Factors Associated with Usage of Oral-PrEP among Female Sex Workers in Nairobi, Kenya, Assessed by Self-Report and a Point-of-Care Urine Tenofovir Immunoassay.

Pre-exposure prophylaxis (PrEP) is highly effective at reducing HIV acquisition. We aimed to estimate usage of oral-PrEP, and factors associated with adherence among female sex workers (FSWs) in Nairobi, Kenya, using a novel point-of-care urine tenofovir lateral flow assay (LFA). The Maisha Fiti study randomly selected FSWs from Sex Worker Outreach Program clinics in Nairobi. Data were collected from 1003 FSWs from June-October 2019, including surveys on self-reported oral-PrEP adherence. Adherence was also measured using the LFA for HIV-negative FSWs currently taking oral-PrEP. Informed by a social-ecological theoretical framework, we used hierarchical multivariable logistic regression models to estimate associations between individual, interpersonal/community, and structural/institutional-level factors and either self-reported or LFA-assessed adherence. Overall, 746 HIV-negative FSWs aged 18-40 participated in the study, of whom 180 (24.1%) self-reported currently taking oral-PrEP. Of these, 56 (31.1%) were adherent to oral-PrEP as measured by LFA. In the multivariable analyses, associations with currently taking oral-PrEP included having completed secondary education, high alcohol/substance use, feeling empowered to use PrEP, current intimate partner, no recent intimate partner violence, having support from sex worker organisations, experiencing sex work-related stigma, and seeking healthcare services despite stigma. Associations with oral-PrEP LFA-measured adherence measured included having only primary education, experience of childhood emotional violence, belonging to a higher wealth tertile, and being nulliparous. Oral-PrEP adherence, measured by self-report or objectively, is low among FSWs in Nairobi. Programs to improve oral-PrEP usage among FSWs should work to mitigate social and structural barriers and involve collaboration between FSWs, healthcare providers and policymakers.

Prevalence and correlates of common mental health problems and recent suicidal thoughts and behaviours among female sex workers in Nairobi, Kenya.

BACKGROUND: Adverse childhood experiences (ACEs), poverty, violence and harmful alcohol/substance use are associated with poor mental health outcomes, but few studies have examined these risks among Female Sex Workers (FSWs). We examine the prevalence and correlates of common mental health problems including suicidal thoughts and behaviours among FSWs in Kenya. METHODS: Maisha Fiti is a longitudinal study among FSWs randomly selected from Sex Worker Outreach Programme (SWOP) clinics across Nairobi. Baseline behavioural-biological survey (n = 1003) data were collected June-December 2019. Mental health problems were assessed using the Patient Health Questionnaire (PHQ-9) for depression, the Generalised Anxiety Disorder tool (GAD-7) for anxiety, the Harvard Trauma Questionnaire (HTQ-17) for Post-Traumatic Stress Disorder (PTSD) and a two-item tool to measure recent suicidal thoughts/behaviours. Other measurement tools included the WHO Adverse Childhood Experiences (ACE) score, WHO Violence Against Women questionnaire, and the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST). Descriptive statistics and multivariable logistic regression were conducted using a hierarchical modelling approach. RESULTS: Of 1039 eligible FSWs, 1003 FSWs participated in the study (response rate: 96%) with mean age 33.7 years. The prevalence of moderate/severe depression was 23.2%, moderate/severe anxiety 11.0%, PTSD 14.0% and recent suicidal thoughts/behaviours 10.2% (2.6% suicide attempt, 10.0% suicidal thoughts). Depression, anxiety, PTSD and recent suicidal thoughts/behaviours were all independently associated with higher ACE scores, recent hunger (missed a meal in last week due to financial difficulties), recent sexual/physical violence and increased harmful alcohol/substance. PTSD was additionally associated with increased chlamydia prevalence and recent suicidal thoughts/behaviours with low education and low socio-economic status. Mental health problems were less prevalent among women reporting social support. CONCLUSIONS: The high burden of mental health problems indicates a need for accessible services tailored for FSWs alongside structural interventions addressing poverty, harmful alcohol/substance use and violence. Given the high rates of ACEs, early childhood and family interventions should be considered to prevent poor mental health outcomes.

