Jpn. J. Infect. Dis.

, 67, 191-196, 2014

Original Article

High-Risk Behavior of HIV/AIDS among Females Sex

Workers in Bangladesh: Survey in Rajshahi City
Sheikh Moin Uddin1, Md. Golam Hossain2*, Md. Ashraful Islam2,
Md. Nurul Islam2, Saw Aik3, and T. Kamarul3
1Population

Services and Training Center, Rajshahi;

of Statistics, University of Rajshahi, Rajshahi, Bangladesh; and
3National Orthopaedic Centre of Excellence for Research and Learning, Department of
Orthopaedic Surgery, University of Malaya, Kuala Lumpur, Malaysia
2Department

(Received April 17, 2013. Accepted November 27, 2013)

SUMMARY: Female sex workers (FSWs) and their clients are one of the major sources of spread of
HIV/AIDS in Bangladesh. The purpose of this study was to determine the rate of unprotected sex
among FSWs in Rajshahi City, Bangladesh. A total of 200 FSWs were randomly selected for the survey
from February to September 2012. The age range of FSWs was 1641 years (average age, 24.52 6.26
years), and the majority of these women (84.4z) were married. More than 88z of FSWs reported practicing unprotected sex because of clients' insistence. Further analysis showed a significantly higher rate
of protected sex among unmarried FSWs (P 0.01). Approximately 32z of FSWs did not undergo
voluntary counseling and testing (VCT) for HIV, and this factor was significantly associated with the
education level (P 0.01), age (P 0.01), and economic status (P 0.05). Furthermore, 89.5z
respondents did not ask their new clients about VCT/HIV status, and this factor was associated with the
resident area (P 0.05), age (P 0.05), and economic status (P 0.01) of FSWs. Authorities in this
country should focus their HIV/AIDS prevention efforts on illiterate FSWs, married FSWs, and FSWs
aged below 21 years or above 30 years.
more than street-based sex workers who have approximately 16 clients per week (7).
Rajshahi is a city at the western border of Bangladesh, separated from India by a branch of Ganges
River (Padma branch). To the northwest of Rajshahi
lies the elevated and undulating Barind region; to the
south is the high, well-drained Padma Valley; and a
swampy depression drains the land in the immediate
vicinity of the city (8). Many young people travel across
the border regularly for various reasons that include
education, business, and work. In addition, many Bangladeshis regularly visit Thailand for various purposes.
India has the greatest number of HIV/AIDS cases in
Asia (9,10), and according to the CIA World Factbook
on 2009 statistics for HIV prevalence by country,
Thailand has the highest prevalence of HIV in Asia (11).
The risk of disease transmission in Rajshahi is likely to
be high because of the large number of young adults
working in India and Thailand. Therefore, the behavioral patterns of at-risk populations in this border city
would be of interest to authorities involved in
HIV/AIDS prevention. We designed this study to assess
the awareness of FSWs and their clients about
HIV/AIDS and related issues, with the hope of providing feedback to the government and relevant nongovernmental organizations (NGOs) on their efforts to
educate this at-risk population.

INTRODUCTION
The prevalence of HIV/AIDS among the general
population in Bangladesh has been reported to be as low
as 1z (1), even among the most at-risk populations
except intravenous drug users (IDUs) (24). From 1989
to 2011, a total of 2,533 HIV/AIDS cases were reported
in Bangladesh; of these, 1,101 AIDS cases and 325
AIDS-related deaths. A more recent study reported 455
new HIV cases in 2011 alone; of these, 251 AIDS cases
and 84 AIDS-related deaths (5). Many researchers are
concerned that these data may be a gross underestimation of the actual incidence of HIV/AIDS in this country, and that escalation into a state of epidemic is imminent based on numerous factors that are associated with
the high risk of disease transmission (6).
Female sex workers (FSWs) and their clients are probably the largest at-risk group in the Bangladesh population for HIV/AIDS infection. Poverty, illiteracy, and
lack of job opportunities contribute to both legal and
illegal sex trades in this country. In 2009, the number of
FSWs in Bangladesh was estimated to be approximately
63,60074,300. Approximately half of these FSWs were
hotel- or residence-based (35,00040,000), followed by
street-based (25,50030,700) and brothel-based (3,100
3,600). Clients of these FSWs were estimated to be approximately 2,714,0003,733,000. Hotel- and residencebased FSWs have an average of 61 clients per week far

