Abstract
Heterosexual anal sex (HAS) could be one of the drivers of the HIV epidemic among female sex workers (FSWs). This study aimed to characterize HAS and its correlates among FSWs in Iran. Data were obtained from a bio-behavioral surveillance survey of 1347 FSWs conducted across 13 major cities in Iran in 2015. FSWs were eligible if they were ≥ 18 years of age and reported penetrative sex with more than one client in the previous year. Data were collected through one-on-one interviews using a standard risk assessment questionnaire. A modified Poisson regression model was used to examine the correlates of recent (i.e., last month) HAS, and adjusted prevalence ratio (APR) and 95% confidence intervals were reported. Recent HAS was reported by 18.5% (95% CI: 13.0, 25.6) of the participants, of whom, 196 (80%) reported inconsistent condom use during their recent HAS practices. Recent HAS was positively associated with younger (≤ 18) age at sex work debut (APR: 1.24), history of group sex in last month (APR: 1.62), higher number of clients in last month (APR: 2.35), and frequent alcohol use (APR: 1.62). Conversely, recent HAS was negatively associated with being married (APR: 0.52) or divorced/widowed (APR: 0.50) and having used condoms with their last client (APR: 0.73). About one in five FSWs reported HAS, a behavior that was more frequent among FSWs with a higher risk profile. Effective harm reduction initiatives to address the high prevalence of unsafe HAS for both FSWs and their partners/clients are warranted.
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All relevant data are provided in the manuscript. Access to the survey dataset requires permission from the Ministry of Health in Iran.
References
Alexander, M., Mainkar, M., Deshpande, S., Chidrawar, S., Sane, S., & Mehendale, S. (2014). Heterosexual anal sex among female sex workers in high HIV prevalence states of India: need for comprehensive intervention. PLoS ONE, 9(2), e88858. https://doi.org/10.1371/journal.pone.0088858.
Baggaley, R. F., White, R. G., & Boily, M. C. (2010). HIV transmission risk through anal intercourse: Systematic review, meta-analysis and implications for HIV prevention. International Journal of Epidemiology, 39(4), 1048–1063. https://doi.org/10.1093/ije/dyq057.
Baldwin, J. I., & Baldwin, J. D. (2000). Heterosexual anal intercourse: An understudied, high-risk sexual behavior. Archives of Sexual Behavior, 29(4), 357–373. https://doi.org/10.1023/A:1001918504344.
Buffin, J., Roy, A. N., Williams, H., & Yorston, C. (2014). Part of the picture: Lesbian, gay and bisexual people’s alcohol and drug use in England: substance Dependency and Help-Seeking Behaviour 2012. https://clok.uclan.ac.uk/9598/1/POTP%204th%20Year%20Report.pdf.
Cavazos-Rehg, P. A., Krauss, M. J., Spitznagel, E. L., Schootman, M., Peipert, J. F., Cottler, L. B., et al. (2010). Type of contraception method used at last intercourse and associations with health risk behaviors among US adolescents. Contraception, 82(6), 549–555. https://doi.org/10.1016/j.contraception.2010.05.007.
Dal Pogetto, M. R., Marcelino, L. D., Carvalhaes, M. A., Rall, V. L., da Silva, M. G., & Parada, C. M. (2012). Characteristics of a population of sex workers and their association with the presence of sexually transmitted diseases. Rev Esc Enferm USP, 46(4), 877–883. https://www.redalyc.org/pdf/3610/361033319014_2.pdf.
Dormann, C. F., Elith, J., Bacher, S., Buchmann, C., Carl, G., Carré, G., et al. (2013). Collinearity: A review of methods to deal with it and a simulation study evaluating their performance. Ecography, 36(1), 27–46. https://doi.org/10.1111/j.1600-0587.2012.07348.x.
Duby, Z., & Colvin, C. (2014). Conceptualizations of heterosexual anal sex and HIV risk in five East African communities. The Journal of Sex Research, 51(8), 863–873. https://doi.org/10.1080/00224499.2013.871624.
Erfani, A. (2011). Induced abortion in Tehran, Iran: Estimated rates and correlates. International Perspectives on Sexual and Reproductive Health, 37(3), 134–142. https://www.jstor.org/stable/41309590.
