Overview of Structural Interventions to Decrease Commercial Sex Risk

Abstract

The heterosexual transmission of HIV increasingly accounts for higher percentages of new HIV infections in many parts of the world. In sub-Saharan Africa, where 68% of the world’s HIV/AIDS-infected population lives, unprotected heterosexual intercourse is the predominant mode of HIV transmission (UNAIDS, 2010a). In Asia, another part of the world heavily affected by HIV, heterosexual transmission has replaced injection drug use as the leading cause of new HIV cases (UNAIDS, 2010b). Whereas, once HIV was concentrated among core groups of at-risk populations, such as injection drug users or men who have sex with men, the disease has begun spreading to lower-risk populations primarily through unsafe heterosexual behaviors.

Appendices

Case Study 11: Mandatory Condom Law in Nevada Brothels: Using Policy to Change Condom Use Practices

Original Program Developers and Evaluators

A.E.Albert

D.L.Warner

R.A.Hatcher

J.Trussell

C.Bennett

Case Study Contents

• Abstract

• Program at a Glance

• Program Information and Implementation

• Original Program Evaluation

• Implications and Lessons Learned

• Supplementary Materials Available

Bibliography

Albert, A. E., Warner, D. L., & Hatcher, R. A. (1998). Facilitating condom use with clients during commercial sex in Nevada’s legal brothels. American Journal of Public Health, 88(4), 643–645.

Albert, A. E., Warner, D. L., Hatcher, R. A., Trussell, J., & Bennett, C. (1995). Condom use among female commercial sex workers in Nevada’s legal brothels. American Journal of Public Health, 85(11), 1514–1520.

Abstract

In order to help prevent the spread of HIV among Nevada’s brothel sex workers and their clients, Nevada enacted a mandatory condom law in 1988, requiring condoms during all brothel sexual activity. The law was posted on a sign within each brothel, so potential clients learned about it before any sexual activity began. Brothel workers reported that in spite of the risks associated with unprotected sex, some clients still resisted condom use.

In two studies, researchers documented the success that brothel workers had in consistently using condoms with clients. There were no reported instances of commercial sex workers (CSWs) having vaginal intercourse without a condom in either study. With clients who were reluctant to use a condom, CSWs were able to convince them most of the time to use one. The researchers found very few instances (reported retrospectively and tracked prospectively) where condoms broke or slipped off during sex, which meant that CSWs may have developed techniques to achieve less breakage and slippage. Although Nevada CSWs appeared to be using condoms successfully and consistently in professional situations, only a small percentage of the CSWs regularly used condoms in personal relationships. That may have been due to less of a perceived risk by the women or challenges outside of the brothels that made it difficult for women to negotiate condom use.

Program at a Glance

Goal: To increase condom use with clients for Nevada’s brothel CSWs

Target Populations: All Nevada brothel CSWs

Geographic Location and Region: State of Nevada in the United States

Establishment and Duration: In January 1987, the brothel industry in Nevada voluntarily began a condom-use policy. In March 1988, the State Health Department mandated condom use between all Nevada brothel CSWs and clients. The two studies of brothel sex worker condom-use behaviors presented here were conducted in August 1993 and July 1995.

Resources Required and Goods and Services Provided: Policy change only. Nevada brothels were required to post a sign saying that condoms must be used but were not required to provide condoms for their CSWs or clients.

Strategies and Components: Established a mandatory condom-use law in Nevada’s brothels

Key Partners: Unknown

Key Evaluation Findings

Statistically significant

• Low condom breakage and falling off rates

• No reports of unprotected sex with a client

No effect

• Did not increase condom use with noncommercial sex partners

Program Information and Implementation

Background, History, and Public Health Relevance

In response to increased public awareness of the HIV/AIDS crisis, legal brothels in Nevada and the Nevada legislature instituted policies to help prevent transmission of HIV and other STIs between brothel CSWs and their clients. Beginning in 1985, the Nevada Administrative Code required CSWs to submit to STI testing; in 1986, HIV testing also became mandatory in addition to the already required testing for syphilis, gonorrhea, and chlamydia. Before being hired by a brothel, a CSW had to prove that she was disease-free. Once hired, sex workers were required to undergo weekly gonorrhea and chlamydia tests and monthly syphilis and HIV tests. In 1987, the Nevada legislature made it illegal for an HIV-positive individual to work as a prostitute. As public concern over HIV transmission increased, especially when health officials announced that HIV could be spread through heterosexual contact, brothels adopted more stringent policies for their workers. In January 1987, the brothel industry voluntarily adopted a condom-use policy for all CSWs. In March 1988, the State Health Department of Nevada mandated condom use between CSWs in brothels and their clients and required brothels to post signs indicating that condoms must be used in the brothels.

Theoretical Basis

Not stated.

Objectives

The objective of the policy was to ensure condom use in sexual acts between brothel CSWs and clients.

Class and Type of Outcome or Behavior Change Targeted

• □ Decrease IDU risk

• □ Decrease noncommercial sex risk

• ☑ Decrease commercial sex risk

• □ Increase health services utilization (exams, testing, and treatment)

Target Population and Venue for HIV Prevention

The target population was CSWs in brothels in Nevada and their clients.

Pathways for Structural Change

• □ Changes in programs

• ☑ Changes in practices

• ☑ Changes in policies and laws

Strategies and Tactics for Structural Change

The policy made condom use mandatory in brothels in Nevada. In order to support sex workers in implementing the policy with resistant clients, the brothels relied on measures such as buzzers in rooms and security personnel in addition to the posted signage. The CSWs developed strategies for eroticizing condom usage, such as seductively implying that the sexual experience would be better with condoms. The monthly required HIV tests also reinforced the need for the CSWs to comply with the mandatory condom law.

Core Components

The core components of the mandatory condom-use policy in brothels were signs announcing the law, safety measures for the CSWs, and monthly HIV tests along with the required STI testing.

Resources Required

Brothel owners made signs to post on the doors of brothels and over the bars inside brothels. Although condoms were required, facility owners did not supply them in the majority of cases. Rather the CSWs were expected to use their own condoms, resulting in some women charging an “extra” dollar for the condoms used.

Management Structure

In January 1987, the brothel industry adopted a compulsory condom policy in response to a 30–40 % decline in customers. They ratified the policy as law in 1988. The state also requires weekly and monthly testing for STIs/HIV.

Implementation Themes

Although some sex workers continued to confront resistant clients, their work environments supported their actions, resulting in a highly controlled encounter. The contrast with CSWs’ condom usage in their personal lives (noncommercial sexual relationships) was notable, and the researchers speculated that outside of the brothels the CSWs probably encounter the same obstacles as other women to condom use by partners, and since women often have less power (physically, socially, or economically), they may not insist on partners following safer sex practices.

