Dual contraceptive use among female sex workers in high HIV-burden settings in sub-saharan Africa: A systematic review and meta-analysis

Abstract

Background

Female sex workers (FSWs) in sub-Saharan Africa (SSA) face higher risks of unintended pregnancies and sexually transmitted infections, including HIV. This risk can be reduced with correct and consistent use of dual contraception, defined as the concurrent use of a barrier method together with another modern contraceptive methods. However, there are limited and fragmented data on the prevalence and factors associated with dual contraception use among FSWs in SSA.

Objectives

Our systematic review and meta-analysis aimed to determine the pooled prevalence of dual contraceptive use and HIV infection prevalence among FSWs in the high HIV-burden settings of SSA.

Design

A systematic review and meta-analysis.

Data sources and methods

We conducted a comprehensive search of PubMed, MEDLINE, EMBASE, Web of Science, and African Journal Online, from January 1980 up to October 2023. We also reviewed bibliographies of relevant articles to find additional studies. Only observational and interventional studies reporting dual contraceptive use among FSWs in Africa were included, while reviews, case reports, and case series were excluded. Two reviewers evaluated study quality using the modified Newcastle-Ottawa Scale. Data on dual contraceptive use, contraceptives methods, associated factors and HIV prevalence were extracted and analysed using random-effect or fixed-effect meta-analysis models to calculate the pooled prevalence estimates defined as combined average estimates across studies.

Results

We included 11 studies, involving a total of 127,059FSWs from eight countries in SSA. HIV prevalence ranged from 1-55% across studies, with a pooled prevalence of 24% (95% confidence interval (CI): 14-35%, I² = 99.57%, p<0.001). Dual contraception prevalence ranged from 3.8-66.2% across studies, with a pooled prevalence of 26% (95% CI: 12% – 39%, I² =99.9%, p<0.001). The most frequently reported contraceptive method were condoms (n=41,200,32.1%) and oral contraceptive pills (n=20,735, 16.5%), followed by injectables (n=6,349, 5.1%), Implants (n=5,430, 4.3%) and intrauterine device (n=601, 0.5%).

Conclusions

Dual contraceptive utilization remains sub-optimal among FSWs in SSA, with fewer than one in three FSWs utilising this essential reproductive health strategy. Moreover, HIV prevalence remains high in this population. Targeted strategies to improve utilisation of dual contraception among this marginalised population is needed to reduce the risks of unintended pregnancies, HIV infection and other STIs and their negative impacts on FSWs, their clients, families and the entire healthcare systems.

Introduction

Female sex workers (FSWs) constitute a large proportion of the marginalised group in sub-Saharan Africa, particularly in urban centres. ¹ They face significant health and social challenges, including inconsistent condom use and harsh working conditions, which increases their risk of unintended pregnancy and sexually transmitted infections (STIs), including human immunodeficiency virus (HIV). ² Although correct and consistent condom use is known to be an important barrier method that confers protection against both pregnancy and STIs, their use is often low in most sub-Saharan African countries.^3,4 In a recent study from Kigali, Rwanda, only about one-third of FSWs consistently use condoms. ⁵

Pregnancy prevention may be a stronger motivator for condom use among FSWs compared to HIV prevention. ⁶ Yet this is not a target for most program implementers who focus on HIV prevention in this population. Studies have shown that unintended pregnancy is a high-priority issue for FSWs, ⁷ evident by the very high rates of abortion among FSWs compared to national estimates. ⁸ Dual contraception, the concurrent use of condom or other barrier method alongside a modern non-barrier contraceptive method is highly recommended among FSWs. This approach provides effective dual protection against both HIV/STIs and unintended pregnancy, ⁹ especially that both pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) for HIV prevention remains underutilised in sub-Saharan Africa. ¹⁰ However, the use of effective non-barrier contraception methods among FSWs is sub-optimal, resulting in high rates of lifetime experience of unintended pregnancy and STIs/HIV. ⁸

Most of the African countries have limited evidence on unintended pregnancy among FSWs, although a range has been reported among FSWs in Africa from as low as 28.6% in Ethiopia, ¹¹ to as high as 69% in Cote D`Ivoire. ¹ Factors such as having four or more children, being unmarried, being adolescents or being older than 30 years, and use of drugs and alcohol are associated with higher unintended pregnancy rates.^11,12 Many of these pregnancies could potentially be prevented through wider adoption of dual contraception. In Ethiopia, missed injections, skipped pills, and inconsistent condom use were causes of unintended pregnancy among FSWs. ¹¹ A study in Tanzania among FSWs living with HIV found that although most wanted to prevent pregnancy, only 4% reported dual contraception, and only 5% reported using condoms consistently. ¹³ There is wide variation in evidence of unintended pregnancies among FSWs in Africa. However, consistent use of male and female condoms remains an essential tool for preventing HIV infection and other STIs among FSWs. We estimated the pooled prevalence of dual contraceptive use and HIV among FSWs in sub-Saharan Africa to address the gap in reproductive health data and improve health outcomes for this vulnerable group.

