HIV prevalence and behavioral studies in female sex workers in Togo: a decline in the prevalence between 2005 and 2011

Introduction We determined the sero-prevalence of HIV among female sex workers (FSWs) in Togo identified their sexual risk behaviors. Methods We conducted a cross-sectional study from 17 to 27 December, 2011 on 1106 FSWs in Togo. Venous sample were collected to estimate HIV prevalence as per national algorithms. Behavior data were collected by interviewer-administered questionnaires. Results Of the 1106 FSWs (mean age = 27.6 years) surveyed, 17% and 63% had their first sexual intercourse before the age of 15 and 18 years respectively. Overall, 43.4% of the FSWs had more than seven clients per week. Most FSWs (95%) said they had sex using a condom in their lifetime while 8.8% had used a condom during their last sexual intercourse. About 79% of FSWs used a condom during their sexual encounters the previous week and 11.6% had used a condom during each of their sexual encounters the previous day. Most FSWs (62.2%) reported to have been tested for HIV. Of these, 145 (13.1%) were HIV positive. HIV sero-prevalence decreased from 19.4% in the south to 7.5% in the north of the country. Behaviors associated with FSW being HIV positive included: FSW having more than 7 clients per week (p < 0.001), not using condoms at every intercourse act (p = 0.003) or during the last sexual encounter (p = 0.006) and trading sex in brothels (p < 0.001). Conclusion We estimate HIV sero-prevalence among FSWs in 2011 to be 13.1% in Togo, significantly lower than a prevalence of 29.5% estimated previously in 2005. Inconsistent use of condoms was identified as associated with high risk factor for acquiring HIV.


Introduction
By the end of 2011, UNAIDS estimated that the number of People Living With HIV/AIDS (PLWHA) worldwide was 34 million, of which 69% live within sub-Saharan Africa [1]. An estimated 2.5 million new infections occurred in 2011, representing a decrease of 20% compared to 2001 [1]. Over a period of ten years, this decline is notable in Sub-Saharan Africa, where there are a significant number of countries that have seen a reduction by more than 25% [1].
Despite this, Sub-Saharan Africa recorded 71% of all new infections in 2011 in the world. Female sex workers (FSWs) are one of the most important groups propelling the epidemic in most countries in Africa [1,2]. Indeed, even when prevalence rates are generally quite low in a country, they can be very high in this group. HIV prevalence among sex workers is 13.5 times higher than among other women [2].
In Togo, the second generation surveillance conducted by the National AIDS and STI Program (NAP) estimated HIV prevalence in FSWs in the city of Lomé to be 54.7% in 2003; 11 times the prevalence estimated for the general population [3]. To address the problem, a concerted effort was carried out by various actors in the field of prevention of HIV infection between 2003 and 2005 to. In 2005, there was a shift in HIV prevalence among FSWs, declining to 45.4% in Lomé and to 29.5% nationally [3].
Taking into account the importance of FSWs in the dynamics of the epidemic in Togo, specific prevention programs targeting this population have been implemented. Five years after the last survey, a new study was necessary in order to measure changes in the prevalence of HIV among these FSWs and to adjust our strategy for the coming years.

Study population and sampling
This study targeted female sex workers (FSWs). Male prostitution is identified as very limited in Togo. FSW was defined as any female who exchanges sexual favors for a fee, occurring in brothels (brothel-based FSWs), hotspots (street-based and bar-based FSWs) or covert FSWs (private sex workers or client contacts sex worker by phone or via hotel staff).
In the strategy of support, the Togolese National AIDS/STDs Control Programme (PNSL-IST) distinguishes two groups of FSWs: streetbased and/or covert FSWs and brothel-based FSWs who work almost exclusively in brothels.
Togo is a West African country, which had 6 million inhabitants in

Data collection
The study was carried out using the established protocol (the second-generation survey generic protocol developed by WHO and

Data processing and analysis
Completed questionnaires were checked for errors before being computerized. The collected data were entered by trained officers to record information using the software CSPro4.0. The results biological tests were also entered in the database. Data collected were cleaned and analyzed using SPSS software. Descriptive analyses were performed using Chi-square test at a significance level of 5%.

Ethical considerations
The entire study protocol (including questionnaires and consent

Socio-demographic characteristics of FSWs
In total, 1106 FSWs, were surveyed; the response rate was 85%. Of these, 73.4% were covert and street based. The average age was 27.6 years (range: 14 years and 68 years). Most (73.5%) were 18 and 34 years and only 5.6% of them were younger than 18 years.
The majority of FSWs was not in a permanent relationship (66.9%) and had a primary and secondary education level (65.2%).

Discussion
This study has documented HIV sero-prevalence and behaviors of With regards to the use of condoms, 95% of FSWs reported that they have had sex with a condom at least once in their lifetime. This rate is close to the 97% of FSW who reported condom use at least once in their lifetime in Nigeria [5]. Only 11.6% of FSWs have used condoms during their last sexual encounter; this indicates that 88.4% of FSWs were not protected during their latest intercourse.
In our study, 8.8% of FSWs said they had used a condom during their last sexual intercourse. This proportion is substantially lower than that 85% of FSW who reported using a condom during their last sexual intercourse reported by UNAIDS from a survey of capital cities in 85 countries [1]. Likewise, a study in Rwanda showed that 74% of FSWs had used a condom during their last sexual intercourse [6]. In our study, 79% of FSWs used a condom during sexual intercourse with clients in the last week of work. In Uganda, 94% of FSWs reported having used a condom during the previous month of work, and among them, 45% had consistently used it [7].
These results show that the use of condoms by FSWs must be improved if we want to significantly reduce the prevalence of HIV with lasting effect, and attain the Millennium Development Goals by 2015.
In our study, 62.2% of FSWs reported having been tested for HIV, and among them, 93% said they collected their results, implying they knew their HIV status. In Guinea, all FSWs reported having carried out their HIV test, and 92% among them collected their results [8]. Continued awareness campaigns for FSWs by peer educators should be encouraged to explain the importance of screening test and encourage them to know their HIV status.
We measured a HIV prevalence of 13.1% amongst FSWs. This prevalence is four times higher than that of the general population (3.2%), Previous estimates of HIV prevalence among FSWs in sub-Saharan Africa countries ranges from 24 to 46.5% [6,[9][10][11][12][13][14]. In a review by Baral  This study had limitations related to the methodology used. FSWs are difficult to locate due to stigma as well as their illegal status in Togo. We therefore used convenient sampling methods to select the study participants. We did not have information on non-respondents and refuters; but our study had a response rate of 85%. Also, a previous map of sex workers was used to identify brothels and hotspots. Finally, data collection was based on face-to-face administrated questionnaires which method is subject to information bias arising from concealment of information.

Competing interests
Page number not for citation purposes 5 The authors declare that they have no competing interests Authors' contributions PP was responsible for the conception of the study and its overall scientific management, for analysis and interpretation, and the preparation of the final manuscript. KG and DS participated to the study design, undertook the field study, conducted the data collection, analysis and interpretation, and wrote the manuscript.
BS, and DEL were involved in the scientific management, data analysis and interpretation, and guided the manuscript writing and its finalization. SA and SD were involved in the field study, in data collection, analysis and interpretation and wrote the manuscript.
AKB and KD participated in data collection, data analysis and interpretation of results, and reviewed the manuscript. All the authors have read and approved the final manuscript to be submitted for publication. respondents for accepting to participate to this study.  Table 1: HIV sero-prevalence among female sex workers by sociodemographic characteristics, Togo, 2011