Abstract
BACKGROUND: Female sex workers (FSWs) remain disproportionately affected by HIV due to a combination of structural, social, and behavioral factors, including stigma, limited access to health services, gender-based violence, and legal barriers. In Mozambique, where sex work is informal and highly marginalized, monitoring trends in service uptake is essential to guide responsive and equitable HIV interventions. This study analyzes changes in access to and use of HIV prevention services among FSWs between 2011 and 2019. METHODS: We conducted a secondary analysis of cross-sectional bio-behavioral survey (BBS) data collected among FSWs in 2011 and 2019 in three Mozambican urban centers. Standardized questionnaires were used to collect behavioral and biological data, including indicators of HIV prevention service access. Participants were recruited using Respondent-Driven Sampling (RDS). Logistic regression was applied to assess time trends and identify factors associated with service uptake. RESULTS: A total of 1,240 FSWs participants were recruited in 2011 and 1,530 in 2019. Between 2011 and 2019, there was a significant increase in HIV prevalence (from 11.9 to 24.5%). The proportion of participants accessing HIV prevention services more than doubled (from 21.4 to 52.3%), alongside marked improvements in HIV testing uptake (68.0-83.1%) and consistent condom use with clients (74.1-86.3%). Multivariate analysis showed that age ≥ 25, moderate HIV risk perception, and experiences of sexual violence were positively associated with access to prevention services in 2019. In contrast, alcohol use and physical assault were negatively associated with service use. Determinants of access shifted over time; for example, while secondary education was positively associated with service access in 2011, it was negatively associated in 2019. CONCLUSION: There has been substantial progress in access to and use of HIV prevention services among FSWs in Mozambique over the past decade. Nonetheless, the rising HIV prevalence and persistent disparities related to age, education, economic vulnerability, and exposure to violence signal the need for more comprehensive, context-specific, and equity-focused strategies. Reinforcing peer-led outreach, integrating gender-based violence response, and addressing risk misperception are critical to strengthening Mozambique's HIV prevention continuum for this key population.