Reviewer’s report
Title: 
Actions taken by female sex workers (FSWs) after condom failure in semi
urban Blantyre, Malawi
Version: 
2 
Date: 
25 Oct 2020
Reviewer's report:
Overall, this is an interesting and important study. I think it requires more clarity
and richer/in-depth discussions concerning particular issues highlighted by the
authors. My specific comments are below:
Methods: 
Could the authors clarify whether the ten FSWs who assist Mlambe hospital in
health promotion activities are the same 10 who did the in-depth interviews? It's
unclear how the #10 was decided on for in-depth interviews. Also were the in-
depth interviews done before or after the FGDs? Did the two complement each
other?
In the results section, it's noted: "Out of 40 study participants 18 FSWs (45%)
reported incidents of condom failure: ten FSWs had history of condom rupture
and eight experienced condom slippage" - It's unclear whether this was revealed
during the FGDs? Or some during the interviews? How did the researchers
gather this information and also ensure that there was no overlap between FGDs
and interviews?. More clarity around this would be useful.
Could the authors clarify the part where they wrote "The interviews explored the
following topics" - whether this is referring to the FGDs or the in-depth
interviews or both?
Results section: 
It's noted that "The majority of FSWs reported to have stopped immediately and
changed the condom and then resumed sexual Intercourse" -(about how many
out of the 18?) 
In the action taken by FSWs after condom failure subsection of the results, it's
unclear what the numbers look like in terms of those who sought medical care.
Discussion:
The authors note that FSWs who are HIV positive were not concerned about
condom failure. Could this be explained further? Why weren't they worried?
The authors note that "limited knowledge about HIV prevention and
transmission characterize most FSWs". - Could more evidence be provided on
this? - There is hardly any data to support this assertion (particularly the
transmission aspect) in the paper. 
Why is condom failure intentional on the part of the clients? Could the authors
elaborate more? And how would special training on condom use address this
intentionality? Also, can there be more elaboration how addressing negative
attitudes about gender norms would address condom failure (presumable the
clients intentionally causing condom failure)
The authors note that some FSWs use beer to wash their vagina after condom
failure. It would be useful to explain why beer is used (beyond the reference in
an interviewee quotation to 'when water is not available).
"Study findings suggest that negotiation for safe heterosexual sex violates
cultural values and norms that dictate women not to refuse male sexual desire
and demands [37-38]." - This reads as if it's not findings from the researchers'
study…if this is the case (and even if not), could the researchers clarify whether
this is also what their participants think? After all, these men are paying for
sex…so it's not a matter of simple refusal in relation to cultural norms. Did the
participants mention anything about fear of violence? 
In addition to empowering FSWs to refuse having sex - are there laws/policies in
place to also protect FSWs? Or that they can rely on to seek justice if something
goes wrong? I guess the question I'm asking here is: is 'empowerment' enough?
How does this empowerment translate in practice? Are there examples in other
cities/countries where this has worked? A discussion around this would be useful
considering this is a major recommendation.
The authors note that Health care providers should provide contraceptives, PEP,
and PrEP services among FSWs in outreach areas - is this something the FSWs
will take up and not worry about others seeing especially for PEP and PrEP?
In the last sentence of the Discussion section, the authors note that "...it will also
contribute to clients satisfaction" - It's unclear what this means or why this is
here. More context is needed.
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