Dyspareunia, signs of epithelial disruption, and HIV status in female sex workers and men who have sex with men in Nairobi: a cross-sectional study
Authors: Fischer Bastian , Jaoko Walter , Kirui Elvis , Muture Bernard , Madegwa Isaac , Kageni Lisbeth 
Published: April 2022

Abstract
Background: There is need to focus on HIV prevention as the global number of people acquiring HIV has not declined enough to meet set targets. Painful sexual intercourse may be indicative of minor epithelial injury. Epithelial trauma signs are potential risk factors of HIV infection in men who have sex with men (MSM) and female sex workers (FSWs). The objective of the study was to establish whether there is a relationship between HIV serostatus and signs of epithelial disruption in two HIV key population samples. Methods: Participants were randomly selected from registers of two health facilities in Nairobi, namely Bar Hostess and Hoymas, which serve FSWs and MSM respectively. A questionnaire was administered to 322 FSWs and 231 MSM, who provided data on HIV infection status, sexual dysfunction, intercourse frequency and previous abstinence behaviour. Sexual dysfunction scores were created from items of the Female Sexual Function Index (FSFI-19). Additional questions addressed visual and sensory signs of epithelial trauma. Sexual dysfunction scores for MSM used an anal adaptation of questions from the FSFI-19 and additional trauma sign questions. Statistical tests included two-sample t-tests for abstinence gaps and intercourse frequencies, the number of sex partners, vaginal births, and age of sexual debut. Mann-Whitney U tests were used to compare HIV status and the ordinal variables of sexual behaviour, individual factors, dyspareunia and signs of trauma scores. Bivariate logistic regression was used to estimate the magnitude of difference for significant associations. Potential factors influencing the occurrence of sexual dysfunction were evaluated by FSWs, yielding percentages of the assessment options selected by FSWs out of the total sample. Results: Complaint levels for pain and discomfort from sexual intercourse in the previous four weeks were at least moderate for 60% of MSM and 74% of FSWs. Bleeding related to intercourse was reported at least sometimes by 57% of MSM and 51% of FSWs. For FSWs, living with HIV was 0.874 (0.814-0.939) (odds ratio (95% confidence interval)) times less likely with increased intervals (one day) between any instance of vaginal intercourse or comparable object insertion in the previous month. As the level of satisfaction with emotional closeness during sex decreased, the odds of living with HIV increased 1.479 (1.220-1.792) times. The odds of living without HIV decreased 0.807 (0.656-0.994) times with increasing satisfaction with overall sexual life. As the frequency level of pain and discomfort during or following vaginal penetration in the past four weeks increased, risk of living with HIV increased 1.757 (1.379-2.239) or 1.441 (1.125-1.845) times, respectively, while incrementing intensity of discomfort and pain increased the odds of living with HIV 1.398 (1.119-1.747) times. As the frequency level of bleeding signs during or after vaginal intercourse increased, the relative risk of living with HIV increased 1.737 (1.285-2.348) times, and noticing more vaginal itching, burning, or soreness increased the odds of living with HIV 2.145 (1.429-3.220) times. No significant association between self-reported HIV status and sexual dysfunction or sex frequency variables were found in the MSM sample. A majority of FSWs agreed that steady partnerships (81% agreement), regularity of intercourse (74%), foreplay (73%) and lubrication or artificial lubricants (65%) alleviate discomfort and painful vaginal intercourse. Conclusions: Dyspareunia and epithelial trauma signs were highly prevalent in FSWs and MSM. Complaint levels for pain and discomfort as well as bleeding and tenderness signs were associated with living with HIV, providing some evidence that reducing epithelial disruption may be a novel HIV prevention approach. Subjective factor assessments by FSWs may imply prevention methods for further study.