Contraception 84 (2011) 194 198

Original research article

Falling through the cracks: contraceptive needs of female sex workers in Cambodia and Laos,
Guy Morineaua,, Graham Neilsena , Sopheab Hengb , Chansy Phimpachanc , Dyah E. Mustikawatid
b a Family Health International, Asia/Pacific Regional Office, Bangkok 10330, Thailand Technical Bureau, National Center for HIV/AIDS, Dermatology and STIs, Phnom Penh, Cambodia c Center for HIV/AIDS and STDs, Vientiane, Lao PDR d Sub-Directorate for HIV/AIDS and STIs, Ministry of Health, 10560 Jakarta, Indonesia Received 26 January 2010; revised 2 November 2010; accepted 3 November 2010

Abstract Background: Condom is the only method promoted for dual protection among female sex workers (FSWs) in most Asian countries, which may be insufficient to prevent pregnancies given FSWs' high frequency of sexual intercourse. Study Design: Data were obtained from independent cross-sectional surveillance surveys conducted in Cambodia and Laos. Random samples of FSWs provided behavioral information. Results: Respondents numbered 592 in Cambodia and 1421 in Laos. In Cambodia, 28.2% had abortions in the past year despite reporting 99.0% condom use at last commercial sex. Abortion increased with the number of clients, inconsistent condom use, recent condom breakage and recent forced unprotected sex with clients. In Laos, 26.0% of all FSWs had ever aborted as had 89.4% of those who had been pregnant in the past 6 months. Conclusions: FSWs experience higher frequency of abortion than women from the general population. FSWs' reportedly high rate of condom use is insufficient to prevent pregnancies. 2011 Elsevier Inc. All rights reserved.
Keywords: Commercial sex; Abortion; Contraception; Condom failure; Asia

1. Introduction Female sex workers (FSWs) often have high rates of unprotected sex with multiple partners, increasing vulnerability to sexually transmitted infections (STIs; including

This work was supported by Family Health International (FHI) with funds from the US Agency for International Development (USAID). The contents of this article do not necessarily reflect the views of USAID or the United States Government. The survey in Cambodia was conducted with financial and technical support from USAID through the FHI-managed Impact Project. The survey in Laos was conducted with financial support from the Global Fund for AIDS, Tuberculosis and Malaria (GFATM), Round 3, with technical assistance from FHI provided with financial support from the USAID. Corresponding author. Tel.: +66 2263 2300; fax: +66 2263 2114. E-mail address: gmorineau@fhi.org (G. Morineau).

HIV) and unintended pregnancies. In Asia and Africa, the prevalence of reported lifetime abortion among FSWs ranges from 22% to 86% [18]. HIV prevention focuses on condom use as dual protection for STIs and unintended pregnancies. A condom-only prevention strategy for FSWs has epidemiological limitations. While few clients of FSWs can potentially transmit infections, most can impregnate their sexual partners [9]. Condom contraceptive failures (estimated at 1517% per year among the general population) [10,11] are likely to be higher among FSWs who have more frequent intercourse than the general population. Finally, condom use is ultimately client-controlled and FSWs often have limited power to negotiate condom use. We examined unmet contraceptive needs of FSWs approximated by rates of self-reported abortion in Laos and Cambodia. While Cambodia has a concentrated HIV epidemics, Laos is still characterized by a low-level epidemic

0010-7824/$ see front matter 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.contraception.2010.11.003

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[12]. Abortions are restricted in Cambodia but illegal in Laos [2,13,14].

3. Results Survey respondents numbered 592 in Cambodia and 1421 in Laos. In both countries, all women selected for the survey agreed to participate. Demographic and reproductive health characteristics are displayed in Table 1. Compared to Cambodia, Lao FSWs were younger (mean age 20.8 years vs. 25.2), had higher turnover (median duration of selling sex was 7 months vs. 12 months) and reported fewer clients (2.6 clients per week vs. 4.4 clients per day). Almost all FSWs reported condom use at last commercial sex in Laos (95%) and Cambodia (99%). The majority of FSW reported always using condom with clients (94% in the past week in Cambodia and 70% in the past 3 months in Laos). In both countries, about one third of FSWs reported condom breakage in the past 3 months and about half reported having been coerced by clients into unprotected sex. In Cambodia, 3% of FSWs were currently using hormonal contraceptives. Data on uptake of hormonal contraceptives were not available for Laos, but are expected to be low due to poor access to family planning services.
Table 1 Demographic and reproductive health characteristics Characteristics Age in years (mean) 19 2029 30+ Duration since first selling sex in months (mean) 12 months N12 months Marital status Currently married Formerly married Never married Duration since last pregnancy b6 months 6 to b24 months 24 months Currently use hormonal contraceptives Number of clients in last working day, Cambodia; last week, Laos (mean) 13 46 7 Had unprotected sex with regular unpaid partner (past month for Cambodia; past 3 months for Laos) Consistent condom use with regular clients in past month Consistent condom use with non-regular clients (past week for Cambodia; past 3 months for Laos) Experienced condom breakage in the past 3 months Forced by a client not to use a condom (past month for Cambodia; past 3 months for Laos) nd: No data. Cambodia 2007 (n=592) (25.2) 7% 77.7% 14.9% (38.3) 23.6% 76.4% 4.6% 53.5% 41.9% nd nd nd 3.2% (4.4) 47.3% 34.8% 18.0% 18.4% Laos 2008 (n=1417) (20.8) 48.0% 48.4% 3.6% (12.1) 70.3% 29.7% 75.7% 22.5% 1.8% 31.4% 18.9% 49.7% nd (2.6) 76.3% 19.1% 4.5% 13.3%

