Journal Article

Are female sex workers able to negotiate condom use with male clients? The case of mobile FSWs in four high HIV prevalence states of India

Introduction
Condom promotion among female sex workers (FSWs) is a key intervention in India’s National AIDS ControlProgram. However, there is limited understanding of how FSWs negotiate condom use with male clients, particularly in thecontext of their mobility for sex work. The objective of this study is to examine the factors associated with the mobile FSWs’ability to refuse unsafe sex and successfully negotiate condom use with unwilling male clients.

Methods
Data for 5498 mobile FSWs from a cross-sectional survey conducted in 22 districts of four states in southern Indiawere analyzed. Questions assessed FSWs’ ability to refuse clients unprotected sex, convince unwilling clients for condomuse and negotiate condom use in a new location. Logistic regression models were constructed to examine the associationbetween socio-demographics, economic vulnerability, sex work practice, and program exposure and condom negotiationability.

Results
A majority of FSWs (60%) reported the ability to refuse clients for unprotected sex, but less than one-fifth reportedthe ability to successfully convince an unwilling client to use a condom or to negotiate condom use in a new site. Youngerand older mobile FSWs compared to those who were in the middle age group, those with longer sex work experience, withan income source other than sex work, with program exposure and who purchased condoms for use, reported the ability torefuse unprotected sex, to successfully negotiate condom use with unwilling clients and to do so at new sites.

Conclusion
FSWs need to be empowered to not only refuse unprotected sex but also to be able to motivate and convinceunwilling clients for condom use, including those in new locations. In addition to focusing on condom promotion,interventions must address the factors that impact FSWs’ ability to negotiate condom use.