Improvement of clinical algorithms for the diagnosis of Neisseria gonorrhoeae and Chlamydia trachomatis by the use of Gram-stained smears among female sex workers in Accra, Ghana.

BACKGROUND: Screening for cervical infection is difficult in developing countries. Screening strategies must be improved for high-risk women, such as female sex workers. GOAL: To evaluate the sensitivity and specificity of screening algorithms for cervical infection pathogens among female sex workers in Accra, Ghana. STUDY DESIGN: A cross-sectional study among female sex workers was conducted. Each woman underwent an interview and a clinical examination. Biologic samples were obtained for the diagnosis of HIV, syphilis, bacterial vaginosis, yeast infection, Trichomonas vaginalis, Neisseria gonorrhoeae, and Chlamydia trachomatis infection. Signs and symptoms associated with cervicitis agents were identified. Algorithms for the diagnosis of cervical infection were tested by computer simulations. RESULTS: The following prevalences were observed: HIV, 76.6%; N. gonorrhoeae, 33.7%; C. trachomatis, 10.1%; candidiasis, 24.4%; T. vaginalis, 31.4%; bacterial vaginosis, 2.3%; serologic syphilis, 4.6%; and genital ulcers on clinical examination, 10.6%. The best performance of algorithms were reached when using a combination of clinical signs and a search for gram-negative diplococci on cervical smears (sensitivity, 64.4%; specificity, 80.0%). CONCLUSIONS: In the algorithms, examination of Gram-stained genital smears in female sex workers without clinical signs of cervicitis improved sensitivity without altering specificity for the diagnosis of cervical infection.

Prevalence of sexually transmitted infections among clients of female commercial sex workers in Thailand.

BACKGROUND: Clients of commercial sex workers are considered at high risk for the acquisition and transmission of sexually transmitted diseases (STDs). Identification and treatment of infections in this group could help to reduce the transmission of STDs. GOAL: To ascertain the prevalence of sexually transmitted organisms in male clients of female sex workers in Thailand by analysis of seminal fluid collected after intercourse. STUDY DESIGN: Used condoms were collected from 291 male clients attending a brothel in Hat Yai, Thailand during a 7-day period. Nucleic acid was extracted from seminal fluid and tested by polymerase chain reaction for the presence of Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, herpes simplex virus (HSV) and HIV sequences. RESULTS: Overall, 17 (6%), 47 (16%), and 2 (1%) of specimens were positive for C trachomatis, N gonorrhoeae and T vaginalis respectively. HSV sequences were found in 24 (8%) of the specimens: 14 specimens (5%) with HSV type 1, and 11 specimens (4%) with HSV type 2. HIV RNA was detected in two samples (1%). Overall, 75 specimens (26%) were positive for one or more infections, and more than one pathogen was detected in 16 specimens (5%). CONCLUSION: This study reports a high rate of STDs among clients of female sex workers in Thailand. Consequently, this population is a significant risk for transmitting STDs to commercial sex workers and to other noncommercial partners. Strategies that target this population of men are needed to reduce STD and HIV transmission.

Behavioural and serological human immunodeficiency virus risk factors among female commercial sex workers in Cambodia.

BACKGROUND: The spread of human immunodeficiency virus (HIV) in Cambodia is mainly caused by sexual transmission and the high-risk group in this country are female commercial sex workers (CSW). There are two types of CSW, direct CSW (DCSW) and indirect CSW (IDCSW), who are different from each other in sexual activities. This study was conducted in order to describe the risk factors on HIV for each type of CSW, and to establish effective preventive strategies against the HIV epidemic among CSW. METHODS: The participants, 143 DCSW and 94 IDCSW, were interviewed using a questionnaire to determine their demographic characteristics and behaviour. Blood samples were taken for serological tests on HIV, Chlamydia trachomatis and syphilis. The association between their behavioural pattern and their serological results was analysed. RESULTS: The questionnaire study showed that IDCSW had a riskier behavioural pattern than DCSW. The HIV seroprevalence rates of the DCSW and the IDCSW were 52.4% and 22.3%, respectively. Univariate logistic analyses showed a significant association between HIV antibody (HIV-Ab) and current age, age at commencement of commercial sex work, duration of commercial sex work, and the seropositivity of Chlamydia trachomatis-IgG antibody (CT-IgG-Ab) among the DCSW. The analyses also showed a significant relationship between HIV-Ab and CT-IgG-Ab among the IDCSW. CONCLUSIONS: Improving condom use rate is very important in order to prevent an HIV epidemic among the two types of CSW. This study also suggests it is important to prevent sexually transmitted disease (STD) such as Chlamydia trachomatis infection. The STD control programme could be efficient for HIV prevention, especially among DCSW.

