Determinants of STI-Related Care-Seeking Behaviour among Female Sex Workers in South Africa’s Major Metropolitan Cities

Abstract

Background: Sexually transmitted infections (STIs) remain a major global public health concern as they contribute significantly to population morbidity and mortality. Due to their risky sexual behaviours, female sex workers are a key population that has been identified as a group most at risk of acquiring STIs, which is further heightened by their biological susceptibility and other compounding factors. All STIs are manageable, either through curative treatments or long-term management strategies; however, a significant proportion remain untreated. Previous studies have found that only 20.5% of female sex workers who have STIs seek treatment, and 9.2% consult healthcare providers. The disparity in STI-related care-seeking among FSWs persists despite their heightened risk of acquiring and transmitting STIs. The implications are far-reaching, potentially leading to a higher risk of STI transmission and, in extreme cases, fatalities. Though actioned by an individual, care-seeking behaviour is influenced by a complex matrix of factors that operate at the level of the individual, family, and community. There is a paucity of recently published literature that specifically explores the demographic, socioeconomic, and health-related factors associated with FSW STI-related care-seeking behaviour in South Africa in a single study. Part of managing the STI crisis in South Africa entails gaining an understanding, through research, of what factors drive how FSWs behave to either prevent STI acquisition or find a remedy for an STI. Objective: To determine how demographic, socioeconomic, and health-related factors influence STI-related care-seeking behaviour among female sex workers in South Africa’s major metropolitan cities. Methods: This is a quantitative cross-sectional study using secondary unweighted cross- sectional data obtained from the 2018 South African Health Monitoring Study, which was the second round of Biological and Behavioural Surveys among female sex workers in South Africa. Ethical clearance was obtained from the University of the Witwatersrand Humanities Research Ethics Committee, and data access was approved by The Aurum Institute’s Data Sharing Governance Committee. The outcome variable in this study was STI-related care- seeking behaviour (sought advice or treatment for self-reported STI symptoms – abnormal discharge or sore/ulcer near or on the vagina). Binary logistic regression was used to determine xii the association between STI-related care-seeking behaviour and selected demographic, socio- economic, and health-related explanatory variables. Results: Of the 745 FSWs who reported STI symptoms, 88% (n = 657) sought treatment. The demographic factors associated with STI-related care-seeking were the city of Durban (reference category: Cape Town) (AOR = 2.99, p= 0.002, 95% CI: 1.51-5.89) and being single (reference category: married) (AOR = 2.59, p= 0.018, 95% CI: 1.18-5.67). All socio-economic factors namely, personal income, household income, and level of education, were not associated with STI-related care-seeking behaviour. The health-related factor associated with STI-related care-seeking behaviour was knowledge of STIs other than HIV (reference category: no knowledge) (AOR = 9.09, p= 0.003, 95% CI: 2.12-38.96). Conclusion: STI-related care-seeking among FSWs in the three metropolitan cities was high. Living in Durban and being single were positively associated with seeking care, likely due to better service access and greater autonomy. Knowledge of STIs other than HIV was positively associated with STI-related care-seeking behaviour, suggesting that peer-led interventions may be effective in boosting STI awareness and care-seeking behaviours. These findings highlight the need for tailored, context-specific interventions to sustain and enhance STI service uptake. However, recent funding cuts threaten to erode current successes. The people-centred framework, aligning resources with the specific needs of FSWs, may offer a sustainable approach to improve sexual and reproductive health outcomes.