The prevalence of HIV/STIs, sexual exploitations, and its determinants among venue-based FSWs in western Oromia, Ethiopia. A community-based cross-sectional and phenomenological study designs

doi:10.21203/rs.3.rs-1821069/v1

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The prevalence of HIV/STIs, sexual exploitations, and its determinants among venue-based FSWs in western Oromia, Ethiopia. A community-based cross-sectional and phenomenological study designs

https://doi.org/10.21203/rs.3.rs-1821069/v1

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Background: Globally, estimating the number of sex workers is difficult. However, it is well documented that human right violation and the prevalence of HIV/STIs are high among sex workers in many countries, particularly in low and middle-income countries.

Methods: The study was conducted in 4 zonal cities of Western Oromia, Ethiopia. A community-based cross-sectional survey and phenomenological study designs were employed from October 2020 to November 2020. Simple population proportion sampling was used to calculate the sample size. Also, we used Respondent Driven Sampling (RDS) to recruit participants into the in-depth interview. A conventional cluster sampling was employed based on the mapping of solicitation spaces, to recruit hard-to-reach populations by sampling primary units (PSUs). A semi-structured interviewer-administered and pre-tested interview guide tools were used to collect data. Data analysis was conducted by using SPSS 20.0 Statistical package and Respondent Driven Sampling Analysis Tool (RDSAT).

Result: A total of 242 FSWs have taken part in the study, and 239 (98.8%) respondents were included in the analysis. The participants’ mean age was 22.6 years. The sexual behavior of FSWs is very rampant. The multivariate analysis revealed that being illiterate, growing up in rural areas, and using substances in a daily manner, those who started sex work at the age of fewer than 15 years, being raped, and had more than 15 clients per week FSWs were more likely vulnerable to HIV and STIs than their comparison groups. Moreover, FSWs who have inconsistently used condoms, been forced to group sex, and human trafficking were more likely at risk than their comparison groups. However, the FSWs who had ever tested RDT for HIV status and those who scored full marks on the STIs knowledge questionnaire were less likely to be vulnerable than their counterparts.

Conclusion: In Ethiopia HIV and STIs vulnerability among FSWs is linked primarily to drug use, being illiterate, starting sex work at a fewer age (less than 15 years), being raped, and having more clients per week, inconsistently using condoms, human trafficking, and group sex behaviors. Renewed efforts are necessary to intervene effectively to address this high-risk hard-to-reach population by shifting from binary epidemiological simple models “cause and effect” to multilevel models that emphasize multiple contributing factors.

Prevalence

HIV/STIs

sexual exploitation

FSWs

Ethiopia

Globally, estimating the number of sex workers is difficult. However, it is well documented that human right violation and the prevalence of HIV/STIs are high among sex workers in many countries, particularly in low and middle-income countries. Sex workers or their sexual partners can facilitate the transmission of HIV [1, 2]. Therefore, it is important to understand the facilitators and barriers to accessing sexual and reproductive services and HIV/STI prevention programs.

Sub-Saharan Africa (SSA) has one of the highest global HIV prevalence rates (12%) [3]. In SSA, the prevalence among Female Sex Workers (FSWs) is estimated at 53.6%. Research evidence in Zimbabwe shows HIV prevalence is higher among FSWs compared to Non-Sex Workers (NSWs) which accounts for 52.6% vs 19.8% [3]. The risk of HIV/STI acquisition is 2.13 times higher among sex workers who use cocaine, drugs, crack or methamphetamine during sex purchase time [4]. The risk of HIV/STI infection is lower among sex workers who use condoms consistently. The systematic review study conducted in SSA shows 79% had the availability of condoms either for free or sale at the bar. Despite this, a major reason for unprotected sex is the lack of free-of-charge condoms [5]. Client refusal (73%), higher payment (33%), and client brutality (43%) are major reasons for the interruption of consistent condom use among sex workers [6].

In areas where sex workers are poorly organized and have few alternative sources of income, they are often forced to have condom-less sex with clients who refuse to use a condom or are offered more money in exchange for sex without condom use. A quarter of the sex workers in a study by UNAIDS, (2014) reported that they had engaged in unprotected sex for extra money [7]. Condom use varies by type of sexual partner. The lowest condom uses with regular sexual partners due to the trust they have for their regular partners'. Having multiple sexual partners is another risk factor. The majority (70%) of boyfriends of sex workers have one or more sex workers other than their girlfriends [8].

Ethiopia is one of SSA, with the highest burden of HIV prevalence. Ethiopia Demographic Health Survey of 2011 report shows that adult HIV prevalence is estimated at 1.5% [9]. Nowadays, the trend of HIV prevalence and new infections is increasing. The current prevalence of HIV among urban resident adults (age 15-64 years) accounted for 3% (4.1% among females and 1.9 among males) with an annual incidence rate of 0.06% i.e., 7,000 new cases annually [10]. The national Most at Risk Populations (MARPs) report shows about 82.5% of female sex workers in all regional capital cities had been tested for HIV with, 23.8% recording a positive HIV result [11]. Despite the increment of HIV prevalence in Ethiopia, there remains a lack of concurrent research pieces of evidence of HIV prevalence and its contributing factors for MARPs such as female sex workers [11].

