The exchange of money, goods, or services in sexual relationships is a key driving factor for HIV risk in areas where incidence is above elimination rates. We assessed factors that influence condom use and the monetary value of transactional sex encounters among high-risk women in a high prevalence setting in Kenya.
Baseline data were obtained for an ongoing cluster randomized trial of an HIV self-testing intervention among women in 66 community clusters in Siaya County, Kenya (NCT03135067). Clusters included fishing communities along Lake Victoria and market centers with hotspots for female sex workers. Eligibility criteria for for women in clusters included: age ≥18 years, HIV-negative status, and self-report of ≥2 sexual partners in the past month. Data were collected on participants’ most recent transactional sex encounters, including sexual partner characteristics, condom use, and the ‘price’ of each encounter as indicated by the total value of money, goods, and services received. Regression analyses with participant fixed effects were used to assess participant and partner factors that predicted condom use and the price of each encounter.
Among 2,087 participants, 1,396 (67%) reported sex work as one of their income sources and 1,983 (95%) reported on 4,474 transactional sex encounters. Participants had an average age of 27.1 years (IQR 22-31) and for 62.2% the highest education level completed was primary or below. Condom use was reported in 51% of encounters and was significantly more likely with first-time male partners rather than with repeat partners (65% vs. 49%, p<0.001). The median price per encounter was $9.9 (interquartile range $5-$19.8). Prices were $1.8 higher with partners aged >30 years vs. ≤30 years (p<0.05). Higher prices were also reported partners who were wealthier ($5.4 higher, p<0.01) and rated as being handsome ($1.9 higher, p<0.01). Encounters in which either the participant or partner were intoxicated had significantly lower prices. Unprotected sex was associated with a 15% higher price among women with some secondary or higher education (p=0.05) but there was no significant difference among women with primary education or less.
Among high-risk women in Kenya, there is high prevalence of transactional sex and suboptimal condom use. The large monetary value of transactional sex encounters and lower condom use with repeat partners suggests a need for economic and behavioral interventions that facilitate reduced sexual risk-taking.