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Try out PMC Labs and tell us what you think. Learn More. The aim of the study was to compare reproductive health and high-risk behaviors in female sex workers FSWs and single mothers SMs in Zambia's two largest cities, Lusaka and Ndola. A subset completed an interviewer-administered survey. Tailored and targeted reproductive health services are needed to reduce HIV, STI, and unplanned pregnancy in these vulnerable women. Zambia in southern Africa has a population of As elsewhere in Africa, sex work in Zambia is a high-risk activity for exposure to HIV, sexually transmitted infections STIsand unplanned pregnancy.

As expected, HIV prevalence was high Condom use was inconsistent, particularly with nonpaying partners, 6 and poverty was the norm. Risk factors for sex work are generally related to poverty resulting from lack of education and employment opportunities. Single mothers SMs are likely to be at high risk of initiating sex work, particularly those with an unplanned pregnancy or those who have been widowed or abandoned.

The goal of the study sponsors was to identify uninfected women at high risk of HIV for possible inclusion in prevention trials. Two recruitment strategies were used. In the first, SMs who had ly tested HIV negative during antenatal care and were not currently pregnant were referred from infant vaccination services in government clinics.

To protect confidentiality, recruiters distributed invitations to all interested FSWs without asking their HIV status. Women received family planning counseling with the offer of LARC, which were not readily available in government clinics.

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Free condoms were also provided. As there could be overlap between FSWs and SMs despite the different recruitment methods, SMs referred from infant vaccination clinics were asked if they exchanged sex for money and classified as FSWs in these analyses if they responded affirmatively. Women receiving services were ased a unique numeric participantand identifiers were not recorded. A subset of participants provided written informed consent for an interviewer-administered questionnaire assessing demographic and behavioral risk factors for HIV and STI.

Questions included age, marital status, sexual and reproductive history, condom and contraceptive use, fertility goals, and alcohol use. We assessed literacy in local languages Nyanja and Bemba and English. Nyanja and Bemba are Zambia's two most commonly spoken languages. Lusaka is the centrally located capital and home to migrants from all parts of the country.

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Nyanja is the accepted language of communication though it is not the first language for most. Ndola is in the northern Copperbelt region where Bemba is universally spoken as a first language. In general, English is not taught until secondary school. FSW, female sex workers. Women with trichomonas on vaginal wet mount were provided with a 2-g oral dose of metronidazole directly observed therapy.

Women reporting vaginal discharge were treated for candida or bacterial vaginosis based on examination of vaginal wet mounts. Bivariate and multivariate logistic regression models were run after assessing collinearity. Variables and interaction terms by city ificantly associated with outcomes in bivariate models at an alpha of 0.

Final multivariate logistic regressions were arrived at by dropping nonificant variables and interaction terms through backward elimination. Individual variables comprising the interaction terms were also included in the models to ensure that models were hierarchically well formulated.

Contrast statements were used to estimate associations between predictor and outcome by city. All procedures, including counseling, informed consent, and surveys, were administered in English, Nyanja, or Bemba, the predominant local languages in Lusaka and Ndola. Differences in detection of sperm noted on wet mount, an indicator of unprotected sex in the 3 days, were not ificant. SMs in Lusaka were least likely to report using a modern nonbarrier contraceptive method.

When the implant and the IUD were offered at the project clinic, 30 women in Lusaka and 22 in Ndola chose the implant with none choosing the IUD not shown. An additional five women in Lusaka and one in Ndola requested a LARC method but had a positive pregnancy test and did not qualify not shown. At least two-thirds of Lusaka dwellers also understood Bemba easily though only one in five could read Bemba easily Table 2.

English literacy trends paralleled comprehension though at lower levels, with over half of Lusaka respondents able to read English with ease compared with only one in 5 FSWs and one in 20 SMs in Ndola. SMs reported a mean of 0.

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HIV-negative FSWs were asked about steady, nonpaying partners; repeat clients; and nonrepeat clients in the last month. The of repeat clients in the last month mean 4. Figure 1 shows patterns of condom use by city and by partner type. Interestingly, in both cities the proportion of women reporting use of a condom during their first sexual encounter was not different in FSWs and SMs.

When asked whether they had their first sexual intercourse willingly, two-thirds to three-quarters of all groups said yes.

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Similarly, among Lusaka SMs, contraceptive use was not different in women who wanted to have more children and in those who did not. Interaction terms for city were initially included for trichomonas and modern contraceptive use but were not ificant in the multivariate model and were removed through backward elimination Table 4.

The following variables were not ificant in bivariate analyses and are not tabled: Trichomonas on wet mount result, sperm on wet mount result, and pregnancy self-reported. The following variables were not ificant in initial adjusted analyses and were removed from the final multivariate model through backward elimination and are not tabled: interaction terms between city and trichomonas on wet mount and city and current contraceptive method, and current contraceptive method.

