Contraception 93 (2016) 222 – 225

Original research article

Kenyan female sex workers' use of female-controlled nonbarrier modern contraception: do they use condoms less consistently?☆ Eileen A. Yam a,⁎, Jerry Okal b , Helgar Musyoki c , Nicholas Muraguri c , Waimar Tun a , Meredith Sheehy d , Scott Geibel a a

Population Council, 4301 Connecticut Avenue NW, Suite 280, Washington, DC 20008, USA b Population Council, General Accident House, Ralph Bunche Road, Nairobi, Kenya c National AIDS and Sexually Transmitted Infection Control Programme, Ministry of Health, PO Box 19361-00202, Nairobi, Kenya d Population Council, One Dag Hammarskjold Plaza, New York, NY 10017, USA Received 6 July 2015; revised 2 November 2015; accepted 10 November 2015

Abstract Objectives: To examine whether nonbarrier modern contraceptive use is associated with less consistent condom use among Kenyan female sex workers (FSWs). Study design: Researchers recruited 579 FSWs using respondent-driven sampling. We conducted multivariate logistic regression to examine the association between consistent condom use and female-controlled nonbarrier modern contraceptive use. Results: A total of 98.8% reported using male condoms in the past month, and 64.6% reported using female-controlled nonbarrier modern contraception. In multivariate analysis, female-controlled nonbarrier modern contraceptive use was not associated with decreased condom use with clients or nonpaying partners. Conclusion: Consistency of condom use is not compromised when FSWs use available female-controlled nonbarrier modern contraception. Implications: FSWs should be encouraged to use condoms consistently, whether or not other methods are used simultaneously. © 2016 Elsevier Inc. All rights reserved. Keywords: Africa; Family planning; Unintended pregnancy; Women who sell sex; Dual protection

1. Introduction Globally, female sex workers (FSWs) are described as a “key population” that is at elevated risk of HIV exposure and transmission. In Kenya, programs and policies for FSWs focus almost exclusively on promoting condom use and reducing HIV risk as the primary outcomes of interest. However, FSWs also have substantial need for family planning; they typically are women of reproductive age whose risky sexual behaviors place them at great risk of unintended pregnancy [1]. Increasingly, the international community is recognizing the dual protection needs of ☆ Funding: This research was supported by the U.S. President's Emergency Plan for AIDS Relief through cooperative agreement no. 5U62PS224506 from the U.S. Centers for Disease Control and Prevention, Division of Global HIV/AIDS. ⁎ Corresponding author. E-mail address: [email protected] (E.A. Yam).

http://dx.doi.org/10.1016/j.contraception.2015.11.010 0010-7824/© 2016 Elsevier Inc. All rights reserved.

FSWs. In 2014, the Joint United Nations Programme on HIV/AIDS released new guidelines for working with key populations, stipulating that women such as FSWs must have access to comprehensive family planning services to meet their broader sexual and reproductive health needs [2]. Family planning is critical for FSWs not only to ensure that they can time and space childbearing but also to reduce the risk of mother-to-child HIV transition [3]. Furthermore, those faced with unintended pregnancy may resort to unsafe abortion. Though abortion was decriminalized in Kenya in 2010 for cases when the woman's health or life is in danger, clandestine abortions persist, and abortion-related maternal morbidity and mortality persist [4]. Due to ongoing targeted promotional efforts by the government and nongovernmental organizations (NGOs), Kenyan FSWs have easy access to male condoms at low or no cost, most commonly from public and NGO health facilities, neighborhood stores or street vendors and bars. In negotiating condom use with clients, FSWs provide the condoms rather than

E.A. Yam et al. / Contraception 93 (2016) 222–225

the man (2011, Integrated Bio-Behavioural Survey, unpublished data). In contrast to the easy access to male condoms, female condoms are relatively expensive and used infrequently by Kenyan women [5]. Effective nonbarrier contraceptive methods are available at low or no cost in public and NGO health facilities, with injectables and implants being the most popular methods [6]. Nevertheless, since the most effective contraceptives are nonbarrier methods that do not prevent disease transmission, an important question is whether FSWs who use highly effective nonbarrier contraception are less consistent condom users. In some cases, HIV prevention program staff have expressed reluctance about broadening access to more effective contraception, fearing that consistent condom use would decrease if these nonbarrier methods were promoted [7]. This concern is particularly critical and salient in light of the ongoing debate over whether certain hormonal contraceptives increase women's risk of acquiring HIV [8]. In a survey of Bolivian FSWs recruited from public clinics, users of nonbarrier modern contraception were less likely to use condoms consistently with nonpaying partners, but they used condoms no less consistently with paying clients [9]. However, the convenience sampling strategy and the low-prevalence context of that Latin American study are not necessarily informative for a higher-prevalence, sub-Saharan African setting. In contrast, in the hyperepidemic country of Swaziland, a probability-based survey of FSWs found that women who were nonbarrier modern contraceptive users were not less likely to use condoms with either clients or nonpaying partners [10]. Since 2010, the Government of Kenya has instituted a surveillance program to conduct probability-based surveys of FSWs to monitor HIV-related behavioral and biological indicators over time. This secondary analysis of the most recent surveillance data among Nairobi FSWs describes their use of condoms and other contraceptives and investigates whether use of nonbarrier modern contraception is associated with less consistent condom use with clients and with nonpaying partners.

