This study examined the use of LARC among FSWs in Gulu, a district in Northern Uganda. Less than two-thirds (58.6%) of FSWs were using LARC. Among the LARC users, the majority were either on Implants (48.2%) or injectables (42.7%) and only (9.1%) were on IUDs. Independent factors associated with utilization of LARC included: longer duration of sex work (≥ two years), and higher parity (≥ two), history of unintended pregnancy during sex work, and being a brothel/lodge-based sex worker.
In this current study, the prevalence of LARC stood at 58.6%. Compared to the current study, higher proportion of FSWs were found to be using LARC in Zambia {66.6%], Kenya [64.6%], and Ethiopia [69.2%] (32–34). The current level of use of LARC is sub-optimal yet only two-thirds of FSWs were consistently using condoms. Many women in this region avoid using LARC because of their desire to have medium to large numbers of children (35). Therefore, many FSWs tend to depend on condoms even though literature showed that within just one month, nearly half (47.5%) of FSWs experience condom failure (36) which exposes them to the risk of unintended pregnancy in case they were not on the more reliable and effective LARC. Among the users of LARC, the majority were on Implant (48.2%) and injectables (42.7%). This is in agreement with the trend in the utilisation of LARC among general population of women of reproductive age in Northern Uganda whereby Injectables and Implants were also found to be the commonest LARC methods (35).
Secondly, LARC use was 28% higher among brothel-/lodge-based FSWs compared to their counterparts who were not brothel/lodge-based. Previous HIV prevention programs targeting commercial sex workers in developing countries showed that FSWs in brothels/lodges were more likely to use LARC due to the high level of organization and easier access to health care services (37). Besides, participants who had worked longer as a sex worker (two or more years) had a 44% increase in the utilization of modern contraceptives compared to their counterparts who had been a sex worker for periods of less than two years. This finding is however contrary to observations in China and Russia indicating that longer duration of sex work did not affect the use of LARC (16,17). Whereas access to modern contraceptives is not limited in China and Russia, in Northern Uganda, access to modern contraceptives is a challenge especially for the new FSWs who also tend to be younger in age and thus face parental and societal restriction from accessing family planning methods. In fact, in this study, we found that those who had had two or more children had a higher prevalence of LARC use. Chinese and Russian FSWs could have a higher level of LARC awareness, better attitude towards LARC use, and desire of smaller numbers of children like the one child policy in China which could explain the lack of effect of sex work duration on LARC use.
We also found that LARC use was associated with a history of unintended pregnancy. This could further explain the higher use among older women. Those who had ever had unintended pregnancy during sex work were 24% more likely to use LARC compared to their colleagues who never experience unwanted pregnancy during sex work. Further analysis revealed that FSWs who experienced unintended pregnancy during sex work were more likely to terminate their pregnancies (p<0.001). A similar observation was made elsewhere (10). FSWs with unintended pregnancy during sex work and terminated their pregnancies are more likely to use LARC (16). The increased likelihood of LARC use among FSWs with induced abortion is because women who ever had induced abortion may use LARC to avoid the previous bad experience of pregnancy (38,39).
Lastly, FSWs with higher parity [≥ two] had a significant increase (22%) in LARC use compared to their counterparts who had one or no previous pregnancy. Similar findings where lower parity negatively affected LARC use were reported among FSWs in Swaziland (13), India (40), and Tanzania (41). Besides, majority of women (93.4%) in Northern Uganda desire three or more children (35).Therefore, this desire to give birth to more children among the nulliparous and low parity FSWs, made them less likely to use LARC compared to their high parity counterparts. This highlights the need for further sensitization and improvement in the ease of access to LARC, especially among the newer and nulliparous FSWs.
Strengths and limitations of this study
This study provides the evidence needed by health care systems to strengthen family planning policies and practices that would increase the accessibility and uptake of LARC among FSWs. Likewise, unlike most previous studies on FSWs that used non-probability sampling methods, we utilised a simple random sampling technique to select our participants providing more generalizable findings for this group of FSWs and those from similar settings.
The study was cross-sectional and only elicited associations but not causations between LARC use and the various factors investigated. Also, the information collected may have been influenced by recall bias since we asked FSWs about to recall their personal experience. However, most of the information asked were for events within two weeks prior to data collection and thus the possibility for recall bias was reduced. Besides, we collected some sensitive information relating to sex work that might have been difficult to answer and could have resulted in information bias. However, the participants had friendly interview experience with the PI and the female research assistant who had developed close working relationships with the FSWs while providing HIV care, treatment and prevention services to the FSWs in region. Therefore, chances of information bias were greatly reduced