Background: Alcohol and substance use decrease inhibition and are thought to be associated with risk behaviors for HIV transmission. Key populations, including female sex workers (FSW), have historically high risk of HIV acquisition as well as alcohol and substance use. We investigate the association between alcohol use, substance use, and HIV-related risk behaviors among FSW in Kampala, Uganda.
Methods: HIV-naïve or perceived uninfected (no testing < 3 months) Kampala-based FSWs (n= 963) completed quantitative questionnaires in October - November 2016. Participants were asked how often they drank alcohol just before or during sex work (5-point scale, past month) and if they had used any intoxicating substances or drugs (past 12 months). HIV-related behavioral outcomes included 1) condom use with clients and 2) HIV testing (past 6 months). Multivariable logistic regression models adjusting for sociodemographic variables assessed associations between alcohol and substance use and the two behavioral outcomes.
Results: Participants had a median age of 28 years (IQR: 24-32 years) and the majority were literate (822, 85.7%) and reported monthly income < 250,000 UGX/~USD $70 (527, 55.1%). Almost half reported alcohol use before or during sex work “most times” or “every time” (435, 45.2%) and 374 participants (38.8%) reported past 12-month substance use. Inconsistent condom use was reported by 388 participants (40.4%) and 353 participants (33.7%) reported past 6-month HIV testing. Alcohol use (most or every time) before/during work and past 12-month substance use were both associated with increased odds of inconsistent condom use with clients (alcohol: aOR 1.98, 95% CI: 1.51-2.58; substance use: 1.89, 95% CI: 1.44-2.47) and decreased odds of past 6-month HIV testing (alcohol: aOR 0.85, 95% CI: 0.65-1.11; substance use: aOR 0.51, 95% CI: 0.38-0.67); the association between alcohol use and HIV testing, however, was not significant.
Conclusions: Alcohol and substance use are prevalent in this key population of Kampala-based FSWs and strongly associated with inconsistent condom use with clients and reduced HIV testing, behaviors that increase risk of HIV transmission and delay linkage to treatment and care. Interventions that reduce alcohol and substance use in the sex work environment should be developed for FSW in Kampala, Uganda.

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