Correlates of HIV pre-exposure prophylaxis (PrEP) uptake among female sex workers in northern Nigeria

Abstract

Background

Female sex workers (FSWs) face a disproportionately high risk of HIV acquisition, yet uptake of pre-exposure prophylaxis (PrEP) remains low in many settings. We examined PrEP awareness, utilization, and adherence, and identified predictors of uptake among FSWs engaged through One-Stop-Shop (OSS)-linked urban venues in Nigeria.

Methods

A cross-sectional survey was conducted among 146 FSWs using venue-based time-location sampling. Structured, interviewer-administered questionnaires assessed socio-demographic characteristics, PrEP knowledge and use, and exposure to HIV prevention services. Multivariate logistic regression was used to identify independent predictors of PrEP uptake.

Results

PrEP awareness was high (76.7%), and among those aware, 92.0% had ever used PrEP. However, adherence was inconsistent: only 41.7% reported daily use, while the majority reported irregular or on-demand use. Peer educators and community-based HIV prevention workers were the most common information sources (69.6%). After adjusting for potential confounders, only participation in group sessions remained a significant independent predictor of PrEP uptake (adjusted Odds Ratio, aOR = 14.22; 95% confidence interval, CI: 1.44–31.61).

Conclusions

FSWs linked to urban OSS platforms in Nigeria demonstrated high levels of PrEP awareness and use. The emergence of group HIV prevention sessions as an independent predictor of PrEP uptake reinforces the value of peer-led, community-based behavioral interventions in this setting.

Keywords

HIV prevention PrEP female sex workers Nigeria adherence One-Stop-Shop model peer education community-based interventions

Introduction

Key populations, including female sex workers (FSWs) bear a disproportionate burden of the global HIV epidemic. As of 2023, FSWs were 13.3 times more likely to acquire HIV than adult women in the general population.¹ Sub-Saharan Africa, home to over two-thirds of all people living with HIV has a particularly high incidence of HIV among key populations. In Nigeria, key populations accounted for 11% of new HIV infections in 2020, despite representing less than 5% of the population.² HIV prevalence is generally lower in northern Nigeria than in the south, with state-level estimates showing substantial subnational variation. Small-area estimates indicate a national adult HIV prevalence of 1.36%, with state-level prevalence ranging from a low of 0.34% in Zamfara to a high of 4.3% in Akwa Ibom. The estimated adult HIV prevalence in Kano State was 0.6%, well below both the national average and the rate in the highest-prevalence southern states.³ Although overall HIV prevalence is lower in northern Nigerian states such as Kano, FSWs in these areas remain at heightened risk due to intersecting legal, cultural, and other structural barriers to HIV prevention services.⁴

Oral pre-exposure prophylaxis (PrEP) is over 90% effective at preventing HIV transmission when taken consistently,^5,6 and is recommended for individuals at substantial risk, including FSWs.^7,8 Nigeria’s national HIV treatment guidelines have endorsed its integration into HIV prevention programs.⁵ However, PrEP awareness remains limited, especially in regions where sex work is criminalized, and stigma impedes service access. For instance, in 2021 only 9.4% of FSWs in Kano were aware of PrEP, despite a relatively high uptake (56.4%) among those who had heard of it.⁹

Recent investments such as the establishment of key population-friendly One-Stop-Shop (OSS) clinics in urban Kano have sought to address these barriers by offering stigma-free, integrated services.¹⁰ The 2024 Key Population Programme Review (KPPR) conducted in 18 Nigerian states including Kano provides recent programmatic evidence and recommendations for minimum intervention packages for key populations, highlighting the importance of One-Stop-Shop clinics, peer outreach, peer educators, and behavioural, structural, and legal interventions to improve HIV prevention among FSWs.¹¹ Yet evidence on PrEP uptake and adherence among FSWs in these OSS-linked contexts remains sparse. Moreover, much of the existing literature focuses on other parts of Africa (especially east and southern Africa), with minimal empirical data from northern Nigeria, where social/religious conservatism and the criminalization of sex work pose additional constraints.¹² This study aims to fill a critical gap by examining the levels and predictors of PrEP awareness, uptake, and adherence among cisgender FSWs engaged through OSS-linked venues in urban Kano. Drawing on the Social Ecological Model, we explore how multilevel factors including individual characteristics, interpersonal dynamics, and structural constraints shape PrEP use.

