Consistent Condom Use by Female Sex Workers in Kolkata, India: Testing Theories of Economic Insecurity, Behavior Change, Life Course Vulnerability and Empowerment

Abstract

Consistent condom use (CCU) is the primary HIV/STI prevention option available to sex workers globally but may be undermined by economic insecurity, life-course vulnerabilities, behavioral factors, disempowerment, or lack of effective interventions. This study examines predictors of CCU in a random household survey of brothel-based female sex workers (n = 200) in two neighborhoods served by Durbar (the Sonagachi Project) in Kolkata, India. Multivariate logistic regression analyses indicated that CCU was significantly associated with perceived HIV risk, community mobilization participation, working more days in sex work, and higher proportion of occasional clients to regular clients. Exploratory analyses stratifying by economic insecurity indicators (i.e., debt, savings, income, housing security) indicate that perceived HIV risk and community mobilization were only associated with CCU for economically secure FSW. Interventions with FSW must prioritize economic security and access to social protections as economic insecurity may undermine the efficacy of more direct condom use intervention strategies.

Consistent Condom Use by Married and Cohabiting Female Sex Workers in India: Investigating Relational Norms with Commercial Versus Intimate Partners

“…As a result, CCU remains a central goal of Durbar’s programming because condoms protect FSW from other sexually transmitted infections (STIs) and are commonly used as a form of contraception. In a previous analysis with the study population in Kolkata (13), we found that nearly half of FSW reported symptoms of an STI that required treatment within the previous 12 months. Additionally, 92% used condoms as a form of contraception, whereas only 16% used oral contraceptive pills.…”

“…Additionally, 92% used condoms as a form of contraception, whereas only 16% used oral contraceptive pills. Less than 2% used any other form of hormonal or long-acting reversible contraceptives (13). …”

“…More than half are also married or living with a “temporary husband” referred to as a babu (8, 13). The terms husband and babu are sometimes used interchangeably in the study population.…”

“…Within the study setting, the normative expectation for FSW when engaging in commercial sex with clients is to use a condom in every sexual encounter (13). Several factors reinforce this norm.…”

“…Third, trust and familiarity between FSW and clients can alter perceptions of risk, such that an FSW might be more inclined to engage in condomless sex with a regular client than an occasional client (i.e., the intimacy gradient) (25). Finally, financial need can impact decision-making regarding condom use with clients, such that an FSW might be willing to engage in condomless sex in exchange for additional compensation (26), which can undermine CCU particularly for economically insecure FSW (13). Based on these assumptions, we hypothesize that economic factors – income, number of clients, and number of days of sex work in the last week – will be the primary determinants of CCU with clients (Hypothesis 1).…”