What's in a Name? A Mixed Method Study on How Young Women Who Sell Sex Characterize Male Partners and Their Use of Condoms.

INTRODUCTION: Young women who sell sex (YWSS) are at disproportionate risk of HIV. Reducing YWSS' vulnerability requires engaging their male sexual partners. To achieve this, we need to understand the characteristics and dynamics of their sexual partnerships to inform effective interventions. METHODS: We conducted a mixed-methods study to compare YWSS' qualitative descriptions of male partners with categories reported in a behavioral survey. Data were drawn from enrollment into an evaluation of the DREAMS initiative in Zimbabwe in 2017. As part of a respondent-driven sampling survey, we recruited 40 seed participants from 2 intervention and 4 comparison sites. We conducted semistructured interviews with 19 "seeds," followed by a behavioral survey with 2387 YWSS. We interpreted quantitative and qualitative data together to understand how YWSS perceived male sexual partners, assess how well survey variables related to narrative descriptions, and describe patterns of risk behavior within partnerships. RESULTS: Qualitative data suggest survey categories "husband" and "client" reflect YWSS' perceptions but "regular partner/boyfriend" and "casual partner" do not. In interviews, use of the term "boyfriend" was common, describing diverse relationships with mixed emotional and financial benefits. More than 85% of male partners provided money to YWSS, but women were less likely to report condomless sex with clients than regular partners (11% vs 37%) and more likely to report condomless sex with partners who ever forced them to have sex (37% vs 21%). CONCLUSIONS: Reducing HIV risk among YWSS requires prevention messages and tools that recognize diverse and changing vulnerability within and between sexual relationships with different male partners.

HIV self-testing in Pune, India: perspectives and recommendations of female sex workers and peer educators.

Female sex workers (FSW) represent a focal point of the HIV epidemic in India. HIV self-testing (HIVST) could mitigate under-diagnosis of HIV and reduce disease transmission in this population. This study assessed the acceptability of HIVST through focus group discussions (FGD) with FSW. FSW expressed willingness to use HIVST and preference for saliva-based HIVST over blood-based HIVST and preferred that HIVST education, administration, and storage take place in trusted community centers and not in brothels. We provide preliminary recommendations for the implementation of an acceptable and feasible HIVST program for FSW in India.

Effectiveness of health care workers and peer engagement in promoting access to health services among population at higher risk for HIV in Tanzania (KPHEALTH): study protocol for a quasi experimental trial.

BACKGROUND: While there are indications of declining HIV infection rates in the general population globally, Tanzania included, men who have sex with men (MSM), female sex workers (FSW) and people who inject drugs (PWID), now called Key Populations (KP) for HIV epidemic have 2-20 times higher infections rates and contributes up to 30% of new HIV infection. Tanzania have developed a Comprehensive Guideline for HIV prevention among key population (CHIP) to address the epidemic among KPs. However, these populations are stigmatized and discriminated calling for innovative approaches to improve access to CHIP. This project seeks to test the effectiveness of healthcare workers and peer-to-peer engagement in promoting access to CHIP among HIV at risk populations in Tanzania. METHODS: A quasi-experimental design involving Dar es Salaam City as an intervention region and Tanga as a control region will be done. Using respondent driven sampling, 1800 at risk population (900 from Intervention site and 900 from control site) will be recruited at baseline to identify pull and push factors for health services access. Stakeholder's consultation will be done to improve training contents for CHIP among health care workers and peers. Effectiveness of healthcare workers training and peer engagement will be tested using a quasi-experimental design. DISCUSSION: The results are expected to co-create service provision and improve access to services among KPs as a human right, reverse HIV infection rates among KPs and the general population, and improve social and economic wellbeing of Tanzanian. TRIAL REGISTRATION: Retrospectively registered on 28th August, 2019 with International Standard Randomized Clinical Trial Number ( ISRCTN11126469 ).

