An integrated individual, community, and structural intervention to reduce HIV/STI risks among female sex workers in China

Abstract

BackgroundWe assessed the effectiveness of an integrated individual, community, and structural intervention to reduce risks of HIV and sexually transmitted infections (STIs) among female sex workers (FSWs).MethodsThe integration individual, community, and structural intervention was implemented from 2004 to 2009 in six counties of Shandong Province. Post-intervention cross-sectional surveys were conducted in six intervention counties and 10 control counties.ResultsOf 3326 female sex workers were recruited and analyzed in the post-intervention survey with 1157 from intervention sites and 2169 from control sites. No HIV positive was found in both intervention and control counties. The rate of syphilis was 0.17% for intervention sites and 1.89% for control sites (OR = 11.1, 95% CI: 2.7, 46.1). After adjusted for age, marital status, education, economic condition, recruitment venues, the rates of condom use in the last sex with clients(AOR = 2.7; 95% CI: 1.9, 3.8), with regular sex partners(AOR = 1.5; 95% CI: 1.1, 1.9) and consistent condom use in the last month with clients (AOR = 3.3; 95% CI: 2.6, 4.1) and regular sex partners (AOR = 1.7; 95% CI: 1.3, 2.3) were significantly higher in intervention sites than that in control sites. The proportion of participants correctly answered at least six out of eight HIV-related questions (83.3%) in intervention sites is significant higher than that (21.9%) in control sites (AOR = 24.7; 95% CI: 2.5, 42.7), the five indicators related to HIV-related intervention services ever received in the last year including HIV testing(AOR = 4.9; 95% CI: 2.8, 6.7), STD examination and/or treatment(AOR = 5.1; 95% CI: 4.2, 6.4), free condom(AOR = 20.3; 95% CI: 14.3, 28.9), peer education(AOR = 4.3; 95% CI: 3.5, 5.4), education materials(AOR = 19.8; 95%CI: 13.1, 29.8) were significantly higher in intervention sites than that in control sites, the participants in the intervention sites are more likely to seek medical treatment when they had any disorders (AOR = 3.2; 95% CI: 2.5, 4.2).ConclusionThis study found that the integrated individual, community, and structural intervention showed positive impact in reducing HIV and STI risks among FSWs.

Global epidemiology of HIV among female sex workers: influence of structural determinants

“…Where FSWs have constrained rights and access to resources due to their status as sex workers and women, gender-based violence 26, 30 and sex trafficking (forced sexual labour) 28, 30, 31 have been consistently linked to increased odds of HIV infection and condom non-use. By contrast, gender empowerment 29 and higher education and literacy 29, 32 continue to mitigate HIV risk among FSWs.…”

“…The available data for sex worker organisation is largely restricted to India, 25, 39, 40, 41, 42, 43 where substantial resource investments have been made in community empowerment efforts among sex workers as part of broader HIV prevention efforts. Aside from a few reports from China, 32 Kenya, 44 and Latin America, 45, 46 gaps in data for community empowerment up to now can be attributed in large part to scarcity of resources to assess grassroots sex worker efforts and macrostructural constraints of criminalisation and stigma that restrict the ability of FSWs to organise. Community organisation has been considered both as a broad process or intervention of community empowerment, as exemplified by Songachi and Avahan models in India, 25, 39, 47 or as a specific component of community organisation (eg, sex work drop-in spaces or social cohesion).…”

“…Few investigators have examined the nuanced and intersecting influence of policy, social, and physical features of the work environment in the mitigation or conferment of HIV risk among FSWs. The authors of these studies examined how supportive venue-based policies 30, 32, 76, 77, 78, 79, 80, 81 or managerial practices (eg, client sign-in, safety mechanisms, or removal of violent clients) 48, 69, 76, 77, 80, 81, 82, 83, 84, 85 and physical features (eg, types or layout of venues) of sex work establishments are associated with increased condom use, often through synergistic effects with other social features of increased peer or sex worker support 32, 52, 53, 69, 72, 76, 79, 81, 83, 85, 86, 87, 88, 89, 90. Work environments for FSWs are shaped by economic features (eg, economic pressures, client financial incentives for non-condom use, refusal of payment, and bribes or fines by state agents [eg, police] to avoid arrest) resulting from macrostructural forces of poverty, laws, and access to resources and are associated with non-condom use27, 28, 29, 30, 40, 41, 48, 64, 70, 83, 84, 87, 91, 92, 93 and HIV infection among FSWs.…”

“…Where FSWs report adequate access to condoms, sexual health care (eg, STI testing and contraceptives) and HIV care (eg, HIV testing, ART, and sex worker-tailored clinics), increases are noted in condom use and reduced condom breakage, 39, 40, 32, 44, 47, 67, 79, 95, 96, 97, 98, 99 and lower HIV prevalence. 100, 101 Condom coverage must include condom access (eg, free or subsidised condoms at the workplace, the ability to carry condoms while working, and contact with peer condom distribution), availability and affordability, linked to reduced HIV acquisition and transmission among FSWs 25, 30, 39, 40, 44, 47, 68, 70, 79, 82, 84, 87, 93, 95, 97, 98, 99, 102, 103, 104, 105, 106, 107…”

“…105, 132 Sex worker-led outreach can promote consistent condom use directly through enhanced condom coverage in venues and indirectly through peer education around condom negotiation with clients and shifting sex industry norms on condom use. 32, 69, 72, 76, 79, 81, 83, 85, 86, 87, 88, 89, 90 Sex worker-led interventions are a key component of community empowerment, as shown in several low-income and middle-income countries. In Mombasa, peer or sex worker-led outreach implemented between 2000 and 2005 was associated with a more than three-fold increase in consistent condom use, 44 although coverage was less than 30%.…”