Lack of sexual and reproductive health and prevention services is considered to be one of the contributing factors to the increasing rates of new HIV/STI infections in Ethiopia [12]. In the study conducted by Dana C. Beck et.al (2016), risk factors for trafficking and exposing females to sex work push and pull factors. Push factors include poverty, political instability, financial problems, gender discrimination, and pull factors of demand for cheap labor. Labor trafficking is the most widely happening type of trafficking encompassing internal and external trafficking in Ethiopia [13]. In the study conducted by Fernandez, B. (2011), in Ethiopia, high-risk women, girls, and boys aged 10-24 are involved in labor or sexual exploitation in the weaving industry, farm labor, begging, domestic labor, commercial sex work, and child marriage [14]. Females with a lack of limited education or illiteracy are cited as the most vulnerable to trafficking. Sociocultural factors such as early child marriage, lack or limited access to social services in rural areas, limited access to education, limited family education, family discord, dissatisfaction with traditional ways of life, the attraction of paid work to support families, a pregnancy outside of marriage and associated taboo and stigma, dropping of school at an early age and large family size to afford basic needs are identified as factors making children vulnerable to trafficking as well physical and sexual exploitations [15,16].

Therefore, this study sought to estimate the prevalence of HIV/STI and vulnerability to sexual exploitations among FSWs in Ethiopia. We hope the study finding was used to realize the necessary efforts to intervene and address the health problems of this high-risk hard-to-reach population.

Study design and period: The study was conducted in four zonal cities (Nekemte, Gimbi, Nedjo, and Shambu cities) of Western Oromia, Ethiopia. A community-based cross-sectional survey and phenomenological qualitative study designs were employed to estimate the prevalence of HIV/STIs and examine the vulnerability to sexual exploitation among venue-based FSWs in western Oromia, Ethiopia.

Sample and sampling technique- Simple population proportion sampling was used to calculate the sample size. The systematic meta-analysis evidence shows that the pooled HIV prevalence in Ethiopia is accounted for 17.3% (Division of HIV/AIDS Prevention, 20016), hence (p=0.173), CI-95%, margin of error (d=5%), and 10% of non-response rate was added. By using this sampling procedure, a total of 242 study participants have taken part in the study. A conventional cluster sampling strategy was employed based on the mapping of solicitation spaces (venue-based sex workers), to recruit hard-to-reach populations through Sampling Primary Units (PSUs), since venue-based FSWs are time-place fixed populations. Also, we used Respondent Driven Sampling (RDS) to recruit participants into the in-depth interview. The initial plan was to conduct 8 in-depth interviews from 4 seed of participants. We recruited purposive sampling to select one seed and from one seed one respondent-driven to increase participants' behavioral differences. Thereafter, the seeds were the first recruiters of participants into the study. First Seeds were interviewed and instructed to find one of their peers' participants who meet pre-planned eligibility criteria and recruited them into the study. Thus, from each initial seed, a recruitment chain was expected to grow in both size and behavioral differences. However, recruitment continued up to data saturation was reached. Where, information saturation was determined by the redundancy of responses, adding more participants into the study did not result in obtaining additional perspectives of the required information, sub-group homogeneity, and data collectors’ expertise considered. Thus, a total of 12 in-depth interviews were conducted from six seeds.

Procedures to select study participants from large or small cluster unities

First, the researchers determined the minimum required size of PSUs. Then, from selected PSUs large and small PSUs were identified. For large PSUs with a high number of FSWs, Population Proportion Sampling (PPS) strategy was considered by adjusting the measure of size (MOS) to be factored into the sampling methodology. To use the PPS sampling strategy, the first sampling interval (SI) was calculated by dividing a total cumulative measure of size (domain (M)) by the number of units to be selected (a), (SI=M/a). Then, a random number (RS) between 1 and SI was selected and compared with the cumulative measure of the size column. The unit within the was cumulated measure of size the number (RS) falls was the first sample unit. Finally, subsequent units were chosen by adding the sampling interval (SI) to the identified random number (i.e. RS+SI, RS +2SI, RS + 3SI………….) until the large clusters list has been exhausted. However, in the case of roughly comparable size clusters, an equal probability sampling strategy was used, in which small clusters tad the same probability of being sampled as a large cluster. In this case, sampling with equal probability would be appropriate (followed by a take-all approach at the second stage). To use equal probability sampling, first, the researchers were calculated the sampling interval (SI) by dividing the total number of PSU in the domain (M) by the number of units to be selected (a) i.e. SI=M/a. Then, select a random number (RS) between 1 and SI. The PSU on the numbered list corresponding to this number was the first sample unit. Furthermore, subsequent units were chosen by adding the sampling interval (SI) to the number of identified ones up to the list of domains that had been exhausted i.e. RS+SI, RS +2SI, RS +3SI, and…. In such a way, the selection bias of study participants was avoided. Then, we recruited simple random sampling used to recruit participants from large enough of selected PSU. In the case of a small number in the selected PSU, we used the take-all strategy to recruit the whole FSWs found within the small PSU. To increase sampling precision, more PSUs with a small number of respondents were considered from each of the sampled clusters. Therefore, to ensure the representativeness of the sample, more clusters with a small size of participants (15-25) were selected (fig 1).

Adapted from Repeated Behavioral Surveys in Populations at Risk of HIV, Family Health International, 2000.

