Acceptability of the female condom among sex workers in Thailand: results from a prospective study.

BACKGROUND: The female condom may provide women with the first female-controlled barrier method that is effective against sexually transmitted diseases, including HIV infection. GOAL: This study evaluated the acceptability of the female condom among sex workers in Thailand. STUDY DESIGN: Data on use and acceptability of the female condom were collected using a structured questionnaire during an 8-week follow-up. RESULTS: Analyses included 148 women who were still in follow-up at week 8. Sex workers used, on average, 2.8 female condoms per week. The overall satisfaction rate with the female condom was 68%, although, among users, 31% had difficulties in device insertion, 37% had pain from the inner ring, and 22% reported itching sensations. The main reason for using the female condom in the future was its perceived safety, and the main reason for not using it would be the client's refusal. CONCLUSION: Two-thirds of the sex workers were satisfied with the female condom. Difficulties at insertion, discomfort during use, and clients' attitude were potential obstacles to the use of the female condom in the future.

Prevention of HIV transmission from mother-to-child in Srinagarind Hospital.

From January 1996 to December 1999, HIV infected pregnant women and their newborns were studied. Informed consent was obtained and HIV-tests were performed after counselling. ZDV for perinatal prophylaxis starting on week 14 to week 36 of gestation and continued throughout pregnancy was given following an ACTG 076 regimen except that during labour, intravenous ZDV was replaced by oral ZDV 300 mgs, given every 3-hours as a loading dose and ZDV syrup 2 mgs/kg every 6 hours for 7 days orally for the newborns. Newborn HIV-Ab and PCR were done at 6 weeks and 6 months after birth. Eighty-four HIV infected pregnant women were enrolled in the study, eighty-three of whom were delivered. The overall transmission rate was 5.2 per cent, with 3/58 children confirmed infected with HIV by at least two positive PCR test results.

Consumer preference study of the female condom in a sexually active population at risk of contracting AIDS.

To determine the acceptability of the female condom among commercial sex workers in Khon Kaen, Thailand. Twenty sex workers from a massage parlor and 21 from a brothel were trained in the use of the female condom. The voluntary participants were instructed about the risk of HIV and advised that they could use the female condom as an alternative method to the male condom for protection. The female condom was used in 28.4 per cent and 17.8 per cent episodes of sex in each site during the two weeks. Continuation of use of the female condom increased from 0 per cent in the first group to 43 per cent in the second group. The reasons for discontinuing its use were that it was inconvenient and because of their partners' objection. More users said they liked the female condom even though more thought it was difficult to insert and it did cause pain. However, they would recommend it to others and most felt that other women would want to try it. The participants also saw the advantage of the female condom as a back-up method in case of clients' refusal to use the male condom but all prefered the male condom if there was a choice.

A double-blind, adjuvant-controlled trial of human immunodeficiency virus type 1 (HIV-1) immunogen (Remune) monotherapy in asymptomatic, HIV-1-infected thai subjects with CD4-cell counts of >300.

We examined the effect of a human immunodeficiency virus (HIV)-specific immune-based therapy in Thailand, where access to antiviral drug therapy is limited. A 40-week trial was conducted with 297 asymptomatic, HIV-infected Thai subjects with CD4-cell counts greater than 300 microl/mm(3). Subjects were randomized to receive either HIV type 1 (HIV-1) immunogen (Remune; inactivated HIV-1 from which gp120 is depleted in incomplete Freund's adjuvant or adjuvant control at 0, 12, 24, and 36 weeks at five different clinical sites in Thailand. Neither group received antiviral drug therapy. The a priori primary endpoint for the trial was changes in CD4-cell counts with secondary parameters of percent changes in CD8-cell counts (percent CD4, CD8, and CD4/CD8) and body weight. Subsets of subjects were also examined for changes in plasma HIV-1 RNA levels, Western blot immunoreactivity, and HIV-1 delayed-type hypersensitivity (DTH) skin test reactivity. There was a significant difference in changes in CD4-cell counts that favored the HIV-1 immunogen-treated group compared to those for the adjuvant-treated control group (P<0.05). On average, for HIV-1 immunogen-treated subjects CD4-cell counts increased by 84 cells by week 40, whereas the increase for the control group was 38 cells by week 40. This increase in CD4-cell count was associated with increased HIV-specific immunogenicity, as shown by Western blotting and enhanced HIV-1 DTH skin reactivity. No significant differences in adverse events were observed between the groups. The results of this trial suggest that HIV-1 immunogen is safe and significantly increases CD4-cell counts and HIV-specific immunity compared to those achieved with the adjuvant control in asymptomatic HIV-1-infected subjects not taking antiviral drugs.