Addressing broader reproductive health needs of female sex workers through integrated family planning/ HIV prevention services: A non-randomized trial of a health-services intervention designed to improve uptake of family planning services in Kenya.

BACKGROUND: Despite considerable efforts to prevent HIV and other sexually transmitted infections (STI) among female sex workers (FSW), other sexual and reproductive health (SRH) needs, such preventing unintended pregnancies, among FSW have received far less attention. Programs targeting FSW with comprehensive, accessible services are needed to address their broader SRH needs. This study tested the effectiveness of an intervention to increase dual contraceptive method use to prevent STIs, HIV and unintended pregnancy among FSW attending services in drop-in centers (DIC) in two cities in Kenya. The intervention included enhanced peer education, and routine screening for family planning (FP) needs plus expanded non-condom FP method availability in the DIC. METHODS: We conducted a two-group, pre-/posttest, quasi-experimental study with 719 FSW (360 intervention group, 359 comparison group). Participants were interviewed at baseline and 6 months later to examine changes in condom and non-condom FP method use. RESULTS: The intervention had a significant positive effect on non-condom, FP method use (OR = 1.38, 95%CI (1.04, 1.83)), but no effect on dual method use. Consistent condom use was reported to be high; however, many women also reported negotiating condom use with both paying and non-paying partners as difficult or very difficult. The strongest predictor of consistent condom use was partner type (paying versus non-paying/emotional); FSW reported both paying and non-paying partners also influence non-condom contraceptive use. Substantial numbers of FSW also reported experiencing sexual violence by both paying and non-paying partners. CONCLUSIONS: Self-reported difficulties with consistent condom use and the sometimes dangerous conditions under which they work leave FSW vulnerable to unintended pregnancy STIs/HIV. Adding non-barrier FP methods to condoms is crucial to curb unintended pregnancies and their potential adverse health, social and economic consequences. Findings also highlight the need for additional strategies beyond condoms to reduce HIV and STI risk among FSW. TRIAL REGISTRATION: Clinicaltrials.gov NCT01957813.

Empowering sex workers? Critical reflections on peer-led risk-reduction workshops in Soweto, South Africa.

Background: Sex workers in South Africa face various forms of structural and interpersonal violence, including police violence, exclusion from health services, and stigmatization and marginalization within their communities. In an attempt to counteract the harmful health effects of criminalization and exclusion, risk-reduction workshops are a key component of HIV prevention programs globally. This paper offers a critical investigation of Creative Space workshops - a South African model of risk-reduction workshops for sex workers - taking place in Soweto, Johannesburg. Drawing on Paulo Freire's work, the paper explores the potential of these workshops to contribute to the empowerment, health and well-being of sex workers. Objectives: The aim of this paper is to investigate the social and psychological effects of peer-led risk-reduction workshops for sex workers in Soweto, South Africa, with a particular focus on the ways in which they might contribute to community empowerment. Methods: This paper is based on in-depth interviews and focus group discussions with 32 sex workers conducted as part of a 20-month ethnographic study (December 2015 to July 2017). Data was analyzed combining inductive thematic analysis with a theoretical frame based on Freire's theory of community empowerment. Results: Peer-led risk-reduction workshops can serve as a 'safe space' for sex workers and distribute empowering forms of knowledge, particularly regarding health issues and rights. However, divisions between different groups of sex workers and between sex workers and non-sex workers counteract the potential benefits of the workshops. Conclusions: Peer-led sex worker programs are likely to be more empowering when they are committed to raising critical consciousness and creating solidarity, and embedded in community action, focusing on common issues such as institutionalized racism, livelihood insecurity, and lack of access to safe and secure housing. Such actions would have positive outcomes on health and well-being.

Need for Intervention Services for Promotion of Condom Use by Female Sex Workers to Consider Size of Entertainment Venues: A Cross-Sectional Study.