MATERIALS AND METHODS

*Corresponding author: Mailing address: Department of
Statistics, University of Rajshahi, Rajshahi-6205, Bangladesh. E-mail: hossain95yahoo.com

Participant selection: Rajshahi City has a population

of 4,49,756 and covers an area of 96.68 km2 (mean density, 4,890/km2) (12). There is no legal brothel in this
191

Table 1. Descriptive statistics for some characteristics of female

sex workers with their clients

city, and most FSWs are based in hotels or residences.

The number of hotel- and residence-based FSWs has
been estimated to be 1,135 and 450, respectively (13),
but obtaining contact information for these women is
very difficult. Because of frequent checking by law enforcement agencies and harassments from landlords,
neighbors, and clients, FSWs change their addresses and
contact information frequently. For those who came
from other parts of the country, many of them would be
transferred to other cities after 710 days.
We designed the present study according to the principles of Good Clinical Practice. With the cooperation of
organizations that work for the welfare of FSWs in
Rajshahi, we managed to obtain cell phone numbers for
500 FSWs, and among them, 250 were randomly contacted for participation in the survey. Finally, 200
women agreed to be interviewed. From February to September 2012, 2 investigators conducted the interviews
based on standard questionnaires designed in the local
language (Bengali). Most interviews were conducted at a
venue suggested by the respondents, and written informed consent was obtained from all subjects before
the interview began. Information collected included
sociodemographic data and general and specific
knowledge about HIV/AIDS and related issues.
Ethical approach: Because FSWs are not registered
and do not wish to expose themselves socially as a sex
worker for numerous reasons, the ethical approach to
interviewing this population is challenging. To overcome this problem, we assured potential participants
that we would maintain strict confidentiality and would
use our data solely for research purposes. We randomly
selected 200 women for collecting primary data including hotel-, residence-, and street-based FSWs. Only
after giving their consent were FSWs asked to provide
their name, address, and signature.
Analysis of data: Pearson's chi-square/likelihood ratio test was used to determine the association between
sex trade-related characteristics and socioeconomic
factors of FSWs HIV/AIDS harm reduction for awareness. Statistical analyses were performed using the
Statistical Package for the Social Sciences software
version 15 (SPSS, Chicago, IL, USA).

Descriptive
Sex worker age
Client age
Age of sex workers'
first sexual contact

No.

Minimum

Maximum Mean

S.D.

200
200

16
16

41
42

24.52
29.43

6.265
5.868

200

12

18

15.01

1.139

1 sexually transmitted infection (STI), and 68z had at

least 1 session of voluntary counseling and testing
(VCT) for HIV. The FSWs surveyed stated that they
had sex with their clients on the street in 20.5z of cases.
The types of sexual activity most commonly requested
by clients were vaginal (98z), oral (88.5z), anal
(86z), and group (69z), as shown in Table 2. The
great majority (88.5z) of respondents agreed that they
had clients who insisted on having sex without condoms, and 52.5z stated that they regularly had unprotected sex with more than 6 clients a day. Those who
reported having unprotected sex said that they did so because they were offered extra money (28.5z), because
they were forced (1.0z), or because of a combination
of money and force (62.0z); 8.5z of respondents did
not reply to the question. Most (89.5z) of the FSW
would not ask their new clients about their VCT/HIV
status (Table 2).
Currently married FSWs (91.1z) were more likely
than their unmarried counterparts (74.2z) to agree to
have sex with clients without using condoms, and the
women's marital status was significantly associated with
the likelihood of clients insisting on having sex without
a condom (P 0.01). As shown in Table 3, education
was one of the most important factors associated with
the use of VCT for HIV. The proportion of FSWs with
secondary education who had previously undergone
(at least once) VCT for HIV was significantly higher
(84.5z; P 0.01) than that of FSWs with primary education (62.6z) or those who were illiterate (29.2z).
VCT status was also significantly associated with age, as
younger women were more likely to undergo tests than
older women (P 0.01), and with economic status, as
more than 41z of poor FSWs had never been tested for
HIV (P 0.05).
Women who came from urban areas were significantly more likely to ask about their clients' VCT status
(16.3z) than FSWs from rural areas (3.4z) or slums
(12.1z, P 0.05). An interest or willingness to ask
new clients about their HIV status was also significantly
associated with age, as younger FSWs were more likely
to ask than older FSWs (P 0.05) (Table 3). With economic status, as 98.5z of poor FSWs did not ask their
new clients about their HIV (P 0.01) (Table 3).