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with clients, consistent condom use with nonpaying partners and family planning method use in the past 30 days. We then conducted a bivariate analysis using the chi-square test to examine the association between consistent condom use with clients and female-controlled nonbarrier modern contraceptive use (defined as pill, injectable, intrauterine device, implant, female sterilization). Next, we conducted multivariate logistic regression analyses to examine the association between consistent condom use with clients and use of female-controlled nonbarrier modern contraception, after adjusting for age, education, marital/cohabiting status, number of children and self-reported HIV-positive status. We repeated these bivariate and multivariate analyses for the outcome of consistent condom use with nonpaying partners.

3. Results Table 1 displays participant demographic characteristics, HIV status, use of condoms and other contraceptives and abortion prevalence. Nearly all participants (98.8%) reported that they had used male condoms in the past month, though just 64.1% stated that they were consistent users with clients. Among those with nonpaying partners (n= 247), 30.8% used condoms consistently with these men. Half of all participants had used a female-controlled nonbarrier modern contraceptive method in the past month, the most popular of which was the injectable. In bivariate analyses, consistency of condom use with either clients or nonpaying partners was not associated with female-controlled nonbarrier modern contraceptive use. In multivariate analyses, after controlling for demographic characteristics and self-reported HIV status, there remained no association between consistency of condom use and use of female-controlled nonbarrier modern contraception with either partner type. Reported HIV-positive status was significantly associated with consistency of condom use with nonpaying partners (adjusted odds ratio: 3.15, 95% confidence interval: 1.26–7.88) (Table 2).

2. Materials and methods 4. Discussion In 2010, the research team conducted a respondent-driven sampling (RDS) survey of 596 Nairobi women ages 18 years and older who reported selling sex for money, drugs or goods to a man in the past 3 months. RDS is a probability-based peer-referral sampling method that employs statistical adjustments to take into account similarities between peers and differences in participants' network sizes. A detailed description of study methods has been published previously [11]. This subgroup analysis is restricted to participants of reproductive age, defined as ages 18–49 years (n=579). We used Stata version 11.0 to conduct all analyses. We calculated descriptive statistics for basic demographic characteristics, self-reported HIV-positive status, consistent condom use (always using condoms in the past 30 days)

The growing global momentum in support of appropriately integrated HIV and family planning services is a welcome development. With respect to integrated FSW programming in high-prevalence countries such as Kenya, this study yields findings that are both worrisome and encouraging. On the one hand, despite ongoing efforts to promote condom use among Nairobi FSWs, a notable proportion do not use condoms consistently, particularly with nonpaying partners. On the other hand, prevalence of effective, female-controlled nonbarrier method use was quite high, and use of these methods was not correlated with decreased condom use. This finding — coupled with results from previous research among Swazi FSWs [10] — suggests

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E.A. Yam et al. / Contraception 93 (2016) 222–225

Table 1 Participant characteristics and sexual and reproductive health (n=579). No. % Age (years) 18–29 30–49

285 49.2 294 50.8

Education Primary or less Some secondary Married/cohabiting

260 44.9 319 55.1 77 13.3

No. of children 0 1 2+ Self-reported HIV-positive

41 7.1 174 30.1 364 62.9 64 11.1

No. of clients in past week b5 5–9 10+ Used male condom in past 30 days Consistent condom use with clients a Consistent condom use with nonpaying partners a (n=247) Used contraceptive methods in the past 30 days (other than male condoms) (n= 525) b Type of contraceptive method used in the past 30 days (n= 438) Female condom Any female-controlled nonbarrier modern contraception c Pill Intrauterine device Injectable Implant Female sterilization Diaphragm Lactational amenorrhea method Rhythm Ever used emergency contraception Ever had an abortion

176 132 267 572 369 76 438

30.6 23.0 46.4 98.8 64.1 30.8 83.4

39 283 58 5 152 62 6 9 3 5 9 116

8.9 64.6 13.2 1.1 34.7 14.2 1.4 1.6 0.7 1.1 1.6 20.0

Cell frequencies may not sum to the sample size due to missing values. a Defined as always using condoms in the past 30 days. b Among those who reported using contraception in the past 30 days. Responses were not mutually exclusive. c Defined as pill, intrauterine device, injectable, implant or female sterilization. There were two women who reported male sterilization, not included in this category.

