Barriers to Condom Use among Female Sex Workers: A Systematic Review and Meta-Analysis

Background: Sex without a condom poses the highest risk of sexually transmitted infections among (STIs) female sex workers (FSWs). Objectives: This systematic review and meta-analysis was conducted to summarize the evidence related to barriers to condom use among FSWs. Methods: We searched Web of Science, PubMed, and Scopus using keywords, such as "condom use" and "sex worker" and the related synonyms. The pooled effect size was expressed as odds ratios (ORs) with 95% CIs using a random-effects model. Results: Of the 5,854 studies obtained in the initial search, 35 with a sample size of 14,218 met the eligibility criteria and were included in the final analysis. Three factors identified in studies, i.e., marital status (OR = 1.15; 95%CI [0.74, 1.50]), alcohol consumption (OR = 1.22; 95%CI [0.84, 1.59]), and STIs knowledge (OR = 1.07; 95%CI [0.54, 1.59]), were not significantly associated with not using condom among FSWs. Also, 7 factors identified in studies, i.e., history of violence (OR = 1.84; 95%CI [1.36, 2.31]), history of sexual abuse (OR = 1.87; 95%CI [1.36, 2.38]), history of STIs (OR = 1.54; 95%CI [1.10, 1.97]), HIV risk perception (OR = 1.81; 95% CI [1.58, 2.05]), knowledge of condom use (OR = 1.53; 95%CI [1.15, 1.91]), drug use (OR = 1.62; 95%CI [1.10, 2.14]), and condom use self-efficacy (OR = 1.75; 95%CI [1.52, 1.98]), were significantly associated with not using condom among FSWs. Conclusion: Many factors affect condom use among FSWs. However, in this study, the history of sexual abuse, history of violence, and HIV risk perception were identified as the main barriers to condom use among FSWs.