HIV prevention among male clients of female sex workers in Kaolack, Senegal: results of a peer education program.

This article reports the results of a peer-led HIV prevention education and condom promotion program among transport workers in Kaolack, Senegal. As part of a 2-year longitudinal follow-up study, changes in men's AIDS-related knowledge, sexual behavior, condom use, and perceived barriers to condom use were evaluated by self-reports obtained from a systematic sample of transport workers interviewed before and after intervention. In addition to men's self-reports, preintervention and postintervention data on men's sexual and condom use behavior were gathered from a sample of licensed, commercial sex workers, who cited transport workers as their primary source of clients. Significant increases in men's HIV-related knowledge, previous use of condoms (from 30.4% to 53.5%), and consistent condom use with regular sex partners were documented over the study period, as were significant declines in perceived barriers to condom use. Though men reported significantly fewer sexual encounters with casual and commercial partners at follow-up compared to baseline, these data were unreliable. Women's postintervention reports indicate that a greater proportion of clients (including, but not limited to transport workers) "always" agree to use condoms (p < .01) compared with baseline and that fewer men offer more money for unprotected sex (p < .01). However, women also report taking greater initiative in the mechanics of condom use (supplying the condom, putting it on, and taking it off) than they did prior to the intervention, and significantly (p < .05) fewer women think that most of their clients know how to use a condom. The findings indicate that the peer-mediated intervention had a positive impact on several important outcomes measured and suggest that HIV prevention efforts need to focus on male client groups despite the logistical and methodological challenges.

Determinants of condom use in female sex workers in Surabaya, Indonesia.

In the developing world condom use among sex workers and their clients plays a dominant role in the transmission of HIV/STD. In Surabaya, Indonesia, data from the 1993 STD prevalence survey in female sex workers (brothels, street, massage parlours, barber shops, call-girl houses, and nightclubs) reveal that only 5% (33/692) of the brothel workers and 14% (25/177) of the street walkers had condoms in their possession at the time of the interview. During the last paid sexual intercourse, sex workers from the brothels, streets, and nightclubs used condoms infrequently (14%, 20%, and 25%, respectively). Sex workers from massage parlours, barber shops, and call girls were about 5 to 3 times more likely to use condoms than sex workers from nightclubs (adjusted odds ratio of 3.5, 4.9, and 4.2, respectively); thus condom promotion programmes should be targeted at sex workers at brothels, streets, and nightclubs. Programmes should include: (1) free distribution of condoms to sex establishments at the initial stage, and condom social marketing at later stages; (2) penalties, including legal sanctions, against any sex establishments that do not consistently use condoms; (3) participation of brothel owners and madams in encouraging sex workers to consistently have clients use condoms during sexual intercourse; and (4) establishment of sentinel surveillance to monitor STD/HIV and condom-use compliance.

Factors associated with condom use for oral sex among female brothel-based sex workers in Singapore.

BACKGROUND AND OBJECTIVE: The prevalence of oral sex increased from 27.1% in 1992 to 81.1% in 1997, with a concomitant increase in pharyngeal gonorrhea, among female sex workers in Singapore. The extent of condom use for oral sex among them is unknown. GOAL: To determine the prevalence of and factors associated with consistent condom use during oral sex. STUDY DESIGN: A cross-sectional study of 225 women randomly selected from the surveillance scheme register of female brothel-based sex workers with a history of oral sex documented in their medical records. RESULTS: Slightly more than half (56.9%) consistently used condoms for oral sex compared to 97% for vaginal sex. Condom use was significantly higher among middle than high class sex workers (adjusted rate ratio: 1.52, 95% CI: 1.01-2.29) and those with negotiation skills (adjusted rate ratio: 1.95, 95% CI: 1.32-2.07). CONCLUSION: Sex workers should be taught skills to negotiate condom use for oral sex.

