The authors have declared that no competing interests exist.
Pre-exposure prophylaxis (PrEP) is an element of the biomedical interventions of Human Immunodeficiency virus (HIV) prevention. The level of protection is strongly correlated to PrEP drug adherence. In Nigeria, the prevalence of HIV among female sex workers (FSW) is 15.5%. The 2020 integrated biological and behavioral surveillance survey did not report on PrEP adherence among FSW. This study therefore assessed the level of adherence to PrEP and its predictors among FSW in South-Western Nigeria.
This cross-sectional analytical study was conducted in 2021. Study population were brothel-based FSW at Gambari Ogbomoso and Lagos, Nigeria. A total of 156 FSW participated in the study. Data was collected using interviewer-administered semi-structured questionnaire and analyzed using IBM SPSS Version 25.
One hundred and forty-nine properly completed questionnaires were analyzed. Ninety-nine respondents (66.4%) have been working for more than 5years as a FSW and 65(43.6%) had initiation of sex work before 18 years of age. Respondents’ sexual behavior showed that 55 (36.9%) of total respondents had consistent use of condom. One hundred and thirty-four respondents (89.9%) had good knowledge of PrEP, 97 (65.1%) had good attitude towards PrEP while 111 (74.5%) had good perception of risk of HIV infection. One hundred and thirty-two (88.6%) reported to be taking PrEP and 119 (79.9%) had good adherence to PrEP. Predictors of adherence to PrEP were educational status, age of commencement of sex work and monthly income. It was found that educated sex workers were 2.67 times more likely to adhere to PrEP (OR=2.67, 95% CI=1.280-5.591, p=0.019). Those who commenced sex work after clocking 18 years of age were 75% times less likely to adhere to PrEP (OR=0.251, 95% CI=0.106-0.597, p=0.001) while those with average monthly income more than #10,000 were 1.65 times more likely to adhere to PrEP (OR=1.65, 95% CI=0.674-4.042, p=0.0275.
The level of adherence to PrEP is considerably high and underscores a positive effect of the efforts of the Government of Nigeria in controlling HIV as a threat by 2030. Further studies would be useful to understand the behavioral factors associated with low adherence to PrEP among FSW who have spent more than 5 years in sex work.
Human Immunodeficiency virus (HIV) continues to be a major global public health issue. Nigeria has a mixed HIV epidemic and the prevalence and transmission dynamics of HIV vary across geo-political zones and population groups. The south-south states have a prevalence of 3.1% while the southwestern states have a prevalence of 1.2%. Six states in Nigeria (Kaduna, Akwa-Ibom, Benue, Lagos, Oyo and Kano) account for 41% of people living with HIV.
Pre-exposure prophylaxis (PrEP) is one of the elements of biomedical interventions of HIV prevention for sex workers. Pre-exposure prophylaxis is a strategy developed to prevent individuals who are Human Immunodeficiency Virus (HIV) negative from developing HIV infection.
In Nigeria, the preferred daily oral dose regimen for PrEP is the combination of TDF +FTC (Tenofovir + Emcitritabine). The alternate regimen for PrEP is a daily dose of TDF. These drugs are to be taken indefinitely until the individual no longer qualifies as high risk for HIV.
In 2012, the World Health Organization (WHO) developed guidelines for PrEP for serodiscordant couples, MSM, and transgender people (TG) at high risk of HIV.
WHO defines sex work as the provision of sexual services for money or goods. FSW exchange anal, vaginal or oral sex for money and other items of value primarily with men. In Nigeria, most sex workers are females. The operational characteristics of female sex workers vary considerably across Nigeria. For example, in Lagos 40% of FSW operate through hotels and lodges, 27% in bars, night clubs or casinos, 21% in brothels and 6% in public places where they solicit for clients. There are several groupings of sex work viz Brothel-based sex work, Street-Based sex work, Home-Based sex work, Venue-Based sex work, Internet-Based sex work etc. The risk of HIV and other Sexually Transmitted Diseases (STDs) is high among persons who exchange sex for money or non-monetary items.
Although sex workers are one of the groups most affected by HIV, they are also one of the groups most likely to respond well to HIV prevention programmes.
In Uganda, PrEP roll out started in 2017 using a phased approached, initially offered at public health facilities that provide care to high-risk populations. A study done four years after showed a large proportion of participants (71.4%) were said to have high adherence to PrEP.