The epidemiology of HIV infection among female sex workers in Nairobi, Kenya: A structural determinants and life-course perspective.

High HIV prevalence among female sex workers (FSWs) is heavily influenced by structural determinants (e.g. criminalisation of sex work; violence) and significant life events (e.g. orphanhood, teenage pregnancy). This study aims to understand the epidemiology of HIV among FSWs in Nairobi, Kenya using a structural determinants and life-course perspective. Baseline cross-sectional survey data were collected June-December 2019 for the Maisha Fiti study with 1003 FSWs (aged 18-45 years). Odds ratios and 95% confidence intervals were estimated using multivariable logistic regression with a hierarchical modelling approach. HIV prevalence was 28.0%, and increased with age (<25 years 5.7%, 25-34 years 19.0%, ≥35 years 40.6%). In adjusted analyses, HIV seroprevalence was associated with childhood and adolescence including violence from militia or soldiers (AOR = 1.60; 95%CI:1.00-2.53), young age at sexual debut (≤15 years old vs. ≥18 years AOR = 0.57; 95%CI:0.39-0.84) and teenage pregnancy (AOR = 1.37; 95%CI:1.00-1.88). For adulthood the factors included lower SES score (lowest vs. highest tertile AOR = 0.63; 95%CI:0.40-0.98); reduced housing insecurity (AOR = 0.52; 95%CI:0.54-0.79); lower alcohol/drug use score (AOR = 0.44; 95%CI:0.31-0.61); and a longer duration of selling sex (0-5 years vs. ≥11 years AOR = 2.35; 95%CI:1.44-3.82). Among HIV-negative FSWs, prevalence of HIV risk factors was high (recent hunger 32.3%; internalised 67.7% and experienced 66.0% sex work stigma; recent police arrest 30.1%; recent physical or sexual violence 65.6%, condomless last sex intimate partner 71.1%; harmful alcohol or substance use 49.1%). Only 24.6% of HIV-negative FSWs reported taking PrEP. Taken together, adverse events in childhood and adolescence were associated with increased odds of living with HIV, and were more strongly associated with HIV serostatus than adulthood structural or behavioural risk factors. HIV-negative FSWs remain at high risk of HIV acquisition. This study highlights the importance of addressing adverse events throughout the life course to reduce HIV risk, and the need to continue multi-level HIV prevention and treatment efforts.

Are violence, harmful alcohol/substance use and poor mental health associated with increased genital inflammation?: A longitudinal cohort study with HIV-negative female sex workers in Nairobi, Kenya.

Violence, alcohol use, substance use and poor mental health have been linked with increased HIV acquisition risk, and genital inflammation enhances HIV susceptibility. We examined whether past 6 month experience of these exposures was associated with increased genital inflammation, thereby providing a biological link between these exposures and HIV acquisition risk. The Maisha Fiti study was a longitudinal mixed-methods study of female sex workers in Nairobi, Kenya. Behavioural-biological surveys were conducted at baseline (June-December 2019) and endline (June 2020-March 2021). Analyses were restricted to HIV-negative women (n = 746). Women with raised levels of at least 5 of 9 genital inflammatory cytokines were defined as having genital inflammation. Multivariable logistic regression models were used to estimate (i) baseline associations between genital inflammation and violence, harmful alcohol/substance use, and poor mental health, and (ii) longitudinal associations between these exposures at different survey rounds, and genital inflammation at follow-up. Inflammation data was available for 711 of 746 (95.3%) women at baseline; 351 (50.1%) had genital inflammation, as did 247 (46.7%) at follow-up. At baseline, 67.8% of women had experienced physical and/or sexual violence in the past 6 months, 33.9% had harmful alcohol use, 26.4% had harmful substance use, 25.5% had moderate/severe depression/anxiety, and 13.9% had post-traumatic stress disorder. In adjusted analyses, there was no evidence that these exposures were associated cross-sectionally or longitudinally with genital inflammation. We report no associations between past 6 month experience of violence, harmful alcohol/substance use, or poor mental health, and immune parameters previously associated with HIV risk. This suggests that the well-described epidemiological associations between these exposures and HIV acquisition do not appear to be mediated by genital immune changes, or that any such changes are relatively short-lived. High prevalences of these exposures suggest an urgent need for sex-worker specific violence, alcohol/substance use and mental health interventions.