Data collection procedure

A questionnaire was adopted from different pieces of works of literature related to the FSWs status of HIV/STIs and vulnerability to sexual exploitation. A semi-structured interviewer-administered questionnaire was used to examine the FSWs’ vulnerability to HIV/STIs and sexual exploitation and its determinants among FSWs. The information collected included socio-economic characteristics, environmental and behavioral factors. The questionnaire was adopted in English, translated into the local language (Afan-Oromo) by experts, and translated back into English by the professionals who speak both languages to check for its consistency. The study questionnaires addressed the outcome variable (Infants and young children feeding practices) and independent variables like socio-demographic, occupation, place of delivery, support from the health facility, and Mothers’ workload. Before, actual data collection the questionnaire was pre-tested on 10% of the sample size. Based on the pre-test results, some amendments to the questionnaire were conducted.

Also, we used a pre-tested interview guide to collect from interviewees. The qualitative data collection lasted for an average of 30 minutes for an in-depth interview. Interviews were conducted by using a tape recorder up to the level of information saturation. All of the data collectors and supervisors have taken the two-days training about the study objectives, procedures, ethics, and the content of the study. Data was collected by seven B.Sc. public health, nurses and supervised by two experienced supervisors. The data quality was maintained through checking for completeness, accuracy, clarity, and consistency by the supervisors and the principal investigator on daily basis. The qualitative data quality is maintained by field supervisors through the wrapped up of recorded data to ensure its completeness and clarity.

Data processing and analysis

First, data were interred into Epi Info 5.3.4 and exported to SPSS 20.0 Statistical package to clean and analyze the data. First, we explored the frequency distribution of socio-demographical, environmental and sexual behaviors of the study subjects, and descriptive statics were used to summarize and present the frequencies, percentages, and tables with 95% CI before the prevalence estimate. The binary logistic regression model was used to identify the determinant factors associated with vulnerability to HIV/STIs and sexual exploitation. Then variables that showed associations with outcome variables in the bivariate analysis were entered into the multivariate logistic regression model. Multiple logistic regression analysis was used to examine the association between the outcome variable and independent variables to avoid other potential confounders. A p-value of less than or equal to 0.05 was used to state the statistical significance.

For the qualitative analysis, transcribed interviews data was imported into qualitative analysis software Respondent Driven Sampling Analysis Tool (RDSAT) for electronic coding. The coding book was developed by the researchers following the objectives and research questions of the study. Data analysis was conducted in stages. In the first stage, an analysis framework was developed and the codebook was organized under different broad themes: In the second stage, coding was conducted through an iteration process and generating many more categories and sub-categories of the study. Many more determinant factors and sub-factors related to female sex workers' sexual vulnerability and HIV/STIs were added for subsequent analyses. In the third stage, final themes were named and defined. In the fourth stage, reports were produced through coding, reorganizing, summarizing, and quoting participants’ responses when needed.

Ethical consideration

The ethical clearance for this study was sought from Wollega University, the Institute of Health Sciences, and ethical review committee. The study methods were performed in accordance with the relevant guidelines and regulations. A formal letter was written to each city municipality authority and permission were secured at all levels. Prior to the IDI, respondents were informed of the purpose of the study and the voluntary nature of the information given and were required to sign the informed consent form. To compensate participants’ time, the researchers provided 200 ETB (4.4 USD) per person. Participation in the study was voluntary and information collected from the study subjects was handled confidentiality.

Sociodemographic characteristics of respondents

A total of 242 FSWs have taken part in the study, and 239 (98.8%) respondents were included in the analysis. Three respondents were excluded from the study due to the gross incompleteness of their data. The participants’ mean age was 22.6 years. the majority 43.1% and 42.8% of participants were orthodox and protestant followers, respectively. Most 87.9% of study participants were of Oromo ethnicity while (8.4%) were Amhara. About (52.7%) of the respondents were grown up in the urban area and the rest of them were from a rural part of the country. Of the total participants, the majority (65%) of them were never married while (30.5%) of them were divorced. Regarding the study participants’ educational background, (illiterate 16.3%), (10% can read and write), (47.3% completed primary school) while (21.7%) and (4.6%) were completed secondary school and college and above, respectively. The majority (40.6%) of participants were from Nekemte city. However, 24.3%, 15.5%, and 19.7% have participated from Ghimbi Nedjo and Shambu cities. Most (45.2%) of respondents were students before joining sex work while (18.8% had no work), (16.3% housemaid), and (17.6%) were waiters. About half (51.5%) of study participants were started sex selling at the age of 18-24 years. However, 9.6%, 15.1%, and 17.6% of them started at less than 15, 15-17, and 25-29 years of age. Of the total, 25.1%, 25.1 and 32.2% of the females were started sex work due to poverty, peer pressure, and family conflict, respectively. Other reasons identified were the death of parents 8.8% and 8.8% dismissal from Colleges and Universities. The majority (95.6%) of participants were do not have other income that paid sex. Only about 15.9% of the respondents were not willing to quit their current job, while the majority of them are willing to leave the job even if they get a less paid job sufficient to sustain their lives (Table I).

