Introduction

HIV/AIDS and other sexually transmitted infections (STI) still pose a significant public health challenge in Cameroon. With a population of about 23 million inhabitants [1], the country has an estimated HIV prevalence of 4.3% among adults aged 15–49 years [2]. Young girls and women continue to be disproportionately affected by HIV than their male counterparts. The prevalence of HIV was reported to be almost twice as high among women (5.6%) compared to men (2.9%)[2]. Among women, the HIV prevalence is higher among those living in urban areas (6.4%) compared to those living in rural areas (4.6%)[2]. Generally, many factors have been reported to increase women’s vulnerability to HIV including biological, social, behavioural, cultural, economic and structural [3–5].

Transactional sex, defined as sex in exchange for money or material gifts [6, 7] has been demonstrated to increase women’s vulnerability to HIV [6, 8, 9]. Women have been reported to engage in transactional sex for a variety of reasons including economic, material and social gains; and access to basic necessities such as food, shelter, protection, clothing, hygiene requirements and school necessities [10–13]. Studies have shown that women who engage in transactional sex are at an elevated risk of HIV acquisition [8, 9]. Transactional sex has also been associated with risky sexual behaviours including age-disparage sex, multiple concurrent sexual partnerships, unprotected sex and intimate partner violence [9, 14–16]. Studies have reported that many women in sub-Saharan Africa (SSA) who engage in transactional sex do not self-identify themselves as sex workers due to the stigmatising connotation attached to sex work [6, 13, 16].

Although HIV vulnerability and transactional sex has been extensively studied among many women’s group including female sex workers [17], female bar workers (FBWs) represent a subgroup of women whose HIV vulnerability has received little attention in scholarly research. FBWs are women who work in the informal alcohol industry, promoting the sale of beer and alcoholic drinks to customers in bars, karaoke, beer parlours and casinos. These women are encouraged by their employers to socialize with male customers to increase the sale and consumption of beer [18]. Due to their low income, FBWs are forced to sell sex on a regular basis or occasionally to their male customers to supplement their income [19, 20]. This explains why these women are sometimes classified as indirect sex workers [20–22].

Studies have established a positive association between alcohol consumption and risky sexual behaviours [23, 24] including transactional sex among the general population [25]. Previous research conducted among FBWs in Cambodia showed that these women frequently consume alcohol [26] and some are invited by their male customers to drink with them. These FBWs are forced to drink alcohol upon invitation to increase the sale of beer and receive tips from their male customers [19]. In certain situations, they may have sex with their male customers after consuming alcohol which increases their HIV vulnerability. In Cambodia, FBWs have been reported to have unprotected sex with their male customers and this sometimes occurred under the influence of alcohol [27].

In Cameroon, alcohol consumption is a common practice in many socio-cultural milieu. There are many FBWs (although their estimated population is unknown) promoting beer consumption in bars, karaoke, beer parlours and casinos in the country. However, there has been no research conducted among this subgroup of women to examine their HIV vulnerability. As a result, little is known about the extent to which these women are vulnerable to HIV and STI infection and what factors contribute to their risky sexual practices. Furthermore, while the relationship between alcohol use and risky sexual behaviour among women in the general population has been established [7, 25, 28], this association has not been investigated among this subgroup of women. The lack of empirical data has made it difficult to determine their level of HIV and STI vulnerability and this perhaps explains why there has been limited HIV prevention interventions targeted at this subgroup of women in Cameroon. Rather, most HIV prevention interventions have targeted high risk groups of women like female sex workers due to evidence of their vulnerability to HIV and STI [29].

The objective of this study was to examine the association between socio-demographic characteristics, alcohol use and transactional sex among FBWs in Yaoundé, Cameroon. Understanding these relationships will fill the knowledge gaps and provide the evidence that will inform HIV prevention strategies and interventions among this subgroup of women in the country.