Sex workers are among the highest risk groups for HIV. Globally, they make up to 9% of the total number of new HIV infections. They are 13 times more at risk of HIV compared to the general population due to an increased likelihood of being economically vulnerable, unable to negotiate consistent condom use and experiencing violence, criminalization and marginalization.
A major risk factor for HIV infection among female sex workers in Nigeria is their underestimation of the risk of infection. They rationalize, defend or justify their high-risk behaviours. “They believe in fatalism, predestination and faith-based invulnerability to HIV infection. They also experience a high level of HIV related stigma. Brothel based female sex workers reported less condom use with boyfriends and casual partners than non-brothel based female sex workers, whereas injection-drug use was reported higher among non-brothel based than among brothel- based female sex workers.”
Nigeria has the fourth largest epidemic in the world as 1.7million people
The estimated sex workers population in Nigeria is 874,000.
A study done in Nigeria revealed that fewer than half of the female sex workers were interested in the use of PrEP, however numerous individual and structural barriers such as stigma, cost, frequency of HIV counseling and treatment services required, lack of peer educators and HIV test counselors who would provide information and refer clients to clinics that provide PrEP; are predictors to adherence.
Nigeria may not reach its UNAIDS goals to end AIDS by 2030 without specifically addressing the epidemics among key populations including female sex workers. Many literatures in Nigeria have focused on assessing interventions for HIV prevention including acceptability of PrEP among FSW, specific considerations on predictors of adherence of female sex workers to PrEP is lacking. For instance, the 2020 integrated biological and behavioral surveillance survey did not report on PrEP adherence among FSW. Our study therefore assessed the level of adherence to PrEP and its predictors among FSW in South-Western Nigeria. We hope that the results of this study will be used to inform a nationwide scale up of PrEP among FSW as part of a comprehensive HIV prevention package.
The study was cross-sectional analytical in design and was conducted between August and September 2021. A sample size of 149 was used for this study. The study population were brothel-based female sex workers in Gambari Ogbomoso and Lagos; both in Southwest, Nigeria. A non-probability sampling technique was used to select the study participants above the age of 18 years who gave consent to participate in the study. Data was collected using interviewer-administered semi-structured questionnaire and analyzed using IBM SPSS version 25. Descriptive statistics was done for sociodemographic characteristics and to depict the respondents’ sexual behavior. Chi-square test was used to test for association between sexual behavior, knowledge, risk perception attitude and adherence to PrEP among female sex workers. Multivariate logistic regression analysis was done to identify the predictors of adherence to PrEP.
Ethical clearance was sought and received from the Ethical Review Committee of LAUTECH Teaching Hospital, Ogbomoso, Oyo State.
One hundred and forty-nine (149) questionnaires were collected and analysed. Of the total respondents 16 (10.7%) were university graduates,73(48.9%) were school drop-outs (both primary and secondary schools) and 12 (8.1%) did not have any formal education. In terms of duration of sex work, 99 (66.4%) respondents have been working for more than 5years and 65(43.6%) had initiation of sex work before 18 years of age. The number of FSW who practice their work every day were one hundred and fifteen (77.2%). The average monthly income (both from sex work and other works) earned by 36.2% of respondents was above #20,000 while 49 (32.9%) respondents earned less than #10,000. The location of practice for 99(66.4%) FSW was Lagos while 50(33.5%) were working in Gambari Ogbomoso. As regards marital status 7(11.4%) were married while the others were unmarried (
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No formal | 12 | 8.1 |
Did not complete primary school | 31 | 20.8 |
Completed primary education | 27 | 18.1 |
Did not complete secondary education | 42 | 28.2 |
Completed secondary education | 21 | 14.1 |
Graduate | 16 | 10.7 |
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≤ 5 | 99 | 66.4 |
6-10 | 39 | 26.2 |
>10 | 11 | 7.4 |
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≤ 15 | 17 | 11.4 |
16-18 | 48 | 32.2 |
>18 | 84 | 56.4 |
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≤ 5 | 37 | 24.8 |
6-10 | 52 | 34.9 |
>10 | 41 | 27.5 |
