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Characterizing Multi-level Determinants of HIV Prevalence Among Female Sex Workers in Maseru and Maputsoe, Lesotho


Lesotho has a broadly generalized HIV epidemic with nearly one in three reproductive-aged women living with HIV. Given this context, there has been limited research on specific HIV risks. In response, this study aimed to characterize the burden of HIV and multi-level correlates of HIV infection amongst female sex workers (FSW) in Lesotho. Respondent driven sampling was used to recruit 744 FSW from February to September 2014 in Maseru and Maputsoe, Lesotho. Robust Poisson regression was used to model weighted prevalence ratios (PR) for HIV, leveraging a modified social ecological model. The HIV prevalence among participants was 71.9% (534/743), with a mean age of 26.8 (SD 7.2). Both individual and structural determinants involving stigma were significantly associated with HIV. Women with the highest enacted stigma score (≥ 5) had a 26% higher prevalence of HIV than individuals that did not experience any stigma (PR 1.26, 95% CI 1.01, 1.57). These data reinforce the extraordinarily high burden of HIV borne by FSW even in the context of the generalized HIV epidemic observed in Lesotho and across southern Africa. Moreover, stigma represents a structural determinant that is fundamental to an effective HIV response for FSW in Lesotho.

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  1. 1.

    UNAIDS. Global aids response progress report 2015. Lesotho Country Report. 2015;20–5.

  2. 2.

    United Nations. Population pyramids of the World from 1950–2100. 2015.

  3. 3.

    Ministry of Health and Social Welfare Maseru, Lesotho. Demographic and Health Survey Lesotho. 2009.

  4. 4.

    Coburn B, Okano J, Blower S. Current drivers and geographic patterns of HIV in Lesotho: implications for treatment and prevention in Sub-Saharan Africa. BMC Med. 2013;11:224.

  5. 5.

    Merrigan M, Tafuma T, Okui L, Lebelonyane R, Bolebantswe J, Makhoala K, et al. HIV prevalence and risk behaviors among female sex workers in Botswana: results from the 2012 HIV/STI bio-behavioral study. AIDS Behav. 2015;19(5):899–908.

  6. 6.

    Baral S, Ketende CE, Adams D. Reconceptualizing the HIV epidemiology and prevention needs of female sex workers (FSW) in Swaziland. PLoS ONE. 2014;10:3–17.

  7. 7.

    Baral S, Beyrer C, Muessig K, Poteat T, Wirtz AL, Decker MR, et al. Burden of HIV among female sex workers in low-income and middle-income countries: a systematic review and meta-analysis. Lancet Infect Dis. 2012;12(7):538–49.

  8. 8.

    Baleta A. Lives on the line: sex work in sub-Saharan Africa. Lancet. 2015;385(9962):e1–2.

  9. 9.

    Dunkle K, Beksinska M, Rees V, Ballard R, Htun Y, Wilson M. Risk factors for HIV infection among sex workers in Johannesburg, South Africa. Int J STD AIDS. 2005;16(3):256–61.

  10. 10.

    Fonner VA, Kerrigan D, Mnisi Z, Ketende S, Kennedy CE, Baral S. Social cohesion, social participation, and HIV related risk among female sex workers in Swaziland. PLoS ONE. 2014;9(1):e87527.

  11. 11.

    Shushtari ZJ, Hosseini SA, Sajjadi H, Salimi Y, Latkin C, Snijders TAB. Social network and HIV risk behaviors in female sex workers: a systematic review. BMC Public Health. 2018;18(1):1020.

  12. 12.

    Government of Lesotho. Lesotho HIV prevention response and modes of transmission analysis. Lesotho: Maseru; 2009.

  13. 13.

    Link B, Phelan JC. Conceptualizing stigma. Annu Rev Sociol. 2001;27:363–85.

  14. 14.

    Benoit C, McCarthy B, Jansson M. Stigma, sex work, and substance use: a comparative analysis. Sociol Health Illn. 2015;37(3):437–51.

  15. 15.

    Bowen R, Bungay V. HIV, gender, race, sexual orientation, and sex work: a qualitative study of intersectional stigma experienced by hiv-positive women in Ontario, Canada. Cult Health Sex. 2016;18(2):186–99.

  16. 16.

    Ministry of Health. Demographic and health survey, Lesotho. 2014.

  17. 17.

    McLeroy KR, Bibeau D, Steckler A, Glanz K. An ecological perspective on health promotion programs. Health Educ Q. 1988;15(4):351–77.

  18. 18.

    Minitry of Development Planning. Lesotho bureau of statistics [Internet]. 2017.

  19. 19.

    Heckathorn DD. Respondent-driven sampling: a new approach to the study of hidden populations. Soc Probl. 1997;44(2):174–99.

  20. 20.

    Ministry of Health. National guidelines on the use of antiretroviral therapy for HIV prevention and treatment. 2016.

  21. 21.

    Poteat TC, Logie CH, Adams D, Mothopeng T, Lebona J, Letsie P, et al. Stigma, sexual health, and human rights among women who have sex with women in Lesotho. Reprod Health Matters. 2015;23(46):107–16.

