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

Forskningsoutput: AvhandlingDoktorsavhandling (sammanläggning)

112 Nedladdningar (Pure)


Due to legal, cultural, and social factors, female sex workers (FSWs) experience an
elevated level of violence, heavy alcohol consumption, and sexual abuse. These
individual and societal factors create a web of vulnerabilities that facilitate the
spread of HIV within this population group. Moreover, stigma and discrimination
are common among HIV-positive FSWs, contributing to poor HIV treatment
adherence, drug resistance, and treatment failure. Effective HIV prevention
programs among FSWs are therefore crucial to halt the spread of HIV not only
among sex workers but also among the general population. Nevertheless, FSWtargeted
programs and research activities are limited in quality, quantity, and
coverage in Ethiopia. Thus, the general aim of this thesis was to explore the
experiences of FSWs in Ethiopia to gain a better understanding of factors that
contribute to the increased risk of HIV infection among FSWs.
Papers I, II, and III are based on a cross-sectional bio-behavioral study conducted
among 4900 FSWs in eleven major towns in Ethiopia. The data collection was
conducted using a respondent-driven sampling technique (RDS). A blood sample
was collected for HIV, CD4, viral load and drug resistance testing. For paper IV, a
qualitative study was conducted among 17 FSWs using a snowball sampling.
Logistic regression was used as the main tool for analysis in the cross-sectional
studies, and content analysis was used for qualitative data.
The results of Paper I showed that 17.5% of FSWs had been physically beaten
within 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, and
khat chewing were significant predictors of physical violence (beating). The
significant predictors of sexual violence (rape) were low income, high consumption
of alcohol and khat chewing. Paper II revealed that 29.1% of the study participants
experienced HED in the past month. Significant determinants of HED were being
younger, being forced into selling sex, working in a bar/hotel, having a higher
income, and chewing khat frequently. In turn, HED was significantly associated
with physical beating and condom breakage. Paper III showed that the prevalence
of pre-treatment drug resistance (PDR) among ART naïve FSWs was 16.5%, which
is classified as high according to WHO criteria. Viral load non-suppression was
significantly associated with being forced into selling sex, age ≥35 years, and low
CD4+ T-cell counts (<350 cells/mm3). Only low CD4 counts were significantly
associated with acquired drug resistance (ADR) and PDR respectively. Finally,
Paper IV showed that FSWs who were taking PrEP faced stigma, due to the
similarity of the PrEP pill to the ART pill, and experienced adherence-maintaining
challenges. Reasons for not starting to take PrEP included fear of side effects, poor
confidence, and/or misconceptions.
The findings indicated that different individual and structural factors among FSWs
played a role in increased exposure to violence and HED, which in turn may increase
vulnerability to HIV acquisition and transmission. The findings also suggest the
need for targeted interventions to improve ART access and routine virological
monitoring to control the transmission of both HIV and HIVDR. In addition, the
challenges and barriers to PrEP uptake among FSWs need to be addressed to better
facilitate the uptake of PrEP.
Tilldelande institution
  • Institutionen för kliniska vetenskaper, Malmö
  • Agardh, Anette, handledare
  • Balcha, Taye Tolera, Biträdande handledare
  • Sanders, Eduard, Biträdande handledare
  • Abate, Ebba, Biträdande handledare, Extern person
Tilldelningsdatum2021 dec. 20
ISBN (tryckt)978-91-8021-157-4
StatusPublished - 2021

Bibliografisk information

Defence details
Date: 2021-12-20
Time: 13:00
Place: Agardh föreläsningssal, CRC, Jan Waldenströms gata 35, Skånes Universitetssjukhus i Malmö
External reviewer(s)
Name: Atuyame, Lynn
Title: Associate Professor
Affiliation: School of Public Health, Makerere University, Uganda

Ämnesklassifikation (UKÄ)

  • Folkhälsovetenskap, global hälsa, socialmedicin och epidemiologi


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