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≤ 5 | 71 | 47.7 |
6-10 | 41 | 27.5 |
>10 | 37 | 24.8 |
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≤ 10 | 13 | 8.7 |
10-20 days | 21 | 14.1 |
Everyday | 115 | 77.2 |
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≤ 10000 | 49 | 32.9 |
11000 - 20000 | 46 | 30.9 |
>20000 | 54 | 36.2 |
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Lagos | 99 | 66.4 |
Gambari Ogbomoso | 50 | 33.5 |
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Never married | 97 | 65.1 |
Married | 17 | 11.4 |
Widow/widower | 1 | 0.7 |
Divorced | 26 | 17.4 |
Separated | 8 | 5.4 |
*Multiple responses allowed
Variables | Frequency | Percentage |
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Never | 4 | 2.7 |
Sometimes | 32 | 21.5 |
Most of the time | 58 | 38.9 |
Every time | 55 | 36.9 |
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Yes | 143 | 96 |
No | 6 | 4 |
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Yes | 43 | 28.9 |
No | 106 | 71.1 |
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Yes | 2 | 4.7 |
No | 41 | 95.3 |
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Never | 6 | 4 |
Sometimes | 18 | 12.1 |
Most of the time | 57 | 38.3 |
Every time | 68 | 45.6 |
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Yes | 142 | 95.3 |
No | 7 | 4.7 |
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Yes | 5 | 3.4 |
No | 144 | 96.6 |
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Yes | 1 | 20 |
No | 4 | 80 |
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Yes | 139 | 93.3 |
No | 10 | 6.7 |
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Sometimes | 24 | 17.3 |
Most of the time | 64 | 46 |
Every time | 51 | 36.7 |
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Yes | 93 | 66.9 |
No | 46 | 33.1 |
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Yes | 39 | 28.1 |
No | 100 | 71.9 |
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Yes | 30 | 76.9 |
No | 9 | 23.1 |
The
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Highest level of education you completed | |||||
No formal | 10(83.3) | 2(16.7) | 26.533 | 5 | *<0.001 |
Did not complete primary school | 24(77.4) | 7(22.6) | |||
Completed primary education | 24(88.9) | 3(11.1) | |||
Did not complete secondary education | 40(95.2) | 2(4.8) | |||
Completed secondary education | 15(71.4) | 6(28.6) | |||
Graduate | 6(37.5) | 10(62.5) | |||
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≤ 5 | 82(82.8) | 17(17.2) | 8.756 | 2 | *0.013 |
6-10 | 32(82.1) | 7(17.9) | |||
>10 | 5(45.5) | 6(54.5) | |||
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≤ 15 | 15(88.2) | 2(11.8) | 16.667 | 2 | *<0.001 |
16-18 | 29(60.4) | 19(39.6) | |||
>18 | 75(89.3) | 9(10.7) | |||
In the past week, approximately number of clients (occasional clients) | |||||
≤ 5 | 30(81.1) | 7(18.9) | 6.259 | 2 | *0.044 |
6-10 | 36(69.2) | 16(30.8) | |||
>10 | 37(90.2) | 4(9.8) | |||
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≤ 5 | 53(74.6) | 18(25.4) | 2.192 | 2 | 0.334 |
6-10 | 34(82.9) | 7(17.1) | |||
>10 | 4(100.0) | 0(0.0) | |||
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≤ 10000 | 44(89.8) | 5(10.2) | 9.547 | 2 | *0.008 |
11000 - 20000 | 30(65.2) | 16(34.8) | |||
>20000 | 45(83.3) | 9(16.7) | |||
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Never married | 90(92.8) | 7(7.2) | 37.685 | 4 | *<0.001 |
Married | 13(76.5) | 4(23.5) | |||
Widow/widower | 1(100.0) | 0(0.0) | |||
Divorced | 11(42.3) | 15(57.7) | |||
Separated | 4(50.0) | 4(50.0) |
*Statistically significant at p<0.05
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Variables | Adhere |
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X2 | Df | P-value |
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Poor | 55(82.1) | 12(17.9) | 0.374 | 1 | 0.344 |
Good | 64(78.0) | 18(22.0) | |||
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Good knowledge | 110(82.1) | 24(17.9) | 4.093 | 1 | 0.052 |
Poor knowledge | 9(60.0) | 6(40.0) | |||
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Good | 96(86.5) | 15(13.5) | 5.710 | 1 | *0.017 |
Poor | 38(100.0) | 0(0.0) | |||
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Positive | 79(81.4) | 18(18.6) | 0.43 | 1 | 0.326 |
Negative | 40(76.9) | 12(23.1) |
The seven variables (educational status, duration of sex work, age at commencement of sex work, approximate number of occasional clients, average monthly income, marital status and perception of risk of HIV infection) which were statistically associated with adherence to PrEP in bivariate analysis were included in a multivariate logistic regression analysis to ascertain the predictors of adherence to PrEP. Educational status, age of commencement of sex work and monthly income were found to be independent predictors of adherence to PrEP.