2. Materials and methods Data used for the present analysis were collected for national HIV behavioral sentinel surveillance in Laos and Cambodia. Each country has designed its own survey to address the specificity of their sex industry and assess the gaps in their response to the HIV epidemics. Therefore, the two surveys presented here are unrelated; each survey has a specific design and has gathered information deemed most appropriate for their country. These two surveys were granted approval from both their respective national ethics committees, as well as from the Family Health International (FHI) Protection of Human Subjects Committee. 2.1. Cambodia Data from Cambodia were collected by the Cambodia National Center for HIV/AIDS, Dermatology and STIs as part of their behavioral surveillance activities. Data were collected in May 2007 among brothel-based FSWs from the provincial capitals of five sentinel surveillance provinces. City-specific sampling frames of sex work venues were established by the provincial AIDS offices. Participants were selected through two-stage cluster sampling with equal probability. At the second stage, all FSWs present at selected venues were invited to participate. 2.2. Laos Data from Laos People Democratic Republic (PDR) were collected by the Lao Center for HIV/AIDS and STDs as part of their HIV surveillance activities. Data were collected in January 2008 from both urban and rural districts from six sentinel provinces. The Provincial Committee for the Control of AIDS Secretariat visited all known sex work establishments in selected districts and selected participants through simple random sampling from a list of nicknames. 2.3. Analysis Analysis was performed using Stata 9.0 (Stata Corporation, College, Station, TX, USA). Analysis was not weighted for Cambodia, which was characterized by a selfweighted design. Lao data were weighted for differences in selection probability across provinces. Variables are described by frequency and mean. Associations between categorical variables were tested using the Wald test and a p value b.05 was considered significant. Chi-square test for trends assessed associations between outcome and ordered continuous variables. Logistic regression was used to assess the impact of confounding factors on the associations under scrutiny.

89.4% 94.0%

nd 70.4%

37.2% 48.3%

32.0% 51.0%

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In Cambodia, 28% of FSWs reported having had abortions within the past year. Higher incidence of abortion was found among formerly married FSWs; those currently using hormonal contraceptives, those with many clients (chisquare for trends p=.003); those who reported inconsistent condom use with clients, regular clients or unpaid regular partners; those who reported recent condom breakage; and those reporting recently being forced by clients to have unprotected sex (Table 2). The association between incidence of abortion and client numbers on last working day remained after adjusting for unprotected sex with a regular partner (OR=1.1, p=.001).

In Laos, 28% of FSWs had ever had an abortion. Lifetime prevalence of abortion increased with age (chi-square for trends pb.001) and was more frequent among those reporting selling sex for over 1 year, an association remaining after adjusting for age (OR=2.0, 95% CI: 1.72.3). Prevalence of abortion decreased with duration since last pregnancy (chisquare for trends pb.001). Higher lifetime prevalence of abortion was found among FSWs reporting unprotected sex with their regular partner, those using condoms inconsistently with clients and those who had experienced recent condom breakage. However, condom breakage was not a determinant that could explain why consistent users of

Table 2 Percent who aborted in past 12 months or ever, by demographic and reproductive health characteristics Characteristics All women Age in years 19 2029 30 Duration since first selling sex 12 months N12 months Marital status Currently married Formerly married Never married Duration since last pregnancy b6 months 6 to b24 months 24 months Currently using hormonal contraceptives Yes No Number of clients in last working day, Cambodia; last week, Laos 13 46 7 Had unprotected sex with regular unpaid partner (past month for Cambodia; past 3 months for Laos) Yes No Consistent condom use with regular clients in past month Yes No Consistent condom use with non-regular clients (past week for Cambodia; past 3 months for Laos) Yes No Experienced condom breakage in the past 3 months Yes No Forced by a client not to use a condom (past month for Cambodia; past 3 months for Laos) Yes No % who aborted in the past 12 months, Cambodia 2007 (n=592) 28.2% 25.0% 27.2% 35.2% 23.7% 29.6% 31.6% 33.0% 21.8% nd nd nd p value vs. ref group .756 .234 .178 .860 .182 % who ever had a voluntary abortion, Laos 2008 (n=1417) 28.3% 12.6% 42.1% 49.6% 21.8% 43.6% 58.0% 46.6% 22.1% 89.4% 72.8% 58.5% p value vs. ref group b.001 b.001 b.001 .022 b.001 b.001 b.001

