Micro-level social and structural factors act synergistically to increase HIV risk among Nepalese female sex workers.
OBJECTIVE
Sex workers face stigma, discrimination, and violence across the globe and are almost 14 times more likely to be HIV-infected than other women in low- and middle-income countries. In Asia, condom campaigns at brothels have been effective in some settings, but for preventive interventions to be sustainable, it is important to understand micro-level social and structural factors that influence sexual behaviours of sex workers. This study assessed the syndemic effects of micro-level social and structural factors of unprotected sex and the prevalence of HIV among female sex workers (FSWs) in Nepal.


METHODS
This quantitative study included 610 FSWs who were recruited using two-stage cluster sampling from September to November 2012 in 22 Terai Highway districts of Nepal. Rapid HIV tests and face-to-face interviews were conducted to collect biological and behavioural information. A count of physical (sexual violence and other undesirable events), social (poor social support and condom negotiation skills), and economic (unprotected sex to make more money) factors that operate at the micro-level was calculated to test the additive relationship to unprotected sex.


RESULTS
The HIV prevalence was 1%; this is presumably representative, with a large sample of FSWs in Nepal. The prevalence of unprotected sex with clients was high (24%). For each additional adverse physical, social, and economic condition, the probability of non-use of condoms with clients increased substantially: one problem = 12% (p<0.005), two problems = 19% (p<0.001), and three to five problems = 38% (p<0.001).


CONCLUSIONS
Interactions between two or more adverse conditions linked to physical, social, and economic environments increased the risk of unprotected sex among Nepalese FSWs.
Public Health and Environment Research Center, GPO Box 8973, NPC 473, New Baneshwor, Kathmandu, Nepal; Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden. Electronic address: deuba4k@gmail.com.
Keshab
K
Deuba
Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
Sarah
S
Anderson
Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden; Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden.
Anna Mia
AM
Ekström
FHI360, Kathmandu, Nepal.
Satish Raj
SR
Pandey
Centre for International Health, University of Bergen, Bergen, Norway.
Rachana
R
Shrestha
Department of Public Health, Nobel College, Pokhara University, Kathmandu, Nepal.
Deepak Kumar
DK
Karki
Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden; Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden.
Gaetano
G
Marrone
D000293:Adolescent; D000328:Adult; D003430:Cross-Sectional Studies; D005260:Female; D015658:HIV Infections / Q000209:etiology*; D006801:Humans; D008875:Middle Aged; D009390:Nepal / Q000453:epidemiology; D015995:Prevalence; D012307:Risk Factors; D060386:Sex Workers; D047568:Unsafe Sex / Q000706:statistics & numerical data; D055815:Young Adult
Female sex workers; HIV infections/epidemiology; Nepal; Risk environment; Syndemic