that fears that comprehensive family planning services undermine FSW condom use are unfounded. Regardless of whether FSWs use female-controlled nonbarrier modern contraception, their need for dual protection against both disease and pregnancy means that consistent condom use is essential. Programs and policies regarding FSWs should continue to emphasize the fact that only barrier methods can prevent disease acquisition and transmission. Nevertheless, a continued focus on condom promotion does not preclude health care providers and outreach workers from also offering comprehensive family planning counseling and services, including contraceptive methods other than condoms. FSWs regularly must make difficult tradeoffs between prioritizing disease prevention versus pregnancy prevention, and they should be equipped

Table 2 Adjusted odds ratios for consistency of condom use with clients and nonpaying partners. Consistent condom use with clients Adjusted odds ratio (95% confidence interval)

Consistent condom use with nonpaying partners Adjusted odds ratio (95% confidence interval)

Age (years) 18–29 30–49

Ref. 0.98 (0.61–1.57)

Ref. 1.03 (0.49–2.19)

Education Primary or less Some secondary

Ref. 0.91 (0.60–1.37)

Ref. 0.63 (0.33–1.21)

Married/cohabiting No Yes

Ref. 1.06 (0.59–1.92)

Ref. 1.26 (0.59–2.70)

Children None 1 2+

Ref. 0.86 (0.32–2.28) 1.00 (0.38–2.65)

Ref. 0.83 (0.18–3.76) 0.70 (0.15–3.22)

Self-reported HIV status Negative Positive

Ref. 2.02 (0.99–4.13)

Ref. 3.24⁎ (1.30–8.08)

Female-controlled nonbarrier modern contraceptive use No Ref. Ref. Yes 1.04 (0.68–1.59) 0.94 (0.48–1.83) Multivariate analyses adjust for age, education, marital status, number of children and self-reported HIV status. ⁎ pb.05.

with the knowledge and services to maximize their ability to protect themselves from these dual risks. Attribution of support This publication was made possible by support from the U.S. President's Emergency Plan for AIDS Relief through cooperative agreement no. 5U62PS224506 from the U.S. Centers for Disease Control and Prevention, Division of Global HIV/AIDS. United States Government disclaimer on dissemination products The findings and conclusions in this paper are those of the author(s) and do not necessarily represent the official position of the U.S. Centers for Disease Control and Prevention or the Government of Kenya. References [1] Sutherland EG, Alaii J, Tsui S, Luchters S, Okal J, King'ola N, et al. Contraceptive needs of female sex workers in Kenya: a cross-sectional study. Eur J Contracept Reprod Health Care 2011;16:173–82. [2] Joint United Nations Programme on HIV/AIDS. Consolidated Guidelines on HIV Prevention, Diagnosis, Treatment, and Care for Key Populations. Geneva: UNAIDS; 2014.

E.A. Yam et al. / Contraception 93 (2016) 222–225 [3] Wilcher R, Cates W, Gregson S. Family planning and HIV: strange bedfellows no longer. AIDS 2009;23:S1–6. [4] Mohamed SF, Izugbara C, Moore AM, Mutua M, Kimani-Murage EW, Ziraba AK, et al. The estimated incidence of induced abortion in Kenya: a cross-sectional study. BMC Pregnancy Childbirth 2015;15:185. [5] Thomsen S, Ombidi W, Toroitich-Ruto C, Wong E, Tucker H, Homan R, et al. A prospective study assessing the effects of introducing the female condom in a sex worker population in Mombasa, Kenya. Sex Transm Infect 2006;82:397–402. [6] PMA2020.. Performance, Monitoring & Accountability (PMA) 2014/ Kenya. Baltimore: PMA2020; 2014. [7] Askew I, Berer M. The contribution of sexual and reproductive health services to the fight against HIV/AIDS: a review. Reprod Health Matters 2003;11:51–73.

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[8] Colvin CJ, Harrison A. Broadening the debate over HIV and hormonal contraception. Lancet Infect Dis 2015;15:135–6. [9] Yam EA, Tinajeros F, Revollo R, Richmond K, Kerrigan D, Garcia S. Contraception and condom use among Bolivian female sex workers: relationship-specific associations between disease prevention and family planning behaviors. Health Care Women Int 2013;34:249–62. [10] Yam E, Mnisi Z, Sithole B, Kennedy C, Kerrigan D, Tsui A, et al. Association between condom use and use of other contraceptive methods among female sex workers in Swaziland: a relationship-level analysis of condom and contraceptive use. Sex Transm Dis 2013;40:406–12. [11] Musyoki H, Kellog TA, Geibel S, Muraguri N, Okal J, Tun W, et al. Prevalence of HIV, sexually transmitted diseases, and risk behaviours among female sex workers in Nairobi, Kenya: results of a respondent driven sampling study. AIDS Behav 2015;19:S46–58.

Kenyan female sex workers' use of female-controlled nonbarrier modern contraception: do they use condoms less consistently?

To examine whether nonbarrier modern contraceptive use is associated with less consistent condom use among Kenyan female sex workers (FSWs)...
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