Vulnerabilities and psychological distress among female sex workers in the ANRS 12381 PRINCESSE cohort in San Pedro, Côte d’Ivoire

Background. Despite the many vulnerabilities faced by female sex workers (FSWs), few studies have investigated mental health in this population, especially in West Africa. This study aimed to determine the frequency of psychological distress and identify associated factors among FSWs included in a sexual and reproductive health cohort in Côte d’Ivoire. Methods. The ANRS 12381 PRINCESSE project (2019-2023) was a single-arm interventional cohort of FSWs ≥18 years in San Pedro, Côte d’Ivoire, evaluating a comprehensive and community-based sexual and reproductive health care offer through mobile clinics operating on sex work sites. This cross-sectional sub-study included all FSWs who completed at least one socio-behavioral questionnaire. The Patient Health Questionnaire (PHQ-4) was used to describe signs of psychological distress among FSWs at the first socio-behavioral questionnaire. Multivariable logistic regression was used to identify factors associated with having signs of psychological distress. Results. Among the 489 FSWs in the cohort, 253 completed at least one PHQ-4 questionnaire, and 32% had mild psychological distress. Among the 230 FSWs without missing data, factors associated with mild psychological distress were: advanced age compared to <25 years olds (aOR=5.5 [95% CI=1.5-30.4] in 25-30 years, aOR=6.9 [1.8-37.5] in 31-40 years and aOR=16.5 [3.5-104.0] in >40 years); perceiving their financial situation as very difficult versus fair (aOR=4.1 [1.4-14.0]); being HIV positive (aOR=5.3 [1.8-17.2]); engaging in irregular sex work versus almost daily (aOR=2.9 [1.2-7.4]); reporting violence from a regular partner (aOR=4.7 [1.7-14.5]) or from friends/family (aOR=2.8 [1.1-7.0]); having poor emotional support versus medium or good (aOR=3.9 [1.2-14.4]); and having very low self-esteem versus average or higher (aOR=6.9 [1.9-25.6]).Conversely, FSWs who had sex with a client under the influence of alcohol/beer were less likely to experience mild psychological distress compared to those who did not (aOR=0.4 [0.1-0.9]). Conclusions. FSWs who were isolated, facing financial insecurity, living with HIV, and/or having experienced violence were the most vulnerable to developing signs of psychological distress. These results underline the need to integrate mental health issues into sexual health programs for FSW. Trial registration: The PRINCESSE project was registered on the Clinicaltrial.gov website (NCT03985085) on 13 June, 2019.