The Prevalence of and Factors Associated with Heterosexual Anal Sex Among Iranian Female Sex Workers

Heterosexual anal sex (HAS) could be one of the drivers of the HIV epidemic among female sex workers (FSWs). This study aimed to characterize HAS and its correlates among FSWs in Iran. Data were obtained from a bio-behavioral surveillance survey of 1347 FSWs conducted across 13 major cities in Iran in 2015. FSWs were eligible if they were >= 18 years of age and reported penetrative sex with more than one client in the previous year. Data were collected through one-on-one interviews using a standard risk assessment questionnaire. A modified Poisson regression model was used to examine the correlates of recent (i.e., last month) HAS, and adjusted prevalence ratio (APR) and 95% confidence intervals were reported. Recent HAS was reported by 18.5% (95% CI: 13.0, 25.6) of the participants, of whom, 196 (80%) reported inconsistent condom use during their recent HAS practices. Recent HAS was positively associated with younger (<= 18) age at sex work debut (APR: 1.24), history of group sex in last month (APR: 1.62), higher number of clients in last month (APR: 2.35), and frequent alcohol use (APR: 1.62). Conversely, recent HAS was negatively associated with being married (APR: 0.52) or divorced/widowed (APR: 0.50) and having used condoms with their last client (APR: 0.73). About one in five FSWs reported HAS, a behavior that was more frequent among FSWs with a higher risk profile. Effective harm reduction initiatives to address the high prevalence of unsafe HAS for both FSWs and their partners/clients are warranted.