510554 research-article2013

APHXXX10.1177/1010539513510554Asia-Pacific Journal of Public HealthKamal et al

Original Article

Safer Sex Negotiation and Its Association With Condom Use Among Clients of Female Sex Workers in Bangladesh

Asia-Pacific Journal of Public Health XX(X) 1­–13 © 2013 APJPH Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1010539513510554 aph.sagepub.com

S. M. Mostafa Kamal, MSc, PhD1,2, Che Hashim Hassan, MA(D), PhD1, and Roslan Hj Salikon, Bsc, MSc1

Abstract This study examines safer sex negotiation and its association with condom use among clients of female sex workers (FSWs) in Bangladesh. Data were collected from 484 FSWs living in Dhaka city following a convenient sampling procedure. Overall, 47% of the clients were suggested to use condom during last sexual intercourse and 21% did so. Both bivariate and multivariable binary logistic regression analyses yielded significantly increased risk of negotiation for safer sex with clients among FSWs with higher education. The power bargaining significantly (P < .001) increased the risk of condom use by 2.15 times (95% confidence interval = 1.28-3.59). The odds of condom use were significantly higher among the FSWs with higher education, unmarried, hotel-based, and among those with higher level of HIV/AIDS-related knowledge. The Bangladeshi FSWs have little control over their profession. HIV prevention programs should aim to encourage FSWs through information, education, and communication program to insist on condom use among clients. Keywords Bangladesh, power bargaining, female sex workers, male condom, HIV/AIDS

Introduction Commercial sex plays a critical role in heterosexual transmission of human immunodeficiency virus (HIV).1 The HIV epidemic is predominantly heterosexual and is inferred to be fuelled mainly through unprotected sex with female sex workers (FSWs).2 Thus, heterosexual transmission of HIV through contact with FSWs is of particular concern.3 HIV is transmitted from clients to FSWs and from FSWs to clients or their partners via unsafe sexual intercourse.4,5 Given the lack of an effective vaccine or treatment for HIV, changing of an individual’s risk behaviors is crucial to prevent the spread of HIV. HIV preventive interventions that are targeted toward FSWs have typically focused on increasing the use of condom among clients of FSWs, since the contribution of commercial sex partnerships of FSWs and clients to HIV epidemics is believed to be high in many settings.6,7 Consistent and correct condom use among clients of FSWs are likely to be the most effective way of HIV prevention.7 1University 2Islamic

of Malaya, Kuala Lumpur, Malaysia University, Kushtia, Bangladesh

Corresponding Author: S. M. Mostafa Kamal, Department of Mathematics, Islamic University, Kushtia 7003, Bangladesh. Email: [email protected]

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A growing body of literature argues that many women report having limited control over their sex partners regarding the use of male condoms.8-10 Studies reveal that women with lower decisionmaking power within marital relationships are less likely to use condoms than women with higher decision-making power.8,11,12 Women’s low economic status and resultant dependency on men contribute to their unsuccessful attempts in negotiating safer sexual behavior by using condom during sexual intercourse. Sex workers are not unique in their problems pertaining to sexual negotiation.13 Studies on FSWs in Tanzania found that when FSWs decide individually or jointly with their clients to use condoms, they were significantly more inclined to use condoms than when the partner or client decides.14 Among FSWs in India, a number of different types of power were associated with consistent condom use, including control over the type of sex with clients, amount charged, and economic independence.11 To date, there is limited quantitative as well as qualitative information available on the negotiation regarding safer sex with clients and its association with the use of condom among FSWs from resource-constrained countries15 such as Bangladesh.

HIV/AIDS Situation in Bangladesh The first case of HIV in Bangladesh was detected in 1989. By December 2010, the Ministry of Health and Family Welfare confirmed 2088 cases of HIV, of which 850 developed into acquired immunodeficiency syndrome (AIDS) cases and 241 resulted in deaths.16 In 2007, HIV prevalence was estimated to be less than 0.1% among the general population, and the main routes of transmission were reported to be heterosexual and unprotected sex and sharing of used needles and syringes. As per the ninth round of the National HIV Serological Surveillance 2011, Bangladesh is still a “low prevalence country” in the region, with HIV prevalence of less than 1% among the most-at-risk population group. In 2011, the number of new HIV-infected people was 445, of which 65% were males, 33% were females, and 2% were transgenders.16 Although the HIV infection rate is still low in Bangladesh, the prevalence is increasing gradually in some populations such as injecting drug users and commercial sex workers (CSWs).17 An estimate states that there are approximately 90 000 CSWs in Bangladesh, who are distributed in urban, semiurban, and rural areas, either organized in brothels or working independently.18 Except registered brothels, sex trade is not accepted by Bangladeshi ethical standards. Like in India, FSWs in Bangladesh operate in an adverse legal environment and are substantially stigmatized, and consequently are difficult to reach from a public health perspective.19 Despite this, some women sell sex due to poverty and hunger, whereas some sell sex possibly being attracted by the relatively higher income. Female CSWs play an important role in the heterosexual transmission of HIV. Earlier studies reported that FSWs are relatively young20 and most of them are illicit injecting drug users17 (IDUs). A recent meta-analysis of HIV prevalence studies among FSWs in low-income and middleincome countries suggested that FSWs are most-at-risk population group for STD and HIV.21

Objectives This study aims to examine to what extent FSWs have control over their clients to negotiate for safer sex through using male condom. It also aims to examine what other factors are associated with male condom use among clients of the FSWs.