RESULTS
A total of 200 FSWs were interviewed. The mean age
of FSWs was 24.52 6.26 years (1641 years), while
the mean age of their clients was 29.43 5.87 years
(1642 years). The respondents' first sexual contact had
occurred at a mean age of 15.01 1.14 years (1218
years) (Table 1). While 42.5z of FSWs had completed
secondary education, 45.5z only attended primary
school and 12z were illiterate. Approximately half
(45.5z) had been raised in the slum areas of large
towns, while 25.0z and 29.5z came from urban and
rural areas, respectively. Most (84.4z) were currently
married (Table 2).
When asked HIV causes AIDS, 72.5z of FSWs
strongly agreed and 22.5z mostly agreed. Moreover,
95z of FSWs believed that AIDS causes death, and
92.5z believed that unprotected sex, sharing needles,
and unsafe blood transfusion cause HIV infection.
Most (77z) of respondents reported a history of at least

DISCUSSION
In the early stages of the HIV epidemic in Bangladesh, the highest HIV rate was recorded among male
IDUs from Dhaka (2,14). Because injectable drugs are
readily available across the border, the high rates of
drug use in Rajshahi are not surprising. Moreover,
FSWs in this city are at higher risk because a large number of their clients are IDUs. Many studies in Ban192

Unprotected Females Sex Trade in Bngladesh

Table 2. Socioeconomic, demographic, and sex trade related characteristics of female sex workers HIV/AIDS harm reduction for awareness
Variable
HIV causes AIDS

AIDS causes death

HIV causes

Sex trade place

Clients are interested for

vaginal sex
Clients are interested for
anal sex
Clients are interested for oral sex

Clients are interested for

group sex
Client dominate sex without
condom
If agree, causes

Regular partner/husband
If yes, regular partner use
condom
No. of sexual contact with client
per day
Previous history of STI

If yes, STI history

Group, no. (z)

Variable

Strongly agree, 145 (72.5)

Mostly agree, 45 (22.5)
Ambivalent, 10 (5.0)
Strongly agree, 149 (74.5)
Mostly agree, 41 (20.5)
Ambivalent, 10 (5.0)
Unsafe sex, 42 (21.0)
Unsafe sex, sharing needle, and
unsafe blood transmission,
98 (49.0)
Unsafe sex and sharing needle,
45 (22.5)
Others, 15 (7.5)
Street, 41 (20.5)
Hotel, 81 (40.5)
Residence, 78 (39.0)
Agree, 196 (98.0)
Ambivalent, 4 (2.0)
Agree, 172 (86.0)
Ambivalent, 11 (5.5)
Disagree, 17 (8.5)
Agree, 177 (88.5)
Ambivalent, 13 (6.5)
Disagree, 10 (5.0)
Agree, 138 (69.0)
Ambivalent, 16 (8.0)
Disagree, 46 (23.0)
Agree, 177 (88.5)
Ambivalent, 10 (5.0)
Disagree, 13 (6.5)
Money, 57 (28.5)
Forced, 2 (1.0)
Money and forced, 124 (62.0)
Not apply, 17 (8.5)
Yes, 116 (58.0)
No, 84 (42.0)
Yes, 15 (7.5)
No, 78 (39.0)
Not apply, 107 (53.5)
Up to 5, 95 (47.5)
6 and above, 105 (52.5)
Yes, 154 (77.0)
No, 2 (1.0)
Not apply, 44 (22.0)
Regular, 32 (16.0)
Irregular, 126 (63.0)
Ambivalent, 42 (21.0)

