Determinants of Willingness to Use Pre-Exposure Prophylaxis Among Female Sex Workers in Jimma Town, South West Ethiopia: Unmatched Case Control Study
Abstract
Background: ~35.5 million people globally are believed to have HIV. The use of antiretroviral medications to stop HIV/AIDS infection in a demographic group that is significantly at risk is known as pre-exposure prophylaxis (PrEP). By 2017′s end, only 350,000 people had ever received PrEP.
Objective: To identify determinants of willingness to use PrEP among Female sex workers in Jimma town, Southwest Ethiopia.
Methods: A case–control study centered in a facility was carried out on 343 female sex workers (114 cases and 229 controls). For the control population, convenience sampling was used, and snowball sampling was used for cases. In order to determine the factor influencing the willingness to use PrEP, binary logistic regression analysis was employed. Multivariable logistic regression was used to assess factors affecting PrEP willingness, estimating adjusted odds ratios (AORs) with 95% confidence interval (CIs), considering variables with p < 0.05 significant.
Result: A total of 328 female sex workers were involved, resulting in a response rate of 95.6%. The mean ages of the cases and controls were 30.8 and 27.3 years, respectively. After adjusting the possible confounders, tested for HIV in the last 3 months (AOR = 6.65, 95%CI: 2.27–19.51), not having perceived stigma towards PrEP (AOR = 53.04, 95%CI: 10.10–246.96), no fear of drug side effect (AOR = 6.57, 95%CI: 1.81–23.88), and good family relations (AOR = 19.17, 95%CI: 5.07–72.50) were significantly associated with the willingness of female sex workers to use PrEP.
Conclusion: According to this study, concerns about side effects, family impact, perceived stigma, and prior HIV testing significantly influence female sex workers’ willingness to use PrEP.
1. Strengths and Limitations of this Study
The clients or female sex workers reply in favor of their service providers by concealing their actual practice because the providers performed the interview. Additionally, the interviewer’s desire to give socially acceptable answers could skew the results. Even though this was minimized by providing, training for data collectors and assigning trained supervisors.
2. Background
Approximately 35.3 million individuals worldwide are believed to be living with HIV [1]. Pre-exposure prophylaxis (PrEP) has been shown in clinical studies to be effective in reducing HIV transmission in specific groups. PrEP involves HIV-negative individuals using antiretroviral medicines before to anticipate HIV exposure in order to prevent transmission. The first pharmaceutical treatment that has been shown to be effective in preventing HIV infection in people at high risk of HIV acquisition is PrEP [2–4]. It is one of the biological preventive strategies that has just lately been made available to the public and would significantly reduce the spread of HIV among populations that are already at high risk of contracting the disease [5].
The United Nations General Assembly’s 2016 Political Declaration on HIV andAIDS committed to providing three million people at higher risk of HIV infection with PrEP by 2020. But as of the end of 2017, just 350,000 individuals had ever received PrEP [3, 6]. Research findings from many studies indicate that women are generally more willing to use PrEP. For example, the study conducted in China showed (69%) that proportion of surveyed female sex workers were willing to use PrEP for HIV prevention [7]. Special concern is given to female sex workers who experience an extraordinary high risk of acquiring HIV globally [8].
Over the years, PrEP for HIV prevention has undergone major changes; with clinical trials proving the effectiveness of oral PrEP, the field is scaling-up implementation [9]. This medication has been shown to be safe and effective and should be taken once daily [10]. Offering PrEp is one of the six HIV prevention pillars adopted by Ethiopia and also one of the commitments to reduce new adult HIV infections by 50% by 2020 and ending AIDS as a public health threat by 2030 [11].
Several African countries have adopted the WHO PrEP policy and launched PrEP almost very early and some are late. Kenya is one of the late countries to adopt and implement in May 2017 as a component of her all-encompassing HIV prevention strategy for HIV-affected people, and only 53,291 female sex workers enrolled to PrEP against a target of 500,000 by 2020 [12]. The other African country which adopted early is Uganda with the coverage of estimated 21,500 members of the key population who have accessed oral PrEP [13]. On the other hand, according to the study conducted in Zimbabwe, the majority of female sex workers (FSWs) (89%) were willing to use Pr EP to reduce their risk of contracting HIV infection [14]. According to a report from ministry of health of Ethiopia, pre-exposure service was launched in all region but only six regions are actively providing pre-exposure service in 300 health facilities in both governmental and NGOs. In Ethiopia among an estimated 165,000 female sex workers (FSW), only 10,000 ever started PrEP. Oromia region is one of the six regions which are actively providing PrEP with a coverage of 3513 among estimated 45,0000 female sex workers living in the region so far since the service was launched. Whereas, the report from Jimma town shows among 3821 tested negative and registered, only 415FSW 10.8% of the population ever started PrEP [15].