About 12 interviewees have participated in the qualitative part of the study. The age range of the interviews ranged from 15-35 years. Three of the qualitative respondents were married while others were not. Most of the qualitative respondents live in a common room at hotels arranged as a dormitory. Only two of them live in a private rental home. An eighteen years old participant narrated how she has started the sex work with her friend another lady of 20 years as follows:

‘’…. Hmmm, I have moved to a small town near to this town that we are living in now with my friend. I moved to this town by planning to start a small business like coffee/tea. Unfortunately, we did not get anybody to support us to start the business. While we are struggling to return back to our family, we found one young man and he promised us to help us to start the same business in another town and he took us to this town. However, by that first night, he took us to one hotel and discussed with the owner of the Hotel, and told us to start the sex work business. Since we know nobody, we were forced to start this work and still, we are here starting from that day.’’

Concurrently, the 24 years old woman from a different town told us how she has started the business. “…. I was a well-respected wife with one child and living with my husband. After two years of my baby’s birth date, we quarreled with my husband, and I took my baby to my mother and came to this town to live and work small business. But, I found myself in this work”. Similarly, other participants reported that they have started sex work due to conflict with family; parents, and/or husbands, poverty, and joblessness.

Table 1; Socio-demographic distribution and other background characteristics of 239 study participants across 4 cities, Ethiopia.

Social and sexual behaviors of study participants

The majority (56.1%) of participants have started the first sexual initiation for the love they have with somebody, while 26.4% of them were raped and started the first sexual initiation. About 92.5% of participants have more than 15 clients per week while 38.9% and 7.5% have an average of 10-14 and 2-9 clients per week. The majority (73.6%) of participants earned 200-500 ETB per sex act and 14.2% earned 500 ETB and above per sexual act. More than half (71.1%) were used the condom in the last 12 months during sexual intercourse. However, 28.9% reported they didn’t use condoms in the last 12 months due to (partner refusal 6.3%), (sex was not planned 4.2%), (no money to buy condoms 2.1%), and negotiation to increase sex price with partners 16.3%). About half (51%) of participants used the condom consistently, while 49% used it inconsistently in the last six months. About (40.6%) of participants had a pregnancy history while (59.4%) did not. Of those who had a pregnancy history, their pregnancy out came (14.6%) delivered and, (25.9%) had aborted their pregnancy. Most (89.1%) of respondents were using family planning to backup the condom breaks (35.1%) and to delay the menstruation cycle (54%) while the rest (10.9%) of participants did not use family planning (Table 2).

Interviewees reported abouttheir customer’s sexual behaviors, interactions with female sex workers. “…. Young customers especially students do not behave well. They ask you to perform sex without using a condom, use different sexual positions, and unpleasant sexual activities like oral sex and even they do not pay you well. Older customers especially the married ones behave well as far as you satisfy them and they pay you well and are constant customers. They use condoms regularly probably because they care for their wives”.

Other interviewees reported a unique sexual behavior of the FSWs and by saying “…During the interview, one respondent said as she and her friends, three in number wanted to revenge the young man who is gregarious and proud of himself. One night I have appointed him to spend the night with him in a hotel room and he agreed. I informed two of my best friends to join me and we have spent the night with him he did not sleep the full night and we have revenged him and he lives now normal life as other males now”.

When asked about condom use all of the respondents except three replied as they are using condoms regularly and consistently despite the request from their customers not to use condoms. The two participants said they use condoms with customers but with their boyfriends they did not use condoms. One 28 years’ respondent mentioned as she can forgo the use of condoms with her regular customer. Twenty years old interviewee reported….

“…. I asked him (client) to use a condom. But he (client) told her, he hasn’t got pleasure by using a condom during sexual intercourse. He told her, as he came to enjoy and relax. No need to have paid sex by a condom. I decided to not deny the sex with him. But, I requested and negotiated to add the amount of the payment for the sex without a condom He (the client) told me never mind. Then, we negotiated the amount of payment and had sex without a condom”.

One of the interviewees who was dismissed from a University claimed for a regular consistent condom during sex work.

“…. Look at me. I am an attractive and beautiful female. I have passed my preparatory school (grade 12) and joined a university. But, I was dismissed from the university in the second year of my education. Know, I am working as FSW at this hotel. I have good-looking and high-class clients. I use condoms every time I have paid for sex. If my client refuses to use a condom, I look for another customer who has an interest to use a condom. I never do any things that compromise my health. I am using condoms consistently when I have paid sex”.

Alcohol and substance use behavior of study participants

Regarding the alcohol and substance use behavior of study participants, about 88.7% of them had drunk alcoholic beverages of which89.6% of them used the alcohol daily while 5.7% used it usually. Moreover, about 88.3% of the females have ever chewed Khat, of which 80.6% of them used khat by daily manner. About three-fourths (83.3%) of study participants reported they had ever smoked chewed and/or sniffed any tobacco product. Of those who smoked the cigarette products the frequency of smoking was 86.4% daily, 9% usually and 4.5% smoked and or sniffed sometimes. Also, about one-fourth of study participants reported they had ever taken cannabis products (Table 3).

The majority of women (n=10) reported that drug use and sex work are interconnected situations. They (FSWs) use the drugs to hide from the psychological pain of working for paid sex. Even though they are working for paid sex to live and fulfill their basic needs, they are getting depression for doing the sex work. A twenty-three years old female stated ….

“…. You cannot be out of the circuit. I started drug use after I joined this work (sex work). You initiated the drug use either by your client or peer pressure. I am using cigarettes, khat, and alcohol for three years. I am hiding my psychological pain from sex work by using substances”.

