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Characterizing the Influence of Structural Determinants of HIV Risk on Consistent Condom Use Among Female Sex Workers in Senegal

Twahirwa Rwema, Jean Olivier, MD, MPHa; Lyons, Carrie E., MPHa; Ketende, Sosthenes, MSca; Bowring, Anna L., MPH, PhDa; Rao, Amrita, MSPHa; Comins, Carly, MPHa; Diouf, Daouda, MScb; Drame, Fatou M., PhDb,c; Liestman, Benjamin, MSPHa; Coly, Karleen, MAa; Ndour, Cheikh, MD, PhDd; Turpin, Gnilane, BAa; Mboup, Souleymane, PharmD, PhDe; Toure-Kane, Coumba, PhDf; Castor, Delivette, PhDf; Leye-Diouf, Nafissatou, PhDe; Diop-Ndiaye, Halimatou, PharmD, PhDg; Baral, Stefan, MD, MPHa

JAIDS Journal of Acquired Immune Deficiency Syndromes: May 1, 2019 - Volume 81 - Issue 1 - p 63–71
doi: 10.1097/QAI.0000000000001991
Prevention Research

Background: Female sex workers (FSWs) are disproportionately affected by HIV even in the most generalized HIV epidemics. Although structural HIV risks have been understood to affect condom negotiation among FSWs globally, there remain limited data on the relationship between structural determinants of HIV risk, including violence and socioeconomic status, and condom use among FSWs across sub-Saharan Africa. Here, we describe the prevalence of structural determinants and their associations with condom use among FSWs in Senegal.

Methods: In 2015, 758 FSWs >18 years of age were recruited using respondent driven sampling in Senegal. Data on individual, community, network, and structural-level risks were collected through an interviewer-administered questionnaire. Poisson regression with robust variance estimation was used to model the associations of consistent condom use (CCU) and selected structural determinants.

Results: The respondent driven sampling–adjusted prevalence of CCU in the last 10 sexual acts was 76.8% [95% confidence interval (CI): 70.8 to 82.8]. Structural determinants that were significantly associated with lower CCU were as follows: physical violence [adjusted prevalence ratio (aPR): 0.71; 95% CI: 0.52 to 0.98]; working primarily in a hotel or guest house (aPR: 0.85; 95% CI: 0.73 to 0.99); and difficultly accessing condoms (aPR: 0.72; 95% CI: 0.52 to 0.96). High income from sex work (aPR: 1.23; 95% CI: 1.04 to 1.46) was significantly associated with higher CCU.

Conclusions: Taken together, these data highlight the role of structural risk determinants on condom use among FSWs in Senegal. Moreover, these results highlight the need for structural interventions, including safe working spaces and violence mitigation programs, to support condom negotiation and access. Combined with condom distribution programs, structural interventions could ultimately increase condom use among FSWs in Senegal.

aDepartment of Epidemiology, Key Populations Program, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD;

bEnda Santé, Dakar, Senegal;

cGaston Berger University, Saint-Louis, Sénégal;

dDivision de la Lutte contre le Sida et les IST, Ministry of Health, Dakar, Sénégal;

eInstitut de Recherche en Santé, de Surveillance Epidémiologique et de Formations, Dakar, Sénégal;

fUSAID, Office of HIV/AIDS, Bureau for Global Health, Arlington, VA; and

gLaboratoire Bactériologie-Virologie, CHU Aristide le Dantec, Dakar, Sénégal.

Correspondence to: Jean O. Twahirwa Rwema, MD, MPH, Department of Epidemiology, Key Populations Program, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, E 7133, Baltimore, MD 21205 (e-mail:

The HIV prevention 2.0 (HP2) was supported by the United States Agency for International Development (USAID) under the cooperative agreement No. AID-OAA-A-13-00089. S.B.'s effort was supported in part by the Johns Hopkins University Center for AIDS Research, an NIH funded program (P30AI094189), which is supported by the following NIH Co-Funding and Participating Institutes and Centers: NIAID, NCI, NICHD, NHLBI, NIDA, NIMH, NIA, FIC, NIGMS, NIDDK, and OAR. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

The authors have no funding or conflicts of interest to disclose.

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Received July 12, 2018

Accepted January 16, 2019

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