Fahimfar, N., Sedaghat, A., Hatami, H., Kamali, K., & Gooya, M. (2013). Counseling and harm reduction centers for vulnerable women to HIV/AIDS in Iran. Iranian Journal of Public Health, 42(Supple1), 98–104. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3712587/pdf/ijph-42-98.pdf.
Hamzić, V., & Mir-Hosseini, Z. (2010). Control and sexuality: The revival of Zina laws in Muslim contexts. Women Living Under Muslim Laws. https://eprints.soas.ac.uk/16959/.
Hess, K. L., DiNenno, E., Sionean, C., Ivy, W., Paz-Bailey, G., & NHBS Study Group. (2016). Prevalence and correlates of heterosexual anal intercourse among men and women, 20 US cities. AIDS and Behavior, 20(12), 2966–2975.
Karamouzian, M., Foroozanfar, Z., Ahmadi, A., Haghdoost, A. A., Vogel, J., & Zolala, F. (2016a). How sex work becomes an option: Experiences of female sex workers in Kerman, Iran. Culture, Health & Sexuality, 18(1), 58–70. https://doi.org/10.1080/13691058.2015.1059487.
Karamouzian, M., Madani, N., Doroudi, F., & Haghdoost, A. A. (2017a). Improving the quality and quantity of HIV data in the Middle East and North Africa: Key challenges and ways forward. International Journal of Health Policy and Management, 6(2), 65–69. https://doi.org/10.15171/ijhpm.2016.112.
Karamouzian, M., Mirzazadeh, A., Shokoohi, M., Khajehkazemi, R., Sedaghat, A., Haghdoost, A. A., et al. (2016). Lifetime abortion of female sex workers in Iran: Findings of a national bio-behavioural survey in 2010. PLoS ONE, 11(11), e0166042. https://doi.org/10.1371/journal.pone.0166042.
Karamouzian, M., Nasirian, M., & Hoseini, S. G. (2020). HIV and Other Sexually Transmitted Infections Among Female Sex Workers in Iran: A Systematic Review and Meta-Analysis. Archives of Sexual Behavior, 49, 1923–1937. https://doi.org/10.1007/s10508-019-01574-0.
Karamouzian, M., Sadeghirad, B., Sharifi, H., Sedaghat, A., Haghdoost, A. A., & Mirzazadeh, A. (2017b). Consistent condom use with paying and Nonpaying partners among female sex workers in Iran: Findings of a national Biobehavioral survey. Journal of the International Association of Providers of AIDS Care (JIAPAC), 16(6), 572–578. https://doi.org/10.1177/2325957417732834.
Karamouzian, M., Shokoohi, M., Kaplan, R. L., Noroozi, A., Sharifi, H., Baral, S. D., et al. (2019b). Characterizing the relationship between incarceration and structural risks among female sex workers in Iran: Findings of a nationwide biobehavioral surveillance survey. Annals of Epidemiology, 35, 29–34. https://doi.org/10.1016/j.annepidem.2019.04.011.
Khezri, M., Shokoohi, M., Mirzazadeh, A., Karamouzian, M., Sharifi, H., Haghdoost, A., et al. (2020). Early sex work initiation and its association with condomless sex and sexually transmitted infections among female sex workers in Iran. International Journal of STD and AIDS, 31(7), 671–679. https://doi.org/10.1177/0956462420913431.
Khurana, A., Romer, D., Betancourt, L. M., Brodsky, N. L., Giannetta, J. M., & Hurt, H. (2012). Early adolescent sexual debut: the mediating role of working memory ability, sensation seeking, and impulsivity. Developmental Psychology, 48(5), 1416–1428. https://doi.org/10.1037/a0027491.
Li, J., & McDaid, L. M. (2014). Alcohol and drug use during unprotected anal intercourse among gay and bisexual men in Scotland: What are the implications for HIV prevention? Sex Transm Infect, 90(2), 125–132. https://doi.org/10.1136/sextrans-2013-051195.
Longo, J. D. D., Simaleko, M. M., Diemer, H. S.-C., Grésenguet, G., Brücker, G., & Belec, L. (2017). Risk factors for HIV infection among female sex workers in Bangui, Central African Republic. PLoS One, 12(11), e0187654. https://doi.org/10.1371/journal.pone.0187654.