BACKGROUND Consistent condom use among female sex workers (FSWs) is a key intervention in China's AIDS Control Program. Female sex workers (FSWs) in China are at increased risk for acquiring HIV/AIDS because of low knowledge about HIV transmission and inconsistent use of condoms, the grade of venues may play a role in HIV/AIDS-related knowledge and consistent condom use of female sex workers. MATERIAL AND METHODS A cross-sectional study was conducted among 802 FSWs in 2016 in Fuyang, China. A self-administered questionnaire was used to assess whether there is a need of different intervention services promotion of consistent condom use among FSWs in different-grade entertainment venues. RESULTS Multivariate logistic regression analysis indicated that knowledge scores of HIV transmission routes and peer education were associated with consistent condom use in large-size venues, while peer education was associated with consistent condom use in mid-size venues. Knowledge scores of HIV non-transmission routes, knowledge scores of AIDS prevention/control, and peer education were associated with consistent condom use in small venues. CONCLUSIONS Our data suggested that the strategies for strengthen interventions on health benefits of consistent condom use of FSWs should differ by size of venue.

Societal determinants of HIV vulnerability among clients of female commercial sex workers in Indonesia.

This study aimed to explore societal determinants of HIV vulnerability among the clients of female commercial sex workers (FCSWs) in Belu and Malaka districts, Indonesia. A qualitative inquiry using in-depth interviews was employed to collect data from participants (n = 42) recruited using a purposive and snowball sampling technique. Data analysis was guided by a qualitative data analysis framework. The study results revealed several societal determinants that supported vulnerability to HIV infection among the participants. They included low education level and sexual health literacy including the lack of knowledge and information about HIV transmission and prevention. Additional determinants identified were limited source of HIV/AIDS-related information, availability of and ease of accessibility of brothels and FCSWs, peer influence, and high mobility of the study participants. Findings of this study indicate the needs and call for interventions that aim to protect both FCSWs and their clients, through provision of HIV/AIDS and sexual health education and information and improvement in the availability and accessibility of condoms.

Mobile Link - a theory-based messaging intervention for improving sexual and reproductive health of female entertainment workers in Cambodia: study protocol of a randomized controlled trial.

BACKGROUND: In Cambodia, HIV prevalence is concentrated in key populations including among female entertainment workers (FEWs) who may engage in direct or indirect sex work. Reaching FEWs with sexual and reproductive health (SRH) services has been difficult because of their hidden and stigmatized nature. Mobile-phone-based interventions may be an effective way to reach this population and connect them with the existing services. This article describes study design and implementation of a randomized controlled trial (RCT) of a mobile health intervention (the Mobile Link) aiming to improve SRH and related outcomes among FEWs in Cambodia. METHODS: A two-arm RCT will be used to determine the effectiveness of a mobile-phone-based text/voice messaging intervention. The intervention will be developed through a participatory process. Focus group discussions and in-depth interviews have been conducted to inform and tailor behavior change theory-based text and voice messages. During the implementation phase, 600 FEWs will be recruited and randomly assigned into one of the two arms: (1) a control group and (2) a mobile phone message group (either text messages [SMS] or voice messages [VM], a delivery method chosen by participants). Participants in the control group will also receive a weekly monitoring survey, which will provide real-time information to implementing partners to streamline outreach efforts and be able to quickly identify geographic trends. The primary outcome measures will include self-reported HIV and sexually transmitted infections (STI) testing and treatment, condom use, contraceptive use, and gender-based violence (GBV). DISCUSSION: If the Mobile Link trial is successful, participants will report an increase in condom use, linkages to screening and treatment for HIV and STI, and contraception use as well as a reduction in GBV. This trial is unique in a number of ways. First, the option of participation mode (SMS or VM) allows participants to choose the message medium that best links them to services. Second, this is the first RCT of a mobile-phone-based behavior change intervention using SMS/VMs to support linkage to SRH services in Cambodia. Lastly, we are working with a hidden, hard-to-reach, and dynamic population with which existing methods of outreach have not been fully successful. TRIAL REGISTRATION: Clinical trials.gov, NCT03117842 . Registered on 31 March 2017.