Other interviewees also reported drug use behavior helps them to have many friends and social networks in that particular community. A number (n=9) of female sex workers reported that drug use helps them to have many clients. They said when they use drugs they got many clients and get friends with them. After they developed a friendship at a drug use place, they are ready to have their friend as their customer. Twenty-four years old female interviewees reported that…

“…The number of female sex workers’ initiates drug use because of getting friendships with drug users that make a peaceful relationship with drug-using men and social networks that encourage drug use and provide drugs for me. I introduce myself to him at a drug use place. Later, I make him my regular customer”.

Sexual exploitation among female sex workers in western Oromia

Regarding sexual exploitations among FSWs, about half (50.6% of them forced not to use a condom during sexual intercourse. Others also faced harassment like being (forced to have oral and/or anal sex 59%), (physical beating 81.2%), and (a touch of unwelcomed sex organ 76.6%) of them experienced sexual exploitation in the last six months. Moreover, the majority (82.4%, forced to have an unwelcomed sexual position), (95.4% verbal insult), and (59.4% were forced to trafficking to other cities). About 8% and 34% of respondents reported their partner used paid sex as a source of income and was forced for group sex in the last six months (fig 2).

The interviewees disclosed the sexual exploitations of female sex workers. A 20-year-old interviewee shared with us her experience of violence during her regular work life.

“…. Almost every customer abuses you verbally. Some customers especially when drunk abuse you physically like the beat, slapping and compressing your breasts hard touch. In the study area, there is what they call “mawucha” which means paying for hotel owners. It is the payment that FSW women must pay for the hotel owner just because they use the hotel room even if it is for “short” while the regular payment for the room will be secured by the male”. About 66.7% of interviewees shared similar experiences of sexual exploitation.

Others also questioned sex work activities and their plan to quit sex work in the future. “…. When asked if they like to exit from this work, all interviewees have the interest to leave the work but the two respondents who are living in a private rental home said they will quit the work only if they married the owner of a hotel or other big businesses”.

Fig2, Sexual exploitation among female sex workers in western Oromia

The HIV and STIs status of the study participants

More than half (55.2%) of participants were ever tested (RDT) for HIV status while the rest did not. The majority (84.5%) of respondents were consented to the RDT test of HIV, while 15.5% refused for RDT test due to (not at risk of HIV 13.5%), (fear of might had HIV 37.8%), (fear of others reactions if tested positive 27%), and 21.6% of them recently tested to know their HIV status. Of the total (84.5%) of consent for the RDT test, 18.3% of them were tested reactive for the HIV RTD test. Although 53.6% reported that they have received STI information aimed at sex workers, only 39.1% scored full marks on the STI knowledge questions. About less than half participants (43.1%) reported that they had tested for STI within the last 12 months. About 28.9% of respondents reported they ever had STIs in their life, of which (7.2% worried about its symptoms), (21.7% possible exposure from a partner), (13% exposure from clients), (26.1% convinced by health workers), and (31.9% had the symptoms) of STIs (Table 4).

The interviewees were questioned about HIV/AIDS and STDs status, test for HIV and STIs and we summarized their quotes here below. “…We were having HIV tests sometimes, but it is not a regular activity. However, recently they (health care workers) have stopped giving us the test. When we go for HIV/AIDS they also ask us symptoms of sexually transmitted infections like painful sexual intercourse, burning during urination and vaginal discharge”.

Only about 33.3% of interviewees know the symptoms of STIs like burning during urination, painful sexual intercourse, vaginal discharges probably because they have got some education.

Predictors sexual exploitation, HIV and STIs among female sex workers

The multivariate analysis revealed that being illiterate was about two and a half more likely vulnerable to HIV and STIs than their counterparts (AOR = 2.531; 95% CI (6.125-9.042). The female sex workers who grew up in rural areas, and those who use substances in a daily manner were 3.45 and 2.5 times more likely vulnerable than their comparable groups (AOR =1.133-10.529), and (1.102-11.47). Furthermore, the analysis revealed that those participants who started sex work at the age of fewer than 15 years, raped, and had more than 15 clients per week were about 3, 1.5, and 3.5 more likely at risk of acquiring HIV and or STIs than their comparable group (AOR=3.021-9.05), (10.231-21.031), and (3.073-16.006). Moreover, those who have inconsistently used condoms, those who were forced to human trafficking, and group sex were more likely at risk than their comparison groups.

However, the female sex workers who had ever tested RDT for HIV status and those who Scored full marks on the STI knowledge questionnaire were less likely to be vulnerable than their counterparts AOR=0.234, 95% CI 0.621-0.810) and 0.734; (0.130, 0.661), respectively (Table 5).

This study provided an opportunity to understand estimate the prevalence of HIV/STIs and vulnerability to sexual exploitation among venue-based FSWs in western Oromia, Ethiopia. The study finding revealed that about 17.6% of them started at fewer than 15 years of age. Similarly, the study conducted in Uganda shows that about 62% of FSWs have started sexual doubt at fewer than 14 years of age [17].

