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

Amogne, Minilik Demissie LU orcid (2021) In Lund University, Faculty of Medicine Doctoral Dissertation Series
Abstract
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... (More)
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. (Less)
Please use this url to cite or link to this publication:
author
supervisor
opponent
  • Associate Professor Atuyame, Lynn, School of Public Health, Makerere University, Uganda
organization
publishing date
type
Thesis
publication status
published
subject
keywords
FSW, HIV, Violence, HED, condom failure, Treatment failure, Drug resistance, Experience, PrEP challenge, Ethiopia
in
Lund University, Faculty of Medicine Doctoral Dissertation Series
issue
2021:150
pages
94 pages
publisher
Lund University, Faculty of Medicine
defense location
Agardh föreläsningssal, CRC, Jan Waldenströms gata 35, Skånes Universitetssjukhus i Malmö
defense date
2021-12-20 13:00:00
ISSN
1652-8220
ISBN
978-91-8021-157-4
language
English
LU publication?
yes
id
bf833b4b-2c81-4180-bbf3-a04c0c4fba81
date added to LUP
2021-11-25 11:26:24
date last changed
2023-04-26 15:39:58
@phdthesis{bf833b4b-2c81-4180-bbf3-a04c0c4fba81,
  abstract     = {{Due to legal, cultural, and social factors, female sex workers (FSWs) experience an<br/>elevated level of violence, heavy alcohol consumption, and sexual abuse. These<br/>individual and societal factors create a web of vulnerabilities that facilitate the<br/>spread of HIV within this population group. Moreover, stigma and discrimination<br/>are common among HIV-positive FSWs, contributing to poor HIV treatment<br/>adherence, drug resistance, and treatment failure. Effective HIV prevention<br/>programs among FSWs are therefore crucial to halt the spread of HIV not only<br/>among sex workers but also among the general population. Nevertheless, FSWtargeted<br/>programs and research activities are limited in quality, quantity, and<br/>coverage in Ethiopia. Thus, the general aim of this thesis was to explore the<br/>experiences of FSWs in Ethiopia to gain a better understanding of factors that<br/>contribute to the increased risk of HIV infection among FSWs.<br/>Papers I, II, and III are based on a cross-sectional bio-behavioral study conducted<br/>among 4900 FSWs in eleven major towns in Ethiopia. The data collection was<br/>conducted using a respondent-driven sampling technique (RDS). A blood sample<br/>was collected for HIV, CD4, viral load and drug resistance testing. For paper IV, a<br/>qualitative study was conducted among 17 FSWs using a snowball sampling.<br/>Logistic regression was used as the main tool for analysis in the cross-sectional<br/>studies, and content analysis was used for qualitative data.<br/>The results of Paper I showed that 17.5% of FSWs had been physically beaten<br/>within the last 12 months and 15.2% had been raped since they started selling sex.<br/>Bing young, sex-selling venues (street based), high consumption of alcohol, and<br/>khat chewing were significant predictors of physical violence (beating). The<br/>significant predictors of sexual violence (rape) were low income, high consumption<br/>of alcohol and khat chewing. Paper II revealed that 29.1% of the study participants<br/>experienced HED in the past month. Significant determinants of HED were being<br/>younger, being forced into selling sex, working in a bar/hotel, having a higher<br/>income, and chewing khat frequently. In turn, HED was significantly associated<br/>with physical beating and condom breakage. Paper III showed that the prevalence<br/>of pre-treatment drug resistance (PDR) among ART naïve FSWs was 16.5%, which<br/>is classified as high according to WHO criteria. Viral load non-suppression was<br/>significantly associated with being forced into selling sex, age ≥35 years, and low<br/>CD4+ T-cell counts (&lt;350 cells/mm3). Only low CD4 counts were significantly<br/>associated with acquired drug resistance (ADR) and PDR respectively. Finally,<br/>Paper IV showed that FSWs who were taking PrEP faced stigma, due to the<br/>similarity of the PrEP pill to the ART pill, and experienced adherence-maintaining<br/>challenges. Reasons for not starting to take PrEP included fear of side effects, poor<br/>confidence, and/or misconceptions.<br/>The findings indicated that different individual and structural factors among FSWs<br/>played a role in increased exposure to violence and HED, which in turn may increase<br/>vulnerability to HIV acquisition and transmission. The findings also suggest the<br/>need for targeted interventions to improve ART access and routine virological<br/>monitoring to control the transmission of both HIV and HIVDR. In addition, the<br/>challenges and barriers to PrEP uptake among FSWs need to be addressed to better<br/>facilitate the uptake of PrEP.}},
  author       = {{Amogne, Minilik Demissie}},
  isbn         = {{978-91-8021-157-4}},
  issn         = {{1652-8220}},
  keywords     = {{FSW; HIV; Violence; HED; condom failure; Treatment failure; Drug resistance; Experience; PrEP challenge; Ethiopia}},
  language     = {{eng}},
  number       = {{2021:150}},
  publisher    = {{Lund University, Faculty of Medicine}},
  school       = {{Lund University}},
  series       = {{Lund University, Faculty of Medicine Doctoral Dissertation Series}},
  title        = {{Behavioral and Biological Factors Related to HIV Transmission among Female Sex Workers in Ethiopia}},
  url          = {{https://lup.lub.lu.se/search/files/110669740/Thesis.minilik.pdf}},
  year         = {{2021}},
}