Modeling the Intervention of HIV Transmission across Intertwined Key Populations.

The HIV transmissions between multiple key populations make interventions difficult, particularly with multiple transmission behaviors. It remains unclear how significant the role of bridge individuals (who connect multiple communities) is in HIV transmission, and how to develop more effective intervention strategies targeting different transmission modes across key populations. In this research, we proposed a 2-layer social network framework to simulate the HIV transmissions across female sex workers (FSWs) and persons who inject drugs (PWID) through two behaviors: unprotected sex and needle-sharing. We proposed a set of intervention strategies based on the topological properties of individuals in the social network and estimated the efficacy of these strategies. Simulation studies demonstrated that bridge individuals played a significant role in HIV transmissions across the two networks. Prevention on such bridge individuals could help reduce both the scale and speed of HIV transmissions.

Key Programme Science lessons from an HIV prevention 'Learning Site' for sex workers in Mombasa, Kenya.

OBJECTIVES: In 2013, Kenya's National AIDS and STI Control Programme established a Learning Site (LS) in Mombasa County to support and strengthen capacity for HIV prevention programming within organisations working with sex workers. A defining feature of LS was the use of a Programme Science approach throughout its development and implementation. We provide an overview of the key components of LS, present findings from 23 months of programme monitoring data, and highlight key Programme Science lessons from its implementation and monitoring. METHODS: Routine monitoring data collected from September 2013 through July 2015 are presented. Individual-level service utilisation data were collected monthly and indicators of interest were analysed over time to illustrate trends in enrolment, programme coverage and service utilisation among sex workers in Mombasa County. RESULTS: Over the monitoring period, outreach programme enrolment occurred rapidly; condom distribution targets were met consistently; rates of STI screening remained high and diagnoses declined; and reporting of and response to violent incidents increased. At the same time, enrolment in LS clinics was relatively low among female sex workers, and HIV testing at LS was low among both female and male sex workers. CONCLUSION: Lessons learnt from operationalising the Programme Science framework through the Mombasa LS can inform the development and implementation of similar LS in different geographical and epidemiological contexts. Importantly, meaningful involvement of sex workers in the design, implementation and monitoring processes ensures that overall programme performance is optimised in the context of local, 'on-the-ground' realities. Additionally, learnings from LS highlight the importance of introducing enhanced monitoring and evaluations systems into complex programmes to better understand and explain programme dynamics over time.

Behavioural interventions promoting condom use among female sex workers in sub-Saharan Africa: a systematic review.

The objective of this review was to provide an overview of behavioural interventions promoting condom use amongst female sex workers (FSW) in sub-Saharan Africa. A search of four electronic bibliographic databases from 1990 to September 2016 was carried out. The search was limited to articles published in English. Studies which evaluated behavioural interventions to increase condom use among FSWs were selected and reviewed. Data were extracted on effectiveness, condom use, intervention content, and process outcomes. A total of 20 eligible articles describing 18 interventions in sub-Saharan Africa on HIV prevention with condom use as an outcome measure were identified. Most of the behavioural interventions incorporated a combination of approaches: health education by peers, health workers and project staff, and activities by brothel owners and brothel managers. Most studies showed effectiveness of these interventions on condom use with paying clients. Five studies measuring condom use with regular non-paying partners recorded less consistent condom use with these partners. This review illustrates the existence of sufficient evidence showing the effectiveness of behavioural interventions targeting correct and consistent condom use by FSWs.

Zambian Peer Educators for HIV Self-Testing (ZEST) study: rationale and design of a cluster randomised trial of HIV self-testing among female sex workers in Zambia.

