Condomless sexual encounters among female sex workers included in a longitudinal coital diary study in Zimbabwe

Abstract

Background: Compared with the general female population, female sex workers (FSWs) experience a greater burden of STIs, including HIV. Consistent condom use reduces HIV risk; however, while many FSWs are aware of condom efficacy, this knowledge does not consistently translate into use. This study aimed to assess the frequency of condomless sex among FSWs at the sexual encounter level and identify factors associated with FSW characteristics, partner types, and encounter conditions. Methods: We conducted a longitudinal coital diary study in two Zimbabwe cities between 25 November 2020 and 30 December 2021. Pictorial diaries were developed in collaboration with FSWs. We recruited participants via snowball sampling and asked them to complete a daily diary of their sexual encounters with each partner for one month, repeated over three nonconsecutive months spread over 12 months. The recordedinformation included condom use categorized as none, partial, or full; types of sexual activity; partner types; partner age; FSW age;experiences of violence; and contact with the Key Populations (KP) Programme. To identify factors associated with condomless sex, we used hierarchical Poisson regression modeling. Results: A total of 404 FSWs reported 62,559 sex encounters, with 17,325 (27.7%) reported as condomless. Encounters with permanent partners had the highest likelihood of condomless sex (59.5%; adjusted relative risk [aRR] 3.83, 95% CI: 3.38-4.35), followed by regular partners (25.6%; aRR 1.63, 95% CI: 1.50-1.78) compared with new partners (15.0%). Adjustments included site, FSW age, partner age, violence, and KP programme contact. Compared with FSWs aged ≥25 years (29.7%), those aged ≥35 years were less likely to be condomless (22.1%; aRR 0.79, 95% CI: 0.66-0.94). Compared with those without violence (24.1%), thoseinvolving violence were more likely to be condomless (57.7%; aRR 2.32, 95% CI: 2.00-2.70). Compared with those without contact (32.9%), those with programme contact reported fewer condomless encounters (25.9%; aRR 0.81, 95% CI: 0.90-0.94). Conclusion: Condomless sex ismore common in encounters with regular and permanent partners, younger FSWs, and encounters involving violence, whereas older FSWs and frequent KP programme contacts report fewer condomless encounters. These findings emphasize the need for continued condom promotion, counseling, violence mitigation, and training in condom negotiation skills.