PIP: Oral sex, which was once considered an uncommon sexual behavior, has become a relatively common practice. Its prevalence increased from 27.1% in 1992 to 81.1% in 1997, with a concomitant increase in pharyngeal gonorrhea among female sex workers in Singapore. The extent of condom use for oral sex among them is unknown. This cross-sectional study determined the prevalence of, and factors associated with, consistent condom use for oral sex among 225 female brothel-based sex workers, with paying clients in Singapore. Results indicated that slightly more than half (56.9%) consistently used condoms for oral sex compared to 97% for vaginal sex. Condom use was significantly associated with class of sex workers and negotiation skills. Significantly higher rates of condom use were found among high-class sex workers (adjusted rate ratio: 1.52; 95% CI: 1.01-2.29) and those with negotiation skills (adjusted rate ratio: 1.95; 95% CI: 1.32-2.07). In light of these findings, it is suggested that future interventions provide training to sex workers, particularly high-class ones, on negotiation concerning oral sex.

Predictors of female condom use among women exchanging street sex in New York City.

BACKGROUND: Alternative female-initiated barrier methods, such as the female condom, are needed among women exchanging street sex to enhance their ability to protect themselves from HIV and STD infection. OBJECTIVE: To describe predictors of female condom use among 96 women exchanging sex for money and drugs on the streets of New York City. STUDY DESIGN: A total of 113 sex workers received a baseline interview, a demonstration on proper female condom use, and 10 female condoms. A total of 101 sex workers received a followed-up evaluation at 2 weeks, of which 96 were included in data analysis. Predictors of condom use were analyzed for (1) any type of use; and (2) use with commercial partners. RESULTS: The strongest predictors of female condom use among this sample of sex workers were (1) living with someone with a drug or alcohol problem; (2) having heard of the female condom; and (3) homelessness. Current physical or sexual abuse by a commercial partner and marriage decreased the probability of female condom use. CONCLUSIONS: Female condom distribution encouraged sex workers who may be most vulnerable or who reported characteristics or behaviors associated with the highest sexually transmitted disease and HIV risk to try female condoms with commercial partners. Implications for intervention development include the need to develop innovative programs provided on the street (e.g., through peers) that can access homeless, drug-using sex workers in the most at-risk environments.

PIP: This study investigated the characteristics of street sex workers that influence the initial use of the female condom in New York City. Interviews, demonstration of proper female condom use and distribution of 10 female condoms were conducted among 113 female sex workers. Only 96 respondents were included in the study after a 2-week follow-up evaluation. Measure variables used in the study included sociodemographic characteristics, drug history, sexual risk behavior, and victimization, while dependent variables were female condom use for any reason and female condom use with commercial sexual partners. Results revealed that the 3 strongest variables associated with female condom use were the following: 1) living with anyone with a drug-alcohol problem; 2) having heard of the female condom; and 3) physical or sexual abuse by a commercial partner. This study emphasized the need to develop innovative programs that focus on street workers, with information promotion carried out in areas of sex work strolls which addresses the issues of accessibility and ease of use among sex workers.

AIDS chief says nonoxynol-9 not effective against HIV.

PIP: According to Dr. Peter Piot, executive director of the Joint UN Programme on HIV/AIDS (UNAIDS), the international multi-site trial of the spermicide nonoxynol-9 in gel form has shown that it is not effective in protecting women from HIV infection. This large-scale Phase III efficacy trial was conducted among female sex workers in Benin, Cote d'Ivoire, South Africa, and Thailand. Apart from receiving the trial microbicide or a placebo, participants also received classical HIV prevention support, such as free condoms, free treatment for sexually transmitted infections, counseling, and peer support. One positive outcome of the trial is that fewer of the sex workers who participated became infected with HIV, compared with the sex workers who did not participate at all in the study. However, Piot states that even if the results of the trials are disappointing, the search for an effective microbicide continues. To this effect, at least 36 compounds are at the preclinical testing stage, while 20 are ready for early safety trials in human volunteers and three additional compounds are being considered for large-scale trials.^ieng

Loose women or lost women? The re-emergence of the myth of white slavery in contemporary discourses of trafficking in women.