Childhood and adolescent factors shaping vulnerability to underage entry into sex work: a quantitative hierarchical analysis of female sex workers in Nairobi, Kenya.

OBJECTIVE: To explore factors associated with early age at entry into sex work, among a cohort of female sex workers (FSWs) in Nairobi, Kenya. BACKGROUND: Younger age at sex work initiation increases the risk of HIV acquisition, condom non-use, violence victimisation and alcohol and/or substance use problems. This study aimed to understand factors in childhood and adolescence that shape the vulnerability to underage sex work initiation. DESIGN: Building on previous qualitative research with this cohort, analysis of behavioural-biological cross-sectional data using hierarchical logistic regression. PARTICIPANTS AND MEASURES: FSWs aged 18-45 years were randomly selected from seven Sex Workers Outreach Programme clinics in Nairobi, and between June and December 2019, completed a baseline behavioural-biological survey. Measurement tools included WHO Adverse Childhood Experiences, Alcohol, Smoking and Substance Involvement Screening Test and questionnaires on sociodemographic information, sexual risk behaviours and gender-based violence. Descriptive statistics and logistic regression were conducted using hierarchical modelling. RESULTS: Of the 1003 FSWs who participated in the baseline survey (response rate 96%), 176 (17.5%) initiated sex work while underage (<18 years). In the multivariable analysis, factors associated with entering sex work while underage included incomplete secondary school education (aOR=2.82; 95% CI=1.69 to 4.73), experiencing homelessness as a child (aOR=2.20; 95% CI=1.39 to 3.48), experiencing childhood physical or sexual violence (aOR=1.85; 95% CI=1.09 to 3.15), young age of sexual debut (≤15 years) (aOR=5.03; 95% CI=1.83 to 13.79) and being childless at time of sex work initiation (aOR=9.80; 95% CI=3.60 to 26.66). CONCLUSIONS: Lower education level and childhood homelessness, combined with sexual violence and sexual risk behaviours in childhood, create pathways to underage initiation into sex work. Interventions designed for girls and young women at these pivotal points in their lives could help prevent underage sex work initiation and their associated health, social and economic consequences.

Violence across the Life Course and Implications for Intervention Design: Findings from the Maisha Fiti Study with Female Sex Workers in Nairobi, Kenya.

We examined violence experiences among Female Sex Workers (FSWs) in Nairobi, Kenya, and how these relate to HIV risk using a life course perspective. Baseline behavioural-biological surveys were conducted with 1003 FSWs June-December 2019. Multivariable logistic regression models were used to estimate the adjusted odds ratio (AOR) and 95% confidence intervals (CI) for associations of life course factors with reported experience of physical or sexual violence in the past 6 months. We found substantial overlap between violence in childhood, and recent intimate and non-intimate partner violence in adulthood, with 86.9% reporting one or more types of violence and 18.7% reporting all three. Recent physical or sexual violence (64.9%) was independently associated with life course factors, including a high WHO Adverse Childhood Experiences (ACE) score (AOR = 7.92; 95% CI:4.93-12.74) and forced sexual debut (AOR = 1.97; 95% CI:1.18-3.29), as well as having an intimate partner (AOR = 1.67; 95% CI:1.25-2.23), not having an additional income to sex work (AOR = 1.54; 95% CI:1.15-2.05), having four or more dependents (AOR = 1.52; 95% CI:0.98-2.34), recent hunger (AOR = 1.39; 95% CI:1.01-1.92), police arrest in the past 6 months (AOR = 2.40; 95% CI:1.71-3.39), condomless last sex (AOR = 1.46; 95% CI:1.02-2.09), and harmful alcohol use (AOR = 3.34; 95% CI:1.74-6.42). Interventions that focus on violence prevention during childhood and adolescence should help prevent future adverse trajectories, including violence experience and HIV acquisition.

