HIV prevalence and related behaviors among sex workers in Jamaica.

BACKGROUND: The aims of the study were to estimate HIV prevalence among sex workers (SWs) in Jamaica and to identify risk factors associated with HIV infection. METHOD: Face to face interviews and HIV testing of 450 SWs across Jamaica were conducted in 2005. Participants were identified by key informants. RESULTS: About 9% of SWs were HIV-positive. HIV-positive SWs tended to be older, less educated, have a history of crack/cocaine use, and were less likely to be aware of the Ministry of Health's prevention programme. More than 90% of SWs reported having easy access to condoms and using condoms at last sex with local and tourist clients. However, 30% of SWs used condoms with nonpaying partners. Knowledge of HIV prevention methods was high but only 38.6% of SWs appropriately rejected myths about HIV transmission by mosquito bites and meal sharing. CONCLUSION: Prevention programmes targeting SWs must emphasize the risk associated with both paying and nonpaying sexual partners while providing knowledge about HIV prevention. Increased access to prevention programmes is likely to reduce HIV prevalence among this population.

The challenge of promoting safe sex at sites where persons meet new sex partners in Jamaica: results of the Kingston PLACE randomized controlled trial.

OBJECTIVE: To determine whether a site-based Priorities for Local AIDS Control Efforts (PLACE) HIV prevention intervention in Kingston, Jamaica increased condom use among persons with new or multiple sex partners. METHODS: A total of 147 sites where persons go to meet new sex partners were grouped into 50 geographic clusters and randomized to receive or not receive a multilevel PLACE prevention intervention. Baseline cross-sectional surveys of sites and patrons at sites were conducted in 2005 to determine the nature of social activities at sites to better plan the intervention and to ensure that the two arms of the trial were similar. The intervention was delivered by 50 trained outreach workers between January and June 2006. After the intervention two cross-sectional surveys were conducted to assess the extent of intervention implementation and to estimate the proportion of patrons at sites with recent new or concurrent partnerships and inconsistent condom use. RESULTS: Characteristics of sites and patrons were similar for most variables at intervention and control sites at both baseline and post-intervention. A total of 1535 patrons (723 men, 812 women) were interviewed at intervention sites and 1324 patrons (661 men, 663 women) at control sites 6-9 months after the intervention. There were no significant differences between intervention and control groups in the proportions of men (37.8% and 31.6%) and women (24.6% and 22.6%) who reported new or multiple relationships in the past year and inconsistent condom use. There was no significant difference in the proportion of men or women showing a condom at interview, having a HIV test in the past 12 months or being exposed to the intervention. CONCLUSIONS: An intent-to-treat analysis did not show any intervention effect. This was probably because of difficulty in implementing the intervention, the extent of patron mixing among sites, the intensity of national education campaigns, delay in conducting the post-intervention survey and evidence of other interventions at some control sites.

Reaching key populations through key venues: Insights from the Jamaica HIV Prevention Program.

INTRODUCTION: HIV prevention strategies often include outreach to female sex workers at social venues identified as places where people meet new sexual partners. Patrons and staff at these venues may include female sex workers, their clients, as well as others who have high rates of new sexual partnerships. Few studies have compared HIV/STI among venue-based and general populations, across types of venues, or by sub-group of the venue population. Program planners often assume that the prevalence of infection is highest among female sex workers and considerably lower among other people at these venues, but there are few empiric studies assessing the prevalence of infection by sex worker status and type of venue. METHODS: In 2011, we used the PLACE method to identify public venues where people meet new sexual partners across Jamaica. The study team visited all venues with reported sex work as well as a 10% random sample of other venues and subsequently interviewed and tested a probability sample of 991 venue patrons and workers for HIV and other STI. RESULTS: Community informants identified 1207 venues. All venues where sex work was reported (735 venues) and a random sample of the remainder (134 of 472) were selected for onsite visits. Of these, 585 were found and operational. At a stratified random sample of venues, survey teams interviewed and tested 717 women and 274 men. 394 women reported recent sex work and 211 of these women reported soliciting clients on the street. Women exchanging sex for money were more likely to be infected with HIV (5.4% vs 1.0%; OR = 5.6, 95% CI = 1.8,17.3) or syphilis (11.7% vs. 5.8%, OR = 2.2, 95% CI = 1.7,4,0) than other women, but not significantly more likely to be infected with gonorrhea (8.4% vs 7.8%; OR = 1.1,95% CI = 0.6,1.9), chlamydia (16.2% vs 21.6%;OR = 0.7,95% CI = 0.5,1.0) or trichomoniasis (23.0% vs 17.0%, OR = 1.5,95% CI = 0.9,2.2). Women at venues were more likely to report sex work and multiple partners than women interviewed in a 2008 national population-based household survey commissioned by the Ministry of Health. CONCLUSIONS: In Jamaica, although the highest HIV prevalence was among street-based sex workers, the risk of HIV and STI extends to men and women at high risk venues, even those who do not self-identify as sex workers. Findings confirm the appropriateness of outreach to all men and women at these venues.