This article compares current concerns about "trafficking in women" with turn of the century discourses about "white slavery". It traces the emergence of narratives on "white slavery" and their reemergence in the moral panics and boundary crises of contemporary discourses on "trafficking in women". Drawing on historical analysis and contemporary representations of sex worker migration, the paper argues that the narratives of innocent, virginal victims purveyed in the "trafficking in women" discourse are a modern version of the myth of "white slavery". These narratives, the article argues, reflect persisting anxieties about female sexuality and women's autonomy. Racialized representations of the migrant "Other" as helpless, child-like, victims strips sex workers of their agency. This article argues that while the myth of "trafficking in women"/"white slavery" is ostensibly about protecting women, the underlying moral concern is with the control of "loose women". Through the denial of migrant sex workers' agency, these discourses serve to reinforce notions of female dependence and purity that serve to further marginalize sex workers and undermine their human rights.

Sexual trafficking in women: international political economy and the politics of sex.

A recent manifestation of the North/South, East/West political-economic divide is the international sex trade in women, of which trafficking in women for purposes of sexual employment is a large subset. Trafficking in humans in general, and women in particular, has taken center stage in many nation-states as an issue of a threat to national security and societal cohesion. This article explores some of the basic facts about trafficking and spotlights it as a truly global phenomenon, with its contemporary origins in the international capitalist market system. Furthermore, it argues that the international political economy of sex not only includes the supply side--the women of the third world, the poor states, or exotic Asian women--but it cannot maintain itself without the demand from the organizers of the trade--the men from industrialized and developing countries. The patriarchal world system hungers for and sustains the international subculture of docile women from underdeveloped nations.

The unacceptable face of trade.

PIP: This article provides information on the efforts of Oxfam in addressing the problems of illegal trafficking of women in Asia. Oxfam in Nepal views the trafficking in women as an organized crime, which violates the fundamental rights of women. To this effect, Oxfam has developed a program that works at the community, district, regional, and national levels, to create connections to ensure that real experience informs lobbying for international change. At the grassroots level, Oxfam works with a network of 17 organizations and women's human rights groups in the Sindhupalchock district of Nepal. The program encourages affected communities and families to organize themselves for action, and mobilizes local councilors on village development committees in punishing local traffickers. At the district level, Oxfam works to achieve the political commitment to enforce the law against traffickers. Oxfam has succeeded in collaborating with different organizations. It is shown that there is a great potential, both within Oxfam and externally, for cross-program linking and learning on trafficking in women. Since trafficking is a problem in many regions of the world, better strategies are needed to deal with the global market in trafficking and to involve the international community in finding a solution.^ieng

Women's health and HIV: experience from a sex workers' project in Calcutta.

PIP: This article narrates an inspiring discovery for development professionals who are searching for ways to empower women to protect themselves, their partners and families from HIV infection. This was based on the experience of the author as she came across a movement of sex workers who successfully negotiated safe sex in the heart of Calcutta, India. Employing focus group discussions, informal interviews and home visits during 1999, the author discovered that a Sexually Transmitted Disease/HIV Intervention Project has been set up to promote disease control and condom distribution among these sex workers. Operating on three principles for its work--respect, recognition, and reliance, the program aims to create an impact on the sex workers themselves and their peers. Likewise, the need to build alliances with clients, training the police and forming the Durbar Mahila Samanvaya Committee were deemed as necessary. Several lessons were learned during the course of the research: use of stories and history to rally the community; retaining flexibility, meeting changing needs; using drama to promote communication; and negotiating with men and opposing patriarchy.^ieng

A pragmatic intervention to promote condom use by female sex workers in Thailand.