Materials and methods

Results

Socio-demographic characteristics by transactional sex

A total of 506 respondents were screened and eligible for the study. Of these, 415 agreed to participate (response rate = 82%). However, due to missing data, 5 questionnaires were eliminated leaving 410 for analysis. Table 1 shows respondents’ socio-demographic characteristics by transactional sex. The median age of the 410 study respondents was 29 years (IQR, 25–34). Over half (58.8%) were aged 21–30 years, most (78.5%) were never married, 75.9% attained education below high school, and 67.8% had a monthly income of less than 50,000 FCFA (< 89 US $). The majority (86.6%) had no other source of income apart from what they earn as a FBW. Those who had other sources of income were significantly more likely to have engaged in transactional sex in the past 12 months than those without other sources of income (23.6% vs 13.5%, p = 0.034). About 80.9% were living with someone; those who reported to have engaged in transactional sex where significantly more likely to be living alone compared to those living with others (21.8% vs 13.3%, p = 0.039). An estimated 40.4% were living with 4–6 household members, and almost half (48.1%) had worked as a FBW for at least a year.

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Table 1. Socio-demographic characteristics by transactional sex.

https://doi.org/10.1371/journal.pone.0198853.t001

Sexual behaviour and alcohol use by transactional sex

Table 2 shows associations between sexual behaviour and alcohol use by transactional sex in the past 12 months. About 77.1% of FBWs reported to have had less than 10 life time sexual partners and a minority (5.6%) had 20 or more life time sexual partners. Among this small group with 20 or more partners, a high percentage (39.1%) reported recent transactional sex. The median age of sexual debut for all respondents was 18 years (IQR = 16–19). The median age of those who reported to have engaged in transactional sex was slightly lower than those who did not engage in transactional sex (17 yrs vs 18 yrs, p = 0.050).

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Table 2. Sexual behaviour and alcohol use by transactional sex.

https://doi.org/10.1371/journal.pone.0198853.t002

About 14.4% of the FBWs indicated that they had sex with a male customer in the past 6 months. Those who reported to have had sex with a male customer were significantly more likely to have engaged in transactional sex in the past 12 months (45.4% vs 10.1%, p = <0.001) compared to those who did not have sex with a male customer. Most (83.7%) of the FBWs indicated that they had more than one sexual partner at the time of the study. Nearly half (47.1%) had their last sexual intercourse within a week prior to the study. Those who had sex less than one week prior to the study were more likely to have engaged in transactional sex than those who had their last sexual intercourse five or more weeks prior to the study (19.7% vs 7.4%, p = 0.001). Overall, only 35.6% of respondents used a condom during their last sexual intercourse. Respondents who used a condom during their last sexual intercourse where more likely to have engaged in transactional sex than those who did not use a condom (15.1% vs 14.8%). The majority (73.4%) of participants were alcohol consumers. Among those who consume alcohol, more than half (62.8%) were classified as “Non-frequent” alcohol consumers. Nevertheless, “Frequent” consumers of alcohol were more likely to have engaged in transactional sex in the past 12 months compared to “Non-frequent” consumers, (23.2% vs 9.5%, p<0.001).

Predictors of transactional sex

Table 3 shows the predictors of transactional sex in the past 12 months among FBWs. In weighted univariate analysis, FBWs with other sources of income (OR = 1.97;95%CI = 1.04–3.76, p = 0.37), who had 20 or more life time sexual partners (OR = 4.19;95%CI,1.83–9.63, p = 0.001), who had sex with a male customer in the past 6 months (OR = 7.38; 95%CI = 4.11–13.26, p<0.001), who had sex under the influence of alcohol in the past 6 months (OR = 2.52; 95%CI, 1.14–4.46,p = 0.001) and who were “Frequent” alcohol consumers(OR = 2.87;95% CI,1.56–5.27,p = 0.001) were more likely to have engaged in transactional sex in the past 12 months. Those who were living with others (OR = 0.54; 95%CI, 0.31–0.97, p = 0.041) and who had sex more than a month prior to the study (OR = 0.33; 95%CI, 0.15–0.72, p = 0.005) were less likely to have engaged in transactional sex in the past 12 months.