Increasing age, younger age at first sexual encounter, being single versus widowed, divorced or separated, reading the vernacular Bemba and Nyanja with difficulty or not at all versus reading either easily in Ndola, being forced physically versus engaging willingly at first sexual intercourse in Ndola, receiving money or goods at first sexual intercourse, and ever using alcohol remained ificant predictors of being an FSW versus an SM.

Interestingly, primary and secondary education versus no education were associated with a lower likelihood of being an FSW in Lusaka, while secondary education or higher was associated with a higher likelihood of being an FSW in Ndola Table 5. The following variables and interaction terms were not ificant in initial adjusted analyses and were removed from the final multivariate model through backward elimination and are not tabled: interaction terms between city and marital status and city and current contraceptive method, and current contraceptive method.

In light of these findings, the low rate of condom use—particularly among SMs—the high rate of verbal or physical coercion at first sexual intercourse for both SMs and FSWs, and the frequent use of alcohol during sex by FSWs are especially alarming. Unplanned pregnancy is an additional risk in these women of childbearing age, and use of effective modern contraception is low even among women who state that they do not want to become pregnant.

Substantial differences in HIV and STI prevalence and risk behaviors between the two cities indicate that local characteristics are important to consider in prevention and care programs. While comprehension of the local language in culturally homogeneous areas such as Ndola is universal, cities like Lusaka host migrants from several language groups.

Understanding of Nyanja may be adequate for day-to-day communication, but nuanced or complex HIV prevention messages may not be thoroughly understood. This, in combination with limited English comprehension and vernacular literacy, highlights the limitations of many HIV prevention efforts for these key populations to date.

In both groups, uptake of a LARC method when offered at the research clinic was low. In sub-Saharan Africa, the proportion of women involved in sex work has been estimated at between 0. Targeted services have been effective in several settings, including southern, 24 western, 25 and east-central Africa 2627 as well as on trans-Africa highways. Programs targeting adolescent girls and young women AGYW aged up to 24 years often include educational and economic components deed to prevent entry into the sex industry.

Literacy in the vernacular was poor as was English comprehension, both indications that employment opportunities and comprehension of written HIV prevention materials would be limited. A quarter to a third of both groups had been pressured physically or verbally at first sex, and among SMs a comparable proportion reported receiving goods or money for that first sexual exposure in both cities. This problem of abuse at a young age has been reported elsewhere in Africa. There have been many legal, policy, and sociocultural barriers to HIV prevention and care among key populations, including FSWs.

Lusaka respondents were much less likely to report wanting more children than Ndola respondents, although their of existing children was not different. Paradoxically however, they were also far less likely to be using a modern contraceptive method. Chanda et al. Finally, the practice of sex work may be fluid with temporal transitions and combinations of steady and casual, paying or gifting and nonpaying partners.

Our study had several limitations. Our recruitment strategy targeted sexually active HIV-negative SMs at infant vaccination services in government clinics who responded positively to a referral to the research site. Some women referred from infant vaccination might have been FSWs but declined to respond positively to the question regarding exchange of sex for money, which may have resulted in some misclassification.

Our recruitment strategy for FSWs also did not allow data collection for those who did not respond to the invitation. The study was conducted in two of the largest cities in Zambia. Environmental and socioeconomic factors specific to these cities may affect generalizability of the findings in this study to other areas, for example, border towns where commercial sex work is prominent or rural areas. Despite the study having these limitations, the findings are relevant because they highlight the fact that SMs who have not been identified as a group at ificant risk of HIV infection have similar risk profiles to FSWs.

This, combined with poverty and lack of education, makes these women highly vulnerable. Programs for AGYW should consider expanding age ranges to provide income generation options other than sex work for SMs. We also thank the staff in infant vaccination clinics in the Lusaka and Ndola government clinics whose referrals of single women were critical to our efforts. The funders had no role in study de, data collection and analysis, decision to publish, or preparation of the article. Contributions of coauthors included conceptual all ; implementation of the work and data collection W. All coauthors provided careful review and editing of the article.

National Center for Biotechnology InformationU. Published online Aug Find articles by William Kilembe. Find articles by Mubiana Inambao. Find articles by Tyronza Sharkey. Kristin M. Find articles by Kristin M. Find articles by Rachel Parker. Find articles by Constance Himukumbwa. Find articles by Amanda Tichacek.

Find articles by Kalonde Malama. Find articles by Ana-Maria Visoiu. Find articles by Matt Price. Find articles by Elwyn Chomba. Find articles by Susan Allen. Author information Copyright and information Disclaimer. CopyrightMary Ann Liebert, Inc. This article has been cited by other articles in PMC. Abstract The aim of the study was to compare reproductive health and high-risk behaviors in female sex workers FSWs and single mothers SMs in Zambia's two largest cities, Lusaka and Ndola. Keywords: HIV, contraception, sex work, genital infection, Africa.

Introduction Zambia in southern Africa has a population of Demographic and behavioral survey Women receiving services were ased a unique numeric participantand identifiers were not recorded. Open in a separate window.

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