Main Challenges Faced

The studies relied on self-reported interview data, which may be subject to biases or may be inaccurate for other reasons. The researchers did find that the information gathered from a prospective study seemed to corroborate most of the self-reported data. Additionally, although there were high participation rates in the studies, it is possible that the few women who had problems with condoms in the past opted not to participate (i.e., the sample may have been self-selected for women who use condoms successfully.)

Program Continuity and Present-Day Status

The mandated requirement for condom use in Nevada brothels went into effect in 1988 and continues to the present.

Other Locations and Regions That Have Implemented Similar Programs

A similar 100 % condom-use policy is implemented in Thailand and several other countries in Asia, and the Dominican Republic follows similar laws.

Original Program Evaluation

Study Design

Timeline and Duration

The studies of condom use by brothel CSWs were conducted in August 1993 and July 1995.

Cohorts

• ☑ Cross-sectional (snap shots in time)

• □ Longitudinal (same people followed over time)

Temporal Direction of Data Collection Relative to Intervention

• ☑ Prospective

• ☑ Retrospective

For the 1993 study, the researchers used two tactics to investigate condom use among licensed CSWs in three legal brothels. First, they used a retrospective interview to assess demographics and medical, sexual, and condom-use histories. They assessed condom breakage and slippage during vaginal intercourse in the past week, month, and year. Second, the researchers used a prospective study to assess ten consecutive condom uses for each brothel worker.

For the 1995 study, researchers conducted standardized interviews with female sex workers in two legal Nevada brothels.

Assessment Time Points (Temporal Comparison)

• □ Before and after intervention (baseline and follow-up measures)

• ☑ After only

• □ Serial (more than two measures taken over time)

Implementation Level (Geographic Comparison)

• □ Countries

• □ Regions

• ☑ States

• □ Counties

• □ Cities

• □ Towns

• □ Villages

• □ Households

• □ Couples, pairs, and dyads

• □ Individuals

Sampling Unit

• □ Countries

• □ Regions

• □ Counties

• □ Cities

• □ Towns

• □ Villages

• □ Households

• □ Couples, pairs, and dyads

• ☑ Individuals

Recruitment Techniques

A female interviewer informed the CSWs that none of the information collected would be shared with their bosses, coworkers, or the State. Participants had to be 18 or older and have worked for at least 1 month at the brothel prior to the study.

Randomization

• ☑ No

• □ Yes

  • □ Random assignment

  • □ Random sampling

Study Type

Quasi-prospective

Methods

Data Collection

Data Sources

• ☑ Questionnaire or survey

• □ Chart information or surveillance

• □ Record of biological specimen (e.g., urine sample)

In addition, for the prospective study on slippage and breakage, the used condoms were collected and examined for tears.

Interview

• ☑ Interviewer administered

• ☑ Self-administered

Sex workers completed a standardized interview and condom evaluation forms in the first study, and the researchers administered standardized interviews in the second study.

Instruments

• □ Paper and pencil (data entry after fieldwork)

• □ Computer (ACASI or direct data entry in the field)

  Not reported.

Modality

• ☑ In-person

• □ Mail

• □ Phone

• □ Internet

Data Analysis

Exposure Variables Measured

All study participants were subject to the mandatory condom-use policy.

Outcome Variables Measured

• □ Knowledge, attitudes, and beliefs

• ☑ Behaviors and practices

• □ Biomarker and clinical data

Study participants self-reported their condom-use practices with clients and other sex partners during the past year.

Other Variables Measured

• ☑ Demographics

• □ Risk groups

• □ Behaviors

Statistical Methods

Only univariate descriptive statistics with significance were reported.

Strengths and Weaknesses of the Study Design and Methodology

• □ Cross contamination between intervention and comparison groups

• □ Concurrent interventions occurring in experimental and comparison areas

• □ Historical bias or trend due to historical factors

• ☑ Other

Both studies relied on self-reported data and were conducted among a small sample of brothel CSWs in Nevada—41 women in three brothels in the first study and 40 women in two brothels in the second study.

Results

Sample Size

	Number
Study 1	41
Study 2	40
Total	81

Retention and Loss to Follow-Up (Cohort Studies Only)

Not applicable to this study.

Sample Demographics

Age

The average age of enrolled sex workers was 29 years (range 18–44) in Study 1 and 30 years (range 19–59) in Study 2.

Race or Ethnicity

	Study 1 (%)	Study 2 (%)
Caucasian	68	70
African-American	11	2
Hispanic	2	5
Asian-American	2	5
Multiracial	16	13

Gender

The study participants were all female.

Sexual Orientation

Not reported. However, all noncommercial sex reported occurred with male partners.

Outcome Measures

In both studies, brothel workers reported using a condom during every act of sexual intercourse with a client in the past year. For the first study, the researchers measured condom breakage and falling off by asking women how often these events occurred in the last week, month, and year. The condom breakage rates were 0.14 %, 0.19 %, and 0.12 % in the last week, month, and year, respectively. The rates at which condoms fell off per condom use were 0.81 %, 0.91 %, and 0.25 % in the past week, month, and year, respectively. All of the breakage and falling off rates were lower than previous retrospective studies had found. The researchers also had CSWs collect the used condoms from 10 consecutive condom uses and asked them to complete condom evaluation forms for these condom uses. There were no reports of breakage (verified through visual inspection of condoms) or of condoms falling off during intercourse, and brothel workers reported on several methods that they used to prevent condom breakage and slippage—both results suggested that female CSWs who frequently used condoms with clients developed techniques to circumvent any potential condom problems.

The second study queried participants about their experiences with condom-use refusal by clients and how they handled the challenges and also about condom use in their personal sexual relationships. Although 65 % of workers had encountered at least one client in the last month who did not want to use a condom, no worker reported having vaginal intercourse with a client who refused to wear a condom. Brothel workers shared tips to make condom use more appealing to clients.

Ninety-five percent of brothel workers reported that they had had a nonpaying sexual partner in the past year. Although condom use by brothel workers was consistent with paying clients, only 18 % of brothel workers reported consistent condom use with nonpaying partners. Condom use with nonpaying partners was higher among women with multiple partners (68 %) than among those with a single partner (19 %) but was not consistent. The reason women gave for not using a condom with a regular sexual partner was that they did not perceive a risk of infection.

Conclusions

In both studies, the researchers found that brothel CSWs were consistently using condoms with their clients. In fact, there were no instances of women reporting not using a condom with a client during vaginal intercourse in the past year. Women were also using condoms successfully; rates of breakage and slippage were lower than in most studies to date. The researchers hypothesize that female sex workers who use condoms consistently develop techniques to help them in avoiding breakage and slippage during sex acts.

