Background
Female Sex Workers (FSWs) are predisposed to a broad range of social, sexual and reproductive health problems such as sexually transmitted infections (STIs) including HIV/AIDS, unintended pregnancy, exploitation, stigma and discrimination, and violence [
1‐
3]. FSWs are also ostracized by the community besides suffering legal and human rights violations thereby necessitating clandestine operations that often prevent them from accessing and/or using formal health services [
4]. A qualitative study on the psychological stressors in the context of commercial sex in China showed FSWs face a host of stressors precipitated by poverty, unemployment, lack of social protection, violence from clients, and limited social support from peers and stable partners [
5]. Another qualitative study conducted in Central Kenya identified three barriers to FSWs’ access to contraceptive services which comprise: unsupportive clinic infrastructure, long wait time, user fees, inconvenient operating hours and perceived compulsory HIV testing; discriminatory provider–client interactions, where participants believed negative and differential treatment from female and male staff members impacted FSWs’ willingness to seek medical services; and negative partner influences, including both nonpaying and paying partners [
6].
All these vulnerabilities, coupled with women’s low status, repeated human rights violations, poor educational or economic opportunities and poor attitudes towards sex and sexuality, poor knowledge and access to modern contraceptive methods predispose women, and particularly FSWs, to a host of other STI risk factors [
7‐
9]. The realization that key population groups such as sex workers are at increased risk of STIs led to the implementation of STI control widely adopted as a strategy to mitigate untoward effects of STIs/HIV [
10]. Therefore, public health interventions targeting FSWs are designed to prevent STIs/HIV through correct and consistent condom use [
10,
11]. Despite this, data suggests that unprotected sex and pregnancy are common among FSWs [
12]. Unprotected sex further complicates the reproductive health needs of FSWs by predisposing them to abortion and other associated the risk factors. In Asia and Africa, for example, the prevalence of abortion among FSWs range between 22 and 86%, a pointer that FSWs’ pregnancies are ill attended [
4]. A study among FSWs in Zambia showed that women who reported a lifetime pregnancy also had a history of unplanned pregnancy, depicting a large unmet need for contraception among FSWs [
13]. Additionally, the strategies targeting FSWs remain ineffective by only targeting FSWs and failing to target their clients who are likely to be the decision makers in their sexual relations [
14]. Evidence indicates that correct and consistent condom use may be complicated by the lack of autonomy to insist on condom use especially with steady and emotional partners, or through coercion by other clients who refuse to use condoms by promising to pay more or using violence [
15,
16].
Since FSWs are at an increased risk to both unwanted pregnancy and sexually transmitted diseases, some have resorted to dual protection (simultaneous use of both condoms and female-controlled modern non-barrier methods), known to be an essential component of comprehensive reproductive health services [
11,
13]. Approximately 67% of participants reported using a non-barrier method for contraception, but fewer than 20% of participants reported using both condoms and a non-barrier method. The study concluded that access to and use of dual protection is an essential component of comprehensive reproductive health services, particularly to women without current pregnancy intention [
13].
FSWs need access to comprehensive SRH prevention measures [
17]. Existing programs pay little attention to the broader sexual and reproductive health and rights of these women and often focus on HIV and other STIs prevention, care and treatment while neglecting the reproductive health needs, including awareness and access to a full range of family planning methods [
15]. Also, these interventions have not fully embraced FSWs specific SRH needs like they have with women in the general population [
1,
17]. Further, the challenges are augmented by discriminatory community values and norms, availability and access to the contraceptive methods suitable for FSWs [
18]. This is mainly due to obstructive factors such as long waiting time, inconvenient waiting hours, user fees, and perceived HIV testing among other factors [
17]. Unlike women in the general population, FSWs are prone to higher maternal morbidity and mortality risks because of exposure to risk factors associated with HIV-related mortality and unsafe abortion related deaths [
19]. A study conducted in sub-Saharan Africa established that women who are engaged in commercial sex are at high risk of physical and sexual violence, unwanted pregnancy, and STIs [
1]. The risk of violence further predisposes them to other social and health problems that hinder their access to SRH services which is a fundamental human right [
20]. There are limited studies that have reported pregnancy desires and contraceptive use among FSWs, particularly in Kenya [
15]. The available research, however, demonstrates that FSWs often want to avoid future pregnancies, despite higher rates of unplanned pregnancies and abortions compared to women in the general population [
21,
22]. Although this is the case, they continue facing challenges in initiating and sustaining the use of more efficient contraceptive methods [
15,
17,
23].
