Work-related violence and inconsistent condom use with non-paying partners among female sex workers in Adama City, Ethiopia

Background: Although reported condom use between female sex workers and their clients is high in Ethiopia, condom use with regular, non-paying partners remains low, posing a substantial risk of HIV infection to sex workers, their partners and the general population. Previous studies have identified the synergistic effects of substance abuse, violence and HIV risk, but few have examined these inter-relationships among female sex workers and their regular, non-paying partners. This study explored the associations between work-related violence, alcohol abuse and inconsistent condom use among establishment-based female sex workers and their regular, non-paying partners in Adama City, Ethiopia. Methods. A cross-sectional survey was conducted with 350 establishment-based female sex workers, aged 15-35, at 63 bars, hotels and nightclubs. Multivariate logistic regression analysis was conducted to test the association between work-related violence and condom use with regular, non-paying partners, controlling for age, overall income, education and sex workers' total number of sexual partners in the past week. Alcohol abuse was explored as an effect modifier. Results: Respondents reported a high prevalence of work-related violence (59%) and alcohol abuse (51%). Work-related violence was statistically significantly associated with unprotected sex with regular, non-paying partners among those who abused alcohol (OR: 6.34, 95% CI: 2.43-16.56) and among those who did not (OR: 2.98, 95% CI: 1.36-6.54). Alcohol abuse was not associated with inconsistent condom use within these partnerships, though it may strengthen the effect of work-related violence on unprotected sex. Conclusions: Findings suggest violence against establishment-based female sex workers is associated with HIV risk within regular, non-paying partnerships. Qualitative work is needed to better understand the links between a violent work environment and condom use with regular, non-paying partners and how interventions can be implemented in this context to prevent violence against sex workers and reduce HIV transmission.