The researchers also found that although the brothel sex workers had clients unwilling to use condoms during sex, in most instances, the workers were able to convince their clients to use a condom or to engage in other activities. Nevada’s mandatory condom law and the adherence to the law in brothels successfully contributed to the use of condoms by clients and sex workers in Nevada. An important contribution was the ability of the sex worker to convince clients that a condom is an acceptable part of sexual activity.

Condom use with partners in the sex workers’ personal lives was inconsistent. The researchers speculated that this may be because the controlled atmosphere of the brothel actually makes it easier for women to enforce the condom rule, whereas outside the brothel, workers face the same obstacles to condom use as other women. In addition, women may simply underestimate the risks they are exposed to in a relationship they believe to be safe.

Implications and Lessons Learned

The mandatory condom law implemented by Nevada is likely responsible for the high rates of condom use by CSWs and their clients. However, the importance of CSWs being able to make the condom an acceptable part of sexual activity should not be discounted. Female sex workers must be able to successfully introduce condom use to clients and negotiate for their use in all instances while not estranging or distancing customers.

Supplementary Materials Available

Additional References

World Health Organization. (2004). Experiences of 100% condom use programme in selected countries of Asia. Accessed September 29, 2012, from http://www.wpro.who.int/publications/docs/100_condom_program_experience.pdf

Case Study 12: Compromiso Collectivo: Reducing HIV Risk Among Female Sex Workers in the Dominican Republic

Original Program Developers and Evaluators

Deanna Kerrigan*

Clare Barrington

Michael Sweat

Luis Moreno

Santo Rosario

Bayardo Gomez

Hector Jerez

Ellen Weiss

Case Study Contents

• Abstract

• Program at a Glance

• Program Information and Implementation

• Original Program Evaluation

• Implications and Lessons Learned

• Supplementary Materials Available

Bibliography

Kerrigan, D., Moreno, L., Rosario, S., Gomez, B., Jerez, H., Barrington, C., Weiss, E., & Sweat, M. (2006). Environmental-structural interventions to reduce HIV/STI risk among female sex workers in the Dominican Republic. American Journal of Public Health, 96(1), 120–125.

*Thank you to Deanna Kerrigan, who reviewed earlier versions of this case study.

Abstract

To help prevent HIV and STIs among commercial sex workers (CSWs) and their partners, several countries have adopted community mobilization approaches (such as the Sonagachi Project in India) or government policy initiatives (such as the Thai 100 % Condom Program). Few, however, have combined the strengths of both of these approaches. In 1995, the Dominican nongovernmental organizations (NGOs) Centro de Orientación e Investigación Integral (COIN) and Centro de Promoción y Solidaridad Humana (CEPROSH) combined efforts to adapt the Thai 100 % Condom Use Program to the Dominican Republic including incorporating a greater emphasis on community mobilization. With input from the local CSW organization Movimiento de Mujeres Unidas (MODEMU), they developed and implemented two types of interventions over a 1-year period: community solidarity in Santo Domingo and community solidarity combined with government policy and regulation in Puerto Plata. The intervention period lasted from 1999 to 2000.

To promote solidarity and the collective commitment to prevent HIV and STIs in Santo Domingo, the intervention established workshops and meetings with female CSWs, sex establishment owners and managers, and other employees, such as doormen and deejays. These gatherings focused on female CSWs using condoms with all partners and on exploring issues of trust and intimacy in condom-use negotiation between female CSWs and regular paying and nonpaying partners.

Each sex establishment owner was encouraged to ensure that 100 % condom posters and other awareness-raising materials, as well as glass bowls filled with condoms, were in place within each establishment. Other cues to support condom use included deejay messages about safer sex, information booths at establishment entrances, and interactive theater presentations for the male clients of female CSWs.

In Puerto Plata, a similar model was used but also included a government-sponsored policy that required condom use between female CSWs and all clients. Owners were told that they, not the CSWs, were responsible for ensuring compliance with the policy and with program activities. For those not in compliance, government officials imposed a graduated series of warnings, fines, and other sanctions, including closure of the establishment.

Researchers used a pretest-posttest evaluation design to assess the year-long programs conducted in 34 sex establishments in each city. Structured surveys and non-routine STI testing were conducted among a random cross-sectional sample of approximately 200 female CSWs, age 18 years and older, from the study establishments. Women were recruited at government health clinics in each city, and data were collected at baseline and at the end of the 12-month intervention period. Government health inspectors accompanied by NGO staff visited sex establishments in both cities on a monthly basis to assess compliance with five key elements: the presence of 100 % condom-use posters, availability of at least 100 condoms for clients and CSWs, attendance of all of the establishment’s female CSWs at monthly STI checkups, and a lack of a positive STI diagnosis among female CSWs based at the establishment. Participant observations were also conducted pre- and post-intervention among a random sample of 64 female CSWs in each city, by male NGO staff members posing as clients. Following a strict research protocol, each NGO staffer selected a CSW, talked with her at a table in the establishment, and then asked if she would be willing to have sex without a condom, presenting up to four reasons developed during formative research about why he did not want to use one.

In both cities, there were improvements from pre- to post-intervention in the study’s key outcome variables: consistent condom use, rejection of unsafe sex, and STI prevalence. The type and level of these changes varied by intervention approach. The Puerto Plata model, which included a government policy and enforcement component, appeared to have been more successful in bringing about significant increases in consistent condom use with regular partners. The ability of female CSWs to reject unsafe sex rose significantly only in Puerto Plata.

While both models had a positive impact on reducing vulnerability to HIV, the impact of the intervention appears to have been broader in Puerto Plata. Cost-effectiveness data also show that the Puerto Plata model was more cost-effective than the Santo Domingo model.

Program at a Glance

Goal: To reduce HIV risks and STIs among female CSWs in the Dominican Republic

Target Populations: Female CSWs

Geographic Location and Region: Santo Domingo and Puerto Plata, Dominican Republic

Establishment and Duration: 1999–2000

Resources Required and Goods and Services Provided: The annual cost (in 2005 USD) per female CSW for the community solidarity intervention implemented in Santo Domingo was $181. The annual cost per female CSW for the community solidarity combined with government policy and regulation approach implemented in Puerto Plata was $176. These amounts included administrative and infrastructure costs, training costs, labor, workshops and theater, and commodities (condoms and educational materials). The majority of program costs (61 %) supported the labor expenses of the nongovernmental organizations (NGOs). Although the cost to implement the two interventions was comparable, the combination of community solidarity and government policy and regulation approach implemented in Puerto Plata was estimated to be more than two and a half times more cost-effective.

