Are sex workers propagating one or two HIV epidemics in Kenya? Findings from a behavioral monitoring survey in Coast Province

Abstract

Background: Kenya's Coast Province has high prevalence for commercial sex and substance abuse. While many studies have confirmed the association between HIV and alcohol and injection drug use among female sex workers (FCSWs), little known of HIV risk from other substances such as miraa (Catha edulis alias 'khat') and bhang (cannabis) among FCSWs. Despite numerous adverse consequences of miraa, Kenyan law silent on miraa sale and use. To estimate the burden of khat and bhang use and contribution toward risky sexual behaviour, we conducted a behavioural survey targeting FCSWs in Mombasa. Method: Cross-sectional survey recruited 297 FCSWs using time location sampling. Structured questionnaires administered using Personal Digital Assistants (PDA). Outcome measures: prevalence of substance abuse, sexual violence and perceived HIV risk. Results: 46% FCSWs aged 15-24 years, 68% attained primary level education, 66% full time sex workers. 96% percent used at least one substance: Alcohol most popular (91%) (P< 0.01; df=4); miraa/khat second popular substance (71%); cigarettes (51%), bhang (34%); hard drugs (6%) (p< 0.01; df=3). 88.8% FCSWs multi-substance users, particular users of bhang, heroin, cocaine and glue. 79% miraa users below 20 years age at first paid sex (p< 0.01; df=1; OR=2.16), while FCSWs in sex work > 5 years more likely to smoke cigarettes than those in the trade shorter duration (p< 0.05; df=1; OR=1.65). 47.5% (141/297 reported sexual violence. Although 40.8% of FCSWs perceived risk of HIV acquisition as medium to high, majority (75%) due to multiple partners, rather than rape (1%). Conclusions: Study confirmed high miraa and bhang use among FCSWs, in addition to alcohol and cigarettes. Combined use of alcohol and miraa associated with more sexual partners, increased risk of sexual violence and moderate-high perception of HIV infection. Further research needed on substance careers, networks and causes to determine how to control miraa and bhang use among FCSWs.