Trends in HIV risk perception, condom use and sexual history among Jamaican youth, 1996-2004.

As the number of HIV/AIDS cases continues to increase among youth, aged 15-24 years, it becomes critically important to identify the factors that are contributing to this increase. Trends in perceived risk and risk behaviours were examined among youth by sex and age in an attempt to address this concern. National-level cross-sectional data across three time periods (1996, 2000, 2004) gathered from youths, aged 15-24 years in Jamaica for six outcomes were examined (perceived risk, ever had sex, initiation of sex before age 14, multiple sexual partnerships, condom use at last sex with regular and non-regular partners). Trend analyses were employed for each outcome for the total sample and separately by sex and age. A significant positive increase in condom use emerged; males reported higher levels of condom use at last sex with most recent regular partner (55.7% in 1996, 67.9% in 2004, p < 0.01). Condom use by females with regular and non-regular partners did not increase. There was no significant change in the percent of youths reporting multiple partnerships, the percent initiating sex or age at first sex. Youths did perceive themselves to be at greater risk for HIV in 2004 than in 1996 (40.0% vs. 17.6%, p < 0.001). These analyses revealed inadequate protective behaviour adoption by Jamaican youths. Prevention programs targeting youths need to be expanded significantly, be culturally relevant, and also address social vulnerability.

"Do you think your main partner has other sex partners?" A simple question provides insight into sexual risk in Jamaica.

To estimate the association between a simple measure of sexual partner concurrency and sexually transmitted infection (STI) we conducted a cross-sectional population-based household survey (n = 1795) and targeted surveys of people at venues where people meet sexual partners (n = 1580) to ask about sexual behaviour. Persons interviewed at venues were tested for HIV, gonorrhoea, chlamydia, and trichomoniasis. We compared the association between STI and reporting a partner had other partners. More women than men reported their main partner had other partners. Thirteen percent of all women in the population-based survey and 14.4% in the targeted survey reported having one partner in the past 12 months and that partner had additional partners. STI prevalence was significantly associated with reporting a partner had other partners (36.8% vs. 30.2%; prevalence ratio [PR] 1.2; 95% confidence interval [CI] 1.1, 1.4). Construction of complete sexual networks is costly and not routinely feasible. We recommend adding a question to cross-sectional surveys used to monitor sexual behaviour about whether the respondent believes his or her partner has other sexual partners. Although subject to bias, the question was useful in Jamaica to identify a group of women with only one sexual partner at increased risk of infection.

Understanding the high prevalence of HIV and other sexually transmitted infections among socio-economically vulnerable men who have sex with men in Jamaica.

OBJECTIVES: This study estimates HIV prevalence among men who have sex with men (MSM) in Jamaica and explores social determinants of HIV infection among MSM. DESIGN: An island-wide cross-sectional survey of MSM recruited by peer referral and outreach was conducted in 2011. A structured questionnaire was administered and HIV/STI tests done. We compared three groups: MSM who accepted cash for sex within the past 3 months (MSM SW), MSM who did not accept cash for sex (MSM non-SW), and MSM with adverse life events (ever raped, jailed, homeless, victim of violence or low literacy). RESULTS: HIV prevalence among 449 MSM was 31.4%, MSM SW 41.1%, MSM with adverse life events 38.5%, 17 transgender MSM (52.9%), and MSM non-SW without adverse events 21.0%. HIV prevalence increased with age and number of adverse life events (test for trend P < 0.001), as did STI prevalence (P = 0.03). HIV incidence was 6.7 cases/100 person-years (95% CI: 3.74, 12.19). HIV prevalence was highest among MSM reporting high-risk sex; MSM SW who had been raped (65.0%), had a STI (61.2%) and who self identified as female (55.6%). Significant risk factors for HIV infection common to all 3 subgroups were participation in both receptive and insertive anal intercourse, high-risk sex, and history of a STI. Perception of no or little risk, always using a condom, and being bisexual were protective. CONCLUSION: HIV prevalence was high among MSM SW and MSM with adverse life events. Given the characteristics of the sample, HIV prevalence among MSM in Jamaica is probably in the range of 20%. The study illustrates the importance of social vulnerability in driving the HIV epidemic. Programs to empower young MSM, reduce social vulnerability and other structural barriers including stigma and discrimination against MSM are critical to reduce HIV transmission.