Strategies and Components

• Increased solidarity and collective commitment to prevent HIV and STIs

• Displayed environmental cues (posters and condoms) in sex establishments

• Provided government health inspectors with basic HIV/AIDS information

• Enabled CSW peer educators to provide pre- and posttest HIV and STI counseling

• Monitored and encouraged adherence to program activities by establishment owners

• Implemented a government policy requiring condom use with CSWs (Puerto Plata only)

Key Partners: Two NGOs: Centro de Orientación e Investigación Integral (COIN) and Centro de Promoción y Solidaridad Humana (CEPROSH), and a local CSW organization: Movimiento de Mujeres Unidas (MODEMU)

Key Evaluation Findings

Statistically Significant

Puerto Plata

• Increased verbal ability to reject unsafe sex

• Decreased trichomoniasis prevalence

• Increased reported condom use with regular partners

Santo Domingo

• Increased reported condom use with new clients

No Effect

Puerto Plata

• No change in reported condom use with new clients

• No significant decrease in gonorrhea or chlamydia prevalence

Santo Domingo

• No significant increase in reported condom use with regular partners

• No change in verbal ability to reject unsafe sex

• No significant decreases in STI prevalence

Program Information and Implementation

Background, History, and Public Health Relevance

For many years, two Dominican nongovernmental organizations (NGOs), Centro de Orientación e Investigación Integral (COIN) and Centro de Promoción y Solidaridad Humana (CEPROSH), had implemented peer education, condom distribution, improved STI management, and community mobilization and empowerment strategies to prevent HIV and STIs among CSWs and their clients. Using these approaches, consistent condom use with new clients rose significantly in intervention areas in Santo Domingo and Puerto Plata. Rates of consistent condom use with regular paying and nonpaying partners remained relatively stable and significantly lower than with new clients, however. Qualitative research conducted in Santo Domingo revealed that many CSWs reported that their regular paying and nonpaying partnerships placed them at increased risk for HIV and STIs because they were less likely to use condoms with partners of trust (parejas de confianza). This finding suggested that female CSWs needed greater support and motivation to negotiate condom use in their relationships than prior intervention approaches had provided.

Two approaches that had recently been shown to increase rates of condom use and decrease STI prevalence among female CSWs were (1) community development and mobilization to build a collective commitment to prevention, such as the Sonagachi Project in Calcutta, India, and (2) government-sponsored initiatives, including the 100 % Condom Program in Thailand, which utilized a government policy mandating condom use in brothels. In 1995, COIN and CEPROSH began to explore the possibility of adapting the Thai 100 % Condom Program to the Dominican Republic, placing a greater emphasis on community mobilization. Formative ethnographic research conducted in Santo Domingo with female CSWs and their partners, sex establishment owners and managers, and government officials found significant support for government policies and support systems to promote and monitor the use of condoms in sex establishments. The formative study also identified ways in which CSWs, owners, managers, and other establishment employees assisted and supported CSWs in condom negotiations with clients and found that several sex establishments had already developed their own institutional condom-use policies. The findings confirmed the need to go beyond the original Thai model of government-sponsored policies and activities to include more participatory and community-based strategies to create an environment that fosters condom use in sex establishments.

In collaboration with the Dominican government, The Johns Hopkins University, and the Horizons Program, the two NGOs developed and tested two approaches to promote 100 % condom use in sex establishments: (1) a community-based solidarity model and (2) a community-based solidarity model plus government policy and regulation. The models, built on years of experience gained from CSW peer education programs, drew from the strengths of both community solidarity and government policy initiatives and engaged community members in both program and policy development.

Theoretical Basis

The interventions were based on the Diffusion of Innovation, Harm Reduction, and Information-Motivation-Behavioral skills models.

Objectives

The interventions aimed to increase safer commercial sex practices among female CSWs in Santo Domingo and Puerto Plata, Dominican Republic.

Class and Type of Outcome or Behavior Change Targeted

• □ Decrease IDU risk

• □ Decrease noncommercial sex risk

• □ Decrease commercial sex risk

• ☑ Increase health services utilization (exams, testing, and treatment)

Target Population and Venue for HIV Prevention

The interventions aimed to influence female CSWs in sex establishments in Santo Domingo and Puerto Plata, Dominican Republic, along with sex establishment owners, managers, and other employees.

Pathways for Structural Change

• □ Changes in programs

• ☑ Changes in practices

• ☑ Changes in policies and laws

Strategies and Tactics for Structural Change

The interventions involved a community-based approach that focused on building solidarity among female CSWs, sex establishment owners, and other members of the CSW community. Social marketing, community outreach, training for skills development, and peer education strategies were employed, along with physical changes to the environment in the sex establishments and changes to the legal conditions (Puerto Plata only).

Core Components

The interventions included four components in both Santo Domingo and Puerto Plata and a fifth in Puerto Plata only.

• 1. Building solidarity and collective commitment: Participatory workshops to support female CSWs in negotiating condom use, group-specific educational materials, and monthly meetings

• 2. Facilitating environmental cues to action: Posters and stickers, glass bowls filled with condoms, disk jockey messages, condom information booths, educational materials, and participatory theater

• 3. Promoting respectful clinical services for female CSWs: Needs assessments of public health clinics serving female CSWs; interviews with government health inspectors; training for clinicians and inspectors; equipment, personnel, and medicines for managing STIs; and private offices for peer educators to provide counseling

• 4. Monitoring and encouraging compliance: Monthly visits by government health inspectors and intervention staff members, follow-up education efforts, and certificates of compliance

• 5. Enforcing policy and regulation (Puerto Plata only): 100 % condom-use policy applied to owners of sex establishments and a graduated sanction system including notifications, fines, and closings

Resources Required

The intervention required staff to enforce policies and check CSW establishment adherence to new policies and resources such as posters and condoms for establishments to display and provide.

Management Structure

Not reported.

Implementation Themes

A combination of a community mobilization approach and a government policy initiative were combined to create a community solidarity intervention in Santo Domingo and a community solidarity combined with government policy and regulation intervention in Puerto Plata.

Main Challenges Faced

The owners of sex establishments, not the female CSWs, were responsible for adhering to the policy and associated program activities, and compliance was a concern. Regional public health officials met with establishment owners on a quarterly basis to encourage adherence and discuss barriers to implementation. Sanctions were issued to owners that were not in compliance. During the course of the 1-year intervention, 113 notifications, 18 fines, and 1 temporary closing occurred because of noncompliance.