In Ethiopia, as PrEP service is a new initiative, no amble studies were conducted and documented which reveals the determinants of willingness to use PrEP and suggest the solution so far. Therefore, determinants of willingness to use PrEP were not well known in the study area. In order to determine the factors influencing female sex workers’ willingness to utilize PrEP and suggest potential remedies, this case control facility-based research in a health institution was conducted.
3. Methods
3.1. Study Area, Period, and Design
The study was carried out at Jimma Town, Oromia Regional State, which is located 345 km southwest of the capital, Addis Ababa. One general hospital, one specialized hospital, and four health centers were found in the town. According to information from the HIV care and prevention department of the Jimma town office, there have been 3821 female sex workers recognized and registered in Jimma town overall. The key population clinic is currently functioning and PrEP is administered at Shenen Gibe General Hospital, Jimma Health Centre, and Jimma Higher2 Health Centre. The study was carried out between December 15, 2021, and July 20, 2022.
An unmatched facility-based case–control study was carried out.
3.2. Source and Study Population
All female sex workers who live in Jimma town are the source population. All HIV sero-negative female sex workers who ever started PrEP and lived in Jimma town were cases. All sero-negative female sex workers who did not ever started PrEP and lived in Jimma town were controls.
3.3. Sample Size Determination and Sampling Technique
Sample size was calculated by using the double population formula by using the assumptions of 95% CI, 80% power, 2 : 1 control to case ratio, proportion of control exposed (77%), odds ratio (2.9), and proportion of case exposed (90.4%) [16]. By adding 10% of nonresponse rate, the final sample size was 343.
Convenience sampling was used for the control group. For cases, the snowball sampling technique was used based on the number of sero-negative female sex workers identified and registered healthcare facilities (Shenen Gibe General Hospital, Jimma Health Centre, and Jimma Higher2 Health Centre).
3.4. Measurement of Variables
Knowledge was measured by 12 knowledge questions related to information towards HIV/AIDS in yes or no format. The correct answer was given “1”and “0” was given incorrect and did not know. The total score was computed out of 12 marks (with a range of 0–12). Those who score the mean and above had good knowledge whereas those who scored below the mean value had poor knowledge.
Perceived stigma: Is measured by four perceived stigma questions, related to information towards the use of PrEP in strongly agree, agree, neutral, disagree, and strongly disagree format.
Drug side effect: any person experiences one of the symptoms (nausea, nightmare, and head ache) following taking pre-exposure medication.
Previously tested: female sex workers who have tested for HIV in the last 6 months
HIV risk perception: female sex workers who understand that he is at risk of acquiring HIV.
Having heard of Prep: female sex workers who ever heard about PrEP from any source.
Willingness to use PrEP: the female sex workers who were ever started and using PrEP are considered as having willingness to pre exposure.
3.5. Data Analysis
The collected data was checked for completeness, coded and entered into Epi-Data v. 4.6, and analysed by SPSS v. 23.0. Frequency distributions and cross-tabulations are presented in tables. Binary logistic regression analysis was used and all determinants having p-value < 0.25 in the bivariate analysis were included in multivariate logistic regression models. Finally, the degree of association presented in the adjusted odds ratio with 95% CI, and p < 0.05 was used to declare determinants of willingness to use PrEP.