VCT for HIV

History of sharing needle

History of drug addiction

Sex workers' education level

Sex workers' father education

Sex workers' mother education

Choose sex trade

Do you interest to leave sex

trade?
Sex workers marital status
Sex workers economic
condition
Informed about HIV/AIDS

Do you ask about VCT/HIV

status for new client?
Sex workers residence

gladesh have surveyed knowledge, attitudes, and awareness about HIV/AIDS among high-risk groups such as
sex workers in brothels (15) and boatmen (16). The
prevalence of reproductive tract infections and STIs
among women and FSWs in Bangladesh has been
reported to be increasing tremendously (6). These studies investigated the behavioral patterns of sex trade
(protected or unprotected) and associations with other
parameters including the socioeconomic and demographic backgrounds of FSWs in Bangladesh.
The present study demonstrated that knowledge
about HIV/AIDS among FSWs and their clients is still

Group, no. (z)

Yes, 136 (68.0)
No, 64 (32.0)
Yes, 1 (0.5)
No, 190 (95.0)
Not apply, 9 (4.5)
Yes, 78 (39.0)
No, 115 (57.5)
Not apply, 7 (3.5)
No education, 24 (12.0)
Primary, 91 (45.5)
Secondary, 85 (42.5)
Primary, 160 (80.0)
Secondary, 15 (7.5)
Higher, 25 (12.5)
No education, 89 (44.5)
Primary, 107 (53.5)
Secondary, 4 (2.0)
Personally, 4 (2.0)
Financially, 2 (1.0)
Socially, 1 (0.5)
Not apply, 4 (2.0)
Personally, financially, and
socially, 132 (66.0)
Trapped by friend, 1 (0.5)
Financially and socially, 10 (5.0)
Personally and financially, 41
(20.5)
Personally and socially, 5 (2.5)
Yes, 129 (64.5)
No, 26 (13.0)
Not apply, 45 (22.5)
Married, 168 (84.4)
Single, 32 (15.6)
Poor, 65 (32.5)
Rich, 135 (67.5)
Government, 19 (9.5)
Media, 47 (23.5)
NGO, 134 (67.0)
Yes, 21 (10.5)
No, 179 (89.5)
Slum, 91 (45.5)
Urban, 50 (25.0)
Rural, 59 (29.5)

inadequate in Rajshahi City in Bangladesh. Up to

88.5z of FSWs did not practice protected sex because
of the preference of their clients, although most of them
were aware that protected sex can reduce the risk of
HIV/AIDS. The 3 most important variables that
emerged from our study included (i) how often clients
insist on sex without condoms, (ii) whether FSWs undergo VCT, and (iii) whether FSWs ask their new clients
about their VCT/HIV status.
Considering the rate of condom use among FSWs, we
noted that marital status was an important predictive.
More than 90z of married FSWs were willing to prac193

Table 3. Association between sex trades related factors and some sociodemographic characteristics of female sex workers
Variable
Client dominate sex without condom
Sex Workers education level

Sex workers residence

Sex workers age group (yr)

Sex workers marital status

Sex workers economic condition

Group

No. of respondents (z)

No education
Primary
Secondary
Urban
Rural
Slum
20
21 Age 30
31
Currently married
Single
Poor
Rich

Did you test HIVtest/VCT?