Program Continuity and Present-Day Status

The specific intervention components implemented in Puerto Plata and Santo Domingo ended after funding from the US Agency for International Development ended. However, the two NGOs involved in the intervention program, Centro de OrientaciÓn e InvestigaciÓn Integral (COIN) and Centro de PromociÓn y Solidaridad Humana (CEPROSH), still continue to support HIV prevention efforts and support for individuals living with HIV/AIDS in the Dominican Republic. In addition, the local CSW organization, Movimiento de Mujeres Unidas (MODEMU), currently operates to promote the human rights of commercial CSWs in the Dominican Republic.

Other Locations and Regions That Have Implemented Similar Programs

This program was modeled after aspects of the 100 % Condom Use Program in Thailand, which aimed to increase condom use and safer sex practices during commercial sex by increasing the availability and accessibility of quality condoms, providing STI care for CSWs and clients, and encouraging collaboration between health workers, establishment owners/managers, CSWs, and government officials. In addition, this program mandated the use of condoms during commercial sex exchanges as a government policy.

Another program the current intervention drew inspiration from was the Sonagachi Project, implemented in Calcutta, India. This intervention used a community mobilization approach to empower CSWs to engage in safer sex with clients. By establishing trade unions, CSWs are able to negotiate for the better health of all members and continually respond to the challenges of the sex work profession. This program used peer educators to continually spread STI/HIV prevention messages and encourage the use of health facilities.

Original Program Evaluation

Study Design

Timeline and Duration

The investigators relied on a pretest and posttest design to evaluate the interventions over a period of 1 year (baseline data were collected between September and December 1999; follow-up data were collected during November and December 2000).

Cohorts

• ☑ Cross-sectional (snap shots in time)

• □ Longitudinal (same people followed over time)

Temporal Direction of Data Collection Relative to Intervention

• ☑ Prospective

• □ Retrospective

Assessment Time Points (Temporal Comparison)

• ☑ Before and after intervention (baseline and follow-up measures)

• □ After only

• □ Serial (more than two measures taken over time)

Implementation Level (Geographic Comparison)

• □ Countries

• □ Regions

• □ Counties

• □ Cities

• □ Towns

• □ Villages

• □ Households

• □ Couples, pairs, and dyads

• □ Individuals

• ☑ CSW establishments

The intervention was implemented in 34 commercial sex establishments in Santo Domingo and 34 in Puerto Plata.

Sampling Unit

• □ Countries

• □ Regions

• □ Counties

• □ Cities

• □ Towns

• □ Villages

• □ Households

• □ Couples, pairs, and dyads

• □ Individuals

• ☑ CSW establishments

Recruitment Techniques

Selection criteria for participating sex establishments were based on the potential acceptability and feasibility of implementing the intervention research. Participating establishments included those employing more than five women and those where a set fee was paid by the client to the establishment. Managers of all 68 selected establishments agreed to participate in the intervention activities.

All potential survey and non-routine STI testing participants were recruited from government health clinics. The study team approached every third woman from a participating establishment attending the monthly clinical consultations. The consent rate was 95 %.

Randomization

• □ No

• ☑ Yes

  • □ Random assignment

  • ☑ Random sampling

Study Type

Quasi-experimental

Methods

Data Collection

Data Sources

• ☑ Questionnaire or survey

• ☑ Chart information or surveillance

• ☑ Record of biological specimen (e.g., urine sample)

Interview

• ☑ Interviewer administered

• □ Self-administered

Instruments

• □ Paper and pencil (data entry after fieldwork)

• □ Computer (ACASI or direct data entry in the field)

• ☑ Not reported

Modality

• ☑ In-person

• □ Mail

• □ Phone

• □ Internet

Data Analysis

Exposure Variables Measured

Exposure to the intervention was measured using a 13-item dichotomized scale. These items measured CSW’s exposure to key intervention components such as solidarity and collective commitment, environmental cues, monitoring, and policy and regulation in the past month. Scale scores were divided at the median into high (more than 11 positive responses out of a possible total of 13) versus low scores.

Outcome Variables Measured

• □ Knowledge, attitudes, and beliefs

• ☑ Behaviors and practices

• ☑ Biomarker and clinical data

Condom use was assessed via participants’ self-reports of the percentage of sex acts in which condoms were used in the past month with new clients, regular partners, and all partners. Rejection of unsafe sex was measured through participant observation of female CSWs conducted by intervention staff. STIs were documented by measuring the prevalence of gonorrhea, chlamydia, and trichomoniasis among the individual CSWs that also completed the pre-intervention and post-intervention cross-sectional surveys. The researchers also documented the number of establishments that achieved the goal of no STIs in a given month, per city, over the course of the intervention. Establishment-level information was collected from local public health clinics that serve female CSWs.

Other Variables Measured

• ☑ Demographics

• □ Risk groups

• ☑ Behaviors

The other variables measured included age, education level, civil status, presence of a regular sex partner, number of dates with paying clients, and the amounts charged per client.

Statistical Methods

Chi-square tests of association were conducted to identify differences in sociodemographic characteristics of participants from pre-intervention to post-intervention. Multivariate logistic regression analyses were used to assess (1) pre-intervention to post-intervention changes in HIV- and STI-related outcomes such as condom use and STI prevalence and (2) the relationship between exposure and adherence to the intervention and consistent condom use with all sex partners in the past month and prevalence of STIs.

Strengths and Weaknesses of the Study Design and Methodology

• □ Cross contamination between intervention and comparison groups

• □ Concurrent interventions occurring in experimental and comparison areas

• □ Historical bias or trend due to historical factors

• ☑ Other

Causality cannot be definitively established between exposure to intervention components, adherence to the intervention, and individual-level study outcomes. The study design was not truly experimental in nature since the cities were not randomly assigned to intervention conditions and there was no control or comparison group receiving no intervention program.

Results

Sample Size

Number of Sex Establishments

	Pre-intervention	Post-intervention
Santo Domingo	34	34
Puerto Plata	34	34
Total	68	68

Number of Female CSWs

	Pre-intervention	Post-intervention
Santo Domingo	210	206
Puerto Plata	200	200
Total	410	406

Retention and Loss to Follow-Up (Cohort Studies Only)

Not applicable to this study.

Sample Demographics

Age

	Santo Domingo		Puerto Plata
	Pre-intervention (%)	Post-intervention (%)	Pre-intervention (%)	Post-intervention (%)
18–25	60.8	61.3	54.0	56.6
≥26	39.2	38.7	46.0	43.4

Race or Ethnicity

Not reported.

Gender

	Pre-intervention (%)	Post-intervention (%)
Male	0	0
Female	100	100

Sexual Orientation

Not reported.

