Prevalence of HIV and Other Sexually Transmitted Infections, and Risk Behaviors in Unregistered Sex Workers in Dakar, Senegal

HIV prevalence in Senegal remains low (about 1.8 percent in the general adult population), but the government has long been concerned with the control of sexually transmitted infections (STI) among female sex workers. Since 1969, the government has officially tolerated prostitution among women over 21 who register and attend specific dispensaries for monthly medical visits that include genital examination, laboratory tests, counseling and condom distribution.

"The efficacy of this system is believed to have contributed to the slow increase in HIV seroprevalence and to a reduction in other STI," the authors wrote. "However, many female sex workers remain outside this system, deliberately or though ignorance. In particular, women under the legal age for prostitution, many of whom start as early as 15 or 16 years of age, cannot register and are therefore deprived of specific medical follow-up."

The researchers conducted a one-stage cluster-sample survey in Dakar in 2000, recruiting 390 unregistered sex workers from 80 official and clandestine bars, brothels and nightclubs, to estimate the prevalence rates of HIV and other STI and to describe the workers' sociodemographic characteristics, sexual behaviors and reasons for non-registry. The goal was to design specific public health interventions for this population.

The investigators collected blood, endocervical and vaginal samples from the women, who had a median age of 29 years. Sixty-four women (14.6 percent) were under legal age, and almost all were Senegalese. Most were unmarried, poor, had low levels of education, and were otherwise unemployed. Most had started prostitution recently (median length of prostitution, 24 months) and roughly three-quarters (73.5 percent) reported regular prostitution. Most reported few clients in the week before the survey.

Researchers found that three-quarters of the women had markers for at least one infection. Prevalence rates were 6.0 percent for HIV-1; 3.6 percent, HIV-2; 0.4 percent, HIV-1+2; 23.8 percent, syphilis; 22.0 percent, gonorrhea; 20 percent chlamydial infection; 22.4 percent trichomoniasis; 19 percent, candidiasis; and 28.8 percent, bacterial vaginosis. Women reported their main reason for non-registration as ignorance of the legal system and its procedures (19.4 percent). Some (18.9 percent) simply refused to register. Other reasons for non-registration included the desire for discretion, rejection of the official system by the woman or her partner, lack of identity papers, and postponement of registration.

Nearly all the women (95.7 percent) had heard about AIDS, but few felt they were at high risk of contracting HIV (23.8 percent) or other STI (36.5 percent). Of those who did consider themselves at risk, 60.5 percent and 61.2 percent, respectively, attributed their vulnerability to prostitution, while 23.9 percent and 31.1 percent, respectively, cited either inconsistent condom use or condom fragility. Among women who did not feel vulnerable to HIV (43.3 percent) or STI (44.6 percent), 74 and 74.6 percent, respectively, felt protected by condom use. Thirty percent stated they used condoms with their clients either inconsistently (16.4 percent) or not at all (13.9 percent). Only 17.3 percent of the participants said they used condoms regularly with their boyfriend.

The researchers found that, "compared with recent data on registered female sex workers in Dakar, the HIV seroprevalence was significantly lower in these unregistered sex workers." However, they noted, the seroprevalence is more than five times higher than that of the general population.

"This survey suggests that a multidimensional public health response is needed in Senegal," they concluded, "comprising legal information, downwards revision of the legal age for prostitution, and specific medical follow-up based on education, condom promotion and management of STI for non-registered sex workers."