Of the total, 25.1%, 25.1 and 32.2% of the females were started sex work due to poverty, peer pressure, and family conflict, respectively. Other reasons identified were the death of parents 8.8% and 8.8% dismissal from Colleges and Universities. The majority (95.6%) of participants were do not have other income that paid for sex. Concrentltly, the study conducted in Nigeria shows that about 63% of FSWs are single, 7.4% married and 29.6% are separated sex workers. The finding shows that 29.6% of participants and 25.9% initiated sex work because of partner pressure and financial reason (4). This finding shows that the majority 92.5% of participants have more than 15 clients per week while 38.9% and 7.5% have an average of 10-14 and 2-9 clients per week. Similarly, the study conducted in Uganda shows that the number of clients per week goes up to 20 per week [17].

This study shows that more than half (71.1%) were used the condom in the last 12 months during sexual intercourse. However, 28.9% reported they didn’t use condoms in the last 12 months due to (partner refusal 6.3%), (sex was not planned 4.2%), (no money to buy condoms 2.1%), and negotiation to increase sex price with partners 16.3%). Similarly, the systematic review study conducted in SSA shows 79% had the availability of condoms either for free or sale at the bar. Despite this, a major reason for unprotected sex is the lack of free-of-charge condoms [5]. Client refusal (73%), higher payment (33%), and client brutality (43%) are major reasons for the interruption of consistent condom use among sex workers [6].

This study revealed that about half (51%) of participants used the condom consistently, while 49% used it inconsistently in the last six months. Similarly, the study conducted in China and Uganda shows that about 29 % and 40% of FSWs know how to use condoms, inconsistently [17,18].

Regarding the alcohol and substance use behavior of study participants, this study shows that about 88.7% of them had drunk alcoholic beverages of which89.6% of them used the alcohol daily while 5.7% used it usually. Moreover, about 88.3% of the females have ever chewed Khat, of which 80.6% of them used khat by daily manner. About three-fourths (83.3%) of study participants reported they had ever smoked chewed and/or sniffed any tobacco product. Concurrently, the study conducted in Ethiopia shows that 70% of FSWs consumed alcohol of which 15.8% had drunk daily and about 50% chewed khat and of which 24% of them chewed khat in a daily manner [19].

The finding revealed that about half (50.6% of FSWs were forced not to use a condom during sexual intercourse. Others also faced harassment like being (forced to have oral and/or anal sex 59%), (physical beating 81.2%), and (a touch of unwelcomed sex organ 76.6%) of them experienced sexual exploitation in the last six months. Moreover, the majority (82.4%, forced to have an unwelcomed sexual position), (95.4% verbal insult), and (59.4% were forced to trafficking to other cities). About 8% and 34% of respondents reported their partner used paid sex as a source of income and was forced for group sex in the last six months. Similarly, the study conducted in Kenya shows that a significant portion reported being raped (35%) or physically assaulted (17%) by their clients (10). Also, the evidence in Namibia reported that 72% of FSWs had experienced sexual abuse, including by clients (18%), intimate partners (16%), and the police (9%) (11). Similarly, the study conducted in Ethiopia shows that sexual and physical exploitation among FSWs is huge (physical beating 17.5%), and (15.2% reported being raped) [17]. Concurrently, the evidence in Kenya and Ethiopia shows that about (79%) and (60%) of female sex workers reported work-related violence [18, 19].

This study shows that more than half (55.2%) of participants were ever tested (RDT) for HIV status while the rest did not. The majority (84.5%) of respondents were consented to the RDT test of HIV, while 15.5% refused for RDT test due to (not at risk of HIV 13.5%), (fear of might had HIV 37.8%), (fear of others reactions if tested positive 27%), and 21.6% of them recently tested to know their HIV status. However, the systematic review evidence in SSA shows that female sex workers have the willingness to have HIV testing but fewer participants reported never having tested due to being afraid of being positive. This discrepancy may be due to the pooled results from the systematic review of the literature [20].

The finding shows that about 18.3% of FSWs were tested reactive for the HIV RTD test. Concurrently, the study conducted in Sub-Saharan Africa (SSA) shows that FSWs have the highest HIV prevalence rates (12%), globally. In SSA, the prevalence among Female Sex Workers (FSWs) is estimated at 53.6%. Research evidence in Zimbabwe shows HIV prevalence is higher among FSWs compared to Non-Sex Workers (NSWs) which accounts for 52.6% vs 19.8% [3]. Although 53.6% reported that they have received STI information aimed at sex workers, only 39.1% scored full marks on the STI knowledge questions. About less than half participants (43.1%) reported that they had tested for STI within the last 12 months. About 28.9% of respondents reported they ever had STIs in their life, of which (7.2% worried about its symptoms), (21.7% possible exposure from a partner), (13% exposure from clients), (26.1% convinced by health workers), and (31.9% had the symptoms) of STIs. Concurrently, the study conducted in Shanghai China shows that the STIs prevalence among female sex workers is 17.7% [21].

Recommendations

Therefore, renewed efforts are necessary to intervene effectively to address this high-risk hard-to-reach population. Researching the demarcation of causal pathways to HIV and STIs transmission demands should shift from binary epidemiological simple models cause and effect” to multilevel models, which emphasize HIV and STIs as an outcome of multiple contributing factors interacting together. Public health surveillance systems should be oriented towards monitoring indicators for the social context that mediates high-risk for HIV and STIs among FSWs. The prevention of HIV, STIs, and sexual exploitations should be nested inside strategies that address the social welfare of sex workers, targeting the need to address social determinants of health and inequality including access to health services, prevention of violence, and delineate how micro-entrepreneurship factors combined together to reduce the risk of HIV, STIs and sexual exploitations among this hard-to-reach population.

