Surviving pandemic control measures: The experiences of female sex workers during COVID-19 in Nairobi, Kenya.

At the beginning of the COVID-19 pandemic, the Kenya Ministry of Health instituted movement cessation measures and limits on face-to-face meetings. We explore the ways in which female sex workers (FSWs) in Nairobi were affected by the COVID-19 control measures and the ways they coped with the hardships. Forty-seven women were randomly sampled from the Maisha Fiti study, a longitudinal study of 1003 FSWs accessing sexual reproductive health services in Nairobi for an in-depth qualitative interview 4-5 months into the pandemic. We sought to understand the effects of COVID-19 on their lives. Data were transcribed, translated, and coded inductively. The COVID-19 measures disenfranchised FSWs reducing access to healthcare, decreasing income and increasing sexual, physical, and financial abuse by clients and law enforcement. Due to the customer-facing nature of their work, sex workers were hit hard by the COVID-19 restrictions. FSWs experienced poor mental health and strained interpersonal relationships. To cope they skipped meals, reduced alcohol use and smoking, started small businesses to supplement sex work or relocated to their rural homes. Interventions that ensure continuity of access to health services, prevent exploitation, and ensure the social and economic protection of FSWs during times of economic strain are required.

Syndemic of factors that shape the early lives of women who enter into sex work: a qualitative methods study from Nairobi, Kenya.

OBJECTIVE: To explore the structural and social co-factors that shape the early lives of women who enter sex work in Nairobi, Kenya. DESIGN: Thematic analysis of qualitative data collected as part of the Maisha Fiti study among female sex workers (FSWs) in Nairobi. PARTICIPANTS AND MEASURES: FSWs aged 18-45 years were randomly selected from seven Sex Workers Outreach Programme clinics in Nairobi and participated in baseline behavioural-biological surveys. Participants in this qualitative study were randomly selected from the Maisha Fiti study cohort and were interviewed between October 2019 and July 2020. Women described their lives from childhood, covering topics including sex work, violence and financial management. RESULTS: 48 out of 1003 Maisha Fiti participants participated in the in-depth qualitative interviews. FSWs described how physical and sexual violence, poverty and incomplete education in their childhood and adolescence intertwined with early pregnancy, marriage, intimate partner violence and relationship breakdown in their adolescence and early adulthood. The data analysis found clear syndemic relationships between these risk factors, particularly childhood violence, poverty and incomplete education and highlighted pathways leading to financial desperation and caring for dependents, and subsequent entry into sex work. Women perceived sex work as risky and most would prefer alternative work if possible, but it provided them with some financial independence and agency. CONCLUSIONS: This is the first study in Kenya to qualitatively explore the early lives of sex workers from a syndemic perspective. This method identified the pivotal points of (1) leaving school early due to poverty or pregnancy, (2) breakdown of early intimate relationships and (3) women caring for dependents on their own. Complex, multi-component structural interventions before these points could help increase school retention, reduce teenage pregnancy, tackle violence, support young mothers and reduce entry into sex work and the risk that it entails by expanding livelihood options.

Mental health challenges and perceived risks among female sex Workers in Nairobi, Kenya.