An overview is presented of a multifaceted intervention to promote consistent condom use by female commercial sex workers in Thailand, in the context of the government's 100% condom use policy for preventing spread of human immunodeficiency virus (HIV) infection. The project is described with reference to a succession of stages including pre-programme needs assessment, intervention design, implementation and evaluation. The key elements of the intervention were video scenarios and discussions coordinated by health personnel, and video-depicted open-ended narratives aimed at helping sex workers to explore their personal and work-related dilemmas and concerns. A core objective was to enhance sex workers' self-esteem and perceived future with a view to strengthening their motivation to take preventive action against HIV infection. The intervention was evaluated using a combination of qualitative (process evaluation) and quantitative (outcome) methods. The outcome evaluation was undertaken using a pretest, post-test intervention and control group quasi-experimental design. There were significant increases in consistent condom use among the intervention groups but not among the controls. Pragmatic stability is advocated for the Thai sex industry and recommendations are offered for good quality HIV prevention activities.

PIP: This paper presents an overview of a multifaceted intervention project to promote consistent condom use by female commercial sex workers in Thailand. This project is in context of the government's 100% condom use policy for preventing the spread of HIV. It involves a succession of stages including preprogram needs assessment, intervention design, project implementation and evaluation. A total of 222 cases involving equal proportions of high-income and low-income commercial sex workers were classified into intervention and control groups and completed the pre-test and post-test surveys. The intervention consisted mainly of video scenarios and discussions coordinated by health personnel and of video-depicted open-ended narratives. These methods were aimed at helping sex workers' self-esteem and perceived future with a view to strengthening their motivation to take preventive action against HIV infection. Using a combination of qualitative and quantitative methods in the evaluation process, significant increases in consistent condom use were noted among the intervention groups but not among the control groups.

Sexually transmitted diseases and condom use among female freelance and brothel-based sex workers in Singapore.

BACKGROUND AND OBJECTIVES: Most studies in Asia exclude freelance female sex workers because of difficulties in access and the illegality of their work. Data are lacking on their risk behaviors. GOAL: To compare sexually transmitted disease (STD) rates, condom use, and health screening behavior between freelance and brothel-based sex workers in Singapore. STUDY DESIGN: This is a cross-sectional survey of 111 free-lance sex workers arrested from November 1996 to March 1997 for illicit prostitution and 333 randomly selected brothel-based sex workers. All were tested for STDs. RESULTS: STDs were significantly more prevalent among freelance than brothel-based sex workers (34.8% vs. 24.0%). Inconsistent condom use was significantly higher among freelance than brothel-based sex workers and was significantly associated with younger age, decreasing number of clients, and perception of non-condom use among peers. CONCLUSION: Educational programs to promote condom use should target freelance sex workers and their clients.

PIP: This study compares the prevalence of sexually transmitted diseases (STDs), condom use, and health-screening behavior between freelance and brothel-based sex workers in Singapore. A total of 111 female freelance sex workers arrested from November 1996 to March 1997 for illicit prostitution were interviewed; 333 brothel-based sex workers served as the comparison group for the analysis. STD test results revealed that freelance sex workers (34.8%) have higher STD rates than brothel-based sex workers (24%). The two most common STDs in both groups were chlamydial cervicitis and syphilis. Moreover, condom use was significantly lower among freelance sex workers than brothel-based sex workers and was associated with younger age (25 years old), decreasing number of clients, and perception of non-condom use among peers. In addition, freelance workers were more educated and had equally high knowledge on STDs and AIDS. Since most of these freelance workers practice high-risk behaviors and poor health screening behaviors such as not going for regular medical check-ups, STD services and education programs should target this group.

Measuring the impact of a behaviour change intervention for commercial sex workers and their potential clients in Malawi.

A peer-education HIV/AIDS prevention programme for bar-based sex workers and their potential clients (long-distance truck drivers) in Malawi was evaluated for impact. A mixed method approach was used, the tools being structured questionnaires and focus group discussions. The results showed that in the active districts, the presence of sex worker peer educators led to a increase in condom use with paying partners (90.3 compared to 66.7 and 76.3% in the two other groups--non-active and average) and increased condom distribution. Condom use with regular non-paying partners of sex workers had, however, not increased since the baseline data. The truck driver peer educators were found to be generally inactive but companies where training had occurred were more likely to encourage and distribute condoms. The qualitative data gave a more in-depth view of several areas for concern: the reasons for the non-use of condoms with non-paying partners; acceptance of educators by their peers; and the sex workers' and truck drivers' criteria for condom use based neither on knowledge nor on their own risk awareness. These issues need to be explored further.