Methods Data Source A cross-sectional survey was conducted in Dhaka city—the capital of Bangladesh—from January to July 2012. At the initial stage, we selected 10 key informants purposively. They were assigned

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to provide information of operators or some agents. The operators and agents were then requested to provide cell phone numbers of their known FSWs. Owing to the impossibility of obtaining exact number and location of the FSWs, it was not possible to estimate the number of the required sample size. However, initially a total of 400 FSWs were selected from the list of cell phone numbers provided by the operators and agents following a convenient sampling technique. In addition, randomly selected 125 street-based FSWs were approached directly to participate in the interview after informing them about the objectives of the study. Of the selected FSWs, 9 streetbased, 5 hotel-based, and 4 home-based FSWs could not complete the interviews for various reasons. In addition, a total of 23 FSWs refused to participate in the interview. Thus, 484 FSWs were successfully interviewed. The overall response rate was 92%. Three groups of well-trained enumerators consisting of 2 women in each group were selected to gather information from the participants. The minimum educational qualification of the interviewers was university graduate. A structured questionnaire consisting of 25 questions was used to gather information. There were 2 sections in the questionnaire: socioeconomic and sexual and HIV/AIDS related. The questionnaire was developed after several discussions with experts in sexuality and HIV. A panel consisting of 5 medical doctors helped in developing the questionnaire. Of the doctors, 1 doctor had specialization degree on HIV/AIDS from the United States, 2 were specialists in obstetrics and gynecology, 1 doctor had a doctoral degree in public health, and 1 had an MBBS degree from Banghabandhu Sheikh Mujib Medical University in Bangladesh. After a formal meeting and discussion, the panel of doctors and the corresponding author finalized the questionnaire. The corresponding author of this study himself supervised the survey. Each of the interviews lasted from 45 minutes to 1 hour. Prior to finalizing the questionnaire, a pilot survey was conducted on 20 FSWs. The respondents completed the predeveloped questionnaire. During the pilot survey, it was felt that the FSWs are not ready to confer enough time for such a type of interview. Hence, a few changes were made in the predeveloped questionnaire in view of shortening the duration of the interview. The pretested findings showed that the questionnaire was, overall, well designed. To assess the reliability of the instrument, we performed Cronbach’s α coefficient test. The estimated Cronbach’s α value was found to be .797, indicating quite good internal consistency and reliability of the instrument used in the study.

Outcome Measure The outcome measures of this study are the following: (a) negotiation of safer sex through condom use among clients and (b) use of condom at last sexual intercourse with client. The first outcome measure is based on the response to the question, “Did you ask your last client to use condom for sexual intercourse?” The response provided by the FSWs to this question was recorded either by “yes” or “no.” Following this, the respondents were asked, “Did your last client use condom?” The response to this question was also recorded as either “yes” or “no.”

Exposure Variables The study considers several socioeconomic and demographic factors and HIV/AIDS-related knowledge to assess the negotiation power for safer sex of the FSWs and condom use at sexual intercourse with their clients. The effect of one variable on the outcome measures is likely to be confounded with the effects of other variables. Therefore, socioeconomic, demographic, and HIV/AIDS-related knowledge factors were controlled statistically. The variables included as covariates are the following: current age of the respondents at interview, current marital status, duration in the profession, place of origin, level of education, religion, types of FSWs, exposure

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Table 1.  Sociodemographic Characteristics of the Female Sex Workers (FSWs) in Bangladesh. Characteristics Current age

Place of origin

Education

Marital status

Description Respondents’ age in year at survey

Place of residence before coming to Dhaka city Women’s level of education

Marital status of the women at survey

Duration in profession

For how long (in years) the respondents was engaged in the profession

Religion

Religious affiliation

Types of FSWs

Usually watch TV

Place of selling sex

Whether respondents watch TV regularly

HIV/AIDS-related knowledge score

How much knowledge respondents have regarding HIV/AIDS transmission

Had an STD at the time of survey

Whether respondents have STDs/STIs at survey

Measurement Scale Ordinal

Safer sex negotiation and its association with condom use among clients of female sex workers in Bangladesh.

This study examines safer sex negotiation and its association with condom use among clients of female sex workers (FSWs) in Bangladesh. Data were coll...
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