Outcome Measures

Measure	Finding
Condom use with new clients	Significantly higher condom use with new clients post-intervention in Santo Domingo, but not Puerto Plata
Condom use with regular partners	Significantly higher condom use with regular partners post-intervention in Puerto Plata, but not Santo Domingo
Trichomoniasis prevalence	Significant reduction in trichomoniasis prevalence post-intervention in Puerto Plata, but not Santo Domingo
Verbal rejection of unsafe sex	Significant increase in CSWs’ verbal rejection of unsafe sex post-intervention in Puerto Plata, but not Santo Domingo
STIs in routine monthly screenings of CSWs	Significant increase in the ability of sex establishments achieving the goal of no STIs in routine monthly screenings of CSWs post-intervention in Puerto Plata, but not Santo Domingo

Conclusions

Both of the interventions implemented in two cities in the Dominican Republic had positive impacts on HIV-related outcomes. The majority of significant changes in key intervention outcomes occurred in Puerto Plata, however, where the intervention integrated both a community-based solidarity approach and a government-sponsored policy and regulation approach. In Santo Domingo, the only significant positive change occurred in condom use with new clients. In Puerto Plata, condom-use rate increased with both regular as well as nonpaying customers. In addition, there were positive changes in verbal refusal of unsafe sex and STI outcomes in Puerto Plata. The successes in Puerto Plata point to the importance of integrating government policy with community mobilization strategies to achieve the greatest positive outcomes in HIV prevention programs.

Implications and Lessons Learned

From the time that the success of the interventions was demonstrated in 2000, the focus has been on how to scale up the interventions to continually improve HIV prevention tactics in the Dominican Republic. The program developers noted that any scale-up component should include intervention activities targeting the male clients of CSWs. When female CSWs who tested positive for STIs were asked during posttest counseling how the intervention could help them avoid reinfection, many women expressed a desire for the intervention to also target male clients. In addition, women stated that intervention efforts should differentiate between regular paying customers and regular nonpaying sexual partners, who may play a greater role in STI infections since regular partners may be less willing to use condoms.

Supplementary Materials Available

Movimiento De Mujeres Unidas (MODEMU)

• http://www.gaatw.org/index.php?option=com_content&view=article&id=505:modemu&catid=124:Latin%20American%20Countries

  Centro de Promoción y Solidaridad Humana (CEPROSH)

• Centro de Orientación e Investigación Integral (COIN)

Additional References

Kerrigan, D., Moreno, L., Rosario, S., Gomez, G., Jerez, H., Weiss, E., van Dam, J., Roca, E., Barrington, C., & Sweat, M. (2004). Combining community approaches to government policy to prevent HIV infection in the Dominican Republic. Horizons Final Report. Washington, DC: Population Council.

Sweat, M., Kerrigan, D., Moreno, L., Rosario, S., Gomez, B., Jerez, H., Weiss, E., & Barrington, C. (2006). Cost-effectiveness of environmental-structural communication interventions for HIV prevention in the female sex industry in the Dominican Republic. Journal of Health Communication, 11, 123–142.

Case Study 13: A Social and Structural Intervention in the Philippines: Effect on Condom Use of Establishment-Based Female Sex Workers

Original Program Developers and Evaluators

Donald

Morisky

Judith

Stein

Chi

Chiao

Robert

Malow

Kate

Ksobiech

Case Study Contents

• Abstract

• Program at a Glance

• Program Information and Implementation

• Original Program Evaluation

• Implications and Lessons Learned

• Supplementary Materials Available

Bibliography

Morisky, D. E., Stein, J. A., Chiao, C., Ksobiech, K., & Malow, R. (2006). Impact of a social influence intervention on condom use and sexually transmitted infections among establishment-based female sex workers in the Philippines: A multilevel analysis. Health Psychology, 25(5), 595–603.

Abstract

Although commercial sex work is technically illegal in the Philippines, commercial sex workers (CSWs) based in establishments such as bars, beer gardens, and massage parlors are increasingly contributing to the spread of HIV. An intervention targeted to establishment-based CSWs aimed to increase safer sex behaviors using three tactics: (1) peer education (two peer educators from each establishment were trained to teach information about STIs and HIV to coworkers); (2) manager training (owners of establishments were trained about STIs and HIV and were encouraged to support safer sex among employees and clients); and (3) a combination of peer education and manager training. Three regions in the southern Philippines were randomly assigned to one of these conditions, and a fourth region was assigned as a control. The researchers implemented a 3-year longitudinal study and collected pre-intervention and post-intervention data with structured, face-to-face interviews with female CSWs.

Female CSWs in the group receiving the combination peer education and manager training intervention were more likely to reduce HIV sexual risk and show improvement in HIV/AIDS-related knowledge. At follow-up, they showed more positive attitudes toward condom use, were more likely to have used a condom during their last sexual encounter, and were more likely to use condoms consistently, and their establishments were more likely to promote condom use. A higher percentage of female CSWs in this intervention group had an STI exam in the past 6 months at follow-up and also reported fewer STIs after the intervention compared to pre-intervention levels.

The peer-only and manager-only interventions also showed positive improvement over the control group, but the improvements were not consistent in all areas. In both of these intervention conditions, women showed increases in HIV/AIDS knowledge but reported that their establishments were less likely to communicate rules and promote condom use. Women in the peer-only intervention had better condom-use attitudes after the intervention but were not more likely to have used a condom during their last sexual encounter. Women in the manager-only intervention showed no improvement in condom-use attitudes but were more likely to have used a condom during their last sexual encounter. These women also reported significantly fewer STIs at post-intervention than at pre-intervention.

Program at a Glance

Goal: To reduce risky sexual behaviors and the spread of HIV and other STIs among establishment-based female CSWs in the Philippines

Target Populations: Filipinas working for nightclubs, disco bars, beer gardens, and karaoke bars who were CSWs

Geographic Location and Legion: Four large cities in the southern Philippines: Legaspi, Cagayan de Oro, Cebu, and Iloilo

Establishment and Duration: The overall study and intervention lasted for 3 years, beginning in July–August 1994, when the researchers conducted baseline interviews. Beginning in October 1995, the researchers collected study data from participants.

• 1. Pre-intervention phase: 8–10 mos. before program started. This included social preparation of the community (meetings, etc.) plus baseline interviews.

  • Baseline assessments completed during July–August 1994

• 2. Implementation phase: lasted 2 years. Included establishing advisory committee, owners/managers association, and female bar workers peer counselors association.

  • Cities randomized

  • Peer educators and managers completed 5-day training session

  • Intervention activities

• 3. Posttest survey

Resources Required and Goods and Services Provided: The total cost of the intervention was $14,700 ($7,500 for training and $7,200 for monitoring). Those amounts broke down to approximately $9.50 for each female bar worker and $1.60 for each manager intervention.