PIP: This paper evaluates the impact of a HIV/AIDS prevention education program for bar-based sex workers and their potential clients (truck drivers) in Malawi. The evaluation methodology using mixed-method approach was considered to incorporate both qualitative and quantitative data. Results showed that in active districts increase in condom use with paying partners (90.3%) was high by comparison with nonactive districts due to the presence of peer educators. Data also showed that truck driver peer educators were inactive and that companies where training had occurred were more likely to encourage the use of condoms and to distribute them. Condom use with regular nonpaying partners of sex workers had, however, not increased. Consequently, there have since been several studies on the reliability and validity of self-reported sexual behavior. The discrepancy between knowledge, risk awareness, and actual behavior still requires further investigation.

A prospective study of pharyngeal gonorrhoea and inconsistent condom use for oral sex among female brothel-based sex workers in Singapore.

Oral sex among female sex workers in Singapore has risen sharply from 27.1% in 1992 to 81.7% in 1997. A prospective cohort study was carried out on 724 female brothel-based sex workers who practised oral sex, to determine the risk of contracting pharyngeal gonorrhoea through inconsistent condom use. The prevalence of consistent condom use for oral sex was 70.4% compared to 96.8% for vaginal sex. One hundred and twenty-nine (17.8%) were lost to follow up because they quit prostitution. The other 595 sex workers were followed up for a maximum period of 6 months. Thirty-eight (5.2%) sex workers contracted pharyngeal gonorrhoea compared to 2.5% who contracted cervical gonorrhoea. Sex workers with inconsistent condom use for oral sex were 17.1 times (95% CI: 8.0-36.5) more likely than consistent condom users to develop pharyngeal gonorrhoea, after controlling for ethnic group, class and number of clients. STD control programmes for sex workers should place stress on consistent condom use for oral sex.

PIP: This study examines the risks of pharyngeal gonorrhea due to inconsistent condom use among female sex workers in Singapore. A total of 724 brothel-based female sex workers who practiced oral sex were interviewed between December 1996 and June 1998. Data collected included sociodemographic characteristics, sexual behavior, and use of condom for oral sex. The results demonstrated a 70.4% prevalence of consistent condom use for oral sex as compared to 96.8% for vaginal sex. Of the 595 sex workers that were followed up for a maximum period of 6 months, 38 (5.2%) contracted pharyngeal gonorrhea, while 2.5% contracted cervical gonorrhea. It was revealed that sex workers with inconsistent condom use for oral sex were 17.1 times more likely to develop pharyngeal gonorrhea than consistent condom users. Since the risk of acquiring pharyngeal gonorrhea was significantly higher for inconsistent condom users, sexually transmitted disease control programs for sex workers should also emphasize the need for the consistent use of condoms with oral sex.

Recording sexual behavior: comparison of recall questionnaires with a coital diary.

OBJECTIVE: To compare sexual behavior data obtained using a weekly-recall questionnaire, a daily-recall questionnaire, and a coital diary. DESIGN: Cross-sectional survey of female sex workers from KwaZulu-Natal, South Africa between August and October 1998. METHODS: In this study, 52 weekly-recall questionnaires, 27 daily-recall questionnaires, and 79 coital diaries for dates corresponding to the questionnaires were obtained from female sex workers. Variables examined included: number of clients, number of condoms used with clients and partners, and number and type of sexual acts with clients and partners. Statistical analyses were conducted to examine the degree of agreement between the data collection methods and to assess differences between the mean values of the variables in the questionnaires versus the diary. RESULTS: Comparison of weekly-recall questionnaires with coital diaries indicated a significantly greater mean number of clients (P < 0.001), number of condoms used (P < 0.001), vaginal acts (P < 0.001), and anal acts (P = 0.044) reported in the diary versus the questionnaire. On comparison of daily-recall questionnaire with coital diary, significant differences were revealed between the means detected for the number of clients (P = 0.027), number of days worked (0.009), and anal acts with clients (P = 0.004). CONCLUSIONS: The use of coital diaries for the collection of sexual behavior data may be limited to cross-sectional community surveys. A recall questionnaire may provide more reliable and a better quality of data for longitudinal studies and for human immunodeficiency virus/sexually transmitted disease evaluation programs.