BACKGROUND: HIV testing and knowledge of status are starting points for HIV treatment and prevention interventions. Among female sex workers (FSWs), HIV testing and status knowledge remain far from universal. HIV self-testing (HIVST) is an alternative to existing testing services for FSWs, but little evidence exists how it can be effectively and safely implemented. Here, we describe the rationale and design of a cluster randomised trial designed to inform implementation and scale-up of HIVST programmes for FSWs in Zambia. METHODS: The Zambian Peer Educators for HIV Self-Testing (ZEST) study is a 3-arm cluster randomised trial taking place in 3 towns in Zambia. Participants (N=900) are eligible if they are women who have exchanged sex for money or goods in the previous 1 month, are HIV negative or status unknown, have not tested for HIV in the previous 3 months, and are at least 18 years old. Participants are recruited by peer educators working in their communities. Participants are randomised to 1 of 3 arms: (1) direct distribution (in which they receive an HIVST from the peer educator directly); (2) fixed distribution (in which they receive a coupon with which to collect the HIVST from a drug store or health post) or (3) standard of care (referral to existing HIV testing services only, without any offer of HIVST). Participants are followed at 1 and 4 months following distribution of the first HIVST. The primary end point is HIV testing in the past month measured at the 1-month and 4-month visits. ETHICS AND DISSEMINATION: This study was approved by the Institutional Review Boards at the Harvard T.H. Chan School of Public Health in Boston, USA and ERES Converge in Lusaka, Zambia. The findings of this trial will be presented at local, regional and international meetings and submitted to peer-reviewed journals for publication. TRIAL REGISTRATION NUMBER: Pre-results; NCT02827240.

Combination HIV prevention options for young women in Africa.

Although the number of new HIV infections has declined by over 30% in the past decade, the number of people who acquire HIV each year remains unacceptably high. In 2014 the Joint United Nations Programme on HIV/AIDS (UNAIDS) estimated that there were about 2 million new HIV infections. The virus continues to spread, particularly in key populations, such as men who have sex with men (MSM), transgender individuals, sex workers and people who inject drugs. In Africa, young women have the highest HIV incidence rates. Scaling up known efficacious HIV prevention strategies for these groups at high risk is therefore a high priority. HIV prevention has generally been targeted at HIV-negative individuals or in some instances, entire communities. Prevention efforts are, however, shifting from a narrow focus on HIV-uninfected persons to a continuum of prevention that includes both HIV-negative and HIV-positive individuals. Given that a single HIV prevention intervention is unlikely to be able to alter the epidemic trajectory as HIV epidemics in communities are complex and comprise a mosaic of different risk factors and different routes of transmission, there is need to provide combination prevention. Hence, a mix of behavioural, biomedical and structural HIV prevention options is likely to be needed to alter the course of the HIV epidemic. The combination of HIV prevention interventions needed will vary depending on cultural context, the population targeted and the stage of the epidemic. This paper reviews the available HIV prevention strategies for young women and discusses new HIV prevention approaches in development.

Problematics of empowerment: sex worker HIV prevention in the Pacific.

A recent overview of HIV/STI prevention programmes for sex workers in the Pacific region indicates that, despite a regional policy shift from universal to targeted interventions, Pacific Island countries currently lack core HIV/STI prevention services for sex workers. Across the region, condom distribution, peer outreach and support services for sex workers have ceased even in countries where such programmes had previously existed. This article cautions that the endorsement of empowerment projects does not negate the important role of condom access in HIV and STI prevention efforts for Pacific sex workers. While community empowerment underpins, and is essential to the sustainability of, effective interventions, it does not constitute an adequate form of HIV and STI prevention in and of itself. We contend that in the context of the Pacific Islands, timely and effective HIV prevention measures must specifically attend to the implementation of, and sustained support for, behavioural interventions such as sex-worker-specific peer education, condom and lubricant distribution, and access to appropriate sexual health services. Further, the responsibility for delivery of these should not be borne solely by fledgling sex worker organizations and communities. The evolution of targeted interventions in the Pacific and the current lack of funded condom distribution programmes highlight a more generalizable imperative within HIV prevention to ensure that behaviour change efforts are not considered to be extraneous to, or rendered redundant by, empowerment-based interventions.