Methods

Study design and eligibility criteria

We performed a systematic review and meta-analysis in accordance with the preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. ¹⁴ This study was prospectively registered on the PROSPERO database (Registration ID: CRD42022323848).

Search strategy

With the help of a qualified medical librarian, all studies published from January 1980 to October 2023 were searched from PubMed, MEDLINE, EMBASE, Web of Science, and the African Journals Online (AJOL). We also reviewed bibliographies of relevant articles to find additional studies.

The following search terms were used: “Dual contraceptive” OR “Dual contraception” AND “ commercial sex or sex work” OR “Female sex” OR “sex worker” AND “Africa South of Sahara” OR “sub-Saharan Africa” OR “Angola” OR “Benin” OR “Botswana” OR “Burkina Faso” OR “Burundi” OR “Cameroon” OR “Cape Verde” OR “Central African Republic” OR “Chad” OR “Comoros” OR “Democratic Republic of Congo” OR “Cote d'Ivoire” OR “Djibouti” OR “Eritrea” OR “Eswatini” OR “Ethiopia” OR “Equatorial Guinea” OR “Gabon” OR “Gambia” OR “Ghana” OR “Guinea” OR “Guinea-Bissau” OR “Kenya” OR “Lesotho” OR “Liberia” OR “Madagascar” OR “Malawi” OR “Mali” OR “Mauritania” OR “Mauritius” OR “Mozambique” OR “Namibia” OR “Niger” OR “Nigeria” OR “Rwanda” OR “Sao Tome and Principe” OR “Senegal” OR “Seychelles” OR “Sierra Leone” OR “Somalia” OR “South Africa” OR “South Sudan” OR “Sudan” OR “Tanzania” OR “Togo” OR “Uganda” OR “Zaire” OR “Zambia” OR “Zimbabwe”.

Study selection criteria

Duplicate studies were identified and merged using the Mendeley software Titles and abstracts were screened by independent reviewers to exclude those not related to this study. After the initial screening, full texts of potentially eligible studies were retrieved and examined for eligibility. Studies that met the following inclusion criteria were included.

• 1. Retrospective or prospective observational and interventional studies from January 1980 to October 2023.

• 2. Published in English.

• 3. Reporting prevalence of dual contraceptive use with or without prevalence of HIV among FSWs in sub-Saharan Africa.

• 4. Studies that included broader populations of sexually active women were retained only when the study setting or sampling frame included substantial representation of female sex workers or populations with comparable sexual risk profiles. This decision was made to capture evidence relevant to dual contraception use in contexts overlapping with sex work populations

• 5. Non-primary research publications such as reviews, case reports, case series, editorials, commentaries, technical notes and conference abstracts were excluded. We also excluded studies that included condom use as an intervention.

Data extraction

A pre-designed macros form in Microsoft Excel 2021 was used to extract data from each article. The following items were extracted: Study characteristics; authors, year of publication, study country, study design. Study characteristics: age (mean or median), the sample size of the participants, dual and non-dual contraceptive use, number of participants with HIV (prevalence) and factors associated with dual contraceptive. Independent reviewers extracted data, and any differences were resolved by discussion and consensus. For randomized controlled trials, prevalence of dual contraception use and HIV status were extracted from baseline measurements prior to randomization where available to ensure comparability with observational studies.

Quality assessment

All the eligible studies included were assessed for risk of bias using the Critical Appraisal Skills Programme (CASP) checklist. The risk of bias in individual studies was graded as low, moderate, and high.

Study outcomes

Primary study outcome

Pooled prevalence, trend and factors associated with dual contraceptive use among FSWs in sub-Saharan Africa.

Secondary study outcome

Pooled prevalence of HIV among FSWs in Sub-Saharan Africa.