Access to contraception and reproductive health services remains a significant challenge for many sex workers. Studies suggest that many sex workers who did not want to become pregnant were not accessing a reliable contraceptive method often due to discrimination and fear, unfriendly health facility staff, and opening and closing time of services [
24]. It is also worth noting that to a large extent, contraceptive uptake depends on individual perceptions, experiences, and ease of use [
25]. Dual method approach is reported among FSWs mainly to help prevent unwanted pregnancy and diseases like STIs/HIV. Additionally, the dual method acts as a backup should a condom burst during sexual intercourse [
11,
12]. The aim of this study is, therefore, to explore the experiences of FSWs with existing contraceptive methods while also considering the influence of clients who may act as barriers or offer opportunities for contraceptive use. It is anticipated that these findings will inform future interventions and access to services among FSWs and other key populations.
Methods
The study was conducted from June to December 2008, within two districts - Naivasha and Changamwe – of Kenya’s former Rift Valley and Coast Provinces, respectively. These urban to semi-urban districts are known for having concentrated FSWs population, in part due to the port and tourist trade in the Coastal region in which Changamwe is part of, and to truck drivers, transport and seasonal workers in flower farms in Naivasha [
15]. The locations are about 500 km apart; Naivasha is a vibrant town with a large migrant worker population attracted by its flower, transport and other industry. Other than being the second largest city in Kenya, Mombasa is a port city, trading center and popular tourist destination [
26]. These two locations have long-running HIV and STI prevention programs for FSWs. These programs are run by various organizations providing targeted HIV and SRH services.
Women who reported current sex work, defined as ‘providing sexual services in exchange for money or other material compensation as part of an individual’s livelihood,’ and were 15–49 years were eligible for study participation. FSWs were recruited through local sex workers trained as HIV/AIDS peer educators and through snowball sampling [
15,
26]. We utilized a targeted snowball across the two research sites (in Changamwe and in Naivasha) to recruit FSWs. FSWs serving organizations helped identify FSWs trained as HIV/AIDS peer educators. Initial contacts with FSWs varying in age, site of work, geographic location, and full or part time sex work status were made through trained peer educators already working in the study sites. These contacts were asked for referrals to other potential participants. Sex workers were screened and those found to meet study inclusion criteria were invited to participate in the study (survey/FGD). Approximately 6 FSWs did not meet the eligibility criteria. A total of eight Focus Group Discussions (FGDs) involved 10–12 participants (total 81). Participating women were grouped by similar age, site of recruitment and type of sex worker (full or part time) to enhance open discussion and reduce inhibitions among participants. The FGD guide addressed issues around FSWs health problems, work, health awareness of HIV, dynamics of their relationships with clients and contraceptive use.
The FGDs were conducted in the national language, Swahili, by a trained duo of a focus group moderator and a note taker. The same focus group research pair conducted all focus groups in both study sites to enhance consistency. FGDs were digitally recorded, uploaded to a laptop computer, transcribed verbatim, and translated from Swahili to English by the moderator and note taker. Transcriptions and translations were reviewed for quality by the interview team. The analysis team performed qualitative analyses with NVivo v. 7.0 (QSR International Pty Ltd) qualitative data analysis software. A content-driven theme approach was used for analytic review of the FGD data. Transcripts were read and re-read to identify recurrent themes and to develop a coding tree. Once all the transcripts were coded, memos and display matrices were developed to examine each code in detail for sub-themes, nuances, and patterns across the interviews [
15,
26].