Strategies and Components

• Targeted female CSWs operating in establishments such as beer gardens, bars, nightclubs, karaoke centers, and massage parlors

• Trained peer educators on HIV/AIDS information and how to deliver safer sex messages using role-playing and modeling

• Encouraged managers and owners of establishments to implement a 100 % condom-use policy and to promote safer sexual practices among employees during regular establishment meetings

• Established advisory committees to facilitate data collection and provide advice on educational materials

Key Partners: The research was supported by grants from the National Institute of Allergy and Infectious Diseases, the UCLA AIDS Institute, the University-wide AIDS Research Program, and the National Institute on Drug Abuse.

Key Evaluation Findings

Statistically Significant

• Increased HIV/AIDS knowledge in all of the groups

• Increased positive establishment practices in the combined peer education and manager influence group

• Increased positive condom attitudes in the peer education and combined groups

• Increased the likelihood of having used a condom during last sexual episode in the manager influence and combined groups

• Decreased self-reported STIs in the manager influence and combined groups

No Effect

• Did not increase positive establishment practices in the peer education and manager influence groups

• Did not increase positive condom attitudes in the manager influence group

• Did not increase the likelihood of having used a condom during last sexual episode in the peer education group

• Did not decrease self-reported STIs in the peer education group

Program Information and Implementation

Background, History, and Public Health Relevance

The Philippines has not yet experienced an HIV epidemic as have other parts of Asia such as Thailand and India, and the country’s risk has been classified as low level by UNAIDS. With an estimated 10,000 individuals living with HIV/AIDS by the end of 2001 and heterosexual transmission accounting for almost two-thirds of the cases, concern remains over the potential for an epidemic produced by the pervasive commercial sex trade industry.

While commercial sex technically remains illegal in the Philippines, the sex trade has transitioned from brothels to other venues such as beer gardens, bars, nightclubs, karaoke TV centers, massage parlors, and discos. The female CSWs in these establishments are required by the government to register at local social hygiene clinics (SHCs) and to undergo weekly or bimonthly checkups. In 1993, it was estimated that there were more than 225,000 registered establishment-based female CSWs in the Philippines.

Theoretical Basis

Interventions carried out by researchers in the mid-1990s were based on a combination of two theoretical frameworks: Social Cognitive Theory at the individual level and Social Influence Theory at the organizational level.

Social Cognitive Theory considers cognitive, affective, and biological factors and behavior and environment to affect individual behaviors. The theory argues that safer sex behaviors can be increased by equipping individuals with skills and self-beliefs that enable them to put guidelines into practice consistently. To prevent STIs, individuals must be able to change their own behaviors and also their social environment. A successful intervention should help individuals achieve heightened awareness, knowledge, and the behavioral means, resources, and social support necessary to increase safer sex behaviors.

Social Influence Theory considers power and social influence. Social influence can be exerted by someone else to induce a change in a target individual, which might help to change behaviors, opinions, attitudes, goals, needs, and values. At the organizational level, a successful intervention should seek to use the power of social influence of managers to increase safer sex behaviors among their employees.

Objectives

The interventions aimed to reduce risky sexual behaviors and the spread of HIV and other STIs among establishment-based female CSWs in the Philippines.

Class and Type of Outcome or Behavior Change Targeted

• □ Decrease IDU risk

• □ Decrease noncommercial sex risk

• ☑ Decrease commercial sex risk

• □ Increase health services utilization (exams, testing, and treatment)

Target Population and Venue for HIV Prevention

The intervention targeted Filipinas working as commercial CSWs in nightclubs, disco bars, beer gardens, massage parlors, and karaoke bars in four large cities in the southern Philippines: Legaspi, Cagayan de Oro, Cebu, and Iloilo.

Pathways for Structural Change

• ☑ Changes in programs

• ☑ Changes in practices

• □ Changes in policies and laws

Strategies and Tactics for Structural Change

To implement the intervention, the program staff organized an advisory committee at all the sites except for the control site and included individuals upon the recommendations of local government officials. The committees facilitated collection of baseline data, gave advice on the content of training programs, suggested possible resource speakers, disseminated STI and HIV information in their respective sectors, and gave advice on the design of educational materials.

The intervention consisted of four components: (1) peer education, (2) manager training, (3) a combination of peer education and manager training, or (4) usual care as a control.

For the peer education component of the intervention, two female CSWs from each participating establishment were selected and trained during a 5-day program covering basic information on STIs and HIV, modes of transmission, interpersonal relationships with peers and clients in the work place, sexual negotiation, role-playing and modeling, and normative expectations. The peer educators met monthly with the site coordinator and discussed issues related to sexual negotiations with customers, where the negotiations took place, and establishing limits regarding sexual behavior, alcohol influence, and condom-use negotiations.

Managers were trained on the same topics as the peer educators, in addition to being trained on the manager’s social influence role of providing positive reinforcement of their employees’ healthy sexual practices. The managers were encouraged to meet regularly with employees, to monitor employees’ attendance at social hygiene clinics, to provide educational materials on HIV/AIDS prevention to employees and customers, to reinforce positive STI prevention behaviors, to attend monthly manager’s advisory committee meetings, to promote AIDS awareness in their establishments, to make condoms available to both female CSWs and customers, and to institute a 100 % condom-use policy. A manager association established a loan program to help employees buy medications to treat STIs, with the loan to be repaid within 2 weeks with a low rate of interest.

In the cities where the combined intervention of peer counselors and manager training was implemented, the site coordinator would discuss issues raised with each study group at the individual meetings of managers or peer educators. Managers ensured that there were always at least two peer educators at each establishment, and they worked closely with peer educators to reinforce the establishment’s policy of regular STI checkups and consistent condom use.

Core Components

The core components of the intervention consisted of:

• Advisory committees to give advice on the content of training programs, suggest possible resource speakers, disseminate STI and HIV information in their respective sectors, and advise on the design of educational materials.

• Two female CSWs from each participating establishment acting as peer educators to present information on STIs and HIV, modes of transmission, interpersonal relationships with peers and clients in the work place, sexual negotiations, and normative expectations.

• Managers of participating establishments providing positive reinforcement of their employees’ healthy sexual practices.

• A loan program established by a manager association to help employees buy medications to treat STIs (D. Morisky, personal communication, September 1, 2011).

Resources Required

The total cost of the intervention was $14,700 ($7,500 for training and $7,200 for monitoring). That amount broke down to approximately $9.50 for each female CSW and $1.60 for each manager in the intervention.

Management Structure

The program staff established an advisory committee at each of the study sites except for the control. The committees helped to facilitate study procedures, gave advice on data collection and the content of training programs, shared HIV/AIDS information in their sectors, and gave advice during the development of educational materials.

