Condom use among young women who sell sex in Zimbabwe: a prevention cascade analysis to identify gaps in HIV prevention programming

Abstract

IntroductionAdolescent girls and young women (AGYW), including those who sell sex in sub‐Saharan Africa, are especially vulnerable to HIV. Reaching them with effective prevention is a programmatic priority. The HIV prevention cascade can be used to track intervention coverage, and identify gaps and opportunities for programme strengthening. The aim of this study was to characterise gaps in condom use and identify reasons underlying these gaps among young women who sell sex (YWSS) in Zimbabwe using data from enrolment into an impact evaluation of the DREAMS programme. DREAMS provided a package of biomedical, social and economic interventions to AGYW aged 10 to 24 with the aim of reducing HIV incidence.MethodsIn 2017, we recruited YWSS aged 18 to 24 using respondent‐driven sampling in six sites across Zimbabwe. We measured knowledge about efficacy of, access to, and effective (consistent) use of condoms with the most recent three sexual partners, separately by whether YWSS self‐identified as female sex workers (FSW) or not. Among YWSS without knowledge about efficacy of, not having access to, and not effectively using condoms, we described the potential reasons underlying the gaps in the condom cascade. To identify socio‐demographic characteristics associated with effective condom use, we used logistic regression modelling. All analyses were RDS‐II weighted and restricted to YWSS testing HIV‐negative at enrolment.ResultsWe enrolled 2431 YWSS. Among 1842 (76%) YWSS testing HIV‐negative, 66% (n = 1221) self‐identified as FSW. 89% of HIV‐negative YWSS demonstrated knowledge about efficacy of condoms, 80% reported access to condoms and 58% reported using condoms consistently with the three most recent sexual partners. Knowledge about efficacy of and effective use of condoms was similar regardless of whether or not YWSS self‐identified as FSW, but YWSS self‐identifying as FSW reported better access to condoms compared to those who did not (87% vs 68%; age‐ and site‐adjusted (adjOR) = 2.69; 95% CI: 2.01 to 3.60; p < 0.001). Women who reported experiencing sexual violence in the past year and common mental disorder in the past week were less likely to use condoms consistently (43% vs. 60%; adjOR = 0.49; 95% CI: 0.35 to 0.68; p < 0.001) and (51% vs. 61%; adjOR = 0.76; 95% CI: 0.60 to 0.97; p = 0.029), respectively.ConclusionsDespite high knowledge about efficacy of and access to condoms, there remain large gaps in self‐reported consistent condom use among YWSS. Addressing the structural determinants of YWSS’ inconsistent condom use, including violence, could reduce this gap. YWSS who do not self‐identify as FSW have less access to condoms and may require additional programmatic intervention.

‘I was in need of somewhere to release my hurt:’ Addressing the mental health of vulnerable adolescent mothers in Harare, Zimbabwe, through self-help groups

“…The SHG intervention was delivered as part of Zimbabwe’s nationally scaled HIV prevention and treatment programme for sex workers Sisters with a Voice (Sisters) , which offers a wide range of social and clinical services for high-risk women, including AGYW [ 19 , 22 , 26–29 ]. The intervention was delivered in four high-density communities in Harare, Zimbabwe, characterised by small, clustered houses shared by several families, low education levels of resident adults, low-wage and informal employment, and high turnover of residents.…”

“…In Zimbabwe, high numbers of AGYW experience both early childbearing and HIV risk, many as a result of their involvement in exchanging sex for money or material benefits [ 19 , 20 ]. Nationally, 21.6% of all girls aged 15–19 have begun childbearing, and this is higher among those in the lowest wealth quintile (33.6%) and with primary or lower education (37.8%); by age 25, 91% of the women have given birth at least once [ 21 ].…”

Intervening for HIV prevention and mental health: a review of global literature

“…Several studies demonstrated that poorer mental health (especially severe depression, depression and PTSD, or anxiety) was associated with less consistent condom use or less perceived condom self-efficacy among MSM [80], young women who sold sex [81], and homeless men who also used drugs and traded sex [82]. Condom use self-efficacy and depression were partial mediators of the relationship between sexual stigma and inconsistent condom use among MSM [83].…”

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

“…Pressure from clients and the inability to negotiate condom use may be more difficult for younger sex workers. 32 Women in Zimbabwe FGDs reported fear of loss of income if they refused to engage in sex without protection/ contraceptives. Related, women in LMIC participating in the online survey were also more likely to value contraceptives that are discreet, so that they did not need to disclose to clients that they were avoiding pregnancy or to negotiate condom use.…”