Methods

Study design and setting

This descriptive cross-sectional survey was conducted between June and August 2023 among cisgender FSWs in four metropolitan Local Government Areas (LGAs) of Kano State, Nigeria: Fagge, Nassarawa, Tarauni, and Kumbotso. Kano is one of Nigeria’s most populous and culturally conservative states, where Islamic norms strongly influence statutory law and community practices.¹³ These socio-legal structures contribute to the marginalization and criminalization of sex work, limiting access to HIV prevention tools such as PrEP.¹⁴ The selected LGAs are recognized hotspots for commercial sex work, encompassing brothels, informal venues, and street-based activity. The area also hosts one of the few key population–friendly One-Stop-Shop (OSS) clinics in the state, offering integrated HIV prevention and treatment services specifically tailored to FSWs.¹⁵

Study population and eligibility criteria

Eligible participants were cisgender FSWs aged 18 years or older, who self-reported as HIV-negative or of unknown HIV status and had engaged in transactional sex within the previous 6 months. Individuals who self-identified as HIV-positive or were too ill to participate at the time of data collection were excluded. The study focused on cisgender women, who comprise the majority of Nigeria’s sex worker population and face distinct patterns of risk, access, and service engagement. Transgender or gender-diverse sex workers were not included, given anticipated sample size limitations and the absence of targeted programming in the study area.

Sample size determination

The minimum required sample size was calculated using the single population proportion formula,¹⁶ based on a 9.4% PrEP uptake rate among FSWs in Kano,⁹ with a 5% margin of error and 95% confidence level. This yielded a minimum of 131 participants. Anticipating a 10% non-response rate, the sample size was increased to 146. This sample provided 90% power (α = 0.05) to detect moderate effect sizes in multivariate logistic regression analysis.

Sampling strategy

A venue-based time-location sampling approach was used, as recommended for behavioral surveillance among hard-to-reach key populations.¹⁷ Mapping exercises, conducted with local community-based organizations (CBOs), identified active sex work venues including brothels, hotels, bars, informal hotspots, and street locations. These were paired with peak operational times to form time–venue units. Rotational sampling ensured coverage across days and times, including weekdays, weekends, and night shifts. Repeated visits helped minimize oversampling of more visible participants. Peer navigators and CBO-affiliated facilitators supported venue access and participant engagement.

Data collection and instruments

Data were collected using a semi-structured, interviewer-administered questionnaire adapted from validated tools used among African FSW populations.^6,18,19 The instrument was refined through consultations with local stakeholders and pre-tested among 15 FSWs (10% of the final sample) at non-study sites. Feedback informed adjustments to terminology, item phrasing, and contextual relevance (e.g., barriers related to policing and mobility). The final questionnaire comprised three domains: Socio-demographic and sex work characteristics; awareness, attitudes, and use of PrEP; and multilevel correlates of PrEP uptake, including access, behavioral risk, stigma, and structural constraints.

Interviews were conducted in English or Hausa, based on participant preference. The interviews were face-to-face and conducted in locations chosen by participants to ensure discretion and safety. Bilingual female interviewers, each with prior experience working with key populations, received 5 days of intensive training on research ethics, trauma-informed interviewing, confidentiality, and safety procedures.

Primary outcome (PrEP uptake)

The primary outcome was defined as self-reported “ever use” of oral PrEP among participants who demonstrated awareness of PrEP. PrEP uptake was assessed through the question: “Have you ever taken PrEP pills to prevent HIV infection?” with binary response options (yes/no). Among those reporting ever use, current usage patterns were categorized as: (1) daily use (“I take PrEP every day”), (2) irregular use (“I take PrEP sometimes but not every day”), or (3) on-demand use (“I take PrEP only before and after sex”).