4. Results
4.1. Sociodemographic Characteristics
A total of 328 female sex workers from which 109 cases and 219 controls were interviewed, and the mean age of the cases and controls were 30.8 and 27.3 years, respectively. In terms of educational attainment, 56 (51.4%) of the cases were secondary or higher. The majority of the cases 90 (82.6%) were born in urban areas, whereas the majority of the controls 182 (83.1%) were primary and lower, and above half 124 (56.6%) of the control were born in rural areas (Table 1).
| Variables | Category | Case n (%) | Control n (%) | Total n (%) |
|---|---|---|---|---|
| Age in years | 15–24 | 19 (17.4%) | 79 (36.1%) | 98 (29.9%) |
| 25–34 | 62 (56.9%) | 137 (62.6%) | 199 (60.7%) | |
| 40–65 | 28 (25.7) | 3 (1.4%) | 31 (9.5%) | |
| Educational status | Primary | 53 (48.6%) | 182 (83.1%) | 235 (71.6%) |
| Secondary and above | 56 (51.4) | 37 (16.9%) | 93 (28.4%) | |
| Marital status | Single | 52 (47.7%) | 124 (56.6%) | 176 (53.7%) |
| Married | 3 (2.8%) | 15 (6.8%) | 18 (5.5%) | |
| Widowed | 6 (5.5%) | 8 (7.3%) | 14 (4.3%) | |
| Separated | 5 (4.6%) | 34 (11.9%) | 39 (11.9%) | |
| Divorced | 43 (39.4%) | 38 (17.4%) | 819 (24.7%) | |
| Average monthly income in ETB | 500–1500 | 15 (13.8%) | 102 (47.0%) | 117 (35.9%) |
| 1501–3,000 | 33 (30.3%) | 69 (31.5%) | 102 (31.1%) | |
| >3001 | 61 (56.0%) | 46 (21.0%) | 107 (32.8%) | |
| Residence | Urban | 90 (82.6%) | 124 (56.6%) | 114 (34.8%) |
| Rural | 19 (17.4%) | 95 (43.4%) | 115 (35.1%) | |
| Having children | Yes | 47 (43.1%) | 68 (59.1%) | 115 (35.1%) |
| No | 62 (56.9%) | 151 (68.9%) | 213 (68.9%) | |
- Abbreviation: ETB, Ethiopian Birr.
4.2. HIV Risk Perception, Reason for Testing, and Medical Condition
The majority of controls 189 (86.3%) and almost all cases 109 (100%) both perceived an increased risk of contracting HIV. The majority of patients had positive familial relationships, but the majority of controls 179 of them, or 81.7% had bad ones. While the majority of controls (168; 76.7%) received tests within 6 months or more, a high percentage of cases (87; 79.8%) got tests during the last 3 months. The majority of controls, 179, or 81.7%, claimed that they fear drug adverse effects while the majority of cases, 99 (90.8%), did not (Table 2).
| Variables | Category | Cases n (%) | Controls n (%) | Total n (%) |
|---|---|---|---|---|
| Previous HIV test | Less than 3 months | 87 (79.8%) | 51 (23.3%) | 138 (42.1%) |
| 6 months and above | 22 (20.2%) | 168 (76.7%) | 190 (57.9%) | |
| Fear of drug side effect | Fear drug side effect | 10 (9.2%) | 179 (81.7%) | 189 (57.6%) |
| No fear drug side effect | 99 (90.8%) | 40 (18.3%) | 139 (42.4%) | |
| Family relation/social support | Good | 85 (68%) | 40 (32%) | 125 (38.1%) |
| Bad | 24 (22%) | 179 (81.7%) | 203 (61.9%) | |
| HIV risk perception | Has risk perception | 109 (100%) | 189 (86.3%) | 298 (90.9%) |
| Has no risk perception | 0 (0%) | 30 (13.7%) | 30 (9.1%) | |
4.3. HIV/AIDS-Related Knowledge, Belief and Attitude and Perceived Stigma
A majority of case participants, 82 (75.2%) self-reported having good HIV/AIDS knowledge, 108 (99.1%) wanted to obtain HIV/AIDS knowledge, 105 (96.3%) thought HIV/AIDS was a serious illness, and 109 (100%) had heard of pre-exposure therapy to prevent HIV infection. In 94 cases (86.2%), there was no discrimination against HIV-positive people. The majority of the controls 113 or 51.6% had little awareness of HIV, and around 168, or 76.7%, told they wanted access to it. 93.6% of the controls (a large number) thought HIV was a major problem. The majority of the 129 controls (58.9%) did not discriminate against HIV-positive people. A majority of 186 (84.9%) of the control respondents told they had experienced stigma, and a majority of 212 (96.8%) told they had heard of PrEP (Table 3).
