Condom nonuse among female sex workers in Chennai, India

Synopsis

Efforts are required to promote condom use within trusting commercial sex relationships and to reduce unprotected sex resulting from economic coercion and violence.

There are currently over 2.4 million adults in India living with HIV [1]; commercial sex is uniquely implicated in this epidemic [2]. Over the past 2 decades, extensive HIV prevention and condom promotion efforts among female sex workers (FSWs) have been made, resulting in national surveillance survey reports of over 80% condom use among FSWs and their clients [3].

Given the widespread condom availability and high HIV knowledge among FSWs in India, motivations for condom nonuse are unclear. Clarification is vital for refining HIV prevention efforts because programmatic approaches vary widely according to the reasons for condom nonuse—unprotected sex as a result of limited condom access, for example, would indicate the need to increase condom availability. Relationship intimacy among FSWs and clients may influence nonuse [4], and clients may refuse to use condoms or may offer more money for unprotected sex. These varying reasons indicate a need for independent interventions.

The reasons underpinning condom nonuse are particularly relevant in settings characterized by recent increases in condom access and HIV knowledge among FSWs. Against this backdrop, the present study explored reasons for condom nonuse among FSWs in Chennai, India.

Secondary analyses were conducted on baseline survey data collected in 2008 from FSWs in Chennai as part of a randomized feasibility trial for a microenterprise intervention [5]. In total, 100 FSWs were recruited from street-based venues, including train stations and markets. All study procedures were approved by the Institutional Review Boards at Johns Hopkins Bloomberg School of Public Health, Baltimore, USA, and the YR Gaitonde Centre for AIDS Research and Education (YRG CARE), Chennai, India.

Analyses were limited to the 22 (22.0%) FSWs who reported condom nonuse at either of their 2 most recent paid sexual encounters. Participants selected all applicable reasons for condom nonuse from a list, which included trust (“I trust my partner”), client suggestion (“my partner suggested it”), FSW suggestion (“I suggested it”), unavailability (“condoms were not available”), economic coercion (“he pays more for sex without a condom”), time constraints (“we didn’t have time to put on a condom”), fear of violence (“I am afraid to suggest using a condom because he would hit me”), and other. Descriptive analyses were conducted and pairwise clustering of responses was explored.

Participants had a median age of 35.3 years (range, 26–58 years) and were predominantly Hindu (15 [68.2%]). Primary reasons for condom nonuse were trust (12 [54.5%]) and client suggestion (10 [45.5%]) (Table 1). For half of the trust responses (6 [50.0%]), client suggestion was reported simultaneously. A smaller number of the total participants (3 [13.6%]) indicated that they were offered more money for unprotected sex; this reason was given in conjunction with trust and client suggestion. Although fear of violence was less common (3 [13.6%]), it was reported independently of other factors. Neither FSW-initiated condom nonuse (3 [13.6%]) nor lack of condom availability (3 [13.6%]) was reported as the sole reason for nonuse. Of the 3 (13.6%) participants who selected “other,” 2 indicated that they performed oral sex only and 1 indicated that she “was not asked.”

Table 1.

Reasons for condom nonuse among FSWs (n=22)^a,^b

	Reasons	Total	Sole reason	Response clusters
				Trust client	Client suggested	Economic coercion	Fear of violence	I suggested	Not enough time	Not available	Other
Relationship	Trust client	12 (54.5)	4 (33.3)	—	6 (50.0)	1 (8.3)	0 (0.0)	3 (25.0)	0 (0.0)	1 (8.3)	2 (16.7)
Client	Client suggested	10 (45.4)	2 (20.0)	—	—	2 (20.0)	0 (0.0)	2 (20.0)	0 (0.0)	1 (10.0)	1 (10.0)
	Economic coercion	3 (13.6)	1 (33.3)	—	—	—	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)
	Fear of violence	3 (13.6)	3 (100.0)	—	—	—	—	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)
FSW	I suggested	3 (13.6)	0 (0.0)	—	—	—	—	—	0 (0.0)	1 (33.3)	1 (33.3)
Time and access	Not enough time	1 (4.5)	1 (100.0)	—	—	—	—	—	—	0 (0.0)	0 (0.0)
constraints	Not available	3 (13.6)	0 (0.0)	—	—	—	—	—	—	—	1 (33.3)
Other	Other	3 (13.6)	0 (0.0)	—	—	—	—	—	—	—	—

Abbreviation: FSW, female sex worker.

^aValues are given as number (percentage). Percentages in the response clusters were calculated by row.

^bBecause participants could select more than 1 response, the numbers in the response clusters may exceed the total number of responses for each reason.

The findings from the relatively small present sample illustrate the complexity of condom nonuse among FSWs. A confluence of trust, client suggestion, and (in some cases) economic coercion and fear of violence appears to underpin condom nonuse. The findings demonstrate the importance of relationship dynamics and the active role of male clients, indicating the need for expansion beyond FSW-centered approaches and improving access to encourage condom use.

Consistent with prior evidence indicating the influence of relationship intimacy [4], the most common reason given for nonuse was trust. Client suggestion was selected simultaneously by half of those citing trust, indicating that male clients take an active role in decision making regarding condom use. Raising awareness of the risks posed within trusting relationships is required for both FSWs and clients. Neither lack of condom availability nor FSW-initiated nonuse emerged as an independent reason, again highlighting the centrality of FSW–client decision-making dynamics to nonuse.

Although less commonly selected as reasons for condom nonuse, 2 potential threats to the agency of FSWs to ensure condom-protected sex were reported. Economic coercion was selected jointly with client-initiated condom nonuse and trust, indicating the influence of clients’ relative economic power over FSWs. Condom nonuse that occurs as a result of increased financial gain for FSWs indicates the potential utility of economic development efforts for FSWs. Although fear of physical violence was also less commonly reported, it was indicated solely as an independent reason for condom nonuse. Violence against FSWs can undermine condom use [6], and HIV prevention efforts should consider the potential threat of violence.

The results of the present study should be viewed in light of several limitations: all data were self-reported; within the parent study, condom use was high, resulting in a small sample size for the present investigation; and the extent to which findings may generalize to other settings—particularly those characterized by lower levels of HIV knowledge and condom use—is unclear.

The findings of the present study highlight the role of relationship dynamics in condom nonuse among FSWs and illustrate the role of male clients in decision making regarding condom use. Efforts targeting male clients and FSWs to promote protection within trusting relationships are required, as are efforts to reduce unprotected sex that results from economic coercion and the perceived threat of violence.