"Like Any Other Woman"? Pregnancy, Motherhood, and HIV among Sex Workers in Southern Tanzania

Background: As women of reproductive age, female sex workers (FSWs) have reproductive health needs, fertility intentions, and families. However, given FSWs’ work environments and the societal stigma against them, there are unique dynamics to consider for their sexual and reproductive health, including the heightened risk of HIV and other sexually transmitted infections (STI). This study examined the social context and role of motherhood and fertility in relation to FSWs’ HIV risk and overall health and wellbeing. Methods: FSWs were recruited through purposive sampling. They were eligible if they were at least 18 years, exchanged sex within the last month, and worked in entertainment venues. In-depth interviews (IDIs) were conducted with 30 FSWs, three focus group discussions with 22 FSWs, and 13 key informant interviews with health care workers, bar owners/managers, and staff of non-governmental organizations. Results: FSWs in IDIs were age 20-40, reported 77 pregnancies, and had medians of two pregnancies, live births, and children. FSWs had intended pregnancies with partners and clients; the contexts in which they sought these pregnancies sometimes put them at risk for HIV. When seeking antenatal care, FSWs reported being denied care for attending without husbands. When FSWs used contraception, they accessed care and were treated “like any other woman,” but this care was not tailored to their unique needs based on HIV/STI risk, partner types, and specific fertility desires. Sex workers who were mothers were well aware of the risks they could encounter in their jobs, but with children to support, they were constrained in their choices. This led to both increases and decreases in reported HIV-related risk behaviors. Conclusions: The context of FSWs’ lives as women of reproductive age and as mothers impacts their work and HIV-related risk behaviors. Thus, looking beyond the individual-level risks to the structures and social environments in which FSWs live and work is important to understand the various factors that impact their abilities to protect themselves. In turn, recommendations to inform policy and programmatic interventions for FSWs are highlighted with particular attention to their reproductive health needs and desires as well as their roles and responsibilities as mothers