Prevention and treatment needs of women who started selling sex as minors Ashley L. Grosso 1, Sosthenes Ketende 1, Kim Dam 1, Erin Papworth 1, Gautier Ouedraogo 2, Odette Ky-Zerbo 3, Simplice Anato 4, Felicity Nadedjo 5, Nuha Ceesay 6, Daouda Diouf 7, Zandile Mnisi 8, Xolile Mabuza 9, Stefan Baral 1. 1 Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins University, Baltimore, USA; 2 IRSS, Ouagadougou, Burkina Faso; 3 PAMAC, Ouagadougou, Burkina Faso; 4 Arc-en-ciel, Lome, Togo; 5 FAMME, Kara, Togo; 6 UNAIDS, Banjul, The Gambia; 7 Enda Sante, Dakar, Senegal; 8 Swaziland National AIDS Program (SNAP), Ministry of Health and Social Welfare, Mbabane, Swaziland; 9 Rock of Hope, Mbabane, Swaziland

Methods Female sex workers (FSW) ≥18 years old recruited through respondent-driven sampling in Burkina Faso, Togo, and Swaziland; FSW ≥ 16 years old in The Gambia recruited through snowball sampling Were administered a questionnaire including a retrospective question on the age at which they started selling sex Separate multivariate logistic regressions for each country/ city to examine correlates of start of selling sex under age 18, controlling for current age. 2

Results Proportion of female sex worker study participants who started selling sex as minors Setting Ouagadougou, Burkina Faso Bobo- Dioulasso, Burkina Faso Lomé, Togo Kara, Togo GambiaSwaziland Started selling sex <age % (109/349) 24.4% (85/349) 21.6% (76/352) 46.2% (150/325) 12.6% (27/214) 25.9% (83/321) Among those who started selling sex <age 18 Mean age of start of selling sex (min.-max.) 15.9 (12-17) 15.7 (12-17) 15.5 (12-17) 15.6 (12-17) 15.8 (13-17) 16.0 (14-17) Forced, coerced, pressured or talked into selling sex 12.8% (14/109) 29.4% (25/85) 1.3% (1/76) 8.7% (13/150) Not available 3

Results Compared to FSW who started selling sex as adults, those who started as minors were more likely to report: Behavioral risks –using drugs, having anal sex in the last year, clients removed or paid more not to use condoms Violence –torture, rape, being beaten up Poor service access –less likely attend HIV-related prevention talks or test for HIV > once ever Poor health outcomes –unwanted pregnancy, previous HIV diagnosis 4

Acknowledgements The women who participated in these studies. Without the leadership of these communities, these studies would not have been possible. The study staff Partner organizations and supporters: –Burkina Faso: PAMAC, IRSS –Togo: Espoir-Vie Togo, Arc-en-ciel, FAMME –Swaziland: Swaziland National AIDS Program at the Ministry of Health, National Emergency Response Council on HIV/AIDS –The Gambia: National AIDS Secretariat, Action Aid International, UNAIDS, Network of AIDS Service Organizations – The Gambia, Jobot Laboratories, The Global Fund to Fight AIDS, Tuberculosis and Malaria, and Enda Sante –The studies in Burkina Faso, Togo and Swaziland were implemented by USAID | Project SEARCH, Task Order No. 2: Research to Prevention (R2P). R2P is based at the Johns Hopkins University (JHU) in Baltimore, Maryland, USA. This work was supported by USAID | Project SEARCH, Task Order No. 2, funded by the US Agency for International Development under Contract No. GHH-I , beginning 30 September 2008, and by the President’s Emergency Plan for AIDS Relief. 5