Sexual pleasure and HIV-related worry in female sex workers on oral pre-exposure prophylaxis in south-western Uganda
Lydia Jacenta Nakiganda![https://orcid.org/0000-0002-2284-8411](/media/client/orcid_16x16.png)
![https://orcid.org/0000-0001-5834-8278](/media/client/orcid_16x16.png)
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Abstract
Female sex workers (FSWs) contribute disproportionately to HIV transmission in Uganda, and pre-exposure prophylaxis (PrEP) is effective in preventing HIV among cisgender women. Psychological factors are important for PrEP uptake, but few studies have examined psychosocial changes due to PrEP use in Uganda.
In 2021, we recruited 524 FSWs in three Trans-African Highway towns and four fishing communities in south-western Uganda. We conducted structured interviews among women who were attending routine PrEP follow-up visits in six health units. Bivariable and multivariable modified regression using a robust covariance matrix estimator were used to identify factors associated with experiencing increased sexual pleasure and less worry about HIV because of PrEP.
Overall, 80.9% participants reported that sex was more pleasurable because of taking PrEP. There were statistical trends for sex being more pleasurable when taking PrEP or when having condomless sex with casual paying partners (aPR = 1.19, 95% CI = 1.07–1.32, P = 0.001). Almost three-quarters of the participants (76.3%) were less worried about getting HIV because of PrEP. Condomless sex with casual paying partners (aPR = 1.17, 95% CI = 1.05–1.31, P = 0.032, P = 0.003) and being On PrEP for the past 1–2 years (aPR = 1.18, 95% CI = 1.00–1.38, P = 0.032) was significantly associated with HIV-related worry (aPR = 1.17, 95% CI = 1.05–1.31, P = 0.032, P = 0.003)
We found a positive impact of PrEP in Ugandan FSWs on two key psychosocial dimensions: (1) more pleasurable sex; and (2) less worry about acquiring HIV. Interventions aiming to increase PrEP uptake may find it useful to focus on psychosocial dimensions.
Keywords: attitudes, female sex workers, HIV/AIDS, HIV-related worry, PrEP, sexual health, sexual pleasure, sexual satisfaction, Uganda.
References
1 Muldoon KA. A systematic review of the clinical and social epidemiological research among sex workers in Uganda. BMC Public Health 2015; 15(1): 1226.
| Crossref | Google Scholar |
2 Mujugira A, Nakyanzi A, Kasiita V, et al. HIV self-testing and oral pre-exposure prophylaxis are empowering for sex workers and their intimate partners: a qualitative study in Uganda. J Int AIDS Soc 2021; 24(9): e25782.
| Crossref | Google Scholar | PubMed |
3 Vandepitte J, Bukenya J, Weiss HA, et al. HIV and other sexually transmitted infections in a cohort of women involved in high-risk sexual behavior in Kampala, Uganda. Sex Trans Dis 2011; 38(4): 316-323.
| Crossref | Google Scholar | PubMed |
4 Mayanja Y, Mukose AD, Nakubulwa S, Omosa-Manyonyi G, Kamali A, Guwatudde D. Acceptance of treatment of sexually transmitted infections for stable sexual partners by female sex workers in Kampala, Uganda. PLoS ONE 2016; 11(5): e0155383.
| Crossref | Google Scholar |
5 Hladik W, Baughman AL, Serwadda D, et al. Burden and characteristics of HIV infection among female sex workers in Kampala, Uganda – a respondent-driven sampling survey. BMC Public Health 2017; 17(1): 565.
| Crossref | Google Scholar | PubMed |
9 Kagaayi J, Batte J, Nakawooya H, et al. Uptake and retention on HIV pre-exposure prophylaxis among key and priority populations in South-Central Uganda. J Int AIDS Soc 2020; 23(8): e25588.
| Crossref | Google Scholar | PubMed |
10 Sundararajan R, Wyatt MA, Muwonge TR, et al. Understanding PrEP acceptability among priority populations: results from a qualitative study of potential users in central Uganda. AIDS Behav 2022; 26: 2676-2685.
| Crossref | Google Scholar |
11 Witte SS, Filippone P, Ssewamala FM, et al. PrEP acceptability and initiation among women engaged in sex work in Uganda: implications for HIV prevention. eClinMed 44: 101278.
| Crossref | Google Scholar |
12 Kawuma R, Ssemata AS, Bernays S, Seeley J. Women at high risk of HIV-infection in Kampala, Uganda, and their candidacy for PrEP. SSM Popul Health 2021; 13: 100746.
| Crossref | Google Scholar | PubMed |
13 Nakku-Joloba E, Pisarski EE, Wyatt MA, et al. Beyond HIV prevention: everyday life priorities and demand for PrEP among Ugandan HIV serodiscordant couples. J Int AIDS Soc 2019; 22(1): e25225.
| Crossref | Google Scholar | PubMed |
14 Auerbach JD, Hoppe TA. Beyond “getting drugs into bodies”: social science perspectives on pre-exposure prophylaxis for HIV. J Int AIDS Soc 2015; 18: 19983.
