Characteristics and Population Size Estimation of Female Sex Workers in Bhutan

Abstract

Background: Knowing the number of persons at risk for sexually transmitted diseases (STDs) and their risk behaviors are needed to allocate limited resources, set targets for prevention and care activities, gauge the reach of programs, and assess their impact. Female sex workers (FSWs) are a population at high risk for STD worldwide; little is known about FSW in Bhutan. Methods:We conducted a community-based survey and population size exercise of FSW in Bhutan. The survey used a hybrid venue-based/peerreferral sampling method. Population size estimation methods were key informant mapping, census and enumeration, unique object multiplier, and capture-recapture.Results: Of 517 women surveyed, 67.5% provided sex for money in the last year. Compared with FSWs at venues, FSWs referred by peers were more likely to have sex with alcohol (80.1% vs. 51.5%, P < 0.001) and more paying partners (mean, 3.5 vs. 2.0; P = 0.001), and less likely to have tested for an STD (28.3% vs. 51.0%, P < 0.001) or have outreach worker contact (27.6% vs. 41.5%, P = 0.007). The estimated number of FSWs in the 9 districts was 353 (95% confidence interval, 345-362). Extrapolation to the whole country projected 597 (417-777) FSWs nationally.Conclusions: Our estimate of the number of FSW in Bhutan corresponds to 0.71% of adult urban women, a figure in line with other countries in South and Southeast Asia. Our data highlight the need for outreach beyond venues where women are employed to reach FSW at higher risk for STD but who have less access to interventions.

Redefining the Mode of HIV Transmission through Analysis of Risk Attribution among the Reported HIV Cases from 1993 to 2021 in Bhutan

“…As exhibited in this study, the heterosexual contact with a female sex worker was consistent with the results of several past national studies where the prevalence of female sex workers and high multiple sexual relationships with low condom use were reported [5,22,23]. e 2019 population size estimation (PSE) study also depicted higher sexual partners among women acknowledging sex work, with a mean of 5.8 and 4.5 for female sex workers recruited outside of venues and at venues, respectively, as compared to 1.3 for high-risk women not engaging in sex work.…”

“…The 2019 population size estimation (PSE) study also depicted higher sexual partners among women acknowledging sex work, with a mean of 5.8 and 4.5 for female sex workers recruited outside of venues and at venues, respectively, as compared to 1.3 for high-risk women not engaging in sex work. Consistent condom use was low across all women and partner types, although being higher with paying partners [ 5 ]. Further, the recent sentinel surveillance among the key population in Bhutan also showed 97% of high-risk women exchanging sex for money and also reported the highest level of unprotected sex in the last 30 days (76%) [ 24 ].…”

“…From 2000 to 2013, the annual number of new HIV diagnoses rose from 9 to 51. Since 2013, there has been a plateau in the number of new HIV diagnoses, fluctuating between 49 and 58 annually [ 4 , 5 ]. By June 2022, there were a cumulated 835 (433 males and 402 females) HIV diagnoses, 628 of whom are known to be alive, and 608 (96.8%) of whom are on antiretroviral treatment [ 6 ].…”

Population size estimation of transgender women and men in Bhutan

“…Key informant interviews and focus group discussions were used to arrive at estimates of the numbers of TGW and TGM associated with venues catering to these communities. Details of the methods were previously reported for estimating the number of female sex workers in Bhutan [16] and described in detail by Emmanuel et al [17] and Ndayongeje et al [18]. In brief, primary, secondary, and stakeholder key informants were asked to identify all physical and online venues where TGW and TGM socialize.…”

“…Population size estimation methods included key informant mapping [17,18], wisdom-of-thecrowd [15,19], the service multiplier method [20], and the unique object multiplier method [14]. Results generated from these methods were synthesized using a Bayesian approach called the Anchored Multiplier [21,22].…”