BACKGROUND: Female sex workers (FSWs) in Kenya are at an increased risk of violence, poverty, police arrest, and problematic alcohol and other substance use, all of which are linked to poor mental health and suicidal ideation. Despite the psychological stressors experienced by FSWs, there is no published qualitative methods research investigating their mental health experiences in Kenya. In this paper, we draw on data from in-depth interviews to examine FSWs' lifetime mental health experiences and perceived risk factors. METHODS: We used baseline in-depth interviews of the Maisha Fiti longitudinal study of FSWs in Nairobi. We randomly selected 40 FSWs from 1003 FSWs who attended a baseline behavioural-biological interview as part of the Maisha Fiti study. The interview guide was semi-structured, and participants were asked to detail their life stories, including narrating specific events such as entry into sex work, experiences of violence, mental health experiences, and use of alcohol and other substances. Interviews were recorded in Kiswahili/ English and transcribed in English. Data were coded and thematically analysed in Nvivo (v.12). RESULTS: Results indicated that the majority of participants understood 'mental health' as 'insanity', 'stress', 'depression', and 'suicide'; nevertheless, a number described mental health symptomatically, while a few believed that mental health problems were caused by witchcraft. Interestingly, poverty, low levels of education, poor job opportunities, a lack of family support, harmful gender norms, intimate partner violence and subsequent relationship breakdowns, and family bereavement all contributed to poor mental health and subsequent entry into sex work. In addition, the consequences of sex work such as sexual risks, and ongoing violence from police and clients, further exacerbated poor mental health. CONCLUSIONS: There is a need for both micro- and macro interventions to address poverty and violence against FSWs in Kenya, thereby reducing mental health problems. Addressing violence against women and girls may also reduce entry into sex work. Improving mental health literacy and providing mental health intervention services for 'at-risk' populations such as FSWs should enhance coping strategies and help-seeking efficacy.

Beaten but not down! Exploring resilience among female sex workers (FSWs) in Nairobi, Kenya.

BACKGROUND: In Kenya sex work is illegal and those engaged in the trade are stigmatized and marginalized. We explored how female sex workers in Nairobi, Kenya, utilize different resources to navigate the negative consequences of the work they do. METHODS: Qualitative data were collected in October 2019 from 40 FSWs who were randomly sampled from 1003 women enrolled in the Maisha Fiti study, a 3-year longitudinal mixed-methods study exploring the relationship between HIV risk and violence and mental health. All interviews were audio-recorded, transcribed and translated. Data were thematically coded and analyzed using Nvivo 12. RESULTS: Participants' age range was 18-45 years. Before entry into sex work, all but one had at least one child. Providing for the children was expressed as the main reason the women joined sex work. All the women grew up in adverse circumstances such as poor financial backgrounds and some reported sexual and physical abuse as children. They also continued to experience adversity in their adulthood including intimate partner violence as well as violence at the workplace. All the participants were noted to have utilised the resources they have to build resilience and cope with these adversities while remaining hopeful for the future. Motherhood was mentioned by most as the reason they have remained resilient. Coming together in groups and engaging with HIV prevention and treatment services were noted as important factors too in building resilience. CONCLUSION: Despite the adverse experiences throughout the lives of FSWs, resilience was a key theme that emerged from this study. A holistic approach is needed in addressing the health needs of female sex workers. Encouraging FSWs to come together and advocating together for their needs is a key resource from which resilience and forbearance can grow. Upstream prevention through strengthening of education systems and supporting girls to stay in school and complete their secondary and/or tertiary education would help them gain training and skills, providing them with options for income generation during their adult lives.

Experiences and challenges in sexual health service access among men who have sex with men in Kenya.

Men who have sex with men (MSM) in Kenya bear a heavy burden of HIV/STIs and are a priority population in the national HIV/AIDS response, yet remain criminalised and stigmatised within society. HIV pre-exposure prophylaxis (PrEP) offers an opportunity to significantly impact the HIV epidemic, as does the concept of U = U, whereby those who are living with HIV and on treatment are uninfectious when their viral load has been suppressed so as to be undetectable. However, the value of such innovations will not be realised without sufficient understanding of, and respect for, the sexual health service provision needs of MSM. This paper describes findings from 30 in-depth interviews with MSM living in Nairobi that explored engagement with sexual health service providers, barriers to access and perceived opportunities to improve service design and delivery. Findings indicate concern relating to the professionalism of some staff working within public hospitals as well as feelings that many sexual health services were not considered safe spaces for the discussion of MSM-specific sexual behaviour. Diverse views were expressed relating to comfort in public, community and private sexual health services as well as how these are and should be organised.

Effect of concurrent use of anti-retroviral therapy and levonorgestrel sub-dermal implant for contraception on CD4 counts: a prospective cohort study in Kenya.

