Determinants of condom breakage among female sex workers in Karnataka, India

Background: Condoms are effective in preventing the transmission of HIV and other sexually transmitted infections, when properly used. However, recent data from surveys of female sex workers (FSWs) in Karnataka in south India, suggest that condom breakage rates may be quite high. It is important therefore to quantify condom breakage rates, and examine what factors might precipitate condom breakage, so that programmers can identify those at risk, and develop appropriate interventions. Methods: We explored determinants of reported condom breakage in the previous month among 1,928 female sex workers in four districts of Karnataka using data from cross-sectional surveys undertaken from July 2008 to February 2009. Using stepwise multivariate logistic regression, we examined the possible determinants of condom breakage, controlling for several independent variables including the district and client load. Results: Overall, 11.4% of FSWs reported at least one condom break in the previous month. FSWs were much more likely to report breakage if under 20 years of age (AOR 3.43, p = 0.005); if divorced/ separated/widowed (AOR 1.52, p = 0.012); if they were regular alcohol users (AOR 1.63, p = 0.005); if they mostly entertained clients in lodges/rented rooms (AOR 2.99, p = 0.029) or brothels (AOR 4.77, p = 0.003), compared to street based sex workers; if they had ever had anal sex (AOR 2.03, p = 0.006); if the sex worker herself (as opposed to the client) applied the condom at last use (AOR 1.90, p < 0.001); if they were inconsistent condom users (AOR 2.77, p < 0.001); and if they had never seen a condom demonstration (AOR 2.37, p < 0.001). Conclusions: The reported incidence of condom breakage was high in this study, and this is a major concern for HIV/STI prevention programs, for which condom use is a key prevention tool. Younger and more marginalized female sex workers were most vulnerable to condom breakage. Special effort is therefore required to seek out such women and to provide information and skills on correct condom use. More research is also needed on what specific situational parameters might be important in predisposing women to condom breakage.