Impact of COVID-19 on Female Sex Workers in Africa: Evidence from a Cohort Study in Senegal

Background: The COVID-19 pandemic has the potential to be the most severe and long-lasting economic shock experienced by female sex workers (FSWs) globally due to the high and close contact nature of the profession. Given that there is a positive income premium attached to unprotected sex, FSWs may resort to adopting risky sexual behaviours as a means to cope with the decreased earnings resulting from COVID-19.  Methods: We used data from a cohort study of around 600 Senegalese FSWs in Dakar, Senegal. During the COVID-19 pandemic in June-July 2020, we elicited respondents’ perceptions of how COVID-19 has affected them. We also compared FSWs’ income and sexual behaviours in 2020 with that of previous survey waves in 2015 and 2017. For continuous variables, the mean, median, interquartile range (IQR), 10th and 90th percentiles were reported. A t-test was also carried out to test the differences between the means in 2017 and 2020. For categorical variables, bar charts were shown. Condom use was elicited via the list experiment method to overcome social desirability bias. Heterogeneity analyses were carried out to identify the channels through which COVID-19 affected condom use.  Findings: COVID-19 led to a 70·0% reduction in the number of clients seen in a week from 2017 levels. The steep fall in the number of clients led to a reduction in sex work earnings by 50·3%. Estimated condom use prevalence with the last client was similar in 2015 and 2017, but decreased by 13·1%-pts during the COVID-19 pandemic (p=0·014), corresponding to a drop of 16·8% compared to 2017. Condom use decline was concentrated amongst asset-poor FSWs (22·7%-pts drop (p=0·004); 27·0% reduction in condom use from 2017 levels). However, self-reported STI symptoms did not increase. Furthermore, a substantial proportion of FSWs reported that they have reduced visits to health facilities because of COVID-19, but there was no evidence that this was associated with decreased condom use. Mental health of FSWs has deteriorated, while experience of violence from clients or the police has remained largely unchanged. Interpretation: Condom use has likely to have fallen to alleviate the economic shock brought about by COVID-19. While the plunge in the number of clients may have offset the transmission of HIV and other STIs for now, it remains to be seen whether condom use would resume once business improves, especially if the crisis were to be prolonged. Given the potential public health issue this may create, policies targeting FSWs to dampen the adverse economic impact of the COVID-19 crisis should urgently be considered as a strategy to prevent the transmission of HIV and other STIs. Funding: MRC Public Health Intervention Development Scheme (MR/T00262X/1) Declaration of Interests: There are no conflicts of interest. Ethics Approval Statement: This study has been ethically approved by the UCL Research Ethics Committee (REC). This study was approved by the Ethics Committee of Senegal.