Correspondence Address:
Pallavi Shukla
Assistant Professor, 56/20 Tilpurva, Hussainganj, Lucknow - 226 001, Uttar Pradesh
India

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As a marginalized group, sex workers are normally expected to experience poorer health than comparable age groups of the general population. In addition to their lives on streets, factors such as "forced" sex work expose sex workers to a number of health problems in addition to human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) and sexually transmitted diseases (STDs). Sexually transmitted infections (STIs) and reproductive tract infections (RTI) are important public health problems in India. Community-based surveys have shown that about 6% of adult Indian population suffers from STI and RTI. The prevalence rate of these infections is considerably higher among high risk groups (HRGs), ranging 20-30%. [1]

The predominant mode of transmission of both HIV and other STIs is sexual intercourse. The prevention, control, and management of STI/RTI are well-recognized cost-effective strategies for controlling the spread of HIV/AIDS in the country as well as for reducing reproductive morbidity among the sexually active population.

Though there is a broad understanding that women in sex work are commonly young females who are expected to contribute to their family income, few data are available on their demographic attributes, as many of them do not openly acknowledge that they are sex workers.

HIV positivity among female sex workers (FSWs) in Uttar Pradesh (UP), India is 0.62%. [2] This study was planned to assess the prevalence of STI and knowledge level about STI among the FSWs of Lucknow city, Uttar Pradesh, India along with their biosocial characteristics.

A cross-sectional descriptive study was conducted in Lucknow city, Uttar Pradesh, India on FSWs registered with targeted intervention-nongovernmental organization (TI-NGO) and Uttar Pradesh State AIDS Control Society (UPSACS). This study was done over a period of 1 year starting from August 2012.

FSWs were approached with the help of the only TI-NGO in Lucknow for FSWs registered with UPSACS and the Centre for Rural Entrepreneurship and Technical Education (CREATE). Sampling frame consisted of 634 FSWs registered with the CREATE and a sample size of 288 was calculated considering the prevalence of STI/RTI in FSWs to be from 20% to 30%. [1] Keeping in view the missing and nonresponders found during pilot testing, 27% was added to the sample size. Thus, in order to achieve the required sample size, 366 FSWs were selected from the list of 596 FSWs (excluding the first 38 entries from the register that were included during pilot testing) in the NGO register. They were either home-based or street-based sex workers.

The 366 FSWs came from nine hot spots of Lucknow, Uttar Pradesh, India. Every month, meeting with the FSWs of a particular hot spot was fixed with the help of the outreach workers.

If any FSW was unavailable on the first visit, she was revisited next month and if again the lady was not found, she was considered missing and was deleted from the list.

All registered FSWs residing in Lucknow for ≥6 months were included in this study. Any FSW who was nonresponsive and noncooperative and who was seriously ill was excluded from the study.

The FSWs were interviewed after taking written informed consent from them. Their biosocial characteristics and knowledge regarding STI (symptoms in males and females, prevention from STI, and the STI-HIV link) were recorded on a pretested semistructured interview schedule. STI diagnosis was made as per the WHO syndromic approach. [1] Seropositivity status of the subjects was obtained from the NGO records.

Descriptive statistics for categorical variables was determined and analyzed using the Statistical Package for the Social Sciences (SPSS) (SPSS-Inc., Chicago, US), version 17.0. Appropriate tests of significance were applied and the level of significance was set at <0.05.

The study was approved by the Ethics Review Board of King George Medical University, Lucknow, Uttar Pradesh, India prior to study.

Among the 288 FSWs, 205 were home based and 83 were street based. The average age of the FSWs was 31 years (range 15-58 years).

Most of the FSWs were Hindus and belonged to the general category. Majority of street based FSWs (48.2%) were currently single after marriage (due to divorce or separation or death of spouse). Among home-based FSWs, majority were currently married (68.3%). Majority (55.4% street-based FSWs and 53.7% home-based FSWs) of FSWs belonged to nuclear family. Problem family is one where the FSW is living with her kids and whose spouse has either died or left. Roughly, 6% FSWs in both groups were living in a problem family. Among street-based FSWs 73.5% and among home-based FSWs 52.2% were illiterate [Table 1].{Table 1}

The most common symptom of STI in females is discharge per vaginum (49.4% street based vs 48.8% home based) and in males it is urethral discharge (22.9% street based vs 23.4% home based) [Table 2].{Table 2}

Knowledge about the role of condom in prevention of STI was significantly lesser among home-based FSWs compared to street-based FSWs. There was a significant difference between both groups with respect to their knowledge regarding the STI-HIV link (0.012) [Table 2].