Explanatory factors | B | OR(95% CI) | df | df (p-value) |
Educational status | 0.984 | 2.675(1.280-5.591) | 1 | 1(0.019*) |
Not educated (Ref) | ||||
Educated | ||||
Duration of sex work (years) | -1.443 | 0.236(0.012-4.629) | 1 | 1(0.342) |
≤ 5 (Ref) | ||||
>5 | ||||
Age of commencement of sex work (years) | 0.758 | 0.251(0.106-0.597) | 1 | (0.001*) |
≤ 18 (Ref) | ||||
>18 | ||||
In the past week, approximately number of clients (occasional clients) | -0.043 | 0.958(0.242-3.797) | 1 | -0.951 |
≤ 5 (Ref) | ||||
>5 | ||||
In the past week, approximately number of clients (repeat clients) | 0.685 | 1.984(0.464-8.472) | 1 | -0.355 |
≤ 5 (Ref) | ||||
>5 | ||||
In past month, Average monthly income (include sex work and other work) | 0.500 | 1.648(0.672-4.042) | 1 | (0.0275*) |
≤ 10000 (Ref) | ||||
>10000 | ||||
Marital status | -0.058 | 0.944(0.607-1.467) | 1 | -0.797 |
Never married (Ref) | ||||
Ever Married | ||||
Overall Perception of risk of HIV infection | 0.896 | 0.181(0.023-1.421) | 1 | -0.069 |
Good (Ref) | ||||
Poor |
Omnibus test; X
The socio-demographic distribution of this study population showed that a small proportion of sex workers were university graduates. This finding is similar to the results from another study conducted in Kenya where a proportion of those engaged in sex work were graduates.
Findings here on the duration of sex work of greater than 5 years is different from the result of a previous study where the mean duration of prostitution was 10 years.
Early onset of sex work might invariably lead to new HIV infections as risk perception will be low at such age. Also, the sex workers may not be able to practice safe sexual behaviors’ like insisting on condom use with their clients or even having access to PrEP. These high-risk sexual practices lead to vulnerabilities to HIV and STI. A study conducted in China supports this reasoning by showing that those who initiated sex work over the age of 20 years were negatively associated with condom use and gave possible reason for this as the competition those >20 years face from younger FSW for clients, and as such do not negotiate consistent condom use with clients.
The average monthly income of one third of the respondents was between #11,000 and #20,000 and this finding is lower than the average monthly earning of #50,000 among commercial sex workers in a study conducted in Zaria, Nigeria.
This study revealed a small proportion of participants were married. This is similar to another study where 95.5% were single and 5.5% married.
We found that all respondents have used condom while engaging in sexual activities with their clients which was similar to the findings in a study done at India.
Our study showed that a majority of the respondents had good knowledge about PrEP. This is higher than the outcome of a previous study where just 21% were aware of PrEP.
This study showed that the level of education, early age at initiation of sex work, and average monthly income individually predict level of adherence to PrEP. A study in East Africa also reported an association between young age of initiation of sex work less than 25years and a PrEP adherence of less than 80%.
Those who earn >#10,000 monthly income may adhere to PrEP probably because of the availability of funds to access and procure PrEP medication in clinics where PrEP service is offered. However, to increase access to other FSW whose average monthly income is small, it is important that the drugs be given free just in the same way ARVs are giving free to HIV positive clients.
The level of adherence to PrEP is considerably high and underscores a positive effect of the efforts of the Government of Nigeria in controlling HIV as a threat by 2030. However, there is a low adherence to PrEP among FSW who have spent more than 5 years in sex work.
Considering that low level of education has been identified as a predictor of poor adherence to PrEP, a high level advocacy for a compulsory enrollment in school and the provision of subsidized tuition fees for vulnerable females and the girl child will impart positively in reducing early onset of sex work. There is also a need to promote adolescent health and sexual education in schools. This will go a long way in equipping students with relevant knowledge about sexual health, vulnerability to HIV and HIV prevention packages and in helping them to make informed decisions about PrEP and its adherence if they go into sex work in future.
Government and Non-Governmental Organisations are encouraged to increase awareness of female sex workers on PrEP and adherence to PrEP. There is also a need to use innovative approaches to ease the financial access to key population (KP) friendly clinics and one-stop shops offering PrEP and other HIV prevention services.
Further studies would be useful to understand the behavioral factors associated with low adherence to PrEP among FSW who have spent more than 5 years in sex work.