Sex Workers education level

No education
Primary
Secondary
Sex workers residence
Urban
Rural
Slum
20
Sex workers age group (yr)
21 Age 30
31
Sex workers marital status
Currently married
Single
Sex workers economic condition
Poor
Rich
Do you ask new client about their HIV test/VCT?
Sex workers education level
No education
Primary
Secondary
Sex workers residence
Urban
Rural
Slum
20
Sex workers age group (yr)
21 Age 30
31
Sex workers marital status
Currently Married
Single
Sex workers economic condition
Poor
Rich

Agree
21 (87.5)
83 (91.2)
72 (85.7)
40 (81.6)
55 (93.2)
81 (89.0)
64 (87.7)
79 (88.8)
33 (89.2)
153 (91.1)
23 (74.2)
56 (86.2)
120 (89.6)
Yes
7 (29.2)
57 (62.6)
71 (84.5)
38 (77.6)
40 (67.8)
57 (62.6)
45 (61.6)
72 (80.9)
18 (48.6)
117 (69.6)
18 (58.1)
38 (58.5)
97 (72.4)
Yes
1 (4.2)
8 (8.8)
12 (14.3)
8 (16.3)
2 (3.4)
11 (12.1)
5 (6.8)
15 (16.9)
1 (2.7)
19 (11.3)
2 (6.5)
1 (1.5)
20 (14.9)

Disagree
3 (12.5)
8 (8.8)
12 (14.3)
9 (18.4)
4 (6.8)
10 (11.0)
9 (12.3)
10 (11.2)
4 (10.8)
15 (8.9)
8 (25.8)
9 (13.8)
14 (10.4)
No
217 (70.8)
34 (37.4)
13 (15.5)
11 (22.4)
19 (32.2)
34 (37.4)
28 (38.4)
17 (19.1)
19 (51.4)
51 (30.4)
13 (41.9)
27 (41.5)
37 (27.6)
No
23 (95.8)
83 (91.2)
72 (85.7)
41 (83.7)
57 (96.6)
80 (87.9)
68 (93.2)
74 (83.1)
36 (97.3)
149 (88.7)
29 (93.5)
64 (98.5)
114 (85.1)

Test value

1.33

0.514

3.48

0.176

0.07

0.965

7.29

0.007

0.50

0.482

28.29

0.001

3.25

0.197

14.49

0.001

1.61

0.205

3.89

0.049

2.76

0.252

5.97

0.049

7.76

0.021

0.654

0.540

8.31

0.003

gone at least 1 test compared with fewer than 62.6z of

those with primary school education and less than
29.2z of illiterate women. FSWs with less formal education have to rely on friends, social workers, and even
clients for their knowledge about HIV/AIDS and its
prevention, whereas those with higher levels of education have additional sources of knowledge such as electronic and print media. The age of respondents was
another strong predictor of VCT in this population.
More than 80.0z of FSWs who were aged 2130 years
had undergone VCT, while the percentage was significantly lower among those younger than 21 years
(61.6z) and older than 30 years (48.6z). Young FSWs
may not seek testing because they do not fully appreciate their actual risk of HIV/AIDS. This group of FSWs
is also generally more popular among clients; they may

tice unprotected sex compared with 74.2z of unmarried

FSWs who were willing to do so, and the difference was
significant (P 0.05). The reason for this difference
may have more to do with concerns about unwanted
pregnancy than with awareness of HIV/AIDS prevention. Pregnancy among unmarried women is not well
accepted in Asian cultures. Therefore, these women
may be more likely than their married counterparts to
insist upon condom use for contraceptive purpose.
However, the fact that a large number of clients may
simply refuse to use condoms probably accounts for the
relatively high rate (74.3z) of unprotected sex even
among the unmarried FSWs.
The rate of VCT for HIV among FSWs was clearly influenced by the education level, considering that 84.5z
of those with secondary school education had under194

