of vaginal infections (Trichomonas vaginalis, Candida and bacterial vaginosis), serological syphilis was detected using a semiquantitative Rapid Plasma Reagin card test (Macro-Vue, Becton-Dickinson, Cockysville, Maryland, USA) and the Treponema pallidum Haemagglutination assay test (Welcosyph HA, Murex Biotech, Dartford, UK). Cervical swabs have been collected and stored in the freezer (−80°C) for future detection of Neisseria gonorrhoeae and Chlamydia trachomatis, using PCR (AMPLICOR, Roche, Branchburg, New Jersey, USA). Unfortunately, due to technical issues related to sample storage at the University of Ouagadougou, these assays could not be interpreted.
The study protocol was approved by the research ethics committees of the Ministry of Health of Burkina Faso and the London School of Hygiene & Tropical Medicine. All participants included in this study gave informed written consent to participate in this study.
All consenting women who attended the screening visit and who complied with our definition of FSW were included in the analysis. Logistic regression models were built to assess the determinants of HIV infection and of high-risk behaviours. The latter was a composite variable defined as having a recent unprotected sex (with casual clients over the last week, or with regular clients or regular partners on the last month). The primary covariate of interest (FSW category) was kept in all models. Due to the high number of women not tested for HV-2, this covariate was removed from the final models. Complete case analysis was used to handle missing data.
The total number of FSW contacted by peers and social workers in sex work venues could not be recorded. Overall, 1037 women attended the group information sessions at the study clinic. Among the 712 women who attended the screening visit, 609 women met the inclusion criteria for this work and 602 had a HIV test available. Their median age was 21 years (IQR 19–23). Professional FSW represented 33% of the sample (188/609).
HIV risk and high-risk behaviours
Among the 602 women tested for HIV, 46 were infected, giving a HIV prevalence of 7.6% (95% CI 5.7% to 10.0%). There was no significant difference between professionals and PTSW (10.3% vs 6.5% (p=0.13)). Among all HIV-infected women, only three (6.5%) were aware of their HIV status. In multivariable analysis, the risk of HIV infection increased significantly with age (adjusted OR (AOR)=1.44), being married or cohabiting (AOR=2.70) and with T. vaginalis infection (AOR=9.63) but not with FSW category (table 1). Conversely, previous HIV testing was associated with a much lower risk of HIV infection (AOR=0.18).
The overall rate of high-risk behaviours did not differ significantly between professionals (41.2%, 95% CI 34.4% to 48.3%) and PTSW (47.5%, 95% CI 42.8% to 52.3%) (p=0.15). Overall, high-risk behaviours were driven mainly by recent unprotected sex with regular partners (48.4%).
High-risk behaviours were significantly more frequent among PTSW than FSW (AOR=1.89) and among women with primary (AOR=1.75) or higher education level (AOR=1.80) than women who never went to school (table 1).
In spite of the steady decrease in HIV prevalence in the general population, young FSW remain at high risk of HIV infection in Burkina Faso. The HIV prevalence was 19 times higher than the 0.4% prevalence reported the same year and in the same city among the general population of women of the same age,5 and it did not vary significantly by sex work category. As reported earlier from Bobo-Dioulasso,2 PTSW had significantly more risky behaviours than professionals, despite a much lower number of clients, which correlates with a lower self-perception of HIV risk. Unlike other regions,6 ,7 the vulnerability of these PTSW has merely been reported in West Africa. In Kenya, HIV prevalence among these PTSW (30.6%) was twice higher than that among pregnant,6 and in Tanzania, women working in bars and hotels were also at high risk, with a HIV incidence of 3.7%.7 HIV prevention and research programmes should include PTSW in Africa.
In addition to older age, and vaginal trichomoniasis, cohabitating or being married was the strongest risk factor of HIV for FSW. This result is consistent with the report of much lower condom use with the regular partners. It highlights the crucial role played by regular partners (from boyfriends to protectors and owners) in HIV transmission for FSW.8 In our study, high-risk behaviours were independently and significantly reduced among FSWs who always request their regular partner to use condom. This encouraging finding suggests that an intervention targeting condom promotion and negotiation with regular partners could improve consistent condom use and therefore reduce HIV risk. Besides developing strategies to reach these regular partners, the design and evaluation of safer sex counselling and education modules for FSW (focusing on these partners) should be prioritised.
Although two-thirds of women reported having been tested at least once for HIV, <10% of the HIV-infected women were aware of their HIV status. In this young population, access to regular HIV testing is certainly crucial to initiate ART early as recommended by the WHO. Beside individual benefits, early ART could contribute to reduce the role of FSW on the HIV dynamics.9
The main limitation of our study was that C. trachomatis and N. gonorrhoeae could not be measured.
Professional FSW are only the visible part of sex work in Burkina Faso as certainly in other West African countries, while PTSW play a crucial role in HIV transmission dynamics. Our results highlight the need to adapt interventions for sex workers in West Africa to target also PTSW and to address safer sex with regular partners.
We acknowledge all the women who participated in this study and the non-governmental associations that facilitated the study as well as their involvement in the Community Advisory Boards, the Ministry of Health and the National Programme for AIDS Control.
Abstract in French
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- Abstract in French - Online abstract
Handling editor Jackie A Cassell
Contributors ITT contributed to designing the study, the acquisition, analysis and interpretation of the data. He also wrote the manuscript. NN contributed to designing the study, the acquisition, analysis and interpretation of the data. He also wrote with ITT the manuscript and supervised its development. NM, PVDP and PM contributed to designing the study, interpretation of the data and critically reviewed the manuscript. NMH, DO, FS, RS, AS and IK contributed to the acquisition of the data and critically reviewed the manuscript.
Funding The HIV prevaccine cohort was funded by the European and Developing Countries Clinical Trial Partnership (EDCTP) and by INSERM-ANRS (French National Agency for Research on AIDS and Viral Hepatitis).
Competing interests None declared.
Patient consent Obtained.
Ethics approval Research ethics committees of the Ministry of Health of Burkina Faso (approval number 2008-032) and the London School of Hygiene & Tropical Medicine (approval number 5476).
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement Results reported are related to the data collected at the screening visit. Behavioural, clinical and biological data collected during the follow-up of the cohort have been analysed to assess the impact of the intervention package on HIV, HSV-2 and pregnancy incidences. Please send an email to firstname.lastname@example.org if you need any data for further analysis.