Systematic review of interventions to reduce illicit drug use in female drug-dependent street sex workers.

OBJECTIVES: Most female street-based sex workers (SSWs) are drug users and this group experience particularly poor outcomes in achieving and maintaining abstinence. In 2010 the UK adopted a recovery-orientated Drug Strategy. This strategy did not specifically highlight the complex drug treatment needs of SSWs. Therefore we sought to synthesise and critically appraise existing evidence of interventions to reduce illicit drug use in this group, in order to guide service change toward better provision for the drug treatment needs of SSWs. METHODS: A systematic review of evidence on the effectiveness of interventions to reduce illicit drug use in female SSWs. Following the PRISMA guidelines, a structured search strategy was used. Searches included databases, organisational and government websites to identify published and grey literature, as well as contacting experts in the field, and hand-searching reference lists and journals. RESULTS: Six studies, one experimental and five observational, were identified which met review inclusion criteria. Intervention approaches evaluated included substitute prescribing, educational sessions and motivational interviewing. All studies reported a positive intervention effect but the five observational studies were all subject to a relatively high risk of bias. By contrast, the experimental study provided little or no evidence of positive effect (OR for reduction of illicit drug in intervention compared to controls 1.17 95%CI 0.84-1.66 at 3 months and 1.14 (95% CI 0.8 to 1.61) at 6 months follow-up). All six studies described challenges and solutions to study recruitment, retention and follow-up, which were influenced by issues affecting SSWs' health and social stability. CONCLUSIONS: There is currently no strong evidence for effectiveness of interventions to reduce illicit drug use in female SSWs with problematic drug use. Thus, the development and robust evaluation of effective interventions should be a priority if recovery-orientated goals are to become more achievable for this group.

Sustainability of Evidence-Based Practices for HIV Prevention among Female Sex Workers in Mexico.

OBJECTIVE: This study examined service provider perceptions of requirements for successful sustainment of an efficacious intervention for preventing HIV/AIDS and STIs in female sex workers (FSWs) in Mexico. METHODS: Semi-structured interviews were conducted with 77 leaders and counselors from 12 community-based reproductive health clinics located throughout Mexico participating in a large hybrid effectiveness-implementation randomized controlled trial to scale-up the use of Mujer Segura, a psychoeducational intervention designed to promote condom use and enhance safer sex negotiation skills among FSWs. RESULTS: Five sets of requirements for sustainment were identified: 1) characteristics of the provider, including competence in delivering the intervention, need for continued technical support and assistance from outside experts, and satisfaction with addressing the needs of this population; 2) characteristics of the clients (i.e., FSWs), including client need and demand for services and incentives for participation; 3) characteristics of the organization, including its mission, benefits, and operations; 4) characteristics of the outer setting, including financial support and relationship with the community-based organization's central offices, and transportation and security in areas where FSWs live and work; and 5) outcomes associated with the intervention itself, including a reduction of risk through education and increased outreach through referrals from FSWs who received the intervention. CONCLUSIONS: Although the requirements for successful sustainment of interventions like Mujer Segura are consistent with the factors identified in many models of implementation, the results illustrate the importance of local context in assigning priority to these model elements and suggest that the five categories are not discrete entities but interconnected.

Evaluating HIV prevention strategies for populations in key affected groups: the example of Cabo Verde.

OBJECTIVES: We used an individual-based model to evaluate the effects of hypothetical prevention interventions on HIV incidence trajectories in a concentrated, mixed epidemic setting from 2011 to 2021, and using Cabo Verde as an example. METHODS: Simulations were conducted to evaluate the extent to which early HIV treatment and optimization of care, HIV testing, condom distribution, and substance abuse treatment could eliminate new infections (i.e., reduce incidence to less than 10 cases per 10,000 person-years) among non-drug users, female sex workers (FSW), and people who use drugs (PWUD). RESULTS: Scaling up all four interventions resulted in the largest decreases in HIV, with estimates ranging from 1.4 (95 % CI 1.36-1.44) per 10,000 person-years among non-drug users to 8.2 (95 % CI 7.8-8.6) per 10,000 person-years among PWUD in 2021. Intervention scenarios prioritizing FWS and PWUD also resulted in HIV incidence estimates at or below 10 per 10,000 person-years by 2021 for all population sub-groups. CONCLUSIONS: Our results suggest that scaling up multiple interventions among entire population is necessary to achieve elimination. However, prioritizing key populations with this combination prevention strategy may also result in a substantial decrease in total incidence.

