AIDS and Behavior

, Volume 22, Issue 10, pp 3296–3306 | Cite as

Adapting the Risk Environment Framework to Understand Substance Use, Gender-Based Violence, and HIV Risk Behaviors Among Female Sex Workers in Tanzania

  • Anna M. LeddyEmail author
  • Carol Underwood
  • Michele R. Decker
  • Jessie Mbwambo
  • Samuel Likindikoki
  • Noya Galai
  • Deanna Kerrigan
Original Paper


Female sex workers (FSWs) in sub-Saharan Africa are disproportionately affected by HIV and gender-based violence (GBV). Substance use overlaps with these co-occurring epidemics to further increase FSWs’ risk for negative health outcomes. We explored the relationship between substance use, GBV, and consistent condom use utilizing baseline data from a cohort of 496 FSWs in Tanzania. Results demonstrate high levels of alcohol use and GBV, and low levels of consistent condom use. Frequent intoxication during sex work was associated with increased odds of recent GBV (aOR 1.64, 95% CI 1.07, 2.49; p value 0.02) and reduced odds of consistent condom use with clients (aOR 0.58, 95% CI 0.37, 0.92; p-value 0.02). We adapt the risk environment framework to contextualize our findings in the social and structural context and to gain insight into intervention approaches to address the intersecting challenges of substance use, GBV, and HIV among FSWs in Tanzania and similar settings.


Sub-Saharan Africa Female sex workers Gender-based violence Substance use HIV 



We would like to thank the women who participated in the study and the efforts of the research staff. This work was supported by the National Institutes of Mental Health R01MH104044 and F31MH110303. The content in this paper is solely the responsibility of the authors and does not necessarily represent the official views of the sponsors.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interests.

Ethical Approval

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Anna M. Leddy
    • 1
    • 7
    • 8
    Email author
  • Carol Underwood
    • 1
    • 2
  • Michele R. Decker
    • 3
  • Jessie Mbwambo
    • 4
  • Samuel Likindikoki
    • 4
  • Noya Galai
    • 5
    • 6
  • Deanna Kerrigan
    • 1
    • 9
  1. 1.Department of Health, Behavior and SocietyJohns Hopkins Bloomberg School of Public HealthBaltimoreUSA
  2. 2.Johns Hopkins Center for Communication ProgramsBaltimoreUSA
  3. 3.Department of Population, Family and Reproductive HealthJohns Hopkins Bloomberg School of Public HealthBaltimoreUSA
  4. 4.Muhimbili University of Health and Allied SciencesDar es SalaamTanzania
  5. 5.Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreUSA
  6. 6.University of HaifaHaifaIsrael
  7. 7.San FranciscoUSA
  8. 8.Division of Prevention Sciences, Center for AIDS Prevention StudiesUniversity of California San FranciscoSan FranciscoUSA
  9. 9.Department of SociologyAmerican UniversityWashingtonUSA

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