PIP: This study aimed to compare data obtained from coital diaries (CD) with those collected using weekly recall (WR) and daily recall (DR) questionnaires. 79 female sex workers aged 18-44 coming from KwaZulu-Natal, South Africa, were studied. They were followed up every month with clinical examination and treatment of STDs, provision of condoms, and CD collection. There were 52 WR, 27 DR, and 79 CD records collected from the participants. Results showed that CD records showed a significantly greater mean number of clients compared to the questionnaires (23.3 vs. 13.6, P 0.001), number of condoms used (2.7 vs. 0.5, P 0.001), vaginal acts (6.8 vs. 2.9, P 0.001), and anal acts (1.9 vs. 0.7, P = 0.044). Daily accounts of weekly sexual activity showed significant differences in 1) the number of days worked (6.2 vs. 5.2, P = 0.009), 2) the number of clients (21.7 vs. 17.4, P = 0.027), and 3) the number of anal acts with clients (3.9 vs. 0.8, P = 0.004), with higher means reported in the CD records for all cases. The CD records are an important instrument for gathering preliminary sexual behavioral information; however, their use is limited to long-term data collection. Therefore, a comprehensive recall questionnaire is recommended for future trials.

Sexual intercourse, abuse and pregnancy among adolescent women: does sexual orientation make a difference?

CONTEXT: Although a limited amount of research has retrospectively explored the childhood and adolescent heterosexual experiences of lesbians, little is known about the prevalence of heterosexual behavior and related risk factors or about pregnancy histories among lesbian and bisexual teenagers. METHODS: A secondary analysis was conducted using responses from a subsample of 3,816 students who completed the 1987 Minnesota Adolescent Health Survey. Behaviors, risk factors and pregnancy histories were compared among adolescents who identified themselves as lesbian or bisexual, as unsure of their sexual orientation and as heterosexual. RESULTS: Overall, bisexual or lesbian respondents were about as likely as heterosexual women ever to have had intercourse (33% and 29%, respectively), but they had a significantly higher prevalence of pregnancy (12%) and physical or sexual abuse (19-22%) than heterosexual or unsure adolescents. Among sexually experienced respondents, bisexual or lesbian and heterosexual women reported greater use of ineffective contraceptives (12-15% of those who used a method) than unsure adolescents (9%); bisexual or lesbian respondents were the most likely to have frequent intercourse (22%, compared with 15-17% of the other groups). In the sample overall, among those who were sexually experienced and among those who had ever been pregnant, bisexual or lesbian women were the most likely to have engaged in prostitution during the previous year. CONCLUSIONS: Providers of reproductive health care and family planning services should not assume that pregnant teenagers are heterosexual or that adolescents who say they are bisexual, lesbian or unsure of their sexual orientation are not in need of family planning counseling. Further research should explore the interactions between adolescent sexual identity development and sexual risk behaviors.

PIP: The influence of sexual orientation on adolescents' sexual behaviors and pregnancy histories was investigated in a subsample of 3816 female adolescents, 12-19 years old, who completed the 1987 Minnesota (US) Adolescent Health Survey. 182 identified themselves as bisexual or lesbian, 1753 were unsure of their sexual orientation, and 1881 were heterosexual. Bisexual/lesbian respondents were about as likely as heterosexual respondents ever to have had intercourse (33.0% and 29.3%, respectively), but they had a significantly higher prevalence of childhood physical abuse (19.3% vs. 11.9%) and sexual abuse (22.1% vs. 15.3%) than their heterosexual counterparts. Among sexually experienced respondents, 29.8% of bisexual/lesbian adolescents, 43.5% of those unsure about their identity, and 23.1% of heterosexuals used no contraception and 12.3%, 8.5%, and 14.5%, respectively, of those who used contraception used an ineffective method. 12.3% of bisexual/lesbian women, 6.1% of those unsure about their sexual orientation, and 5.3% of heterosexual adolescents had experienced a pregnancy; 2 or more pregnancies were reported by 23.5%, 15.1%, and 9.8%, respectively, of ever-pregnant teens. Finally, 9.7% of bisexual/lesbian women had engaged in prostitution in the year preceding the survey, compared with 1.9% of heterosexuals and 3.4% of those unsure about their orientation. These findings suggest that adolescents who identify themselves as lesbian or bisexual are at high risk of pregnancy and poor contraceptive practices. Providers of reproductive health care and family planning services should not assume that their pregnant adolescent patients are heterosexual or that lesbian clients or those unsure of their sexual orientation are not in need of contraception.

