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Sex preparation and diaphragm acceptability in sex work in Nairobi, Kenya

Anjali Sharma A B H I , Elizabeth Bukusi A B C , Samuel Posner D , Douglas Feldman E , Elizabeth Ngugi F and Craig R. Cohen G

A Centre for Microbiology Research, Kenya Medical Research Institute, Kenyatta National Hospital, PO Box 19464-00202, Nairobi, Kenya.

B Department of Obstetrics and Gynecology, University of Washington School of Medicine, 1959 NE Pacific St, Box 356460, Seattle, WA 98195, USA.

C Department of Obstetrics and Gynecology, University of Nairobi, Kenyatta National Hospital, PO Box 19676, Nairobi, Kenya.

D Centers for Disease Control and Prevention, 4770 Buford Highway, Atlanta, GA 30341, USA.

E Department of Anthropology, State University of New York College, 350 New Campus Drive, Brockport, NY 14420, USA.

F Department of Community Health Sciences, University of Nairobi, Kenyatta National Hospital, PO Box 19676, Nairobi, Kenya.

G Department of Obstetrics, Gynecology, Reproductive Sciences, University of California, 50 Beale St, San Francisco, CA 94105, USA.

H Present address: Suite 311, 3rd Floor, Theodak Plaza, National Hospital Road, Off Constitution Ave, Central Business District, P.M.B. 69, Garki, Abuja, Nigeria.

I Corresponding author. Email: or

Sexual Health 3(4) 261-268
Submitted: 23 March 2006  Accepted: 6 August 2006   Published: 17 November 2006


Background: Women in sex work stand to benefit if the contraceptive diaphragm alone or combined with a microbicide proves to be an effective barrier method against HIV and sexually transmissible infection (STI). Currently, contraceptive diaphragm users are advised to leave the diaphragm in situ without concomitant use of other intravaginal substances for at least 6 h after intercourse. Methods: We conducted in-depth interviews on sexual behaviour including post-coital intravaginal practices with 36 women in sex work and 26 of their clients and held two focus-group discussions, each with 10 women. Results: The women described adapting several potentially harmful substances, such as cloth and soapy water, for post-coital vaginal use to ensure personal hygiene, disease prevention and client pleasure. Some wanted to clean themselves and remove the diaphragm early, fearing exposure to HIV infection for themselves and their subsequent clients. Clients indicated their desire for ‘dry sex’, vaginal cleanliness and reduced risk of infection through vaginal cleaning. Conclusions: The diaphragm as a female-controlled barrier method for HIV/STI prevention may have limited acceptability among women in sex work if its effectiveness depends on a 6-h post-coital wait before removal, along with avoidance of concomitant use of intravaginal substances. In keeping with the beliefs of the the female sex workers and their needs and practices, alternative intravaginal substances and modes of insertion that will not disrupt vaginal flora, injure vaginal epithelium, damage the diaphragm or counteract potentially beneficial effects of microbicides are needed. The possibility of removing the diaphragm sooner than the recommended 6 h for contraception should be further studied.


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