AIDS prevention strategies for rural families in northeastern Thailand.

The project AIDS Prevention Strategies for Rural Families in Northeastern Thailand aimed to find effective strategies for AIDS education for rural families to promote non-risk behavior, non-discrimination while supporting care for individuals with HIV/AIDS in their families and in the community; to provide opportunities for family members, community leaders and HIV/AIDS organizations to cooperate, exchange ideas, and to participate in campaigns at the community level; and, to find appropriate media to improve the knowledge, understanding and awareness of HIV/AIDS among rural families. Data was collected through interviews by questionnaires, group discussions and in-depth interviews in two districts in the target province. A comparison of pre- and post test data analyzing knowledge of HIV transmission, AIDS prevention and treatment, attitudes and motivations, prevention behavior and women's empowerment all showed a significant improvement in all the above areas for the trial population.

AIDS education and intervention trials among youths in factories: a pilot project.

The project aimed to conduct a pilot study and intervention trials among youths in a factory of Khon Kaen. After contacting and obtaining agreement from owners/managers of factories, a survey using a self administered questionnaire, in-depth interview and focus group with workers to determine their level of knowledge and awareness of AIDS and high risk behaviour. A series of in-depth interviews with 16 workers and group discussion with 8 groups were conducted to find out their possible motivation for prevention and their acceptance of interventions/media. The data was used as a baseline for evaluating change after interventions and to modify the intervention education strategies and content. The study showed that the groups of factory workers which were not involved in the AIDS prevention had a different level of knowledge, attitudes, and behavior related to AIDS prevention than the groups which received the intervention and the methods used in the intervention achieved a level of success. The information we collected also showed that the best kinds of media for this purpose were videos and informational cartoons, which were also of special interest to the study group. It is hoped that the models will be adopted by relevant government and non-government agencies to be used in factories throughout the country.

PIP: This article presents the results of the pilot study and intervention trials conducted among youths in a factory in Khon Kaen, Thailand. A survey using a series of self-administered questionnaire, in-depth interview, and focus group was carried out to determine the level of knowledge and awareness of AIDS and high-risk behavior of the workers. To find out their possible motivation for prevention and acceptance for intervention, 16 workers underwent in-depth interviews and 8 other groups held discussions. The control group (from another factory) that did not receive the intervention was studied as well. The data was used as a baseline for evaluating change after interventions and to modify the intervention education strategies and content. Findings showed that most of the people in groups which received the intervention had better knowledge, attitudes and behavior related to AIDS-prevention than groups which had not yet received the intervention. This shows that the methods used in the intervention achieved a level of success. The information collected also showed that the best kinds of media for this purpose were videos and informational cartoons, which were also of special interest to the study group. It is hoped that the intervention models will be adopted by relevant government and non-government agencies to be used in factories throughout the country.

Protection against sexually transmitted diseases by granting sex workers in Thailand the choice of using the male or female condom: results from a randomized controlled trial.

BACKGROUND: The male condom is the most effective barrier method available for protection against sexually transmitted diseases (STDs), including HIV infection. There is an urgent need to develop and evaluate other prevention methods, such as the female condom. This study estimated the additional protection against STDs offered to sex workers by giving them the option of using the female condom when clients refused to use a male condom. METHODS: Sex establishments in four cities in Thailand were randomized into two study groups: one in which sex workers were instructed to use male condoms consistently (male condom group); and one in which sex workers had the option of using the female condom if clients refused or were not able to use male condoms (male/female condom group). Randomization was done by sex establishments, and not by individuals, to minimize sharing of female condoms across study groups. The proportion of unprotected sexual acts (defined as sexual acts in which condoms were not used, tore, or slipped in or out) and incidence rate of STDs (gonorrhoea, chlamydial infection, trichomoniasis and genital ulcer disease) were measured over a 24-week period and compared between the two study groups. FINDINGS: Results are available from 34 sex establishments (249 women) in the male/female condom group, and 37 sex establishments (255 women) in the male condom group. Condom use was very high in both groups (97.9 and 97.3 % of all sexual acts, respectively, P > 0.05). Male condom use was lower in the male/female condom group when compared with the male condom group (88.2 and 97.5%, respectively, P < 0.001). However, this reduction in male condom use was counterbalanced by the use of female condoms in 12.0% of all sexual acts in the male/female condom group, contributing to a 17% reduction in the proportion of unprotected sexual acts in this group when compared to the male condom group (5.9 versus 7.1%, respectively, P = 0.16). Female condom use was sustained over the entire study period. There was also a 24% reduction in the weighted geometric mean incidence rate of STDs in the sex establishments of the male/female condom group compared to the male condom group (2.81 versus 3.69 per 100 person-weeks, P = 0.18).