Statistical analysis

All analyses were performed using STATA 18.0 statistical software (Stata Corp, College Station, Texas, USA). We calculated pooled prevalence using a random-effects meta-analysis model, which weights individual study estimates by the inverse of their variance; this approach accounts for both within- and between-study variability, and therefore the pooled prevalence may differ from the crude overall prevalence derived by simply aggregating cases and participants across studies. A random effect cumulative meta-analysis was performed to illustrate the trends in the prevalence of dual contraception use among female commercial sex workers and presented in a forest plot. Heterogeneity across studies was assessed using Q statistics and I² value. A funnel plot was generated to assess for publication and sensitivity analysis performed. Descriptive statistics were used to summarize data from individual studies. We interpreted heterogeneity using the Q statistic (p < 0.10 indicating significant heterogeneity) and the I² statistic, with values of 25%, 50%, and 75% representing low, moderate, and high heterogeneity, respectively.

Results

Study selection

From the comprehensive literature search, a total of 242 articles were identified. After deduplication, 38 articles were eligible for screening by title and abstract. Thereafter, full text of 32 articles were retrieved and 11 met the inclusion criteria for this systematic review and meta-analysis. Figure 1 shows the PRISMA flow diagram with details of the study screening and selection process.

Figure 1.

PRISMA flow diagram.

Study characteristics

A total of eleven studies (8 cross-sectional and 3 RCTs) involving 127,059 participants from eight sub-Saharan African countries were included. While most studies specifically recruited FSWs, two studies included broader samples of sexually active women in settings where sex work was prevalent. The included studies were conducted in nine countries: Swaziland (n=2), Kenya (n=2), Tanzania (n=2), Burkina Faso (n=1), Togo (n=1), Madagascar (n=1), Zambia (n=1), and Uganda (n=3) Table 1.

Table 1.

Summarizes the characteristics of all the studies included in the systematic review

Study	Country	Study design	Study population	Age: Median or mean	Sample size (N)	Dual Contraception(n)	People living with HIV(n)
Bongomin et al., 2023 15	Uganda	Cross-sectional	Female sex workers	28.8±6.4	314	208	41
Beckham et al., 2021 16	Tanzania	Randomised control trial	Female sex workers at entertainment venues (bars and hotels)	<=30 years: 186 (54.87%)	399	21	174
				>30 years: 153 (45.13%)
Mbita et al., 202017,*	Tanzania	Cross-sectional	Female sex workers	-	119,728	4548	9404
Bukenya et al., 201918,19	Uganda	Cross-sectional	FSW attending the most at-risk populations initiative’ clinics all over Uganda	<=30 years: 186 (54.87%)	819	475	243
				>30 years: 153 (45.13%)
Kelvin et al., 2019	Kenya 20	Randomised control trial	Female sex workers	25.4	879	232	106
Chanda et al., 201721,22	Zambia	Randomised control trial	Female sex workers	25	946	173	-
Erickson et al., 2015 23	Uganda	Cross sectional	Female sex workers	14	400	180	89
Schwartz et al., 2015 24	Bukina Faso, Togo, Swaziland	Cross sectional	Female sex workers, Togo 16-49, Burkina Faso and Swaziland 18-49	25	1666	150	481
Yam et al., 2013 4	Swaziland	Cross-sectional	Female sex workers	-	325	26	179
Sutherland et al., 2011 25	Kenya	Cross-sectional	Female sex workers	27.4	597	227	54
Behets et al., 2005 26	Madagascar	Cross-sectional	Female sex workers	-	986	46	-

*This study included female sex workers engaged in specific HIV prevention and care programs, which may limit the generalisability of findings to all sexually active women.

Pooled prevalence of dual contraception among female sex workers in sub-Sahara Africa

Overall, 5.30% (n= 6787) FSWs reported using dual contraception. Dual contraception prevalence ranged from 3.8% —66.2% across individual studies with the highest prevalence reported in 2023 and lowest in 2020 (Figure 2), with a pooled prevalence of 26% (95% CI: 12% – 392%, I² =99.9%, p<0.001), Figure 3. The most frequently reported contraceptive method were condoms (n=41,200,32.1%) and oral contraceptive pills (n=20,735, 16.5%), followed by injectables (n=6,349, 5.1%), Implants (n=5,430, 4.3%) and intrauterine device (n=601, 0.5%). Table 2.

Figure 2.

Trend of dual contraceptive use across the year of studies included.