PrEP knowledge assessment

PrEP knowledge was evaluated using a 10-item scale adapted from validated instruments used in similar African settings.^19,21 Knowledge items assessed understanding of indications for PrEP use, dosing, side effects, and target populations. Responses were scored as correct (1 point) or incorrect/don’t know (0 points), with total scores ranging from 0 to 10. Participants scoring ≥7 points (70%) were classified as having “good knowledge,” while those scoring <7 were classified as having “poor knowledge.” Internal consistency was acceptable (Cronbach’s α = 0.72).

Data management and statistical analyses

Data were double-entered into Microsoft Excel and cross-validated before import into SPSS version 22 (IBM Corp., Armonk, NY) for analysis. Descriptive statistics (frequencies, percentages, means, and standard deviations) summarized participant characteristics and PrEP indicators.

Chi-square or Fisher’s exact tests were used to assess bivariate associations between PrEP uptake and explanatory variables. Variables with p-values <0.10 were entered into a multivariate logistic regression model using stepwise forward selection. Adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were calculated to identify independent predictors. Model fit was evaluated using the Hosmer–Lemeshow goodness-of-fit test (p > 0.05 indicating good fit) and the omnibus test of model coefficients. Multicollinearity was assessed using variance inflation factors (VIF), with VIF >5 considered problematic. Potential interaction terms were tested but did not meet criteria for inclusion. Missing data were minimal (<5%) and handled through listwise deletion.

Ethical considerations

Ethical approval was obtained from the Aminu Kano Teaching Hospital Health Research Ethics Committee (Ref: NHREC/28/01/2020/AKTH/EC/3422; dated November 8, 2022). Written and verbal informed consent was obtained from all participants. No identifying information was collected, and all responses were de-identified at the point of entry. Confidentiality and anonymity were maintained throughout. Participants received no direct incentive beyond transport reimbursement. In addition to measures for confidentiality and anonymity, data security was ensured throughout the study. Responses were collected on password-protected electronic tablets and uploaded to encrypted servers accessible only to the study team. Access to raw data was restricted to authorized personnel, and all storage complied with Nigeria Data Protection Regulations and international best practices for research involving key populations.

Results

Sample characteristics

A total of 146 FSWs participated in the study, yielding a 100% response rate (Table 1). Participants had a mean age of 28.2 years (standard deviation, SD = 5.1), with the majority aged 26–30 years (43.8%). Most interviews were conducted in brothels (79.5%), followed by hotels (16.4%). Approximately one-half of participants (50.7%) identified as belonging to minority groups classified as “Other,” while Hausa and Fulani accounted for 18.5% and 17.1%, respectively. About 59% of participants were single. Educational attainment was predominantly at the primary school level (75.3%). At the time of data collection, the vast majority of respondents (85.6%) reported being students, reflecting ongoing enrolment in secondary school level or informal educational programs, despite low completed levels of formal schooling.

Table 1.

Socio-demographic characteristics of respondents (N = 146, except where indicated), Kano, Nigeria.