As per the HIV and syphilis seropositivity test results, 2 FSWs out of 288 were found to be HIV positive and 2 FSWs out of 156 tested positive for syphilis.

The overall prevalence of STI as per syndromic diagnosis was found to be 35.8%. However, the percentage of FSWs with STI was higher among street-based FSWs (50.6%) compared to home-based FSWs (29.8%), and this difference was statistically significant (P value = 0.001) [Figure 1].{Figure 1}

The average age of FSWs was 31 years (ranging 15-58 years), which was similar to the findings of Behavioral Surveillance Survey (BSS) and other studies from Andhra Pradesh and Karnataka. [3],[4],[5]

In the present study, 58.3% of FSWs were illiterate, and interestingly 9.7% had an education level of more than high school. The percentage of illiteracy was higher among the street-based FSWs as compared to home-based FSWs (73.5% vs 52.2%), which was similar to the findings of a study from Karnataka, where the illiteracy rate was found to be 75% and 80% among home-based FSWs and street-based FSWs, respectively. [5] As per the data collected in BSS 2006 overall two-fifths of the FSWs were illiterate and more than half (55%) had studied up to tenth standard. [3] However, in UP 66.8% of FSWs were illiterate and only 0.7% had education level more than high school. Compared to BSS 2006 our study has higher percentage of FSWs attaining education above High School, this may be because the overall literacy rate of UP has increased in the last 5-7 years.

Most of the FSWs were either married or had previously been married but were now separated, deserted, divorced, or widowed. This can be explained by the fact that traditionally in the Indian society, women after marriage are expected to take care of the household but are not encouraged to work outside their household for generating income as that responsibility lies with the men. However, with increasing poverty and decreasing economic opportunities, married women are increasingly seeking work outside their households to generate income. And, it is likely that the earning potential in sex work for the poor and illiterate women is larger to what they could earn through other types of work. Another interesting finding in this study was that the percentage of single women (unmarried/divorced/separated/widowed) was higher in the street-based group as compared to the home-based group (53% vs 31.7%).

In the present study, the lack of knowledge regarding condom usage was significantly higher in the home-based group compared to the street-based group (30.7% vs 10.8%, P value = 0.000). However, as per the BSS [3] about 90% of FSWs in India were aware of consistent and correct use of condom as a mode of prevention of HIV/AIDS. In one of the most successful Indian HIV prevention programs, stressing "no condom, no sex" among FSWs in West Bengal, a decline in HIV prevalence has been reported. [6]

According to 49.4% street-based and 48.8% home-based FSWs, vaginal discharge in female indicated some form of STI. [7],[8],[9] However, only 23.3% of FSWs had the knowledge that urethral discharge in males was indicative of an STI. This reflects that FSWs were aware of the symptoms that they might develop if they had an STI but were unable to recognize those symptoms in their male partners, and thus this difference can be important while planning STI prevention education for this target group. A precondition of health-seeking behavior is the recognition of symptoms.

In the present study, the diagnosis of STI was made according to the world health organization (WHO) syndromic approach. [1] The overall prevalence of STI was found to be 35.8% in this present study that is consistent with most of the literature. [1] Interestingly, there was a higher prevalence of STI among the street-based FSWs as compared to the home-based FSW. This may be explained on the basis that street-based FSW had more number of nonregular multiple partners, lack of family support making them a vulnerable group, and poor health-seeking behavior. [10]

This study shows that majority of the FSWs were single and illiterate. Majority of FSWs were also unaware of all the symptoms of STI and the fact that discharge per vaginum or per urethral was the most commonly quoted symptom of STI. On comparing the home-based and street-based FSWs, a significant number of home-based FSWs were found to be unaware of the role of condom in prevention of STI and the STI-HIV link. The prevalence of STI (by syndromic approach) was significantly higher among street-based FSWs.

Home-based FSWs are a hidden group and are exposed to same risk factors for STI as compared to street-based workers. Therefore, general health camps with special emphasis on information education and communication (IEC) regarding STI and HIV need to be organized in areas predominantly inhabited by home-based FSWs.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References