Trends and determinants of HIV prevalence among female sex workers in Ghana: a decade of evidence from national bio-behavioural surveys

Female sex workers (FSWs) in sub-Saharan Africa continue to experience a disproportionately high burden of HIV. In Ghana, national Bio-Behavioural Surveys (BBS) have documented declines in HIV prevalence among FSWs over the past decade; however, the extent to which these trends reflect programmatic gains or shifts in the composition of the sex work population remains unclear. FSWs in Ghana are commonly classified as roamers (street- or venue-based) or seaters (brothel- or establishment-based), reflecting different modes of operation and potential HIV risk exposures. This study assessed temporal trends in HIV prevalence, examined consistent predictors of infection, and evaluated the influence of population dynamics, including duration in sex work, using three rounds of nationally representative BBS data. We conducted a pooled analysis of secondary data from the 2011, 2015, and 2020 BBS rounds. Eligible participants were biological females aged ≥ 16 years who had exchanged sex for money or gifts within the previous 6 months. Variables common to at least two survey rounds were harmonized across datasets. Descriptive statistics summarized sociodemographic, behavioural, and programmatic indicators. Bivariate analyses explored associations with HIV status, and multivariable logistic regression model identified independent predictors of HIV infection. Adjusted odds ratios (AORs) and corresponding 95% confidence intervals (CIs) were estimated. A duration-stratified trend analysis was conducted to examine changes in HIV prevalence over time according to duration in sex work, categorized as less than 5 years, 5–9 years, 10–14 years, and 15 years or more. HIV prevalence trends were assessed within and across duration categories over the three survey rounds. The analysis included 2,707 FSWs in 2011, 4,751 in 2015, and 7,000 in 2020. HIV prevalence declined by more than half over the study period, from 10.9% in 2011 to 5.3% in 2020, while the proportion of new entrants (< 5 years in sex work) increased from 19% to 56%. Age, educational attainment, marital status, type of sex work, and duration in sex work were independently associated with HIV infection. Compared with FSWs aged 16–19 years, those aged ≥ 35 years had significantly higher odds of HIV infection (AOR = 2.49; 95% CI: 1.64–3.794). Higher educational attainment was protective, with tertiary education associated with 58% lower odds of HIV infection than no formal education (AOR = 0.41; 95% CI: 0.25–0.68). Widowed FSWs had over fourfold higher odds of HIV infection than currently married women (AOR = 4.00; 95% CI: 2.4–7.11), while seater FSWs were more likely to be HIV-positive than roamers (AOR = 1.53; 95% CI: 1.29–1.82). Duration-stratified trend analysis showed declining HIV prevalence across all duration categories between 2011 and 2020, although women with ≥ 15 years in sex work remained disproportionately affected. HIV prevalence among female sex workers in Ghana declined by more than half between 2011 and 2020, with reductions observed across all durations of sex work. Nevertheless, older age, lower educational attainment, marital disruption, seater-based sex work, and prolonged engagement in sex work remained independently associated with HIV infection. While changes in the composition of the FSW population may have contributed to the observed decline, HIV prevalence remained consistently higher among long-term sex workers. Sustained and differentiated HIV programming is therefore needed to address the persistent vulnerability of both new entrants and FSWs with prolonged exposure to the sex work environment.