Figure 3.

The pooled prevalence of dual contraception among female commercial sex workers in Africa.

Table 2.

Prevalence of the difference contraceptive methods.

Study	Condom n (%)	IUD n (%)	Implants n (%)	Injectable n (%)	Oral pills n (%)
Bongomin et al., 2023 15	301 (95.9)	55 (17.5)	109 (52.4	47 (22.6)	52 (16.5)
Beckham et al., 2021 16	83 (20.8)	5 (1.5)	399 (14.8)	72 (21.2)	15 (4.4)
Mbita et al., 2020 17	37,947 (31.7)	460 (0.4)	4556 (3.8)	4139 (3.5)	19549 (16.3)
Bukenya et al., 2019 18	748 (91.3)	-	109 (13)	308 (37.6)	71 (8.7)
Kelvin et al., 2019 20	440 (50)	14 (1.6)	199 (22.6)	196 (22.3)	73 (8.3)
Chanda et al., 2017 21	102 (10.8)	18 (1.9)	120 (12.7)	547 (57.8)	260 (27.5)
Erickson et al., 2015 23	359 (89.8)	8 (2)	25 (6.3)	162 (40.5)	28 (7)
Schwartz et al., 2015 24	17 (1)	55 (3.3)	140 (18.4)	645 (38.7)	621 (37.3)
Yam et al., 2013 4	50 (15.4)	-	-	-	-
Sutherland et al., 2011 25	460 (77)	-	12 (2)	233 (39)	66 (11)
Behets et al., 2005 26	193 (19.6)	-	-	-	-
Total n/N (%)	41,200/128,351 (32.1)	601/123,453 (0.5)	5,430/125,349 (4.3)	6,349/125,349 (5.1)	20,735/125,349 (16.5)

Pooled prevalence of HIV among female sex workers in sub-Sahara Africa

Overall, 11,002 (8.6%) study participants reported living with HIV. The prevalence of HIV ranged from 7.9-55.1% across studies (Figure 4), with a pooled prevalence of HIV being 24% (95%: 14-35%, I ² : 99.57%, p<0.001), Figure 5. Across the included studies, age was not consistently associated with uptake of dual contraception.

Figure 4.

Trend of HIV across the year of studies included.

Figure 5.

The pooled prevalence of HIV among female commercial sex workers in Africa.

Discussion

This systematic review synthesized data from thirteen studies and examined dual contraceptive use among FSWs in sub-Saharan Africa. The pooled utilization of dual contraception was 26%. The results advance a small but growing body of evidence regarding the sexual and reproductive health needs of FSW and begin to shed much-needed light on the intricate interplay of condom and female-controlled modern non-barrier contraceptive use among this population in Africa. FSW with no pregnancy intentions, should have access to and use of dual protection. This is an essential component of comprehensive sexual and reproductive health services and FSW may also want children and need access to comprehensive reproductive health and family planning.^9,27

Female-controlled modern non-barrier contraceptive methods are the most effective approaches for preventing unintended pregnancy; however, they do not provide protection against HIV transmission. For FSWs, access to and use of these methods (e.g., oral pills, injectables, implants, and intrauterine devices) are critical to safeguarding their reproductive health and autonomy. ²¹ Condom use remains essential for HIV prevention and, when combined with a female-controlled method, offers dual protection against both unintended pregnancy and HIV.

Condoms were the most frequently reported contraceptive method (32.1%), likely reflecting their widespread availability in many sex work venues. Greater access to condoms in workplaces may facilitate their use and strengthen condom negotiation between FSWs and clients. ²¹ However, overall condom use remained suboptimal, leaving FSWs at continued risk of HIV and other sexually transmitted infections, unintended pregnancies, and potential mother-to-child transmission. Structural factors also influence condom negotiation. In settings where sex work is criminalized, FSWs may be compelled to operate in remote or unsafe environments, limiting their ability to negotiate safer sexual practices. Stigma, lack of legal protection, and exposure to violence from clients can further undermine their ability to screen clients or insist on condom use during sexual encounters.^28–30