Characteristic	Frequency (%)
Location of interview
Brothel	116 (79.5)
Hotel	24 (16.4)
Hostel/lodge	4 (2.7)
Beauty salon	1 (0.7)
Park	1 (0.7)
Age (in years)
≤25	46 (31.5)
26–30	64 (43.8)
31–35	19 (13.0)
36–40	17 (11.6)
Mean ± SD	28.2 ± 5.1
Ethnicity
Hausa	27 (18.5)
Fulani	25 (17.1)
Yoruba	4 (2.7)
Igbo	16 (11.0)
Other^a	74 (50.7)
Religion
Islam	54 (37.0)
Christianity	92 (63.0)
Marital status
Single	86 (58.9)
Married	2 (1.4)
Divorced	36 (24.7)
Widowed	13 (8.9)
Separated	9 (6.2)
Highest level of education
No formal education	19 (13.0)
Primary	110 (75.3)
Secondary	17 (11.6)
Occupation
Student	125 (85.6)
Domestic worker	11 (7.5)
Shop assistant	10 (6.8)
History of previous pregnancy
Yes	116 (79.6)
No	30 (20.4)
Number of children (n = 116)
≤3	107 (92.2)
>3	9 (7.8)
Median (IQR)	2 (1–3)
Living situation
Living alone	133 (91.1)
With sex partner	6 (4.1)
With family	5 (3.4)
With unrelated adult	2 (1.4)
Relationship with family
Good	98 (67.1)
Normal	44 (30.1)
Bad	4 (2.7)
General life satisfaction
Dissatisfied	46 (31.5)
Neutral	79 (54.1)
Satisfied	21 (14.4)
History of incarceration
Yes	28 (19.2)
No	118 (80.8)

^a“Other” include Tiv, Idoma, Igala, Edo, Margi, and other minority ethnic groups. Education refers to the highest completed level. Occupation reflects primary self-reported role; “student” retained due to contextual dual roles in education and sex work.

Most respondents reported living alone (91.1%) and having a history of pregnancy (79.6%). Among those previously pregnant (n = 116), 92.2% had three or fewer children. Only 14.4% of participants expressed satisfaction with their lives, and 19.2% had a history of incarceration.

Awareness and use of PrEP

Of the 146 respondents, 112 (76.7%) reported being aware of PrEP. Among these, 86.6% demonstrated good knowledge, with peer educators and community-based prevention workers cited as the primary information sources (69.6%). Among PrEP-aware FSWs, 92.0% (n = 103) reported ever using PrEP. However, usage patterns varied: 41.7% reported daily use, 49.5% used it irregularly, and 8.7% used PrEP on demand (Figure 1).

Figure 1.

Awareness and use of PrEP among FSWs in Kano (N = 146).

Bivariate associations with PrEP uptake

On bivariate analysis we found PrEP uptake to be significantly higher among single FSWs compared to those who were ever married (97.3% vs 82.1%, respectively, p = 0.01), and among Christians (97.2%) relative to Muslims (82.5%, p = 0.01) (Table 2). Participants who reported more than three clients daily were more likely to use PrEP than those with three or fewer clients (98.2% vs 85.5%, respectively, p = 0.02). Participation in group HIV prevention sessions in the past year was also strongly associated with PrEP use (p = 0.01), as was a history of using drugs to treat sexually transmitted infections (p = 0.04). FSWs not working under gatekeeper control had significantly higher uptake (100%) compared to those under gatekeeper control (100% vs 85.5%, respectively, p < 0.01). No significant associations were observed with age group, ethnicity, pregnancy history, education level, incarceration, living arrangement, duration in sex work, time since last HIV test, perceived HIV risk, condom use consistency, or history of client violence.

Table 2.

Factors associated with PrEP use among female sex workers who expressed awareness of PrEP (n = 112), Kano, Nigeria.

Factor	Ever used PrEPYes, n (%)	Ever used PrEPNo, n (%)	Total n (%)	p-value
Age (in years)
<30	66 (90.4)	7 (9.6)	73 (100)	0.50
≥30	37 (94.9)	2 (5.1)	39 (100)
Ethnicity
Hausa/fulani	36 (85.7)	6 (14.3)	42 (100)	0.08
Non-Hausa/Fulani	67 (95.7)	3 (4.3)	70 (100)
Marital status
Single	71 (97.3)	2 (2.7)	73 (100)	0.01^a
Ever-married	32 (82.1)	7 (17.9)	39 (100)
Religion
Islam	33 (82.5)	7 (17.5)	40 (100)	0.01^a
Christianity	70 (97.2)	2 (2.8)	72 (100)
Ever used drug to treat STI
Yes	95 (94.1)	6 (5.9)	101 (100)	0.04^a
No	8 (72.7)	3 (27.3)	11 (100)
Group HIV prevention session (last 12 months)
Yes	71 (97.3)	2 (2.7)	73 (100)	0.01^a
No	32 (82.1)	7 (17.9)	39 (100)
Gatekeeper control
Yes	53 (85.5)	9 (14.5)	62 (100)	<0.01^a
No	50 (100)	0 (0.0)	50 (100)

^aStatistically significant at p < 0.05.

