BACKGROUND: Access to one’s preferred contraception is a vital component of quality sexual and reproductive health care and improves overall contraceptive use. Barriers to accessing contraception are common for marginalized groups at high risk of HIV such as sex workers and gender-diverse individuals, however, few studies have examined the effect of these overlapping identities.
METHODS: Through the Ritshidze Community-Led Monitoring Programme, sex workers were recruited for a cross-sectional survey via community-based snowball sampling at sex work hotspots in 21 districts across 7 provinces in South Africa from August 2021- September 2022. Sex workers who reported ever having tried to access contraception at a public health facility (n=1,330) were included. Multivariable logistic regression models, adjusted for age and location, were built to assess differences in sex workers' ability to access their preferred contraception method by gender category (cisgender n=897, transgender n=208, and non-binary n=225). Differences in reasons for contraception non-access are described and assessed by gender groups using multivariable logistic regression.
RESULTS: Overall, 24% (n=292) of sex workers could not access their preferred contraception. The most requested methods were the injection (50% n=660), pill (42% n=555) and internal condom (19% n=248). Adjusted models showed that both non-binary and transgender sex workers were significantly less likely to access their preferred contraception compared to cisgender sex workers (aOR 0.65, 95% CI: 0.44-0.96, and aOR 0.61, 95% CI: 0.42-0.89 respectively). Common reasons for non-access were contraception non-availability (37% n=107) and access denial for being a sex worker (32% n=92). Transgender sex workers were significantly more likely to be denied access based on sex work status than their cisgender colleagues (aOR 1.77, 95% CI: 1.06-2.96, p = .03).
CONCLUSIONS: Sex workers using public health facilities experience difficulties accessing their preferred contraceptive method due to stockouts and denial of services based on sex work status. These barriers are worse for transgender and non-binary sex workers who report significantly higher levels of service denial. Discrimination against sex workers and gender-diverse individuals is compounding and must be addressed at public health facilities in order to improve integrated sexual and reproductive health care for these high-need populations.

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