HIV remains a major public health problem around the world, claiming the lives of nearly 33 million people to date 19. More than two-thirds of people living with HIV are in the WHO 21 African Region (25.7 million). HIV / AIDS affects all social strata, including sex workers. While HIV is prevalent in the general population of this region, there is an increasing number of new infections in key groups such as sex workers 22. Sex workers are a key population in the HIV epidemic in sub-Saharan Africa because they have high HIV prevalence, have unprotected sex and have multiple partners. Globally, sex workers account for 9% of the total number of new HIV infections 18. Although there is some regional variation, the estimated prevalence of HIV in the sex worker population is 10 to 20 times higher than in the general population 18.

In Mali, the prevalence of HIV is 1.2% in the general population 19. This prevalence is much higher among key populations. Sex workers are among the groups most at risk of contracting HIV. About 18,000 sex workers have been registered throughout Mali with an HIV / AIDS prevalence of 8.7% 19. An earlier study conducted in Mali on the prevalence and factors associated with HIV and sexually transmitted infections among 353 sex workers in Bamako reported that the HIV prevalence was 20.4%, while 35.1% of sex workers had at least one sexual transmitted infection. This study highlighted the high prevalence of HIV and curable STIs among sex workers in Bamako (Tounkara et al., 2020). There is therefore a need to improve the effectiveness of interventions for sex workers in Mali to reduce the burden of HIV and STIs among them and prevent the spread of HIV to the general population.

Stopping the spread of HIV / AIDS was one of the Millennium Development Goals (MDGs). All the countries including Mali have tried to achieve this objective. Despite some progress towards MDG 6, the HIV / AIDS epidemic continues to have a devastating impact on health. The prevalence of sex workers remains worrying compared to that of the general population. This study would like to contribute to the achievement of the objective of sustainable development 3 "Promote health and well-being for all and at all ages" through the following target "3.3 By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases”

This study highlighted the sexual behaviors of female sex workers in Mali. Most female sex workers were single, became sexually active before the age of 18, entered the sex trade after age 20, and had at least or more than two years of experience. These figures were similar to a previous study done by Tadesse et al. (2020) in which they found that most of female sex workers were single and the median age at which women entered the sex trade was 26 years with an average of 4 years of sex work experience.

Overall knowledge about HIV/AIDS transmission and prevention was generally good and similar to previous studies35 in which female sex workers showed good knowledge. Despite acceptable overall knowledge among female sex workers, some misconceptions about HIV/AIDS transmission persist. Only 24% believe that having sex with an apparently healthy partner can transmit HIV. Less than 40% still believe that HIV can be transmitted by a mosquito bite, and this was much better than the previous study in Guangzhou, China 23, where 69% of participants responded that HIV can be transmitted by mosquito bite. Female sex workers having misconceptions could be explained by their illiterate level of education.

Negative attitudes were reported by female sex workers. More than half of female sex workers expressed negative attitudes toward sharing food and toilets with an HIV-positive person, respectively, and this negative attitude was similar to the 4. study (2008) in which a large percentage of the female sex workers expressed negative attitudes toward their HIV- positive colleagues, stating that they would never work in the same places as them.20

Negative risk behaviors have been shown by female sex workers. Although condom availability among female sex workers has increased in recent years, nearly half of female sex workers had unprotected sex with their clients. This is almost similar with a study conducted in Burkina Faso among 609 female sex workers where 45.6% reported high-risk behaviors that were primarily driven by inconsistent condom use with regular partners 16.

Anal sex was practiced by one-third of female sex workers which is a risk factor for HIV to STIs. Female sex workers practicing anal sex were more likely to have symptoms related to a sexually transmitted infection than those practicing only vaginal sex 7. Another study in China found that 66% of female sex workers reported having non-client sexual partners (most were identified as boyfriends or husbands) and 33% of female sex workers reported having experiences with commercial sex without condom use 1. Drinking alcohol and smoking cigarettes before having sex with their clients was a common practice among less than 20% of female sex workers and this finding was similar to the study by 9 in India and 13 in Ethiopia. A study in Nigeria found that among female sex workers, 67.8% were drinkers and up to 20.7% were current smokers, while 19% were dual users. 6. A significant proportion of unprotected sex could be due to alcohol and cigarette use among the female sex workers in this study. Alcohol has independent effects on decision-making about sex and skills in negotiating condoms and their correct use 2. The links between substance abuse and sex work can be difficult to disentangle, however, as in some cases the former can account for women's entry into the sex industry itself 12. Our results like previous studies 1014 reported that knowledgeable female sex workers reflected a positive attitude and had good practices. These findings reflect the importance of HIV/AIDS and STI information, education, and communication for social behavior change.

This study has some limitations. First, sex work is illegal in Mali and, therefore, it was difficult to obtain a large sample of sex workers. In addition, our study was based on self-reported information, which could be biased by the participants' ability to remember.

This study had several strengths. Demographic factors and knowledge-attitude & practice variables were used to determine sexual risk behaviors instead of looking for the relationship between HIV knowledge-attitude & practice variables 8. In addition, this study focuses on female sex workers as a target group in the HIV/AIDS response in Mali.

This research provided an understanding of the perceptions of female sex workers in Mali regarding HIV/AIDS. All sex workers in this study had heard of AIDS, but their knowledge varied. Some misconceptions about HIV/AIDS transmission persist in the minds of female sex workers and this may be due to their level of education. Therefore, HIV/AIDS interventions should focus on public education. The results of the study highlight negative risk behaviors of female sex workers such as not using condoms consistently, anal sex, alcohol consumption and smoking. The results of the study can also be used by HIV/AIDS organizations and the Ministry of Health to formulate actions to help female sex workers affected by HIV/AIDS. In addition, the results of this study highlighted the importance of education or other interventions targeting HIV/AIDS to improve the knowledge, attitude, and practice of female sex workers in Mali

We would like to thank all female sex workers who participated in this study

All authors participated in the conceptualization and the design of this manuscript. All authors have read and approved the final version for submission.

The authors received no financial support for this study.