PrEP: pre-exposure prophylaxis; STI: sexually transmitted infection.

Multivariate predictors of PrEP uptake

Participation in group HIV prevention sessions in the previous 12 months emerged as the sole independent predictor of PrEP uptake (Table 3). FSWs who attended these sessions had significantly higher odds of PrEP use compared to those who did not (aOR = 14.22; 95% CI: 1.44–31.61; p = 0.02). The model demonstrated good fit (Hosmer–Lemeshow χ² = 8.21, p = 0.17).

Table 3.

Predictors of PrEP utilisation among female sex workers, Kano, Nigeria.

Factor	Crude OR (95% CI)	Adjusted OR (95% CI)	p-value
Ethnicity
Hausa/Fulani	1	1
Non-Hausa/Fulani	1.06 (0.83–3.46)	0.88 (0.67–2.24)	0.16
Religion
Islam	0.14 (0.03–0.68)	0.11 (0.01–1.21)	0.07
Christianity	1	1
Ever used drug to treat STI
Yes	5.94 (1.25–28.35)	1.33 (0.09–18.89)	0.83
No	1	1
Participation in group HIV prevention session in the past 12 months
Yes	7.77 (1.53–39.47)	14.22 (1.44–31.61)	0.02^a
No	1	1
Working under control of gatekeepers
Yes	0.12 (0.09–3.42)	0.19 (0.12–2.42)	0.99
No	1	1
Marital status
Single	7.77 (1.53–39.47)	1.41 (0.15–13.27)	0.76
Non-single	1	1
Average number of clients per day
≤3	0.11 (0.01–0.87)	0.10 (0.01–1.34)	0.08
>3	1	1

^aSignificant at p < 0.05.

OR: odds ratio; CI: confidence interval.

Hosmer–Lemeshow χ² = 8.21, p = 0.17.

The logistic model includes marital status, religion, ethnicity, client volume, STI treatment history, participation in group HIV prevention sessions, and gatekeeper control.

OR: odds ratio; PrEP: pre-exposure prophylaxis; STI: sexually transmitted infection.

Discussion

This study provides one of the first empirical assessments of PrEP awareness, uptake, and correlates among FSWs in Northern Nigeria, a socially conservative environment characterized by legal prohibition of sex work and institutional stigma. Our findings indicate unexpectedly high levels of PrEP awareness (76.7%) and reported ever-use (92.0%) among FSWs sampled in urban Kano. While these estimates exceed those from prior studies in similar African settings,^20–22 they should be interpreted with caution given the proximity of participants to peer-led One-Stop-Shop (OSS) clinics that offer integrated, key population–friendly services. Moreover, while no refusals were recorded during recruitment, we recognize that the “100% response rate” likely reflects community trust in peer navigators and may overrepresent individuals already linked to prevention services.

Our finding that 86.6% of PrEP-aware FSWs demonstrated good knowledge despite low levels of formal education aligns with growing evidence from East Africa. In Central Uganda, a multi-group study found that initial PrEP awareness among key populations was relatively low, with only 35% aware at baseline; however, targeted training for healthcare workers significantly increased PrEP awareness to 76%, and accurate understanding of PrEP rose from 54% to 74% post-intervention.²⁴ These results underscore the effectiveness of tailored, health-worker–mediated education in enhancing knowledge among marginalized groups, including FSWs. High willingness to use PrEP was also reported (93% at baseline), although barriers such as stigma, transport costs, and pill burden remained persistent. Together, these findings suggest that while education level may not strongly predict PrEP knowledge, well-designed, peer- or provider-led interventions can substantially improve literacy and uptake. Public health campaigns should therefore leverage trusted health workers and community-based networks to amplify PrEP messaging, close knowledge–behavior gaps and overcome persistent stigma.

