Research Article: Prevalence and predictors of unmet contraceptive need in HIV-positive female sex workers in Mombasa, Kenya

Date Published: June 19, 2019

Publisher: Public Library of Science

Author(s): Jessica E. Long, Gladys Waruguru, Krista Yuhas, Kate S. Wilson, Linnet N. Masese, George Wanje, John Kinuthia, Walter Jaoko, Kishorchandra N. Mandaliya, R. Scott McClelland, Sphiwe Madiba.


Female sex workers (FSWs) in sub-Saharan Africa are a key population for HIV prevention and treatment interventions, but less attention is given to their family planning needs. We evaluated the prevalence and predictors of unmet contraceptive need in HIV-positive FSWs.

This cross-sectional analysis used data from an existing longitudinal study of FSWs in Mombasa, Kenya. This analysis included women who were HIV positive, age ≥18 years, pre-menopausal, not currently pregnant or desiring pregnancy, and reported exchanging sex for cash or in-kind payment at the time of enrollment. Unmet contraceptive need was defined as non-use of modern non-barrier contraceptives and not currently trying to become pregnant. Poisson regression was used to identify factors independently associated with unmet contraceptive need.

Among 346 HIV-positive FSWs, 125 (36.1%) reported modern non-barrier contraceptive use, leaving 221 (63.9%, 95%CI 58.8–68.9%) with unmet contraceptive need. Condom use was the only form of contraception for 129 (37.3%) participants. In unadjusted analyses, unmet contraceptive need was associated with physical abuse in the past year by someone other than a regular partner (PR 1.2, 95%CI 1.0–1.5), desire for (more) children (PR 1.3, 95%CI 1.1–1.5), and having 2–3 previous pregnancies compared to 0–1 prior pregnancies (PR 0.8, 95%CI 0.6–0.9). In adjusted analyses, lower number of previous pregnancies and having desire for future children remained significantly associated with a higher prevalence of unmet contraceptive need.

Unmet need for modern non-barrier contraception was found in two-thirds of HIV-positive FSWs who reported that they were not currently trying to become pregnant, and was higher in women with the lowest number of prior pregnancies (0–1 prior pregnancies) and in those reporting desire for (more) children in the future. These findings highlight the need for concerted efforts to identify and eliminate barriers to contraceptive use in FSWs living with HIV.

Partial Text

In sub-Saharan Africa, 37% of female sex workers (FSWs) are estimated to be living with HIV, making this a key population for prevention and treatment interventions [1–3]. Considerable emphasis has been placed on HIV testing and condom promotion among FSWs to target the HIV epidemic [2,4]. In contrast, there has been little effort to address the family planning needs of FSWs [2,5,6]. Unintended pregnancy among FSWs can result in loss of clients, violence from partners, and financial burden [7]. Numerous studies in sub-Saharan Africa have reported high rates of unintended pregnancy and induced abortion, often illegal and conducted in unsafe conditions, as well as low levels of reliable contraceptive use in FSWs [6–12].

Between October 2012 and April 2017, 471 HIV-positive FSWs were enrolled. For this analysis, 125 participants were excluded (69 post-menopausal, 51 trying to become pregnant, 3 pregnant, 2 missing data on contraceptive use) leaving an analysis population of 346. Their median age was 38 years (interquartile range [IQR] 31–42), and 263 (76.0%) reported ever being married (Table 1). The median number of reported pregnancies was 3 (IQR 2–4) and 67 (19.4%) women reported a desire to have children (or have more children) in the future. Half of the women reported experiencing controlling behavior (172, 49.9%), and 74 (21.4%) reported intimate partner violence by their current or most recent regular partner in the past 12 months.

In this population of FSWs living with HIV who reported that they were not currently trying to become pregnant, nearly 90% of women reported condom use during all acts of sexual intercourse in the past week. However, two thirds of women had unmet need for modern non-barrier contraception. A higher prevalence of unmet contraceptive need was independently associated with lower number of previous pregnancies and with desire for more children in the future.