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Table 3. Logistic regression models for predictors of transactional sex.

https://doi.org/10.1371/journal.pone.0198853.t003

In weighted multivariate analysis, those who had sex with a male customer in the past 6 months (aOR = 7.34; 95%CI, 3.63–16.98, p<0.001), who had sex under the influence of alcohol in the past 6 months (aOR = 2.42; 95% CI, 1.18–4.96, p = 0.016) and “Frequent” alcohol consumers (aOR = 2.06; 95%CI, 1.04–4.10, p = 0.038) were more likely to have engaged in transactional sex in the past 12 months. Those who had their last sexual intercourse four weeks or more prior to the study (aOR = 0.26; 95% CI, 0.08–0.84, p = 0.024) were less likely to have engaged in transactional sex in the past 12 months.

Discussion

This study was designed to test the hypothesis that FBWs are exposed to male customers and due to their limited financial means, some engage in transactional sex. Our findings also support the hypothesis that because these women promote the sale of alcoholic drinks, some of them consume alcohol which increase their likelihood of engaging in risky sexual behaviour and HIV and STI vulnerability. To our knowledge, this is the first comprehensive study conducted in SSA to have investigated HIV vulnerability and transactional sex among this subgroup of women.

This study found that FBWs earn low wages with a majority earning less than 50.000FCFA (the minimum wage in Cameroon as at August 2017 was 36,270 FCFA). Although monthly income was not statistically significantly associated with transactional sex, our results demonstrate that FBWs with a monthly income of less than 50,000 FCFA (< 89 US $) were more likely to have engaged in transactional sex (15.8% vs 12.9%) in the past 12 months. Over the years, there has been an increase in the cost of living in the city of Yaounde and some of these FBWs may have children, siblings and parents who depend on them for food and other livelihoods. Due to economic pressure and the need to care for dependents, these women have a likelihood of engaging in transactional sex to supplement their low income. The study found a marginally significant association between having other sources of income and engaging in transactional sex. The finding may suggest that transactional sex may have been one of the other sources from which these women made extra money.

In this study, 14.9% of FBWs indicated that they had engaged in transactional sex in the past 12 months. Additionally, 13.4% had sex with one or more of their male customers in the past 6 months. Similar findings have been reported in Cambodia [19] and Malawi [11] where FBWs were found to have sex with their male customers. In the Malawian study, FBWs indicated that money was the main reason why they sold sex to their male customers and some mentioned that without engaging in transactional sex, they will have nothing to eat [11]. In this study, it is important to keep in mind that these women may have engaged in transactional sex with either their male customers or with other sexual partners.

There was a strong positive association between having sex with a male customer and engaging in transactional sex which may suggest that the primary reason for having sex with male customers could have been for the exchange of money or gift [31, 32]. While some FBWs may be promoting the sale of beer, some may also be indirectly selling sex [33] to their male customers. This perhaps fits the categorization that some FBWs may be indirect sex workers as they supplement their income by selling sex on a regular basis or occasionally [19–21]. However, as reported in previous research, most women who engage in transactional sex would not identify themselves as sex workers [6, 16]. The above findings support the evidence that economic and food insecurity as well as survival needs may be motivating factors for engaging in transactional sex among women particularly those with dependents [4, 34, 35].

This study did not find any association between educational attainment, living arrangements and transactional sex among FBWs. Similar findings have been reported in a study conducted among a group of young women in Liberia [36]. Contrary to previous studies among women in the general population [16, 36], this study did not find any significant association between multiple sexual partners and engaging in transactional sex. Those who had their last sexual intercourse more than four weeks prior to the study were less likely to have engaged in transactional sex in the past 12 months. This may suggest that transactional sex was mainly carried out by FBWs who frequently had sexual intercourse. Nearly half (47.1%) of the FBWs in this study had sex within a week prior to the study. The explanation for this finding is unclear, but it is plausible that the existence of multiple and concurrent sexual partnership may be the reasons why most of the FBWs had their last sexual intercourse within a week.