57.9% 27.2%

.003

nd nd

23.9% 28.7% 40.0%

.237 .002

27.1% 28.5% 31.5%

.388 .248

39.5% 25.7%

.004

49.6% 24.7%

b.001

26.8% 53.9%

b.001 .006

nd nd

27.1% 48.6%

30.6% 25.8%

.001

34.6% 24.5%

.009

31.6% 25.8%

b.001 .585

36.0% 20.9%

b.001

28.0% 27.2%

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condoms with clients had experienced more abortion since breakages were more prevalent among inconsistent than among consistent condom users (37% vs. 24%, pb.001).

4. Discussion A high unmet contraceptive need exists among FSWs in Cambodia and Laos. Compared with the 5% of all Cambodian women of reproductive age estimated to have aborted in 2000 [15], the incidence of induced abortions among FSWs was high. More than a quarter of FSWs reported an abortion in the past year, despite 94% reporting consistent condom use with clients in the past week. The incidence of abortion increased with client numbers independently of exposure to unprotected sex with regular partners. This suggests that the number of sexual episodes in sex work contributes to unintended pregnancies. In Laos, lifetime prevalence of induced abortion (26%) was low compared with FSW data from other developing countries [3-8]. However, the prevalence of lifetime abortion was substantially higher among FSWs who had pregnancies occurring in the past 6 months, suggesting that many pregnancies occurring during sex work were voluntarily terminated. Current uptake of hormonal contraception among FSWs in Cambodia was low (3%) but the frequency was more than doubled if they had aborted in the past year. This suggests that hormonal contraceptive use was often motivated by prior unintended pregnancies. However, those having aborted in the past year did not use more condoms with clients and, on the contrary, they were more likely to have been forced by clients to have unprotected sex. This perhaps counterintuitive finding may be related to groups of FSWs who prioritize immediate financial success in their competitive environment rather than future health consequences [16,17]. Indeed, in Vietnam, FSWs who have children use more condoms and have lower prevalence of HIV than childless women, suggesting that they are exercising their personal power in enforcing condom use [18]. In addition, conventional thinking regarding condom-use decision making between FSWs and clients usually neglects FSWs' desire to fulfill the deeper meaning and role of their sexual involvement with their partner. Indeed, the symbolic meaning of unprotected sex is derived from desires such as love, trust, becoming a prospective wife, power relationships, intimacy, preventing the loss of a partner, turning the relationship status of the partner from client to boyfriend and to find more social support network for a safer life [19]. Against this background, more qualitative research is needed to better understand the determinants of unprotected sex, beyond the classical victimization of FSWs and reducing their agency in decision making. Both incidence and prevalence of induced abortions were associated with inconsistent condom use with clients or unpaid regular partners. HIV prevention programs should continue to emphasize the dual protection conferred by

condoms. The prevalence of reported condom breakage in the past 3 months was high, and condom failures were associated with abortions. FSWs do not necessarily use condoms properly because they use them frequently, although some studies show that FSWs in some settings become skilled condom users [20,21]. Condom use is often suboptimal among FSWs in developing countries, and clients usually apply condoms [22,23]. Condom use remains male controlled, and FSWs are often subjected to sexual violence. The reported rates of forced unprotected sex seem to contradict the reporting of consistent condom use, but it is likely that FSWs do not report episodes of risky intercourse when they are non-consensual. Our study is limited by reliance on self-reported abortion to approximate unmet contraception needs. Reporting bias due to social desirability may have caused over-reporting of condom use and underreporting of abortions. Indeed, women underreport induced abortions in face-to-face interviews, particularly among unmarried women (as seen in Table 2), and in countries where abortion is illegal such as Laos [3,2427]. The increased attention to HIV prevention, care and treatment may have had a negative impact on family planning programs in developing countries [28]. Despite being the most effective reversible contraceptive method [11], injectable and oral contraceptives are not included in most packages of services offered to FSWs, which focus narrowly on clinical STI and HIV services. Although some stakeholders involved in the response to HIV epidemics had concerns that hormonal contraception would threaten condom-dominated HIV prevention strategies [2], a study found that consistent condom use with clients was higher among users of hormonal contraceptive than among non-users [1]. While female condoms could increase women decision power to prevent pregnancies, they remain expensive compared to the cost of sex, are not widely available and are uneasy to insert. Access to contraception can reduce abortions, and FSWs have greater need for contraception than women in the general population. Abortion-related mortality and morbidity (including subsequent impact on their future fertility) among these young women have major social and economic costs. As a cost-efficient public health investment, FSWs would benefit from contraception counseling and services integrated with their HIV and STI services, which could enhance services uptake. References
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