Magnusson, B. M., Masho, S. W., & Lapane, K. L. (2012). Early age at first intercourse and subsequent gaps in contraceptive use. Journal of Women’s Health (Larchmt), 21(1), 73–79. https://doi.org/10.1089/jwh.2011.2893.
Magnusson, B. M., Nield, J. A., & Lapane, K. L. (2015). Age at first intercourse and subsequent sexual partnering among adult women in the United States, a cross-sectional study. BMC Public Health, 15, 98. https://doi.org/10.1186/s12889-015-1458-2.
Maheu-Giroux, M., Baral, S., Vesga, J. F., Diouf, D., Diabaté, S., Alary, M., et al. (2018). Anal intercourse among female sex workers in cote d’ivoire: prevalence, determinants, and model-based estimates of the population-level impact on HIV transmission. American Journal of Epidemiology, 187(2), 287–297. https://doi.org/10.1093/aje/kwx244.
Mirabi, P., Vasel, M. Y., Moazen, B., Sehat, M., Rezazadeh, M., & Ahmadi, K. (2013). Unprotected anal Intercourse among Iranian intra-venous drug users. Front Public Health, 1, 34. https://doi.org/10.3389/fpubh.2013.00034.
Mohebbi, M. (2005). Female sex workers and fear of stigmatisation. Sexually Transmitted Infections, 81(2), 180–181. https://doi.org/10.1136/sti.2004.010512.
Motaghi, Z., Poorolajal, J., Keramat, A., Shariati, M., Yunesian, M., & Masoumi, S. Z. (2013). Induced abortion rate in Iran: a meta-analysis. Archives of Iranian medicine, 16(10), 594–598. https://pubmed.ncbi.nlm.nih.gov/24093141/.
Owen, B. N., Baggaley, R. F., Elmes, J., Harvey, A., Shubber, Z., Butler, A. R., et al. (2019). What proportion of female sex workers practise anal intercourse and how frequently? A systematic review and meta-analysis. AIDS and Behavior. https://doi.org/10.1007/s10461-019-02477-w.
Phillips, G., 2nd, Magnus, M., Kuo, I., Rawls, A., Peterson, J., West-Ojo, T., et al. (2014). Correlates of group sex among a community-based sample of men who have sex with men (MSM) in Washington, DC. AIDS and Behavior, 18(8), 1413–1419. https://doi.org/10.1007/s10461-013-0527-8.
Prior, P. M., & Hayes, B. C. (2001). Marital status and bed occupancy in health and social care facilities in the United Kingdom. Public Health, 115(6), 401–406. https://doi.org/10.1038/sj/ph/1900806.
Ramanathan, S., Nagarajan, K., Ramakrishnan, L., et al. (2014). Inconsistent condom use by male clients during anal intercourse with occasional and regular female sex workers (FSWs): Survey findings from southern states of India. BMJ Open, 4, (11). e005166. https://doi.org/10.1136/bmjopen-2014-005166.
Rhodes, T. (2002). The ‘risk environment’: A framework for understanding and reducing drug-related harm. International Journal of Drug Policy, 13(2), 85–94. https://doi.org/10.1016/S0955-3959(02)00007-5.
Risser, J., Padgett, P., Wolverton, M., & Risser, W. (2009). Relationship between heterosexual anal sex, injection drug use and HIV infection among black men and women. International Journal of STD and AIDS, 20(5), 310–314. https://doi.org/10.1258/ijsa.2008.008394.
Rostamzadeh, E., Rahim, R. A., & Mohseni, F. (2016). Historical background of prostitution and typology: A social-legal perspective. Mediterranean Journal of Social Sciences, 7(5), 232–240. https://doi.org/10.5901/mjss.2016.v7n5p232.
Sajadi, L., Mirzazadeh, A., Navadeh, S., Osooli, M., Khajehkazemi, R., Gouya, M. M., et al. (2013). HIV prevalence and related risk behaviours among female sex workers in Iran: Results of the national biobehavioural survey, 2010. Sexually Transmitted Infections, 89(Suppl 3), iii37-40. https://doi.org/10.1136/sextrans-2013-051028.
