Exploring the Interplay of Social and Physical Factors in Risk Dynamics and Transitions Across the Life-Course of Female Sex Workers in Blantyre, Malawi: A Longitudinal Narrative Study

Sexual risk amongst female sex workers (FSW) varies across the life-course and is influenced by socio-economic and interpersonal factors that affect behavioural choices and engagement in HIV/STI care. We explored transitions in the life-course of FSW to understand the dynamics of sexual risk in Blantyre, Malawi. We implemented a nested longitudinal qualitative study as part of the AMETHIST Consortium, a study testing approaches to reduce HIV transmission in sex work. We conducted consecutive narrative interviews with 30 FSW at three-time points over 12 months, with a three- to four-month break between each time point. We compared narratives to understand sex work transitions, HIV risk and engagement with HIV services. We identified factors (social and physical) related to sexual risk at the points of (1) transitions into sex work, (2) continuing sex work, and (3) breaks in sex work. At the entry stage, sexual risk was heightened when women lacked the knowledge and skills for protection against HIV/STI. Whilst continuing sex work, women's immediate financial needs were prioritised over their HIV/STI risk. These behaviours occurred whether they were aware of the associated HIV/STI risk. During breaks, women perceived lower risk and reduced engagement in prevention strategies, particularly when they had stable partners, which paradoxically increased their risk. These narratives reveal how social context informs and limits access to health care while concurrently promoting risky behaviours. A multifaceted and dynamically responsive approach that considers risk differentiation from a temporal perspective can strengthen targeted interventions, effectively addressing the multiple challenges faced by FSW.