Mental health and social vulnerability among HIV negative female sex workers in Tanzania – a cross-sectional analysis of data from a female sex worker cohort

Introduction: Poor mental health is closely linked to sex work and HIV risk, but has received limited attention in research among female sex workers in Sub-Saharan Africa. Inspired by syndemic framework, which recognizes that the epidemics of HIV, substance use and poor mental health are interrelated, we investigate mental health outcomes among female sex workers at high risk of HIV in Tanzania. Methods: Data from a cohort of female sex workers initiating HIV pre-exposure prophylaxis use (PrEP) in Dar es Salaam was analysed. Participants were recruited through respondent driven sampling (RDS), and interviewed about depression (PHQ-2), anxiety (GAD-2) and hazardous alcohol use (AUDIT). We conducted weighted descriptive analysis and assessed sociodemographic predictors of mental distress (positive screen for PHQ-2, GAD-2 or both) using modified Poisson regression with robust standard errors. Results: A total of 470 women with a median age of 25 years were recruited. Nearly a third (n=143; 30%) screened positive for mental distress (n=106; 25.3% for depression, n=89; 18.4%, for generalized anxiety). More than two thirds (n=360; 69.6%) were categorized with hazardous alcohol use (AUDIT≥8). Predictors of mental distress were less social support (aPR=1.37, CI: 1.05-1.79) and working outside a bar setting (aPR= 1.52 CI: 1.13-2.06). Sex work stigma showed borderline significance (aPR=1.34, 0.99-1.80). Discussion: Our findings indicate that female sex workers in Tanzania are vulnerable to poor mental health outcomes, which is related to social disadvantage. Health programs and initiatives should acknowledge the presence of syndemics by offering comprehensive interventions that meet the range of health needs of female sex workers.