  22. 22.

    Livingston JD, Boyd JE. Correlates and consequences of internalized stigma for people living with mental illness: a systematic review and meta-analysis. Soc Sci Med. 2010;71(12):2150–61.

  23. 23.

    Logie CH, James L, Tharao W, Loutfy MR. HIV, gender, race, sexual orientation, and sex work: a qualitative study of intersectional stigma experienced by HIV-positive women in Ontario, Canada. PLoS Med. 2011;8(11):1–12.

  24. 24.

    Zhang C, Xiaoming L, Liu Y, Qiao S, Zhang L, Zhou Y, et al. Stigma against people living with HIV/AIDS in China: does the route of infection matter? PLoS ONE. 2016;11(3):e0151078.

  25. 25.

    Biradavolu MR, Blankenship KM, Jena A, Dhungana N. Structural stigma, sex work and HIV: contradictions and lessons learnt from a community-led structural intervention in southern India. J Epidemiol Community Health. 2012;66(Suppl 2):95–9.

  26. 26.

    Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606–13.

  27. 27.

    Fitzgerald-Husek A. Measuring stigma related to sex worker identity and MSM identity: a systematic review. In APHA; 2014. Accessed 27 Nov 2017.

  28. 28.

    Brown R. Perceived stigma, medical social support and quality of life among people living with HIV/AIDS in Hunan, China. Appl Nurs Res. 2015;28(2):169–74.

  29. 29.

    Lekas H, Seigel K, Leider J. Felt and enacted stigma among HIV/HCV-coinfected adults: the impact of stigma layering. Qual Health Res. 2011;21(9):1205–19.

  30. 30.

    Zou G. A modified poisson regression approach to prospective studies with binary data. Am J Epidemiol. 2004;159(7):702–6.

  31. 31.

    StataCorp. Stata statistical software: release 14.1. College Station, TX: StataCorp, LP; 2016.

  32. 32.

    Baral S, Holland C, Shannon K, Logie C, Semugoma P, Slithole B, et al. Enhancing benefits or increasing harms: community responses for HIV among men who have sex with men, transgender women, female sex workers, and people who inject drugs. J Acquir Immune Defic Syndr. 2014;66(3):S319–28.

  33. 33.

    King EJ, Maman S, Bowling JM, Moracco KE, Dudina V. The influence of stigma and discrimination on female sex workers’ access to HIV services in St. Petersburg, Russia. AIDS Behav. 2013;17(8):2597–603.

  34. 34.

    Hong Y, Fang X, Li X, Liu Y, Li M, Tai-Seale T. Self-perceived stigma, depressive symptoms, and suicidal behaviors among female sex workers in China. J Transcult Nurs. 2010;21(1):29–34.

  35. 35.

    Lyons C, Ketende S, Diouf D, Drame F, Liestman B, Coly K, et al. Potential impact of integrated stigma mitigation interventions in improving HIV/AIDS service delivery and uptake for key populations in Senegal. J Acquir Immune Defic Syndr. 2017;74(1):S52–9.

  36. 36.

    Prakash R, Bhattacharjee P, Blanchard A, Musyoki H, Anthony J, Kimani J, et al. Effects of exposure to an intensive HIV-prevention programme on behavioural changes among female sex workers in Nairobi, Kenya. Afr J AIDS Res. 2018;17(2):99–108.

  37. 37.

    Mishra S, Marie-Claude B, Schwartz S, Beyrer C, Blanchard JF, Moses S, et al. Data and methods to characterize the role of sex work and to inform sex work programs in generalized HIV epidemics: evidence to challenge assumptions. Ann Epidemiol. 2016;26(8):557–69.

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We would like to acknowledge and thank the sex work community for their participation and effective mobilization to disseminate messages about this study. We also wish to thank the study staff and interviewers who worked on this project at personal risk, including disclosure of sexual orientation to their families or communities. The Lesotho Ministry of Health was instrumental in the oversight, direction, and supervision of the study, and we are grateful for the considerable government engagement and ownership of this work.


This study was funded by the U.S. Agency for International Development (USAID, AID-674-A-00-00001), and implemented by Population Services International/Lesotho (PSI). Stefan Baral’s efforts were supported in part by the Johns Hopkins University Center for AIDS Research, an NIH funded program (1P30AI094189), which is supported by the following NIH Co-Funding and Participating Institutes and Centers: NIAID, NCI, NICHD, NHLBI, NIDA, NIMH,NIA, FIC, NIGMS, NIDDK, and OAR. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

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Correspondence to Mitra Moazzami.

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All procedures performed in studies involving human participants 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.

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Appendix 1

Appendix 1

See Table 4.

Table 4 Category groupings for stigma characteristics [response options: (Yes/No)]

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Moazzami, M., Ketende, S., Lyons, C. et al. Characterizing Multi-level Determinants of HIV Prevalence Among Female Sex Workers in Maseru and Maputsoe, Lesotho. AIDS Behav 24, 714–723 (2020).

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  • HIV
  • Lesotho
  • Stigma
  • Female sex workers
  • Epidemiology