All FGDs took place at a neutral, confidential location secured by the research team in the study sites. Each participant was allocated a unique number, R1, R2…Rx to allow participant identification in each FGD. Additionally, the FGDs were labeled 1–4 in each location (Changamwe and Naivasha) and further the same criteria used to identify participant insights in the presentation of the findings. Cash compensation at a standard flat rate of Kshs 300 (approximately USD $4.29 at the time of data collection) was provided to all study participants upon arrival at the FGD site. This compensation was provided to reimburse participants’ transportation costs to the FGD site, and was approved by two institutional review boards, the Family Health International’s Protection of Human Rights Committee and the Kenyatta National Hospital Ethical Review Committee. At the close of the FGD, all participants received information on readily available service delivery points for Family Planning (FP) and HIV Counselling and Testing services [
15,
26]. During the FGDs, the words ‘Kunga’ and ‘Sigalame’ were used to refer to FSW.
Ethical considerations
Permission to conduct this study was obtained from Family Health International’s Protection of Human Subjects Committee (USA), the Kenyatta National Hospital/University of Nairobi - Ethical Review Committee (Kenya), and the National Council for Science and Technology (Government of Kenya) approved the study protocol. Consent was not sought from parents/guardians of participants aged below 18 years for this study because a sex worker is emancipated, sexually active and most often live alone. Verbal consent was provided by the study participants and waiver of signed informed consent was requested in accordance with 45 CFR 46. The study posed minimal risk to participants and the only record linking participants with the study would be the signed informed consent form. Oral informed consent with signature by the Research Assistant attesting to adherence to proper informed consent procedures and to the reception of the informed consent of the participant was therefore used in the place of signed informed consent forms. No identifying information was connected with the interviews or retained following the completion of the analysis.
Discussion
This study makes a contribution by highlighting the experiences of female sex workers with contraceptives. We note that while some FSWs know that contraceptives are useful for pregnancy prevention, general knowledge remained poor with some resorting to abortion to terminate an unwanted pregnancy. Elsewhere, a study in China conducted among adolescent FSWs also found general sexual and reproductive health knowledge to be low, and while 98% reported not wanting the pregnancy, less than half (43%) reported consistent condom use with another 28% reporting current use of another contraceptive method [
27]. A separate study examining contraceptive use among female entertainment sex workers in Cambodia found several factors to be linked to unwanted pregnancy such as the increase in a number of clients, inconsistent condom use, condom breakage and forced unprotected sex [
28]. Elsewhere, unwanted pregnancy was more common among older married women who additionally had lower contraceptive knowledge [
29].
The study also highlights the vulnerability of FSWs to unintended pregnancy or worse HIV/AIDS among those who have to balance between their livelihoods and pregnancy prevention with different types of sexual partners. In examining these FSWs’ contraceptive needs, it was clearly evident that on a daily basis these women were exposed to difficult situations that can have far-reaching implications on their overall health and well-being. In our analysis, we found that typically clients do not care much about contraceptive use – regardless of the partner type – most clients care less about using different contraceptive methods. Further, condom use for HIV/AIDS prevention was also difficult as some clients offer to pay more money to have unprotected sex while others turned violent against the women. This behavior by clients brings a lot of confusion to women. On the one hand, they have to make a difficult decision on whether or not to use condoms when enticed with a lot of money and on the other hand they are continually exposed to danger for proposing condom use to the clients. Nevertheless, it was common for women to describe pregnancies that occurred during sex work - commonly unintended.
Participants’ accounts of their contraceptive use (or non-use) with clients, also highlight the substantial diversity in women’s relationships with their clients. Whereas it was apparent that FSWs found it substantially difficult to discuss contraceptive use with casual clients, it appeared, however, that in ongoing relationships with regular clients, including boyfriend, lover, and emotional partner, there was consensus to use or not use contraceptives. Likewise, the extent to which women proposed contraceptive use to their clients or other sex partners varied dramatically by partner type. Women spoke about how their desire to use contraceptives with casual clients was in most cases dismissed by these clients whose interest is mainly sexual pleasure, and who sometimes forced them to have sex without any form of protection, from STIs/HIV. Although most women were open about discussing contraceptive use with their more familiar partners, most women revealed that most men deserted them when they learned that they were pregnant. For several women, getting pregnant and having children was a woman’s responsibility.