| Variables | Category | Cases n (%) | Controls n (%) | Total n (%) |
|---|---|---|---|---|
| HIV knowledge | Good knowledge | 82 (75.2%) | 106 (48.4%) | 188 (57.3%) |
| Poor knowledge | 27 (24.8%) | 113 (51.6%) | 125 (38.1%) | |
| Wish to access knowledge of HIV/AIDS | Yes | 108 (99.1%) | 168 (76.7%) | 276 (84.1%) |
| No | 1 (0.9%) | 51 (23.3%) | 52 (15.9%) | |
| AIDS serious | Yes | 105 (96.3%) | 205 (93.6%) | 310 (94.5%) |
| No | 4 (3.7%) | 14 (6.4%) | 18 (5.5%) | |
| Worried about family members infected with HIV | Yes | 82 (75.2%) | 129 (58.9%) | 211 (64.3) |
| No | 27 (24.8%) | 90 (41.1%) | 117 (35.7%) | |
| Perceived stigma | Yes | 6 (5.5%) | 186 (84.9%) | 192 (58.5%) |
| No | 103 (94.5%) | 33 (15.1%) | 136 (41.5%) | |
| Attitude toward HIV/AIDS patients | Discriminatory | 10 (9.2%) | 69 (31.5%) | 79 (24.1%) |
| Hard to say | 5 (4.6%) | 21 (9.6%) | 26 (7.9%) | |
| Nondiscriminatory | 94 (86.2%) | 129 (58.9%) | 223 (68%) | |
| Having heard PrEp | Yes | 109 (100%) | 212 (96.8%) | 321 (97.9%) |
| No | 0 (0%) | 7 (3.2%) | 7 (2.1%) | |
4.4. Determinants of Willingness to use Exposure Prophylaxis
Perceived stigma, drug side effect, familial ties, and previous HIV testing were all independent variables associated with willingness to use PrEP. The results showed that those tested during the last 3 months were 6.95 times more likely to use PrEP than those tested within the last 6 months, with an AOR of 6.65 (95% CI 2.27, 19.51).
Female sex workers who do not experience stigma are more willing to use PrEP than those who do, according to a study with an AOR of 53.04, and a 95% confidence interval (10.10, 246.96). Female sex workers, who have no fear of drug side effect, were 6.66 times more likely to use PrEP than those who have a fear of drug side effect. With AOR of 6.66 (95%CI 1.81, 23.88) and female sex workers those who have good family relations were 23.82 times more likely have willingness to use PrEP than those who have bad family relations with AOR of 19.17 (95% CI 5.07,72.50) (Table 4).
| Variables | Category | COR (95%CI) | AOR (95%CI) | p-Value |
|---|---|---|---|---|
| Educational level | Primary | 1 | — | — |
| Secondary & + | 5.197 (3.10, 8.71) | 0.31 (0.23, 1.15) | 0.079 | |
| AMI | 500–1500 ETB | 1 | — | — |
| 1501–3000 ETB | 3.25 (0.16, 0.61) | 0.42 (0.10, 1.90) | 0.26 | |
| >3001 | 0.111 (0.057, 0.215) | 1.24 (0.22, 6.94) | 0.81 | |
| Previous HIV test | <3 months | 13.03 (7.42, 22.87) | 6.95 (2.32, 20.88) | 0.001∗ |
| >6 months | 1 | — | — | |
| Fear of drug side effect | Yes | 1 | — | — |
| No | 44.30 (21.24, 91.41) | 6.66 (1.81, 23.88) | 0.004∗ | |
| Family relation/social support | Good | 15.85 (8.98, 27.97) | 23.82 (5.88, 96.45) | 0.001∗ |
| Bad | 1 | — | — | |
| HIV knowledge | Good knowledge | 3.24 (186, 0.514) | 0.71 (0.23, 2.21) | 0.900 |
| Poor knowledge | 1 | — | — | |
| Perceived stigma | Yes | — | — | — |
| No | 96.76 (39.24, 238.59) | 53.04 (10.01, 246.96) | 0.001∗ | |
- Abbreviation: AMI, average monthly income.
- ∗ indicates p < 0.05.
5. Discussion
The aim of this study was to determine the factors that determine female sex workers in Jimma Town’s willingness to utilize PrEP.
