Mental health status, perceived and actual risks of HIV/AIDS Acquisition among female sex workers: a cross-sectional study in a Nigerian semi-urban community

Female sex workers (FSWs) are disproportionately affected by HIV globally. Mental health conditions are also very common in this population and exacerbate HIV vulnerability by impairing decision-making and lowering self-efficacy for safer sex practices. To evaluate the mental health status, perceived HIV risk, and actual HIV risk behaviour profile of FSWs in Nsukka, Enugu State, Nigeria. A cross-sectional questionnaire-based survey was conducted among 98 FSWs recruited using snowball sampling at sex work venues across Nsukka. The structured interviewer-administered instrument assessed sociodemographic characteristics, mental health symptoms using modified single-item screening questions based on the Patient Health Questionnaire-2 (PHQ-2) and Generalised Anxiety Disorder-2 (GAD-2), perceived HIV risk on a 5-point likelihood scale, and actual risk behaviour and prevention indicators. Bivariate associations were assessed by chi-square (χ 2 ) and Fisher's Exact tests, and factors independently associated with high perceived risk were identified using Firth-penalised multivariable logistic regression. Participants were predominantly aged 19–35 years (72.4%); 67.3% were single and 89.8% had secondary school education or below. Reported depressive symptoms occurred in 44.9% ( n = 44) and anxiety symptoms in 51.0% ( n = 50). Self-reported risk indicators were common: 87.8% had ever had a sexually transmitted infection (STI), 55.1% engaged in sex work every day of the week, 55.1% consumed alcohol or substances before sexual activity, and only 10.2% had ever used pre-exposure prophylaxis (PrEP). Three-quarters (76.5%) perceived their HIV risk as high. In Firth-penalised multivariable logistic regression, condom use at last sexual intercourse was associated with lower odds of high perceived risk (aOR 0.18; 95% CI 0.03–0.77) and alcohol or substance use before sex with higher odds (aOR 2.79; 95% CI 1.04–7.81); anxiety symptoms were not associated after adjustment. FSWs in Nsukka face multiple co-occurring vulnerabilities including frequently reported HIV-related risk behaviours and STI history, high prevalence of reported mental health symptoms, and high perceived HIV risk in three-quarters of participants. Despite high perceived risk, PrEP uptake and consistent condom use remain low, highlighting the need for integrated interventions addressing mental health symptoms, PrEP access, and structural barriers.