2. Differences in Demographic Profiles and Sexual Behaviors among Female Sex Workers (FSW) in Zambia´s Two Largest Cities
Muyunda Mulenga1, Ruth Kanswe1, Pamfred Hasweeka1, Rachel Parker2, Linda Kimaru1, Yuna Hammond3, Tyronza Sharkey3, Amanda Tichacek2, William Kilembe3, Mubiana Inambao1, Susan Allen2
1Zambia Emory HIV Research Project, Ndola, Zambia, 2Rwanda Zambia HIV Research Group,
Atlanta, United States, 3Zambia Emory HIV Research Project, Lusaka, Zambia

3. Introduction
Sub-Saharan Africa remains the most severely HIV-affected region in the world, accounting for 69% of those living with HIV worldwide.1,2
The spread of HIV in sub-Saharan Africa occurs primarily through heterosexual contact, with women representing more than half (58%) of all people living with HIV.
Gender inequalities, differential access to services, and sexual violence increase women’s vulnerability to HIV.3

4. Introduction
Female sex workers (FSW) in sub-Saharan Africa are exposed to multiple sexual partners, have limited access to HIV prevention services, and are often powerless to negotiate safer sex with their male clients.
Commercial sex work is often the only recourse that women have to survive. Understanding the demographic profiles and sexual behaviors of women engaged in commercial sex work is necessary for development of HIV prevention materials.

5. Methods
1764 female sex workers (FSW) from Lusaka (N=814) and Ndola (N=950) were recruited from known hotspots for commercial sex activity. Demographic and sexual behavior profiles were collected.
FSW were offered free HIV testing and counseling, screening and treatment for syphilis, and symptom directed gynecologic exam with appropriate treatment for other sexually transmitted infections (STI). Any woman who became pregnant or infected with HIV during study participation was referred for appropriate care.

6. Results: Demographics
FSW were grouped by HIV status and location to assess their similarities and differences with regard to:
Average age
Marital status
Literacy in the local language
English comprehension and literacy

7. HIV- FSW were significantly younger than their HIV+ counterparts in both cities
In both cities, HIV+ women (shown in green) were on average significantly older than HIV- women (shown in blue) by several years.

8. HIV- women were more likely to be never married, while HIV+ women were more likely to be divorced or widowed
HIV+ FSW (shown in green) in both cities were significantly less likely to be single (56%) than HIV- FSW (shown in blue) (70% in Lusaka and 77% in Ndola). Among HIV+, those in Lusaka were more likely to be divorced/separated (31% vs 20% in Ndola) and less likely to be widowed (10% vs 16% in Ndola).

9. Ndola FSW were more likely to be literate in Bemba than Lusaka FSW were to be literate in Nyanja.
Bemba is universally spoken in Ndola, while Lusaka inhabitants have migrated from
areas with many different languages. While Nyanja is the lingua franca in Lusaka, it
is the maternal language for fewer than a third of Lusaka dwellers.
HIV+ women in Ndola reported higher literacy in Bemba than their HIV-
counterparts, while the opposite was true in Lusaka.
Literacy in the local language (Nyanja in Lusaka, Bemba in Ndola) differed significantly by city for HIV+ (shown in green) and HIV- women (shown in blue). Significantly higher literacy was observed among women from Ndola, with 43% of HIV+ and 35% of HIV- able to read easily, compared to Lusaka where only 16% of HIV+ and 28% of HIV- can read easily.

10. Though Lusaka FSW were less literate in the local language, they were more likely to understand and read English than their Ndola counterparts.
In Lusaka, HIV- women were significantly more likely to understand and read
English than HIV+ FSW
Understanding and reading English was not common in Ndola (25-29% and 19-20% respectively) with no significant difference between HIV+ women (shown in green) and HIV- (shown in blue). In contrast, among Lusaka dwellers HIV- women reported significantly higher levels of English comprehension (52% understand easily and 50% read easily) than HIV+ women (34% and 28%, respectively).
English Understanding
English Literacy
Statistically significant (p<0.05)

11. Sexual Behaviors in Zambian FSW
All women reported vaginal sex with clients, with few reporting oral (2%-6%) or anal (3%- 11%) sex.
Most FSW reported using condoms sometimes, with fewer than 10% reporting always using condoms
In Ndola, only 15% reported use of condoms all or most of the time with no difference between HIV+ women (shown in green) and HIV- women (shown in blue). In Lusaka, more HIV- FSW reported using condoms all or most of the time (28%) compared with HIV+ (17%), though this difference was not significant. Among HIV- women, those living in Lusaka were significantly more likely to use condoms always or most of the time (28%) than those in Ndola (15%).

12. Conclusions
HIV+ FSW were older and more likely to have lost a spouse to death or divorce than HIV- women in both cities.
Consistent condom use with clients is universally low but highest among HIV- women in Lusaka.
Ndola is linguistically homogeneous with higher levels of literacy in the local language than Lusaka, the centrally located capital, home to migrants from all 5 major language groups.
In contrast, half of HIV- FSW in Lusaka could read and understand English.
Overall, literacy was low which limits the usefulness of written educational and referral materials. English lessons and literacy training may be helpful both for HIV prevention and to increase opportunities for alternative income generation.

13. References
1. UNAIDS. Global Health Policy Fact Sheet on HIV/AIDS
2. UNAIDS. Report on the Global AIDS Epidemic. Geneva, Switzerland: HIV/AIDS JUNPo; 2012.
3. UNAIDS. Report on the Global AIDS Epidemic. Geneva, Switzerland: Joint United Nations Program on HIV/AIDS, 2006.
Contact
Muyunda Mulenga
Zambia Emory HIV Research Project