According to the study’s findings, female sex workers who had their test within the previous 3 months were 6.95 times more likely to be willing to use PrEP than those who had their test more than 6 months ago. This conclusion is supported by a study done in Gahanna that revealed that female sex workers who had tested positive for HIV in the 6 months prior to the study were 13% more likely to be willing to use PrEP than those who hadn’t [13]. The difference in time of test is probably due to different countries using different schedules and strategies depending on their level of development and HIV prevalence for HIV testing [17]. Both studies confirmed the concept that those recently tested have a higher tendency to use PrEP than those who had HIV test in a longer period than 6 months.
Another finding of this study is that female sex workers are 6.66 times more likely to use PrEP than those who are afraid of drug adverse effects. This result is comparable to that of a study conducted in China and India [7, 18].
Similarly, female sex workers who do not perceive stigma are more likely to use PrEP than those who do. It is also strongly suggested that commercial sex workers and their sexual partners may perceive stigma or believe they are HIV positive. This element has a negative correlation with low PrEP use willingness. This finding is consistent with research on the problems surrounding oral PrEP use among female sex workers in India and the Asia-Pacific region for HIV prevention. The main obstacle to obtaining adequate services has remained social stigma. Accessing oral PrEP medications caused FSWs to be careful [19].
The results of this study showed that female sex workers with good family relationships are associated with willing to utilize PrEP than those with poor family relationships. This result contradicts a study from China that found that PrEP acceptance is correlated with worse connections to family [20]. However according to a study on HIV PrEP among young men in the US who have sex with men, good parent–adolescent communication regarding HIV and sexual health can boost the use of PrEP and enhance adherence to PrEP among young men who have sex with men (AMSM) [21]. In other words, it is thought that having a strong family bond will make PrEP more acceptable. This is because several studies have found that the quality of one’s intimate and/or marital relationships significantly influences one’s willingness or adherence to utilize PrEP [20].
6. Conclusion and Recommendations
This study found that worries regarding the adverse effects of the medications, family relationships, perceived stigma, and past HIV test histories had a substantial impact on FSWs’ willingness to use PrEP for HIV prevention among female sex workers. Health facilities should provide health education for female sex workers on drug side effects and reassure them. Health facilities should teach the community about the benefits of frequent HIV testing and promote frequent HIV testing as recommended by world health organization. In particular for female sex workers, women and child welfare offices and other faith-based organizations should engage in establishing positive family relationships. Health facility should educate the community and female sex workers on PrEP drug utilization related to perceived stigma reduction.
Nomenclature
-
- AIDS:
-
- Acquired immunodeficiency syndrome
-
- FSW:
-
- Female sex worker
-
- HIV:
-
- Human immunodeficiency virus
-
- KP:
-
- Key population
-
- Pr Ep:
-
- Pre exposure prophylaxis
-
- TDF:
-
- Tenofovir disoproxil fumarate
-
- UNAIDS:
-
- Joint United Nations Program on HIV/AIDS
-
- WHO:
-
- World Health Organization
Ethics Statement
A letter of ethical clearance from the ethical clearance committee of the public health faculty of Jimma University. Discussions were undertaken with representatives from higher levels of the Town Health Office’s organizational structure (from the Town Health Office to the relevant Health Facility).
Disclosure
As this research is part of a thesis submitted to fulfill the requirements for the Master of Public Health in Epidemiology, the preprint of the study has been submitted to Jimma University, with the thesis available at the following link: https://repository.ju.edu.et//handle/123456789/7676.
Conflicts of Interest
The authors declare no conflicts of interest.
Author Contributions
Each author provided input into the data analysis, helped to draft or revises the paper, approved the final version before publication, chose the current journal for the article was submitted, and agreed to be responsible for all elements of the work.
Funding
There was no funding for this study.
Acknowledgments
We would like to acknowledge Shenen Gibe General Hospital, Jimma Health Center, and Jimma Higher2 Health Center, supervisor and data collectors, for their unreserved effort. We also thank Jimma University for helping us write our letter of ethical clearance and for giving us the opportunity to conduct the study for this thesis, which is the basis of this manuscript.
Open Research
Data Availability Statement
The data supporting the study’s conclusions will be made available upon reasonable request from the corresponding author.