Acceptability of female condom use among women exchanging street sex in New York City.

Greater access to alternative female-initiated barrier methods, such as the female condom, is needed among women exchanging street sex. This study describes knowledge of and experience with the female condom among 101 women exchanging sex for money and drugs on the streets of New York City, and examines the acceptability of female condom use as an alternative barrier method for HIV/STD prevention among this population. Female condom use among this sample of sex workers was found to be related to having a regular sexual partner, living with someone who is a drug or alcohol abuser, not being homeless, using alcohol or intravenous heroin, having heard of the device, and having discussed the device with other women or with a regular sexual partner. Despite decreased acceptability post-use, most sex workers indicated an intention for future female condom use.

PIP: This study describes the knowledge and experience of the female condom among 101 women exchanging sex for money and drugs on the streets of New York City, and examines the acceptability of female condom use as an alternative barrier method for HIV and sexually transmitted disease (STD) prevention among this population. Samples included were African American, never married, and with an average age of 35.9 years. The result shows that women who were single and never married were more likely to use the female condom than those who were married, separated, divorced, or widowed. Moreover, those who lived with someone having drug or alcohol problems were more likely to use female condoms than their counterparts than those who were homeless, women with a place to live were more likely to use female condoms. These suggest that the female condom may be feasible alternative barrier method for STD and HIV prevention among women engaging in commercial sex work. Despite decreased acceptability post-use, most sex workers indicated an intention for future female condom use.

AIDS-related perceptions and condom use of prostitutes in Korea.

The purpose of this study was to assess the impact of AIDS-related knowledge and attitudes of prostitutes on condom use from diverse 'sex markers' in Korea. The data were collected by interviewers at five different 'sex markets'. During March 1993, research assistants at the Institute of Health Services Research interviewed 371 prostitutes visiting sexually transmitted disease (STD) clinics. Multiple regression method was used in identifying the determinants of condom use. The level of condom use was regressed on personal characteristics of prostitutes, AIDS-related perceptions, and market type. Prostitutes' level of condom use turned out to be different across the markets featuring diverse types of services and fees. Neither perceived vulnerability nor perceived seriousness of AIDS had significant effects on condom use. Our findings suggested that the many AIDS-preventive educational efforts by STD clinics are ineffective. Hence, individual STD clinics need to develop AIDS-preventive education programs which are suitable for the unique circumstances of their respective 'sex markets'.

PIP: This study evaluates the impact of AIDS-related knowledge and the attitudes of prostitutes on condom use in diverse ¿sex markets¿ in Korea. The data were collected by interviewers at five different ¿sex market¿ sites, namely: Miari and Chunhodong in Seoul, Bujundong and Wanwalldong in Pusan, and Inchon. The dependent variable in this study was the level of condom use, specifically the level of condom use request. A multiple regression method was used in identifying the determinants of condom use. The following independent variables were included in the multiple regression equation: sociodemographic variables, health variables, AIDS-related perception variables, and market-related variables. Prostitute level of condom use turned out to be different across the markets, which featured diverse type of services and fees. Neither perceived vulnerability to AIDS nor perceived seriousness of it had significant effects on condom use. The many AIDS-preventive educational efforts by STD clinics had turned out to be ineffective. Individual STD clinics need to develop AIDS-preventive education programs which are suitable for the unique circumstances of their respective ¿sex markets.¿ Local health care specialists should be encouraged and trained to develop a comprehensive understanding of the sociocultural rituals as well as the clinical health conditions of each market.