Intimate partner and client‐perpetrated violence are associated with reduced HIV pre‐exposure prophylaxis (PrEP) uptake, depression and generalized anxiety in a cross‐sectional study of female sex workers from Nairobi, Kenya

Abstract

Introduction UNAIDS has identified female sex workers (FSW) as a key HIV at‐risk population. FSW disproportionately experience gender‐based violence, which compounds their risk of HIV acquisition and may contribute to adverse mental health outcomes. Pre‐exposure prophylaxis (PrEP) is a powerful but underused HIV prevention tool for these women. This study explored the associations between intimate partner violence (IPV) and client‐perpetrated violence against FSW, mental health outcomes and PrEP use. Methods An anonymous questionnaire was administered to a convenience sample of 220 Nairobi FSW attending dedicated clinics from June to July 2019, where PrEP was available free of charge. A modified version of the WHO Violence Against Women Instrument assessed IPV and client‐perpetrated violence, and the Patient Health Questionnaire‐9 (PHQ‐9) and Generalized Anxiety Disorder‐7 (GAD‐7) assessed depressive and anxiety symptoms respectively. Multivariable logistic regressions evaluated predictors of depression, generalized anxiety and PrEP use. Results Of the total 220 women (median [IQR] age 32 [27‐39]), 56.8% (125/220) reported depression (PHQ‐9 ≥ 10) and 39.1% (86/220) reported anxiety (GAD‐7 ≥ 10). Only 41.4% (91/220) reported optimal use of PrEP (taken correctly six to seven days/week) despite the cohort pursuing sex work for a median of 7 (4 to 12) years. Most women reported experiencing any violence in the past 12 months (90%, 198/220). Any recent IPV was frequent (78.7%, 129/164), particularly emotional IPV (66.5%, 109/164), as was any client‐perpetrated violence in the past 12 months (80.9%, 178/220). Regression analyses found that violence was independently associated with depression (adjusted OR [aOR] 9.39, 95% CI 2.90 to 30.42, p = 0.0002) and generalized anxiety (aOR 3.47, 95% CI 1.10 to 10.88, p = 0.03), with the strongest associations between emotional IPV and both depression and anxiety. Recent client‐perpetrated emotional violence (aOR 0.23, 95% CI 0.07 to 0.71, p = 0.01) was associated with decreased PrEP use, whereas client‐perpetrated physical violence was associated with increased PrEP use (aOR 3.01, 95% CI 1.16 to 7.81, p = 0.02). Conclusions There was a high prevalence of recent violence by different perpetrators as well as depression and anxiety among FSW from Nairobi. PrEP use was relatively infrequent, and recent client‐perpetrated emotional violence was associated with PrEP non‐use. Interventions to reduce gender‐based violence may independently enhance HIV prevention and reduce the mental health burden in this community.

Younger age of initiation of selling sex and depressive symptoms among female sex workers in Eswatini

“…These findings are consistent with other studies of FSW in sub-Saharan Africa that have shown a high burden of depression. 17,23,47-49 In this study, 16.6% of FSW in Eswatini started selling sex as minors, which is comparable to the prevalence in other countries in the region such as South Africa (18%), 20 , Lesotho (20%), 5 Zimbabwe (10%), 50 and Malawi (17%). 9 Depression and underage initiation of selling sex in this study were both associated with selling sex to feed oneself or one’s family, perceived sex work stigma in healthcare settings, and condoms breaking or slipping.…”

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

“…These common mental health problems were associated with a range of factors including poverty, violence and increased harmful alcohol/drug use [ 18 ]. Violence against FSWs is prevalent in Kenya with a recent survey among 220 FSWs in Nairobi reporting that 81 and 79% of respondents had experienced client-perpetrated and intimate partner perpetrated violence, respectively, in the past 12 months [ 19 ]. This study reported a high prevalence of depression (56.8%) and generalised anxiety (39.1%), both of which were independently significantly associated with a recent violent experience [ 19 ].…”

“…Violence against FSWs is prevalent in Kenya with a recent survey among 220 FSWs in Nairobi reporting that 81 and 79% of respondents had experienced client-perpetrated and intimate partner perpetrated violence, respectively, in the past 12 months [ 19 ]. This study reported a high prevalence of depression (56.8%) and generalised anxiety (39.1%), both of which were independently significantly associated with a recent violent experience [ 19 ]. FSWs in Kenya are also at high risk of violence from the police with respondents in a survey in 2015 reporting having experienced high levels of arrest for selling sex (62%) as well as verbal (59%) and physical (45%) abuse at least once in the past 12 months [ 20 ].…”

“…Despite the substantial body of evidence demonstrating the increased risk of violence, police arrest, and harmful alcohol use among FSWs in Kenya, there is a paucity of research on their mental health experiences and needs. A limited number of quantitative studies have investigated mental health and associated risk factors among FSWs in Kenya [ 19 , 25 , 26 ], including quantitative research from the baseline Maisha Fiti study, but there is little research using qualitative research methods to understand FSWs’ mental health experiences and determinants. This paper uses qualitative in-depth interviews with FSWs enrolled in the Maisha Fiti study in Kenya to investigate their lifetime mental health experiences and perceived risk factors.…”

Transient Increases in Inflammation and Proapoptotic Potential Are Associated with the HESN Phenotype Observed in a Subgroup of Kenyan Female Sex Workers

“…Despite the tremendous efforts put forth, the number of new HIV infections remained stable at around 1.3 million per year for the last 3 years [ 1 , 2 , 3 ]. The success of preventative measures, such as increased condom use, pre-exposure prophylaxis (PrEP), and treatment as prevention (TasP) remain suboptimal and dependent on the level of adherence [ 4 , 5 , 6 , 7 , 8 , 9 ]. There is an ever-urgent need for novel preventative tools, which require better understanding of the protective mechanisms against HIV-1 infection.…”