Condom Negotiation Strategies Among Female Sex Workers in Nepal: Use, Strategies, and Consequences

Background:Condom promotion is a key intervention strategy for HIV/AIDs prevention among female sex workers (FSWs). Despite their importance, nearly one-third of FSWs do not use or inconsistently use condoms. This may be because condom use depends upon successful negotiation with male clients who typically hold greater decision-making power than women do in low-resource contexts, such as Nepal (where this study is set). While a few studies report that FSWs lack the skills necessary to negotiate condom use, relatively little is known about the strategies FSWs use to negotiate condom use with clients - given the increased implementation of global programs aimed to increase and sustain use of condoms. Therefore, the purpose of the qualitative study was to fill this gap by exploring how FSWs in Nepal are able to negotiate condom use with male clients.

Methods:Thirty semi-structured, in-depth interviews were conducted in December 2016 with independent, FSWs residing in Kathmandu, Nepal. Due to the highly stigmatizing nature of sex work in Nepal, we partnered with a local university and NGO to recruit FSWs using purposive theoretical sampling. Interviews were recorded, transcribed verbatim, translated, and coded thematically using NVivo 12. Analysis was guided by the narrative analysis approach with the goal of assessing women’s perceptions and meanings of phenomena through the way in which they discuss their lived experiences. Participants were between the ages of 24-54 and reported first entry into sex work between the ages of 17-32. On average, the duration of their involvement with sex work was 7.5 years.

Results:Data analysis revealed three key themes. First, FSWs report high prevalence of condom use with clients. A few women indicated that condom negotiation and use was difficult with particular clients (e.g., married men and regular clients), but several women reported that, by and large, male clients desire to use condoms. Participants reported that many men and women are aware of HIV/AIDs and openly discuss sexual health promotion with one another. Second, FSWs use several types of strategies to negotiate condom use, including: refusal of sex if a client is unwilling to use condoms, convince the unwilling through negotiating tactics, and asking clients to bring condoms. Finally, condom negotiation can incite anger and verbal and physical violence among unwilling/hostile male clients and denial of payment by clients. Several FSWs reported violent incidents because of their desire to use condoms, and some FSWs reported that male clients pressure women into drinking alcohol as to avoid condom use during sex.

Conclusions:Few studies have investigated condom negotiation strategies among FSWs in low-resource contexts. The findings of this study provide insight into strategies used by FSWs to negotiate condom use with male clients in Nepal, and highlight the repercussions of condom negotiation, such as physical and verbal violence against FSWs and denial of payment. The findings highlight the need for additional sexual health interventions on other types of negotiation tactics (e.g., nonverbal communication and reward strategies) to mitigate harm and violence against FSWs, an already vulnerable population of women.