Unprotected Females Sex Trade in Bngladesh

need to entertain more clients leaving them less time to

go for testing themselves. Many FSWs who are older
than 30 years may have an erroneous belief that their
HIV risk is lower because of their comparatively smaller
number of clients. They may also have a false sense of
security because of the perception of being ``lucky,''
considering that they have survived over their years.
Economic status plays an important role in determining whether FSWs seek VCT. Only slightly more than
half of FSWs classified as poor had undergone VCT,
whereas the testing rate was 72.4z among those classified as not poor. Screening tests are free of charge in
Bangladesh; therefore, the cost of testing itself should
not be a factor. However, poverty among FSWs may be
associated with lower literacy levels, as well as a greater
sense of desperation to increase their income that may
overshadow any concerns about safety. Even if FSWs
know that HIV screening tests are free, they may not be
interested in going to VCT centers, because these facilities are open only during standard business hours on
week days (from 9:00 am to 5:00 pm). These women
may be embarrassed to be recognized or associated with
sex work in the open. Moreover, the VCT centers are
not available all over the city.
The rate of VCT also seemed to be low among the
clients of the FSWs surveyed. The availability of
HIV/AIDS testing could also be a challenge for these
clients, who may be occupied by their own employment
during business hours, when the VCT centers are open.
Most FSWs did not ask their clients about their
VCT/HIV status. Young FSWs below the age of 21 usually accept more clients than older women. Thus, it is of
concern that only 6.8z of FSWs in this age group asked
their new clients about their VCT status. The percentage
was higher in the 2130 age group (16.9z), but it
declined again after the age of 30 (2.7z). It is logical to
consider that similar factors may influence both the willingness of these FSWs to get themselves tested for HIV
and the initiative needed to inquire about the test status
of their clients.
In Bangladesh, few male clients seemed to insist on
protected sex with FSWs, partly because of lack of
awareness of HIV/AIDS and its impact. Most clients
are unmarried men younger than 30 years, and many
apparently share the belief that sex using a condom is
less enjoyable to both partners. Some male clients
would expect FSWs to provide a condom, although
condoms are not always available to FSWs.
Most FSWs in the present study were aware that
HIV/AIDS exists and that the condition is related to
death. However, only approximately 40z of these
FSWs believed that unprotected sex is an important
cause of HIV/AIDS, and most of them did not use
condoms regularly. Approximately 32z of FSWs had
never been tested for HIV, especially those younger
than 21 years and older than 30 years. Low educational
level, low economic status, and a residential origin in a
rural area or slum were all associated with reduced
awareness of HIV status among these FSWs. The fact
that a large number of clients insist on unprotected sex
is a major risk factor for the spread of HIV/AIDS in
this region.
The Government of Bangladesh and NGOs should
pay special attention to FSWs, helping them and their

clients to gain awareness about HIV/AIDS and to

reduce their risk of infection. Official registration of
FSWs, provision of more accessible facilities for screening of these diseases, and enforcement of policies that
protect these women from behaviors that expose them
to increase risk against their wishes are some of the
measures that can be taken to achieve these goals. Based
on our findings, we suggest that authorities should
focus their efforts on FSWs who are illiterate, married,
and below 21 or above 30 years of age to ensure that
those at higher risk will receive proper information and
protection.
One major limitation of our research was the fact that
FSWs in Rajshahi were extremely scattered throughout
the city, and most of them had migrated from another
city. Many were constantly moving from one place to
another, often guided by a broker, clients, or Mokkhirani (team leaders). Most of FSWs were known by
more than one name and had multiple addresses and
contact numbers. To overcome this problem, the current cell phone numbers of FSWs were collected from
different government and NGO entities who work with
sex workers in Rajshahi. We then corresponded with
them to identify their address and finally contacted
them.
Acknowledgments We would like to thank Rajshahi City Corporation, Population Services and Training Center (PSTC), Urban Primary Health Care Project (UPHCP), Khulna Mukti Seba Sangstha
(KMSS), Tilottoma-Smiling Sun Franchising Project (SSFP), which
are implementing program to fight against HIV/AIDS at Rajshahi
City Corporation in Bangladesh.
Conflict of interest None to declare.
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