This study found a positive association between alcohol consumption and engaging in transactional sex in the past 12 months. Participants who were “Frequent” alcohol consumers were more likely to have engaged in transactional sex. This finding is consistent with a previous study in Cambodia which reported that FBWs consume alcohol and some engaged in transactional sex [19]. Among women in the general population, similar findings in South Africa [37, 38] and Uganda [39] also reported that heavy alcohol consumption was associated with transactional sex. The above finding supports available evidence that alcohol consumption is associated with a number of risky sexual behaviours including transactional sex[25, 28], unprotected sex and inconsistent condom use [40, 41].

In the current study, about 17.6% of FBWs indicated that they had unprotected sex under the influence of alcohol in the past 6 months. Studies have reported that alcohol impairs cognitive functioning which leads to poor sexual decision-making [42, 43] and increases the risk of HIV and STI acquisition. Moreover, it is likely that some of these women may have had transactional sex with male partners who had consumed alcohol. Studies have reported that alcohol use is a risk factor for unprotected sex which increases the risk of HIV infection [44, 45].

The current study is of public health significance as it has identified some of the risky sexual practices among FBWs which increase their risk of acquiring HIV and STIs. The study demonstrates that FBWs represent a high-risk group for HIV and STI acquisition. The strength of this study relates to the fact that data were collected across all the seven administrative zones of Yaounde, and because the data were weighted, the findings could be generalised among FBWs in the city. Although the study findings are important to guide the design and implementation of HIV prevention programmes among FBWs, they must be interpreted in light of the following study limitations. Firstly, sensitive data (e.g., having sex with a male customer, number of life time sexual partners) were collected by self-report through face-to-face interviews, which may have resulted in under-reporting of risk behaviours due to social-desirability bias. Secondly, because the study was cross-sectional, it is not possible to draw any causal inferences. Thirdly, data were collected only during broad daylight and non-pick hours from the venues and due to safety and security reasons, data were not collected from nightclubs. Consequently, the study missed out some FBWs who work during peak hours and night shifts and their experience may have been different from those working during the day. Lastly, our study did not quantify alcohol consumption, as a result we recommend future studies to ask respondents about the quantity of alcohol they consume.

Despite these limitations, the current study has increased our knowledge and understanding of the risky behaviours that predispose FBWs to HIV and STI acquisition. It highlights the fact that FBWs are a subgroup of women at increased risk of HIV and STI infection. Future studies are needed to further understand the HIV and STI vulnerability among this group of women. A study to estimate the population size of FBWs would also be beneficial and epidemiological studies are needed to estimate the prevalence of HIV and STI among this subgroup of women.

Conclusions

This study concludes that FBWs are a group of women whose profession exposes them to men and given that they promote beer consumption to male customers, most of these women also consume alcohol. These factors motivate them to engage in risky sexual practices which increases their risk of acquiring HIV and STI. Additionally, these women also earn low wages and due to limited socio-economic opportunities, some engage in transactional sex with their male customers as a means of survival. These findings are useful as they will inform the design and implementation of HIV prevention interventions to target this group of women. Although interventions aimed towards reducing risky sexual behavior are important, there is a need for economic empowerment interventions directed towards these women. Such interventions will enable them to be financially viable which may decrease their likelihood of engaging in transactional sex and hence reducing their HIV and STI vulnerability.

Supporting information

Acknowledgments

We thank all the young girls and women who participated in the study. The authors also thank Mr Nchoutpouen Limi Cyrille for his support during data collection and study management. We are grateful to everyone who reviewed the earlier draft of this manuscript.