Promoting condom-only brothels through solidarity and support for brothel managers.

Brothel workers in Thailand are at high risk of HIV infection but they alone do not have adequate bargaining power to insist on condom use with all clients. Brothel managers, on the other hand, are a source of influence over both clients and their workers and can promote universal condom use in their establishments. To test whether brothel managers in Khon Kaen City would adopt and successfully implement a condom-only policy in their establishments, all 24 brothel managers in Khon Kaen City attended a meeting on the dangers of HIV and benefits of an all-condom policy. Ideas on how to implement the policy were discussed. Follow-up visits were made once a month to brothels to resupply condoms, provide reinforcement and to collect data. All brothel managers approved of the condom-only in principle and are now implementing the policy. Results of the evaluation of condom use and degree of solidarity in these 24 brothels are available for the AIDS prevention programme. However, a condom-only policy in brothels can only succeed if managers and brothel workers show solidarity in rejecting all non-condom using clients. Laws to promote condom use may not be needed if brothels are given the opportunity to implement a condom-only policy using their own resourcefulness and determination.

PIP: Although brothel workers in Thailand are at high risk of HIV infection, they do not have adequate bargaining power to insist upon condom use with all clients. Brothel managers, however, are in a position to influence the behavior of both their workers and clients. These managers can do much to promote universal condom use in their establishments. All 24 brothel managers in Khon Kaen City attended a meeting on the dangers of HIV and the benefits of implementing and maintaining a policy of universal and consistent condom use in their establishments. Ideas on how to implement the policy were discussed. Follow-up visits were then made once per month to brothels to resupply condoms, provide reinforcement, and to collect data. All of the managers approved of the condom-only principle and are now implementing the policy. This condom-only policy in brothels can succeed only if managers and brothel workers show solidarity in rejecting all non-condom using clients. Laws to promote condom use may not be needed if brothels are given the opportunity to implement such policy on their own.

Levels of HIV risk behaviour and AIDS knowledge in Thai men having sex with men.

Although many of the earliest cases of AIDS and HIV infection in Thailand were men who had sex with other men (MHSWM), transmission by heterosexual intercourse and needle sharing rapidly became dominant. This resulted in comparatively little attention being given to studies of risk behaviour and seroprevalence in groups of MHSWM with a consequent lack of information about these populations relevant to designing effective interventions. In the Partner Relations Survey, 3.3% of male Thais described their orientation as bisexual or homosexual, most probably an underestimate of the occurrence of same sex behaviour in Thai males. This paper briefly reviews the situation and presents results from a survey in the northeast of Thailand among men who have sex with men. Substantial levels of risk behaviour were found in MHSWM in the Northeast, with high rates of partner exchange and low levels of consistent condom use in insertive and receptive anal intercourse. Significant defects in AIDS knowledge existed implying a strong need for enhanced and expanded interventions in this community. Factors relevant to the design of interventions are highlighted and recommendations for further studies of MHSWM in Thailand are presented.

PIP: The percentage of boys and men in Thailand which identifies itself as bisexual or homosexual is most likely larger than the 3.3% suggested by data in the Partner Relations Survey. Accordingly, this study was conducted with the purpose of examining the sexual behavior, AIDS knowledge, and networks of sexual contacts of men who have sex with men in northeast Thailand. Findings are based upon information from 157 surveyed men aged 15-57 of mean and median ages 26.4 and 24 years, respectively. 95.5% of the participants were single and 77.1% lived in the metropolitan area. Examination of the data indicates that these men have a great deal of unprotected sexual intercourse with many different partners of varying types; partners include male and female prostitutes as well as strangers. Only low levels of consistent condom use exist during insertive and receptive anal intercourse. Moreover, most men with lovers have substantial levels of sex outside of the relationships without protection. Significant deficiencies in AIDS knowledge point clearly to the need for HIV preventive interventions in the community. These interventions should attempt to increase the levels of condom use and safer sex practice, reduce the number of partners, improve the recognition and early treatment of sexually transmitted diseases which may enhance HIV transmission, and improve the knowledge of AIDS/HIV and its prevention. While interventions could be made at the policy level or through the mass media to increase the awareness and perceptions of personal risk in the general population, interpersonal interventions are most likely to be effective. Recommendations are made for the further study of men who have sex with men in Thailand, while opening sections discuss the background of the Thai AIDS epidemic, the prevalence of male homosexual behavior, and behavioral and seroprevalence studies to date.