Limitation of the Study: This study was conducted only in four cities of west Oromia, hence needing further research allowing dozens of cities in the country.

The finding shows that the majority of FSWs joined sex work due to joblessness, divorce, conflict with parents, dismissal from education, and peer pressure are among the factors that lead them to this job. In Ethiopia HIV and STIs vulnerability among FSWs is linked primarily to drug use, being illiterate, starting sex work at a fewer age (less than 15 years), being raped, and having more clients per week, inconsistently using condoms, human trafficking, and group sex behaviors. The FSWs in Ethiopia are the more exposed group to HIV, STIs, and sexual exploitations due to high-risk sexual behaviors and drug use. The prevalence of HIV among FSWs accounted for (18.3% tested reactive for the HIV RTD test). Although 53.6% reported that they have received STI information aimed at sex workers, only 39.1% scored full marks on the STI knowledge questions, which shows the FSWs’ knowledge of STIs is poor. The sexual exploitation among FSWs is highly widespread, forced not to use a condom (50.6%), forced to have oral and/or anal sex (59%), physical beating (18.2%), unwelcomed sex organ touch (76.6%), forced to have an unwelcomed sexual position (82.4%,) verbal insult (95.4%), and forced to trafficking to other cities (59.4%).

ETB: Ethiopian Birr, FSW- Female sex workers, IDIs- In-Depth-Interviews, PSU-Sampling Primary Unit, STIs -sexually transmitted infections, SSA-Sab-Saharan Africa, RDT-Rapid Diagnostic Test, RDS-Respondent Driven Sampling, RDSAT- Respondent Driven Sampling Analysis Tool

Ethics Approval and Consent to Participate: The ethical clearance for this study was sought from Wollega University, the Institute of Health Sciences, ethical review committee. A formal letter was written to each city municipality authority and permission were secured at all levels. Prior to data collection, respondents were informed of the purpose of the study and the voluntary nature of the information given and were required to sign the informed consent form. To compensate participants’ time, the researchers provided 200 ETB (4.4 USD) per person. Participation in the study was voluntary and information collected from the study subjects was handled confidentiality.

Consent for Publication: Not applicable

Availability of Data and Material: the datasets used/analyzed during the current study available from the corresponding author on a reasonable request.

Competing Interests: The authors declare that he has no competing interests

Funding: The author received no specific funding for this work

Authors’ Contribution: All authors conducted this research from the inception to manuscript write-up and its submission.

Acknowledgments: The author would like to have heartfelt thanks for the study participants.

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Table 1: Socio-demographic distribution and other background characteristics of 239 study participants across 4 cities, Ethiopia.

Variables		Frequency	%
Age (years)	15-24	82	34.3
	25-34	103	43.2
	35+	54	22.6
Religion	Orthodox	103	43.1
	Protestant	102	42.8
	Muslim	24	10
	Others	10	4.2
Born place	Rural	113	47.3
Born place	Urban	126	52.7
Ethnicity	Oromo	210	87.9
	Amhara	20	8.4
	Others	9	3.8
Marital status	Never married	155	64.9
	Married/cohabited	8	3.3
	Divorced	73	30.5
	Widowed	3	1.3
educational status	Illiterate	39	16.3
	Can read and write	24	10
	Primary and	113	47.3
	Secondary school	52	21.7
	College and above	11	4.6
Current residence	Nekemte	97	40.6
	Ghimbi	58	24.3
	Nedjo	37	15.5
	Shambu	47	19.7
Occupation before sex work	No work	45	18.8
	Farmer	5	2.1
	Student	108	45.5
	Housemaid	39	16.3
	Waiter	42	17.6
Sex selling started at the age of	Less than 15	23	9.6
	15-17	36	15.1
	18-24	123	51.5
	25-29	42	17.6
	30 and above	12	5.0
The reason why engaged in sex work	Poverty/lack of money	60	25.1
	Peer pressure	60	25.1
	Death of parents	21	8.8
	Family conflict	77	32.2
	Dismissal from school/University	21	8.8
Now living with	Live with husband	3	1.3
Now living with	Alone/rental	110	46.0
	With friends in the hotel dorm	126	52.7
Place of your work	Hotel based	203	84.9
	On-call where the customer preferred	20	8.4
	Going to the customers’ house	16	6.7
Other income than FSW	No	229	95.6
Other income than FSW	Yes	10	4.4
Do you have a willingness to quit this job?	Yes	2001	84.1
Do you have a willingness to quit this job?	No	38	15.9

Table2: Social and Sexual behavioral characteristics of the participants in western Oromia, 2020.