When participants described contraceptive use or pregnancy prevention, in most cases, the women either faced barriers to discussing contraceptive use with their partners or they had not used contraception consistently. Although most women seemed aware of the need to prevent pregnancy and were aware of other contraceptive methods, they clearly had difficulties in using them effectively with the different partner types due to violence; the lure of money; fear of losing them to their colleagues; or limited communication with their partners. Previous studies elsewhere in Sub-Saharan Africa demonstrate that interventions that sensitized male partners led to a significant increase in couple communication and a consequent increase in contraceptive use among couples [
30]. Programs and providers that offer family planning services should, therefore, ensure that FSWs are empowered to use contraceptive methods, have access to contraception and that male partner are sensitized on the importance of contraception.
Consistent with previous studies among FSWs, inconsistent condom use was very common among participants. Compared to FSWs in similar settings as Kenya, women in our study face multiple barriers in ensuring that they have protected sex by having their clients use condoms [
5]. Based on their accounts, most participants wished to use condoms with casual clients, however, convincing their clients to use condoms was not always easy. Although there was a notable concern from the women of fear of being infected with HIV or other STIs, some of the clients seemed not to share these concerns. Most of these clients ultimately forced or lured the women to have unprotected sex.
Most of the time, sex with the emotional partner or boyfriend was without condom use as many FSWs reported a preference for the injection or calendar method with these partners. Similar findings have also been reported in a study conducted in Nyanza where FSWs reported unprotected sex with their regular or romantic partners. Female sex workers interviewed in Kibera in Nairobi also reported not using condoms with their intimate partners as this was a sign of intimacy and trust [
31]. Overall, despite reported use of other contraceptive methods, there was over-reliance on condoms which offer dual protection.
Dual protection was a valuable tool for prevention of unwanted pregnancy and STIs/HIV. Some FSWs reported using condoms and other forms of contraceptives such as injectables and pills to offer dual protection. While condoms are effective at preventing STIs/HIV, they may not be very effective in preventing unwanted pregnancy. On the other hand, non-barrier contraceptive methods do not offer protection against STIs/HIV hence the need to use both to offer dual protection [
11]. Fear of condom breaking was also reported as a motivation for dual protection to offer protection against unwanted pregnancy. On the other hand, it was worth noting that dual protection was not common with the emotional partner or boyfriend with whom the FSW reported to use either the calendar method or injectables and their relationship is based on trust. Elsewhere, use of non-barrier methods and condoms was found to be less among FSWs and their non-commercial, often more intimate partners [
11]. Additionally, a study in Gulu, northern Uganda reported low dual contraceptive use as a result of police presence which led to rushed negotiations with clients thereby increasing the FSW risk to STIs/HIV and unwanted pregnancy [
32]. The use of female condoms was also reported to offer protection, especially with clients who refused to use the male condom. This was mainly used by FSW who were concerned about STIs/HIV and unwanted pregnancy. The female condom has been found to offer dual protection from both STIs/HIV and unplanned pregnancy; it also acts as a tool for women’s empowerment.
Reported barriers to contraceptive uptake among FSWs include side effects which interfere with their business of sex trade such as continuous bleeding, dizziness, and nausea for the injectables. Other barriers were those related to access to the services which included fear of getting tested for HIV whenever they visited family planning clinics, competition in clinic time and time for clients, among other barriers. To increase family planning uptake among FSW in Cambodia, the government and NGOs provide free and friendly sexual and reproductive health services, despite this, some FSW still reported barriers such as discrimination by providers thereby making them resort to using of private providers [
28].