Sexual health needs of female sex workers in Côte d’Ivoire: a mixed-methods study to prepare the future implementation of pre-exposure prophylaxis (PrEP) for HIV prevention

Abstract

ObjectiveTo describe sexual and reproductive health (SRH) needs of female sex workers (FSWs) to inform the future implementation of pre-exposure prophylaxis (PrEP) for HIV prevention in this population.Design and settingThe ANRS 12361 PrEP-CI cross-sectional and mixed-methods study was designed and implemented with two community-based organisations in Côte d’Ivoire.ParticipantsA convenience sample of 1000 FSWs aged ≥18, not known as HIV-positive, completed a standardised questionnaire assessing sociodemographic characteristics, sexual practices, use of community health services and a priori acceptability of PrEP. Twenty-two indepth interviews and eight focus group discussions were also conducted to document FSWs’ risky practices and sexual behaviours, experiences with violence and discrimination, attitudes regarding HIV and sexually transmitted infections (STIs), and barriers to SRH services.ResultsAlthough 87% described consistent condom use with clients, more than 22% declared accepting condomless sexual intercourse for a large sum of money. Furthermore, condom use with their steady partner and knowledge of their partner’s HIV status were low despite their acknowledged concurrent sexual partnerships. While inconsistent condom use exposed FSWs to STIs and undesired pregnancies, the prevalence of contraceptive strategies other than condoms was low (39%) due to fear of contraception causing sterility. FSWs faced obstacles to accessing SRH care and preferred advice from their peers or self-medication.ConclusionsDespite adoption of preventive behaviour in most cases, FSWs are still highly exposed to HIV. Furthermore, FSWs seem to face several barriers to accessing SRH. Implementing PrEP among FSWs in West Africa, such as in Côte d’Ivoire, constitutes an opportunity to consider the regular follow-up of HIV-negative FSWs. PrEP initiation should not condition access to SRH services; conversely, SRH services could be a way to attract FSWs into HIV prevention. Our results highlight the importance of developing a people-focused approach that integrates all SRH needs when transitioning from PrEP efficacy trials to implementation.

Awareness, Willingness, and Perceived Efficacy of Pre-exposure Prophylaxis among Adolescent Sexual Minority Males

“…As PrEP was not the primary focus of the original MyPEEPS study, PrEP-related survey items were not as detailed as some other studies [29,30]. Awareness and willingness were represented by dichotomous variables which may simplify participants' more complicated attitudes about PrEP.…”

Values and preferences of contraceptive methods: a mixed-methods study among sex workers from diverse settings

“…As documented elsewhere, sex workers reported more frequent condom use with clients than with other sexual partners, 33 highlighting the need for information and counselling to support safer sex practices with non-client sexual partners and to make HIV testing and partner-testing services more easily available to inform HIV prevention choices.…”

A community-based healthcare package combining testing and prevention tools, including pre-exposure prophylaxis (PrEP), immediate HIV treatment, management of hepatitis B virus, and sexual and reproductive health (SRH), targeting female sex workers (FSWs) in Côte d’Ivoire: the ANRS 12381 PRINCESSE project

“…Based on a pilot qualitative and quantitative survey and cobuilt with community NGOs [ 5 ], the PRINCESSE project for FSWs is one of the first interventions offering HIV oral PrEP as part of a more global sexual healthcare package, targeting both HIV-negative and HIV-positive women. A second innovation is the combination of HIV PrEP and viral hepatitis B care.…”

“…In Côte d’Ivoire, HIV prevalence among FSWs was estimated to be 11.4% in Abidjan in 2014 [ 2 ], and HIV incidence was 3.2% in San Pedro and 1.5% in Abidjan in 2016–2017 [ 3 ] vs. 0.5% in the general population in 2019 [ 4 ]. FSWs are exposed to HIV, as they do not systematically use condoms with their male partners—primarily because of coercion, the primacy of men’s sexual pleasure, or to obtain protection from their partner against the threat of violence [ 5 – 7 ] —or with their clients in order to earn more, or because of violence from some clients [ 5 , 8 – 12 ]. However, this population often lacks access to adequate services to prevent HIV acquisition and access to HIV care when HIV-positive [ 13 ].…”

“…In 2016–2017, we conducted the ANRS 12361 PrEP-CI, a cross-sectional and mixed-methods study, to explore sexual healthcare needs that should be considered within a PrEP program targeting FSWs in Côte d’Ivoire, in order to better describe the experiences of FSWs who are reached via peer educators, and to test the pertinence and a priori feasibility of such programs [ 5 ]. Implemented at prostitution sites in two Ivorian cities (Abidjan and San Pedro) in collaboration with two Ivorian community-based organizations (Espace Confiance and Aprosam), the PREP-CI study included (i) a quantitative survey among 1000 FSWs who had never been tested or previously tested HIV-negative, including a socio-behavioral questionnaire, HIV testing, and, for those who tested HIV-positive, collecting a dried blood spot for a recent infection assay to estimate HIV incidence; and (ii) a qualitative survey based on individual interviews and focus-group discussions among 66 FSWs.…”