Community resistance to a peer education programme in Zimbabwe.

BACKGROUND: This paper presents community perceptions of a state-of-the-art peer education programme in Manicaland, Zimbabwe. While the intervention succeeded in increasing HIV knowledge among men and condom acceptability among women, and reduced HIV incidence and rates of unprotected sex among men who attended education events, it did not succeed in reducing population-level HIV incidence. To understand the possible reasons for this disappointing result, we conducted a qualitative study of local perspectives of the intervention. METHODS: Eight focus group discussions and 11 interviews with 81 community members and local project staff were conducted. Transcripts were interrogated and analysed thematically. RESULTS: We identified three factors that may have contributed to the programme's disappointing outcomes: (1) difficulties of implementing all elements of the programme, particularly the proposed income generation component in the wider context of economic strain; (2) a moralistic approach to commercial sex work by programme staff; and (3) limitations in the programme's ability to engage with social realities facing community members. CONCLUSIONS: We conclude that externally-imposed programmes that present new information without adequately engaging with local realities and constraints on action can be met by resistance to change.

Sex workers as safe sex advocates: Sex workers protect both themselves and the wider community from HIV.

Since the advent of HIV, significant changes have made the Australian sex industry one of the safest in the world. Creating this safety has been in large part due to the ability of sex workers to act as safe sex advocates through peer-based health promotion; to negotiate with sex business owners; and to inform and participate in the development of government policy. Empowerment of sex workers through legislative reform and government funding of sex worker organizations has been central to the prevention of HV transmission, as has been the development of genuine partnership between sex worker organizations, government departments and those working in public health. The paper describes these responses in some detail and explores some of the current issues facing sex workers in Australia.

HIV, syphilis, and behavioral risk factors among female sex workers before and after implementation of harm reduction programs in a high drug-using area of China.

OBJECTIVE: To evaluate the impact of harm reduction programs on HIV and syphilis infection and related risk behaviors among female sex workers (FSWs) in a drug trafficking city in Southwest China. DESIGN: Before and after harm reduction program study. METHODS: Two cross-sectional surveys were conducted among FSWs before and after harm reduction programs were launched in Xichang city, Sichuan province. The first and second cross-sectional surveys were conducted in 2004 and 2010, respectively. Temporal changes in odds of HIV, syphilis, and behavioral risk factors were assessed by multivariable logistic regression while controlling for socio-demographics. RESULTS: The 2004 and 2010 cross-sectional surveys recruited 343 and 404 FSWs, respectively. From 2004 to 2010, the odds of syphilis infection decreased by 35% and was of borderline statistical significance (AOR: 0.65, 95% CI: 0.41-1.03), while odds of HIV infection rose, but not significantly (AOR: 4.12, 95% CI: 0.76-22.45). Although odds of unprotected sex with primary sex partners did not significantly change over time (AOR: 0.96; 95% CI: 0.61-1.50), odds of unprotected sex with clients declined significantly and remarkably (AOR: 0.14, 95% CI: 0.09-0.21). Notably, the odds of reporting ≥10 new sex partners in the previous month increased by 37% (AOR: 1.37; 95% CI: 0.98-1.90). CONCLUSIONS: Harm reduction strategies may be an effective means of reducing unprotected sex with clients among FSWs. Future research is needed to better target both FSWs and IDUs and interrupt bridging networks for HIV transmission in high drug-using areas of China.