Our study has identified several significant determinants that influence inconsistent condom use and risky sexual behavior among FSWs, highlighting the complexity of factors that contribute to sexual health risks in this population. In the first BBS conducted in the country a condom was used at last sex with the most recent client among 85.8% of FSW in Maputo, 73.4% in Beira, 62.8% in Nampula, while approximately half of FSW used a condom with their most recent non-client partner (5). These findings emphasize the importance of addressing the multifaceted challenges FSWs face in practicing safer sex, not only with clients but also within their personal relationships. The variance in condom use across different contexts underscores the need for targeted interventions that address both the environmental and individual-level determinants of risky sexual behaviors.
In our analysis older FSWs demonstrated higher odds of both inconsistent condom use and risky sexual behavior compared to younger FSWs This observation suggests that with age, FSWs may encounter unique challenges, including entrenched behavior patterns, varying degrees of power in negotiating condom use during sexual encounters, and economic pressures that escalate risk-taking behaviors (21). These findings align with existing literature, which suggests that the accumulation of personal, health, and occupational challenges over time profoundly impacts FSWs' sexual health behaviors. Moreover, the observed increase in risky sexual behaviors among older FSWs could be attributed to prolonged exposure to the sex work environment, potentially leading to desensitization to risk or diminished optimism regarding future health outcomes (22). A previous study conducted in the country demonstrated that while underage FSWs exhibit a lower prevalence of HIV, this risk markedly increases with age. This trend underscores the critical intersection between consistent condom use and HIV risk among FSWs as they age (23).
Nationality emerged as a significant determinant, with FSW of foreign nationality less likely to report inconsistent condom use compared to their Mozambican counterparts. This distinction could be attributed to differing levels of awareness or access to sexual health education and services across nationalities, potentially influenced by variations in cultural attitudes towards condom use, the legal environment surrounding sex work, and the availability of health care services for FSWs (24).
The study further identified the site of study as a significant factor, with FSW in cities such as Beira, Tete, Quelimane, and Nampula more likely to report inconsistent condom use than those in Maputo City. This geographic disparity may mirror the regional differences in the availability and accessibility of condoms and sexual health services, as well as variations in commercial sex practices prevalent in these areas (25). It underscores the importance of geographically tailored public health strategies that address the unique challenges faced by FSW in different cities and regions of Mozambique.
Our analysis reveals a significant association between the age of sexual initiation and engagement in both inconsistent condom uses and risky sexual behaviors among FSWs. This suggests that early sexual initiation may be associated with a lower likelihood of engaging in protective behaviors, possibly due to limited sexual health knowledge at younger ages, reduced capacity, or power to negotiate condom use, and potentially more coercive or exploitative sexual relationships. Implementing comprehensive sexuality education that reaches young people before they become sexually active could help delay sexual debut and promote safer sexual practices (21, 26). The elevated rates of risky behaviors among those who start sex work at a younger age also underscore the urgency for interventions targeting younger populations within the FSW community.
Drug consumption was found to be associated with both inconsistent condom uses and higher engagement in risky sexual behavior. Substance use can impair judgment and decision-making, leading to increased vulnerability and risk STIs, including HIV among FSW. This correlation has been well-documented in previous research, where substance use among FSWs has been identified as a key factor contributing to heightened sexual and health risks (27–29). Additionally, our study found that binge drinking was significantly associated with inconsistent condom. This relationship further emphasizes the critical intersection between substance use, specifically alcohol, and sexual health behaviors. Binge drinking, defined as consuming a large amount of alcohol in a short period, can severely impair judgment and decision-making capacities, similar to the effects of drug consumption. This impairment can lead to increased vulnerability and risk-taking behaviors among FSW, including the failure to use condoms with both regular and casual partners (30, 31).
Finally, the number of clients and the level of income were significant predictors of both inconsistent condom use and engagement in risky sexual behavior. Economic pressures may compel FSW to engage in riskier behaviors to meet their financial needs, including forgoing condom use at the request of clients who pay more for unprotected sex (21, 24).
Our study, while providing valuable insights into the factors influencing inconsistence condom use and risky sexual behavior among FSWs, is not without limitations. Our study uses a pooled sample and RDS methodology, which, while effective for reaching hidden populations like FSWs, may introduce biases related to network size and the homophily within participant networks and also may mask variations and specificities within subgroups of the FSW population. The cross-sectional design restricts our ability to infer causality between identified determinants and sexual health outcomes. Additionally, the reliance on self-reported data may introduce bias, as participants might underreport behaviors perceived as socially undesirable or stigmatized or even due to recall bias. Despite these constraints, the findings offer a critical foundation for future research and the development of targeted interventions aimed at improving the sexual health and well-being of FSWs.