HIV, sexual violence, and termination of pregnancy among adolescent and adult female sex workers in Malawi: A respondent-driven sampling study

Abstract

Female Sex Workers (FSWs) are a hard-to-reach and understudied population, especially those who begin selling sex at a young age. In one of the most economically disadvantaged regions in Malawi, a large population of women is engaged in sex work surrounding predominantly male work sites and transport routes. A cross-sectional study in February and April 2019 in Nsanje district used respondent driven sampling (RDS) to recruit women ≥13 years who had sexual intercourse (with someone other than their main partner) in exchange for money or goods in the last 30 days. A standardized questionnaire was filled in; HIV, syphilis, gonorrhea, and chlamydia tests were performed. CD4 count and viral load (VL) testing occurred for persons living with HIV (PLHIV). Among 363 study participants, one-quarter were adolescents 13–19 years (25.9%; n = 85). HIV prevalence was 52.6% [47.3–57.6] and increased with age: from 14.7% (13–19 years) to 87.9% (≥35 years). HIV status awareness was 95.2% [91.3–97.4], ART coverage was 98.8% [95.3–99.7], and VL suppression 83.2% [77.1–88.0], though adolescent FSWs were less likely to be virally suppressed than adults (62.8% vs. 84.4%). Overall syphilis prevalence was 29.7% [25.3–43.5], gonorrhea 9.5% [6.9–12.9], and chlamydia 12.5% [9.3–16.6]. 72.4% had at least one unwanted pregnancy, 17.9% had at least one abortion (40.1% of which were unsafe). Half of participants reported experiencing sexual violence (SV) (47.6% [42.5–52.7]) and more than one-tenth (14.2%) of all respondents experienced SV perpetrated by a police officer. Our findings show high levels of PLHIV-FSWs engaged in all stages of the HIV cascade of care. The prevalence of HIV, other STIs, unwanted pregnancy, unsafe abortion, and sexual violence remains extremely high. Peer-led approaches contributed to levels of ART coverage and HIV status awareness similar to those found in the general district population, despite the challenges and risks faced by FSWs.

HIV and Pregnancy among Adolescents in Sub-Saharan Africa: A Scoping Review

“…The studies that were included reported qualitative and quantitative data on the experiences of adolescent mothers affected by HIV from sub-Saharan African countries: 12 studies from South Africa [4,11,12,13,15,22,23,24,25,26,29,32], 2 from Malawi [17,21], 1 from Zimbabwe [16], 6 Kenyan studies [18,20,27,31,33,34] (n=6), 1 from Lesotho [28] 1 from Uganda [19], and 2 multi-country studies [14, 30].…”

“…The majority of the studies reported on quantitative data [4,11,12,14,15,17,18,19,20,22,24,26,28,29,31,32,33,34], five reported qualitative data [13,21,25,27,30], and one study used mixed methods [16]. The total number of participants included is 178,227, and the age range is between 12-18 years.…”

“…Conversely, a study in Malawi focused on female sex workers (FSWs) revealed that 14.7% of them were between the ages of 13–19 and were living with HIV. Additionally, among the 363 participants, 52.3% had encountered their first pregnancy before turning 19 years old [18].…”

“…Kenyan studies [18,20,27,31,33,34] (n=6), 1 from Lesotho [28] 1 from Uganda [19], and 2 multicountry studies [14,30].…”

“…Adolescents also had increased risks of maternal mortality, first presentation in labour, and stillbirth. [23,31] Seven studies reported the low use of maternal health care services, including use of PMTCT, skilled attendance and postnatal/postabortion care for pregnancies which might end in adverse outcomes such as miscarriage, stillbirth or abortion among HIV-positive female adolescents [12,14,15,18,20,30,32,34].…”