INTRODUCTION: Simultaneous use of contraceptive hormones and anti-retroviral therapy (ART) may theoretically lessen the effectiveness of both. Women on ART need assurance that hormonal contraception is safe and effective. The sub-dermal implant is an ideal product to study: low and steady progestin release and no adherence uncertainties. We sought to determine if the medications' effectiveness is compromised. METHODS: We conducted a prospective cohort study among women on first line ART (stavudine or zidovudine and lamivudine+nevirapine). We recruited new implant users and matched them to women not using hormonal contraception, based on age and baseline CD4. Participants were followed prospectively for up to two years, recording serial CD4 measures and medical histories. We used generalized growth curve models and Wald chi-square tests to compare changes in CD4 counts across study groups. Prospective CD4 measures were censored (excluded) if any of the following events occurred: change in ART, implant removal or use of any hormonal contraception among controls. We examined incidence of opportunistic infection and pregnancy. RESULTS: We matched 48 implant users to 33 non-hormonal controls. Over time, CD4 counts for both groups rose slightly but did not deviate significantly from each other (p=0.44). Opportunistic infection rates did not differ between the groups. None of the implant users and one of the non-hormonal controls became pregnant during follow-up. CONCLUSIONS: This small study found concurrent use of contraceptive implants and ART to be safe and effective. Although other hormonal contraceptive products and ART regimens may interact in unknown ways, the results of this study are reassuring.

Feasibility of recruitment for an efficacy trial of emergency contraceptive pills.

BACKGROUND: The efficacy of emergency contraceptive pills (ECPs) is currently uncertain. The best way to obtain a robust efficacy estimate would be to conduct a placebo-controlled randomized trial. We aimed to assess the feasibility of identifying women eligible for such a trial. STUDY DESIGN: We conducted a survey of women aged 18-35 years in five sexually transmitted disease clinics and urgent care centers in Kenya and the United States in 2006. RESULTS: Of 177 women surveyed, only 10 (6%) reported no reasons for exclusion from a potential efficacy trial. Of the rest, 149 (83%) had not recently had sex that conferred a substantial risk of pregnancy. At all sites combined, the rate of identification of potentially eligible women was 0.6 per day of interviewing. CONCLUSION: A placebo-controlled efficacy trial of ECPs would likely require several thousand participants. Recruitment for such a trial in these types of sites would be prolonged.

Personal involvement of young people in HIV prevention campaign messages: the role of message format, culture, and gender.

To examine young people's reactions to and understanding of HIV prevention messages developed for MTV's global HIV prevention campaign Staying Alive, videotaped campaign materials were shown to focus group discussion (FGD) participants living in urban areas of Brazil, Kenya, Nepal, and Senegal. Responses related to "personal involvement" with the message were identified in the data from these FGDs and were examined in relationship to the emerging message themes, the message format (public service announcements [PSAs] vs. documentary), cultural context (site), and participant gender. Across groups, greater personal involvement (measured by personal connections, emotional reactions, and lessons learned) was found in responses about the documentary format compared to the PSA format. Exceptions were found for specific PSAs that were considered more relevant within specific gender or cultural contexts. Implications of findings for global campaigns were considered.

A qualitative study of condom use among married couples in Kampala, Uganda.

Twenty-five years into the HIV/AIDS epidemic, condom use among married/stable couples remains low and under-researched in developing countries, even countries with high HIV prevalence. Introducing condoms into a long-standing relationship, in spite of HIV risk, is likely to be awkward. We conducted a qualitative study in Kampala, Uganda, with 39 couples reporting 100% condom use in the previous three months. The women were recruited from among women in a clinical trial who were using condoms and whose partners also agreed to participate. Twenty-two of the women and six of the men reported having taken the initiative to suggest condom use; the remaining couples disagreed who raised the subject first. Women used insistence, refusal to have sex, persuasion, and condoms for family planning or to protect children, which helped to deflect distrust and get their partner to agree. Some men resisted initially but their reactions were often more positive than expected. Men's reasons for accepting condoms were to please their partner, protect her from HIV, protect their children, protect themselves and, in some cases, continue having other partners. Although condom use is a couple behaviour, an encouraging environment and condom availability are all crucial to increasing condom use by couples in settings like Uganda.