Behavioral and Biological Factors Related to HIV Transmission among Female Sex Workers in Ethiopia

Abstract: Due to legal, cultural, and social factors, female sex workers (FSWs) experience anelevated level of violence, heavy alcohol consumption, and sexual abuse. Theseindividual and societal factors create a web of vulnerabilities that facilitate thespread of HIV within this population group. Moreover, stigma and discriminationare common among HIV-positive FSWs, contributing to poor HIV treatmentadherence, drug resistance, and treatment failure. Effective HIV preventionprograms among FSWs are therefore crucial to halt the spread of HIV not onlyamong sex workers but also among the general population. Nevertheless, FSWtargetedprograms and research activities are limited in quality, quantity, andcoverage in Ethiopia. Thus, the general aim of this thesis was to explore theexperiences of FSWs in Ethiopia to gain a better understanding of factors thatcontribute to the increased risk of HIV infection among FSWs.Papers I, II, and III are based on a cross-sectional bio-behavioral study conductedamong 4900 FSWs in eleven major towns in Ethiopia. The data collection wasconducted using a respondent-driven sampling technique (RDS). A blood samplewas collected for HIV, CD4, viral load and drug resistance testing. For paper IV, aqualitative study was conducted among 17 FSWs using a snowball sampling.Logistic regression was used as the main tool for analysis in the cross-sectionalstudies, and content analysis was used for qualitative data.The results of Paper I showed that 17.5% of FSWs had been physically beatenwithin the last 12 months and 15.2% had been raped since they started selling sex.Bing young, sex-selling venues (street based), high consumption of alcohol, andkhat chewing were significant predictors of physical violence (beating). Thesignificant predictors of sexual violence (rape) were low income, high consumptionof alcohol and khat chewing. Paper II revealed that 29.1% of the study participantsexperienced HED in the past month. Significant determinants of HED were beingyounger, being forced into selling sex, working in a bar/hotel, having a higherincome, and chewing khat frequently. In turn, HED was significantly associatedwith physical beating and condom breakage. Paper III showed that the prevalenceof pre-treatment drug resistance (PDR) among ART naïve FSWs was 16.5%, whichis classified as high according to WHO criteria. Viral load non-suppression wassignificantly associated with being forced into selling sex, age ≥35 years, and lowCD4+ T-cell counts (<350 cells/mm3). Only low CD4 counts were significantlyassociated with acquired drug resistance (ADR) and PDR respectively. Finally,Paper IV showed that FSWs who were taking PrEP faced stigma, due to thesimilarity of the PrEP pill to the ART pill, and experienced adherence-maintainingchallenges. Reasons for not starting to take PrEP included fear of side effects, poorconfidence, and/or misconceptions.The findings indicated that different individual and structural factors among FSWsplayed a role in increased exposure to violence and HED, which in turn may increasevulnerability to HIV acquisition and transmission. The findings also suggest theneed for targeted interventions to improve ART access and routine virologicalmonitoring to control the transmission of both HIV and HIVDR. In addition, thechallenges and barriers to PrEP uptake among FSWs need to be addressed to betterfacilitate the uptake of PrEP.