Addressing broader reproductive health needs of female sex workers through integrated family planning/ HIV prevention services: A non-randomized trial of a health-services intervention designed to improve uptake of family planning services in Kenya

Abstract

Background Despite considerable efforts to prevent HIV and other sexually transmitted infections (STI) among female sex workers (FSW), other sexual and reproductive health (SRH) needs, such preventing unintended pregnancies, among FSW have received far less attention. Programs targeting FSW with comprehensive, accessible services are needed to address their broader SRH needs. This study tested the effectiveness of an intervention to increase dual contraceptive method use to prevent STIs, HIV and unintended pregnancy among FSW attending services in drop-in centers (DIC) in two cities in Kenya. The intervention included enhanced peer education, and routine screening for family planning (FP) needs plus expanded non-condom FP method availability in the DIC. Methods We conducted a two-group, pre-/posttest, quasi-experimental study with 719 FSW (360 intervention group, 359 comparison group). Participants were interviewed at baseline and 6 months later to examine changes in condom and non-condom FP method use. Results The intervention had a significant positive effect on non-condom, FP method use (OR = 1.38, 95%CI (1.04, 1.83)), but no effect on dual method use. Consistent condom use was reported to be high; however, many women also reported negotiating condom use with both paying and non-paying partners as difficult or very difficult. The strongest predictor of consistent condom use was partner type (paying versus non-paying/emotional); FSW reported both paying and non-paying partners also influence non-condom contraceptive use. Substantial numbers of FSW also reported experiencing sexual violence by both paying and non-paying partners. Conclusions Self-reported difficulties with consistent condom use and the sometimes dangerous conditions under which they work leave FSW vulnerable to unintended pregnancy STIs/HIV. Adding non-barrier FP methods to condoms is crucial to curb unintended pregnancies and their potential adverse health, social and economic consequences. Findings also highlight the need for additional strategies beyond condoms to reduce HIV and STI risk among FSW. Trial registration Clinicaltrials.gov NCT01957813

Unmet Need for Family Planning and Experience of Unintended Pregnancy Among Female Sex Workers in Urban Cameroon: Results From a National Cross-Sectional Study

“…Although there is growing evidence that integrated HIV and family planning delivery in a single location facilitates contraceptive uptake, 71,74,75 there are several considerations for implementation within existing community-based HIV services. There is empirical evidence that providing multiple contraceptive options improves uptake.…”

“…76 Elsewhere, making longer-acting methods readily available to FSWs at a drop-in center alongside counseling on methods suited to a woman's needs and current fertility intentions significantly increased demand and uptake of effective contraceptives. 75 However, the predominance of lower cadres of health care workers and peer outreach workers who often staff community-led FSW services may limit the number of staff with specific training and skills for contraception administration, especially when considering voluntary LARCs. 77,78 Physical space with adequate privacy and space for an examination table required for LARC administration may also be limited in drop-in centers.…”

“I did not plan to have a baby. This is the outcome of our work”: a qualitative study exploring unintended pregnancy among female sex workers

“…Expanding such community-based model which reaches out to FSWs in their areas of work, to further include family planning services can be an effective strategy to reduce unintended pregnancy among FSWs. There is a growing body of research suggesting that integration of HIV and family planning services in a single location as well as providing multiple contraceptive options suited for fertility intentions increase demand and uptake of contraceptives [18,[78][79][80]. One study in Uganda showed that FSWs were more likely to receive contraceptive services if they had accessed HIV testing [10].…”

“…Condom failure or condom breakage and non-use among FSWs are common because of physical or sexual violence and drug or alcohol intoxication during sex work [20][21][22][23]. Further, sex workers´ financial and emotional dependence to their partners undermine their autonomy to insist on the use of condom or make them forgo condom use for extra payment [4,18,[24][25][26][27], leading to unintended pregnancy [28,29]. Unintended pregnancies that result in live birth have socio-economic implications that may intensify HIV risk associated with sex work [30][31][32].…”

Sexual behaviour change following HIV testing services: a systematic review and meta‐analysis

“…Thirty-two studies reported on this outcome [57][58][59][60][61][62][63][64][65][66][67][68][69][70][71][72][73][74][75][76][78][79][80][81][82][83][84][85][86][87]89,90]. Fifty effect estimates from 27 studies were included in the meta-analysis ( Figure 3).…”