| Crossref | Google Scholar | PubMed |
15 World Health Organization. Defining sexual health. 2024. Available at http://www.who.int/reproductivehealth/topics/sexual_health/sh_definitions/en/
16 Kawuma R, Nabalwanyi Z, Seeley J, Mayanja Y. “I prefer to take pills when I plan to have sex”: perceptions of on-demand versus daily oral pre-exposure prophylaxis among adolescents in Kampala, Uganda. Afr J AIDS Res 2022; 21(1): 8-14.
| Crossref | Google Scholar | PubMed |
17 Nakiganda LJ, Grulich AE, Poynten IM, et al. Self-reported and pill count measures of adherence to oral HIV PrEP among female sex workers living in South-Western Uganda. PLoS ONE 2022; 17(11): e0277226.
| Crossref | Google Scholar |
18 Kiwanuka N, Ssetaala A, Nalutaaya A, et al. High incidence of HIV-1 infection in a general population of fishing communities around Lake Victoria, Uganda. PLoS ONE 2014; 9(5): e94932.
| Crossref | Google Scholar | PubMed |
19 Zou G. A modified Poisson regression approach to prospective studies with binary data. Am J Epidemiol 2004; 159(7): 702-706.
| Crossref | Google Scholar |
20 Zou GY, Donner A. Extension of the modified Poisson regression model to prospective studies with correlated binary data. Stat Methods Med Res 2013; 22(6): 661-670.
| Crossref | Google Scholar | PubMed |
21 Martinez BAF, Leotti VB, Silva GdSe, Nunes LN, Machado G, Corbellini LG. Odds ratio or prevalence ratio? An overview of reported statistical methods and appropriateness of interpretations in cross-sectional studies with dichotomous outcomes in veterinary medicine. Front Vet Sci 2017; 4: 193.
| Crossref | Google Scholar | PubMed |
22 Mujugira A, Nakyanzi A, Nabaggala MS, et al. Effect of HIV self-testing on PrEP adherence among gender-diverse sex workers in Uganda: a randomized trial. J Acquir Immune Defic Syndr 2022; 89(4): 381-389.
| Crossref | Google Scholar |
23 Grant RM, Koester KA. What people want from sex and preexposure prophylaxis. Curr Opin HIV AIDS 2016; 11(1): 3-9.
| Crossref | Google Scholar | PubMed |
24 Eakle R, Bothma R, Bourne A, Gumede S, Motsosi K, Rees H. “I am still negative”: Female sex workers’ perspectives on uptake and use of daily pre-exposure prophylaxis for HIV prevention in South Africa. PLoS ONE 2019; 14(4): e0212271.
| Crossref | Google Scholar | PubMed |
25 Ddaaki W, Strömdahl S, Yeh PT, et al. Qualitative assessment of barriers and facilitators of PrEP use before and after rollout of a PrEP program for priority populations in south-central Uganda. AIDS Behav 2021; 25(11): 3547-3562.
| Crossref | Google Scholar |
26 Whitfield THF, Jones SS, Wachman M, Grov C, Parsons JT, Rendina HJ. The impact of pre-exposure prophylaxis (PrEP) use on sexual anxiety, satisfaction, and esteem among gay and bisexual men. J Sex Res 2019; 56(9): 1128-1135.
| Crossref | Google Scholar |
27 Randolph ME, Pinkerton SD, Bogart LM, Cecil H, Abramson PR. Sexual pleasure and condom use. Arch Sex Behav 2007; 36(6): 844-848.
| Crossref | Google Scholar |
28 Collins SP, McMahan VM, Stekler JD. The impact of HIV pre-exposure prophylaxis (PrEP) use on the sexual health of men who have sex with men: a qualitative study in Seattle, WA. Int J Sex Health 2017; 29(1): 55-68.
| Crossref | Google Scholar |
29 Mabire X, Puppo C, Morel S, et al. Pleasure and PrEP: pleasure-seeking plays a role in prevention choices and could lead to PrEP initiation. Am J Men’s Health 2019; 13(1):.
| Crossref | Google Scholar |
30 Mujugira A, Baeten JM, Donnell D, et al. Characteristics of HIV-1 serodiscordant couples enrolled in a clinical trial of antiretroviral pre-exposure prophylaxis for HIV-1 prevention. PLoS ONE 2011; 6(10): e25828.
| Crossref | Google Scholar |
31 Grabowski MK, Mpagazi J, Kiboneka S, et al. The HIV and STI syndemic following mass scale-up of combination HIV interventions in Uganda: a population-based cross-sectional study. medRxiv 2022;
| Crossref | Google Scholar |
32 Verster JC, Sandalova E, Garssen J, Bruce G. The use of single-item ratings versus traditional multiple-item questionnaires to assess mood and health. Eur J Invest Health Psychol Educ 2021; 11(1): 183-198.
| Crossref | Google Scholar | PubMed |