AIDS and Behavior

, Volume 22, Issue 10, pp 3273–3286 | Cite as

Patterns of Gender-Based Violence and Associations with Mental Health and HIV Risk Behavior Among Female Sex Workers in Mombasa, Kenya: A Latent Class Analysis

  • Sarah T. Roberts
  • Brian P. Flaherty
  • Ruth Deya
  • Linnet Masese
  • Jacqueline Ngina
  • R. Scott McClelland
  • Jane Simoni
  • Susan M. Graham
Original Paper


Gender-based violence (GBV) is common among female sex workers (FSWs) and is associated with multiple HIV risk factors, including poor mental health, high-risk sexual behavior, and sexually transmitted infections (STIs). Prior studies have focused on GBV of one type (e.g. physical or sexual) or from one kind of perpetrator (e.g., clients or regular partners), but many FSWs experience overlapping types of violence from multiple perpetrators, with varying frequency and severity. We examined the association between lifetime patterns of GBV and HIV risk factors in 283 FSWs in Mombasa, Kenya. Patterns of GBV were identified with latent class analysis based on physical, sexual, or emotional violence from multiple perpetrators. Cross-sectional outcomes included depressive symptoms, post-traumatic stress disorder (PTSD) symptoms, disordered alcohol and other drug use, number of sex partners, self-reported unprotected sex, prostate-specific antigen (PSA) in vaginal secretions, and a combined unprotected sex indicator based on self-report or PSA detection. We also measured HIV/STI incidence over 12 months following GBV assessment. Associations between GBV patterns and each outcome were modeled separately using linear regression for mental health outcomes and Poisson regression for sexual risk outcomes. Lifetime prevalence of GBV was 87%. We identified 4 GBV patterns, labeled Low (21% prevalence), Sexual (23%), Physical/Moderate Emotional (18%), and Severe (39%). Compared to women with Low GBV, those with Severe GBV had higher scores for depressive symptoms, PTSD symptoms, and disordered alcohol use, and had more sex partners. Women with Sexual GBV had higher scores for disordered alcohol use than women with Low GBV, but similar sexual risk behavior. Women with Physical/Moderate Emotional GBV had more sex partners and a higher prevalence of unprotected sex than women with Low GBV, but no differences in mental health. HIV/STI incidence did not differ significantly by GBV pattern. The prevalence of GBV was extremely high in this sample of Kenyan FSWs, and different GBV patterns were associated with distinct mental health and sexual risk outcomes. Increased understanding of how health consequences vary by GBV type and severity could lead to more effective programs to reduce HIV risk in this vulnerable population.


Gender-based violence Female sex workers Sexual risk behavior Mental health Latent class analysis 



We are grateful to the study participants and our research, clinical, laboratory, outreach, and administrative staff for making this study possible. This research was funded by a supplement award from the University of Washington Center for AIDS Research (CFAR), an NIH funded program under Award Number P30AI027757 which is supported by the following NIH institutes and Centers: NIAID, NCI, NIMH, NIDA, NICHD, NHLBI, NIA, NIGMS, NIDDK. S.T.R. was supported by a Ruth L. Kirschstein National Research Service Award from NIMH (F31MH107258), the University of Washington Center for STD and AIDS training grant (T32AI007140) and the ARCS© Foundation Seattle Chapter Endowment Fund. Additional support for the Mombasa Cohort was provided by NIH Grants R01 AI38518 and R01 HD072617. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Compliance with Ethical Standards

Conflict of interest

Sarah Roberts, Brian Flaherty, Ruth Deya, Linnet Masese, Jacqueline Ngina, R. Scott McClelland, and Susan Graham declares that they have no conflict of interest.

Ethical Approval

All procedures involving human participants were in accordance with the ethical standards of the ethics committees at the University of Washington and the Kenyatta National Hospital, and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.

Informed Consent

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

Supplementary material

10461_2018_2107_MOESM1_ESM.docx (15 kb)
Supplementary material 1 (DOCX 15 kb)


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Authors and Affiliations

  1. 1.Women’s Global Health ImperativeRTI InternationalSan FranciscoUSA
  2. 2.Department of PsychologyUniversity of WashingtonSeattleUSA
  3. 3.Institute of Tropical and Infectious DiseasesUniversity of NairobiNairobiKenya
  4. 4.Department of Global HealthUniversity of WashingtonSeattleUSA
  5. 5.Department of MedicineUniversity of WashingtonSeattleUSA
  6. 6.Department of EpidemiologyUniversity of WashingtonSeattleUSA

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