Longitudinal experiences and risk factors for common mental health problems and suicidal behaviours among female sex workers in Nairobi, Kenya.

Background: Female sex workers (FSWs) are at high risk of mental health problems and suicide risk. Few longitudinal studies have examined risk factors for poor mental health among FSWs. Methods: Maisha Fiti is a longitudinal study among FSWs randomly selected from Sex Worker Outreach Programme clinics across Nairobi. Behavioural-biological survey data were collected at baseline (n = 1003, June-December 2019), midline (n = 366) (Jan-March 2020) and endline (n = 877) (June 2020-Jan 2021). Women reporting mental health problems were offered counselling services. Multivariable mixed logistic regression models were used to examine factors associated with mental health problems and suicidal behaviours. Results: There was a decline in the proportion of women reporting any mental health problem (depression and/or anxiety and/or PTSD) (baseline: 29.9%, midline: 13.3%, endline: 11.8%). There was strong evidence that any mental health problem was associated with recent hunger (aOR 1.99; 95% CI 1.37-2.88) and recent violence from non-intimate partners (2.23; 95% CI 1.55-3.19). Recent suicidal behaviour prevalence was similar across survey rounds (baseline: 10.2%; midline: 10.2%; endline: 10.4%), and was associated with recent violence from non-intimate partners (aOR 1.96; 95% CI 1.31-2.95), recent hunger (aOR 1.69; 95% CI 1.15-2.47) and having an additional employment to sex work (aOR 1.50; 95% CI 1.00-2.23). Conclusions: Our study found a decline in mental health problems but high levels of persistent suicidal behaviours among FSWs. Syndemic risk factors including food insecurity and violence were longitudinally associated with mental health problems and recent suicidal behaviours. There is a need for accessible mental health services for FSWs, alongside structural interventions addressing poverty and violence.

Harmful Alcohol and Drug Use Is Associated with Syndemic Risk Factors among Female Sex Workers in Nairobi, Kenya.

Background: Female Sex Workers (FSWs) are at high risk of harmful alcohol and other drug use. We use quantitative data to describe the prevalence of alcohol and other drug use and identify associated occupational and socio-economic risk factors, and aim to elucidate patterns of alcohol and drug use through information drawn from qualitative data. Methods: Maisha Fiti was a mixed-method longitudinal study conducted in 2019 among a random sample of FSWs in Nairobi, Kenya. We used baseline date from the behavioural−biological survey, which included the WHO Alcohol, Smoking and Substance Involvement Screening Test that measures harmful alcohol and other drug use in the past three months (moderate/high risk score: >11 for alcohol; >4 for other drugs). In-depth interviews were conducted with 40 randomly selected FSWs. Findings: Of 1003 participants, 29.9% (95%CI 27.0−32.6%) reported harmful (moderate/high risk) alcohol use, 21.5% harmful amphetamine use (95%CI 19.1−24.1%) and 16.9% harmful cannabis use (95%CI 14.7−19.2%). Quantitative analysis found that harmful alcohol, cannabis and amphetamine use were associated with differing risk factors including higher Adverse Childhood Experience (ACE) scores, street homelessness, food insecurity (recent hunger), recent violence from clients, reduced condom use, depression/anxiety and police arrest. Qualitative interviews found that childhood neglect and violence were drivers of entry into sex work and alcohol use, and that alcohol and cannabis helped women cope with sex work. Conclusions: There is a need for individual and structural-level interventions, tailored for FSWs, to address harmful alcohol and other drug use and associated syndemic risks including ACEs, violence and sexual risk behaviours.