The pooled prevalence for various female-controlled modern non-barrier methods showed injectables (5.1%), implants (4.3%), oral contraceptive pills (16.5%), and intrauterine devices (0.5%). The proportionate use of condoms and non-barrier contraceptive method especially, implants shows that FSWs appear to prioritise pregnancy prevention methods as well as HIV/STI transmission, among the sector of this population using contraception. Furthermore, this study showed no significant association between the age of the FSW and dual contraception uptake. Younger FSWs were not found as more or less likely to take up dual contraceptives. However, the study by Mbita G et al., 2020 found that FSWs who tested positive for HIV were less likely to use any condoms, likely increasing the risk of acquiring HIV and, potential onward transmission. ¹⁷

Strengths and limitations

This review identified 13 eligible studies and, to the best of our knowledge, is the first in Africa to assess dual contraceptive uptake among FSWs. An extensive search was performed using a sensitive strategy developed and translated in consultation with a medical librarian across major databases. To enhance rigor, titles and abstracts were independently screened by multiple reviewers.

A limitation of the review process is that the review did not include grey literature such as conference abstracts, which may have resulted in omission of relevant unpublished findings. Additionally, only English-language studies were included; however, we believe this had minimal impact given that most articles are published in or translated into English. Furthermore, two included studies sampled sexually active women rather than exclusively female sex workers, which may have introduced heterogeneity and should be considered when interpreting pooled estimates.

Previous research suggests that use of non-barrier contraception among FSWs is significantly associated with inconsistent condom use with clients. This could not be consistently confirmed from the included studies, which means our review may underestimate the true unmet need for contraception in this key population. It is also possible that some FSWs reported using both condoms and non-barrier methods without necessarily using them simultaneously, which could further overestimate dual method uptake. Moreover, heterogeneity in how dual contraception and condom use were defined across studies may have introduced bias and affected comparability of findings.

Some included studies, such as Mbita (2020), ¹⁷ specifically recruited FSWs engaged in structured HIV prevention and care programs, which may limit the generalisability of our pooled findings to all sexually active women. High heterogeneity across included studies likely reflects differences in study design, populations, and measurement approaches. The pooled prevalence of HIV of 24% derived from the meta-analysis differed substantially from the crude overall proportion of participants living with HIV across studies, likely reflecting the influence of study-level weighting, heterogeneity in study populations, and differences in sample sizes across included studies. Although we applied a random-effects model to account for variability, residual heterogeneity remains and should be considered when interpreting the pooled estimates. Finally, because our inclusion criteria required studies to report on both HIV and dual contraception use, some studies of HIV prevalence among FSWs in sub-Saharan Africa were excluded. This selective inclusion may have introduced bias and limits the generalisability of the pooled HIV prevalence estimate.

Conclusions

Dual contraception remains low among FSW in Africa, with fewer 1 in 3 individuals utilising these essential reproductive health package. Moreover, HIV prevalence remains substantial in this population. Targeted strategies to improve utilisation of dual contraception among this marginalised population is recommended to reduce the incidence of HIV infection and other STIs. These outcomes indicate that interventions to expand access and use of dual contraception (condoms and female-controlled non-barrier methods) may help improve reproductive health outcomes among FSW in Africa. The unmet contraceptive need and risk for unintended pregnancy and transmission of HIV/STIs among FSWs is still great. The availability of condoms in the FSWs workplaces may support increased use, which could contribute to reduced unplanned pregnancy and abortions. This may be because women working in settings where condoms are available may have greater power with condom negotiation with clients, which helps reduce both HIV/STI transmission and unintended pregnancies.

The present research demonstrates the need to promote access to effective female-controlled non-barrier contraceptive methods for those who seek pregnancy prevention, while emphasizing the dual protection afforded by condoms for HIV prevention. This is owing to the relatively lower contraceptive efficacy of condoms due to failure of users to remain consistent with usage at all sexual encounters. Some studies have suggested that adoption of non-barrier contraception may be associated with reduced condom use, although this relationship was not consistently observed in the studies included in this review. Furthermore, criminalized work environments continue to pose barriers to contraceptive use for FSWs, and stigma from health workers also presents a barrier for acquisition of contraception. Therefore, there is a need for policy changes to promote utilization of SRH services, general health, and safety.

ORCID iDs

Felix Bongomin https://orcid.org/0000-0003-4515-8517

Jerom Okot https://orcid.org/0000-0002-4160-6418

Pebalo Francis Pebolo https://orcid.org/0000-0002-1205-1150

Ethical considerations

Ethical approval was not required for this study because it is a systematic review and meta-analysis based solely on previously published studies and did not involve collection of primary data from human participants.

Data Availability Statement

All underlying data have been included within the manuscript.*