Variable	Category	Frequency	%
Reason for the first time sexual initiation of sexual debut	Love/friendship	134	56.1
	Marriage	29	12.1
	Raped	63	26.4
	Paid sex	13	5.4
Number of clients per a week	1	7	2.9
	2-9	18	7.5
	10-14	93	38.9
	More than 15	121	92.5
Price per sex act	Less than 200	29	12.1
	200-500	176	73.6
	500 and above	34	14.2
Condom use in the last 12 months	Yes	170	71.1
Condom use in the last 12 months	No	69	28.9
If not used why	Partner refusal	15	6.3
	Sex was not planned	10	4.2
	No money to buy	5	2.1
	Negotiation to increase sex price with partners	39	16.3
Condom use in the last six months with clients	Consistent	122	51
Condom use in the last six months with clients	Inconsistent	117	49
Did you got pregnancy in your life	Yes	97	40.6
Did you got pregnancy in your life	No	142	59.4
What were your pregnancy outcome	Delivered	35	14.6
	Abortion	62	25.9
Use of Family planning	Used	213	89.1
	Not used	26	10.9
Reason of use of the contraceptives	As back up if the condom breaks	84	35.1
Reason of use of the contraceptives	To delay menstrual flow	129	54.0
Did you get the SRH services regularly from health workers	Yes	41	17.1
Did you get the SRH services regularly from health workers	No	198	82.9

Table3: Alcohol and substance use behavior of study participants in western Oromia, Ethiopia 2020

Variables		Frequency	%
Have you ever drunk any alcoholic beverage	Yes	212	88.7
Have you ever drunk any alcoholic beverage	No	27	11.3
Alcohol consumption frequency (212)	Daily	190	89.6
	Usually	12	5.7
	Sometimes	10	4.7
Have you ever chewed khat	Yes	211	88.3
Have you ever chewed khat	No	28	11.7
chewed khat frequency (211)	Daily	170	80.6
	Usually	31	14.7
	Sometimes	10	4.7
Have you ever smoked chewed or sniffed any tobacco product	Yes	199	83.3
Have you ever smoked chewed or sniffed any tobacco product	No	40	16.7
smoked chewed or sniffed consumption frequency (199)	Daily	172	86.4
	Usually	18	9.0
	Sometimes	9	4.5
Have you ever taken any cannabis	Yes	56	23.4
Have you ever taken any cannabis	No	183	76.6

Table 4: HIV and STIs status of the study participants in western Oromia, Ethiopia 2020

Variables	Category	Frequency	%
Had you ever tested RDT for HIV status	Yes	107	44.8
Had you ever tested RDT for HIV status	No	132	55.2
Can you consent to test RDT HIV to know your status	Yes	202	84.5
Can you consent to test RDT HIV to know your status	No	37	15.5
If not consent, why	I am not at risk	5	13.5
	I fear I might have HIV	14	37.8
	Fear of other people’s reactions if tested positive	10	27.0
	Tested for HIV recently	8	21.6
HIV test result (202)	Reactive	37	18.3
HIV test result (202)	Not reactive	165	81.7
Have you received STI information aimed specifically at sex workers in the last 12 months	Yes	128	53.6
	No	111	46.4
Scored full marks on the STI knowledge questionnaire (128)	Yes	50	39.1
Scored full marks on the STI knowledge questionnaire (128)	No	78	60.9
Have you tested for STI in the last 12 months	Yes	103	43.1
Have you tested for STI in the last 12 months	No	136	56.9
Ever had STIs	Yes	69	28.9
Ever had STIs	No	170	71.1
If yes, how did you know as you had STIs (69)	No symptoms but worried	5	7.2
	Possible exposure from partner	15	21.7
	Possible exposure from clients	9	13.0
	Convinced by health workers	18	26.1
	Had symptoms	22	31.9

Table 5: Predictors sexual exploitation, HIV and STIs among female sex workers in western Oromia, Ethiopia 2020

Variables	Category	p-value	COR (95% CI)	p-value	AOR, (95% CI)
Educational background (illiterate)	Illiterate	0.003	6.361 (4.015-7.903)	0.002	2.531;(6.125-9.042)
Grow up place	rural	0.002	4.320 (3.201-9.021)	0.01	3.45 (1.133-10.529)
Grow up place	Urban	Ref.
Substance use behavior	Daily		3.521 (2.678-8.025)	0.03	2.5 (1.102-11.47)
Alcohol use	Yes	0.003	5.213 (7.017-13.042)	0.002	1.503 (6.032-14.021)
	No	Ref.
Sex selling started at the age of	Less than 15	0.001	6.037 (5.389-9.034)	0.02	3.1(3.021-9.05)
Reason for the first time sexual initiation of sexual debut	Raped	0.002	3.503 (11.034-21.045)	0.04	1.52(10.231-21.031)
Number of clients per a week	More than 15	0.002	2.020 (9.102-15.005)	0.001	3..521(3.073-16.006)
Condom use in the last 12 months	Yes	0.001	0.783(0.364-0.679)	0.001	0.401 (0.567-0.945)
	No	Ref.
Condom use in the last six months with clients	inconsistent	0.001	5.120 (17.102-21.025)	0.002	2.501(6.023-13.026)
Sexual exploitation	Forced to trafficking	0.002	7.023 (10.071-18.027)	0.003	1.049 (5.810-12.430)
	Forced for group sex	0.001	2.812 (5.026-9.036)	0.002	1.502 (2.043-7.032)
Had you ever tested RDT for HIV status	Yes	0.004	0.542 (0.678-0.917)	0.002	0.234 (0.621-0.810)
	No	Ref.
Scored full marks on the STI knowledge questionnaire	Yes	0.001	0.601 (0.021-0.450)	0.001	0.734; (0.130, 0.661)
	No	Ref.

No competing interests reported.

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The prevalence of HIV/STIs, sexual exploitations, and its determinants among venue-based FSWs in western Oromia, Ethiopia. A community-based cross-sectional and phenomenological study designs

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