Although PrEP uptake was high, only 41.7% of users reported daily adherence, consistent with global trends among FSWs, where mobility, work demands, and autonomy over health behaviors often limit sustained use.^23–26 These patterns underscore the importance of integrating differentiated adherence support into PrEP programs, for example, mHealth reminders, flexible refill options, and peer-led motivational counselling.

Only participation in group HIV prevention sessions was independently associated with PrEP uptake in the adjusted model (AOR = 14.22; 95% CI: 1.44–31.61). Grounded in Bandura’s Social Cognitive Theory,²⁷ group sessions likely facilitate observational learning, peer support, and norm-shifting dialogue, which are all vital in contexts where individual autonomy is constrained by structural inequities. Our findings align with studies from Kenya and Zimbabwe demonstrating that collective empowerment approaches enhance HIV prevention among key populations.^21,28

While community-based interventions have shown success in increasing PrEP uptake, their sustainability is threatened by structural barriers. In northern Nigeria, the criminalization of sex work, policing practices, and lack of legal protections continue to undermine health system trust and restrict access to HIV prevention services for key populations.¹³ The finding that gatekeeper control was associated with lower uptake in bivariate analysis (but not in our multivariate model) suggests the likely relevance of power asymmetries in our study setting. Without broader legal and policy reforms such as decriminalization, anti-discrimination legislation, and rights-based service frameworks, programmatic gains may remain fragile and unevenly distributed.

Key strengths of this study include the use of time-location sampling, culturally adapted instruments, and data collection by trained female interviewers with key population experience. However, several limitations merit attention. The cross-sectional design precludes causal inference, and reliance on self-reported behaviors may introduce social desirability or recall bias. Given that participants were largely drawn from OSS-engaged networks in urban Kano, findings may not be representative of FSWs in rural or non-service-linked contexts. Finally, although no refusals were documented, participation may have been shaped by prior contact with community facilitators, limiting extrapolation to more marginalized subgroups.

Conclusion

Despite operating within a criminalized and socially restrictive environment, this study reveals promising levels of PrEP awareness and use among FSWs in Kano, largely driven by peer-led and group-based programming. Importantly, participation in HIV prevention peer group sessions emerged as the only independent predictor of uptake, reinforcing the importance of collective, relational approaches to biomedical prevention. Sustaining and scaling gains in PrEP uptake will require embedding community-centered models like OSS within a broader agenda of structural reform. Decriminalization of sex work, legal protections against discrimination and multi-sectoral collaboration for the integration of HIV prevention interventions (e.g., in social development, education, transport, power and housing) will be important steps to advance health equity and uphold the rights of key populations.

Footnotes

Acknowledgements

We acknowledge the assistance of our research staff and participants.

ORCID iD

Muktar H. Aliyu

Ethical considerations

Ethical approval was obtained from the Aminu Kano Teaching Hospital Health Research Ethics Committee (Ref: NHREC/28/01/2020/AKTH/EC/3422; dated November 8, 2022).

Consent to participate

Written and verbal informed consent was obtained from all participants.

Consent for publication

No identifying information was collected, and all responses were de-identified at the point of data entry.

Author contributions

AAS and ZI are the lead authors and conceptualized the study with the input of other authors. MHA and HMS are the senior authors. AAS, ZI and RSA conducted the statistical analyses. All authors contributed to the writing and editing and approve the final submitted version of the paper.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article

Data Availability Statement

Data will be made available on a case-by-case basis and in strict accordance with Nigeria data privacy regulations. Please contact the corresponding author for any requests.*

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