Shahesmaeili, A., Karamouzian, M., Shokoohi, M., Kamali, K., Fahimfar, N., Nadji, S. A., et al. (2018). Symptom-based versus laboratory-based diagnosis of five sexually transmitted infections in female sex workers in Iran. AIDS and Behavior, 22(1), 19–25. https://doi.org/10.1007/s10461-018-2130-5.
Sharifi, H., Karamouzian, M., Baneshi, M. R., Shokoohi, M., Haghdoost, A., McFarland, W., et al. (2017). Population size estimation of female sex workers in Iran: Synthesis of methods and results. PLoS ONE, 12(8), e0182755. https://doi.org/10.1371/journal.pone.0182755.
Sharifi, H., Mirzazadeh, A., Shokoohi, M., Karamouzian, M., Khajehkazemi, R., Navadeh, S., et al. (2018). Estimation of HIV incidence and its trend in three key populations in Iran. PLoS ONE, 13(11), e0207681. https://doi.org/10.1371/journal.pone.0207681.
Shokoohi, M., Noori, A., Karamouzian, M., Sharifi, H., Khajehkazemi, R., Fahimfar, N., et al. (2017). Remaining gap in HIV testing uptake among female sex workers in Iran. AIDS and Behavior, 21(8), 2401–2411. https://doi.org/10.1007/s10461-017-1844-0.
Simon, W., & Gagnon, J. H. (1986). Sexual scripts: Permanence and change. Archives of Sexual Behavior, 15(2), 97–120. https://doi.org/10.1007/BF01542219.
Stein, J. A., Nyamathi, A., Ullman, J. B., & Bentler, P. M. (2007). Impact of marriage on HIV/AIDS risk behaviors among impoverished, at-risk couples: A multilevel latent variable approach. AIDS and Behavior, 11(1), 87–98. https://doi.org/10.1007/s10461-005-9058-2.
Tucker, S., Krishna, R., Prabhakar, P., Panyam, S., & Anand, P. (2012). Exploring dynamics of anal sex among female sex workers in Andhra Pradesh. Indian Journal of Sexually Transmitted Diseases and AIDS, 33(1), 9–15. https://doi.org/10.4103/0253-7184.93787.
van den Boom, W., Davidovich, U., Heuker, J., Lambers, F., Prins, M., Sandfort, T., et al. (2016). Is group sex a higher-risk setting for hiv and other sexually transmitted infections compared with dyadic sex among men who have sex with men? Sexually Transmitted Diseases, 43(2), 99–104. https://doi.org/10.1097/olq.0000000000000389.
Woolf, S. E., & Maisto, S. A. (2009). Alcohol use and risk of HIV infection among men who have sex with men. AIDS and Behavior, 13(4), 757–782. https://doi.org/10.1007/s10461-007-9354-0.
Zou, G. (2004). A modified poisson regression approach to prospective studies with binary data. American Journal of Epidemiology, 159(7), 702–706. https://doi.org/10.1093/aje/kwh090.
Acknowledgements
The authors are thankful to the study participants for their valuable contribution to our study. We also acknowledge the provincial supervisors, interviewers, harm reduction facilities’ staff, outreach team, and administrative team for their assistance in collecting the survey data.
Funding
Global Fund to Fight AIDS, Tuberculosis and Malaria and Iran’s Center for Disease Control (CDC) funded the survey. MK is supported by the Vanier Canada Graduate Scholarship (Vanier CGS) and the Pierre Elliott Trudeau Doctoral Scholarship. MS is supported by a Canadian Institutes of Health Research (CIHR) Postdoctoral Fellowship. For this particular paper, we also received support from the University of California, San Francisco’s International Traineeships in AIDS Prevention Studies (ITAPS), U.S. NIMH, R25MH064712.
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The study protocol was reviewed and approved by the Research Ethics Committee of Kerman University of Medical Sciences (Ethics Code: K/93/209).
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Rahmani, A., Mirzazadeh, A., Allahqoli, L. et al. The Prevalence of and Factors Associated with Heterosexual Anal Sex Among Iranian Female Sex Workers. Sexuality & Culture 25, 646–659 (2021). https://doi.org/10.1007/s12119-020-09787-5
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DOI: https://doi.org/10.1007/s12119-020-09787-5