Managers associations were formed in two of the study sites. The associations met once a month with the goals of helping the departments of health and city health offices prevent HIV/AIDS and other STIs, training and educating entertainers, deporting managers who violated ordinances, providing good entertainment to the public, providing protection for workers against violence and maltreatment, monitoring the female CSWs, and helping solve any problems in the establishments.

Implementation Themes

Building support for safer commercial sex practices helped to ensure that female CSWs were able to reduce HIV sexual risk.

Main Challenges Faced

A challenge for the research and analysis was that the city was confounded with the intervention. The selected cities may have differed in significant political, economic, social, and cultural factors, which may have affected the outcomes of interest. Geography, by itself, could have introduced variables related to commercial CSWs and bar manager attitudes, beliefs, values, and status that were uncontrolled.

Another challenge was that a number of female CSWs were re-infected with STIs throughout the course of the study. The researchers found that while the infections were being detected by frequent clinic visits, the workers often had money to buy one or two doses of medication, which resulted in drug resistance and eventually led to increasingly difficult-to-cure infections. In response to this problem, the manager associations established a loan program for workers to borrow enough money to purchase the recommended doses of medication to treat STIs.

Program Continuity and Present-Day Status

The National Institutes of Health provided 5 years of funding for the project. One of the inherent perks of a structural intervention, however, is the internalization and institutionalization of skills and concepts over time. The program originally relied on a Diffusion of Innovation model, where structural and social changes facilitate the passage of skills and knowledge to all. The program changed the social and contextual landscape in which female CSWs made health decisions, bringing to light the importance of HIV prevention and the role of the establishment managers.

Other Locations and Regions That Have Implemented Similar Programs

In an earlier study, Levine et al. (1998) reported positive findings from an intervention program implemented with female CSWs in Bolivia. This program improved STI clinical care and lab testing for STIs. In addition, individual and group counseling services were added to increase safer sex practices and promote condom use. Prevalence of gonorrhea, syphilis, and genital ulcer disease decreased from program efforts, and self-reported condom use increased.

Laga and others (1994) reported positive results from a study of an HIV prevention and STI treatment program conducted in Kinshasa, Zaire. With the establishment of a women’s health center, the program offered expanded STI screening and treatment for female CSWs in addition to condom promotion. With the program, CSWs increased use of condoms and decreased HIV incidence among regular attendees of clinic appointments.

Original Program Evaluation

Study Design

Timeline and Duration

The overall study and intervention lasted for 3 years, beginning in July–August 1994, when the researchers conducted baseline interviews. Beginning in October 1995, the researchers collected study data from participants.

Cohorts

• ☑ Cross-sectional (snap shots in time)

• □ Longitudinal (same people followed over time)

Temporal Direction of Data Collection Relative to Intervention

• ☑ Prospective

• □ Retrospective

Assessment Time Points (Temporal Comparison)

• ☑ Before and after intervention (pre- and post-intervention measures)

• □ After only

• □ Serial (more than two measures taken over time)

Implementation Level (Geographic Comparison)

• □ Countries

• □ Regions

• □ Counties

• ☑ Cities

• □ Towns

• □ Villages

• □ Households

• □ Couples, pairs, and dyads

• □ Individuals

The study was conducted in four large cities in the southern Philippines: Legaspi, Cagayan de Oro, Cebu, and Iloilo.

Sampling Unit

• □ Countries

• □ Regions

• □ Counties

• □ Cities

• □ Towns

• □ Villages

• □ Households

• □ Couples, pairs, and dyads

• ☑ Individuals

Recruitment Techniques

Female CSWs were recruited from social hygiene clinics, which they were required to attend either weekly or bimonthly. All managers/owners of entertainment establishments at each site were asked to participate.

Randomization

• ☑ No

• □ Yes

  • □ Random assignment

  • □ Random sampling

The four participating cities were picked based on noncontiguous geography and a lack of current HIV prevention programs. The four cities were randomly assigned to a condition, but participating establishments and female CSWs could not be randomly assigned because interventions were implemented at the city level.

Study Type

Quasi-experimental

Methods

Data Collection

Data Sources

• ☑ Questionnaire or survey

• □ Chart information or surveillance

• □ Record of biological specimen (e.g., urine sample)

Interview

• ☑ Interviewer administered

• □ Self-administered

Instruments

• □ Paper and pencil (data entry after fieldwork)

• □ Computer (ACASI or direct data entry in the field)

• ☑ Not reported

Modality

• ☑ In-person

• □ Mail

• □ Phone

• □ Internet

The Filipinas interviewed for this study worked as CSWs at establishments such as nightclubs, discos, beer gardens, massage parlors, and karaoke bars. They were required to attend social hygiene clinics either weekly or bimonthly. Most of the surveys were conducted in social hygiene clinics, although a few were conducted in business establishments or residences.

Data Analysis

Exposure Variables Measured

Participants reported experiences of social influence such as establishment practice and manager training. Establishment practices included three items addressing rules and communications that were (1) whether a coworker at her establishment had ever tried to convince her to use a condom with a client, (2) whether her establishment has a rule that all workers must use condoms when having sex with customers, and (3) whether her boss ever talked to her about using condoms. Three items, reported by managers, were used to quantify their AIDS training activities. The items asked whether the manager had attended an AIDS training education/class, participated in monthly community meetings with other managers, and whether or not the manager had attended a condom-use class.

Outcome Variables Measured

• ☑ Knowledge, attitudes, and beliefs

• ☑ Behaviors and practices

• □ Biomarker and clinical data

The surveys measured indicators or safer sex and condom use including:

• 1. Perceived risk: This construct measured how concerned the female CSWs were about getting AIDS and their perceived chances of getting AIDS.

• 2. AIDS knowledge: This construct provided a measure of the women’s knowledge of risk behaviors contributing to AIDS and knowledge of factual items regarding AIDS.

• 3. Establishment practices: This construct provided a measure of the rules and communications regarding condom use that the establishments presented to the female CSWs.

• 4. Condom attitude: This construct measured positive beliefs about condoms.

• 5. Outcome variables: These variables included whether the female CSWs had used a condom the last time she had sex with a customer, among others. As an indicator of safe sexual practices, the number of STIs they self-reported in the past 6 months was assessed.

Other Variables Measured

• ☑ Demographics

• □ Risk groups

• □ Behaviors

  Demographics included age, years of schooling, work duration, weekly wage, marital status, and how she had been recruited into sex work.

Statistical Methods

The EQS structural equations program was used to estimate a two-level model using a maximum likelihood approach. The between-levels portion of the multilevel model was of particular interest in assessing the impact of the intervention. Effect of intervention status could not be analyzed in the within-subjects portion of the model because all the female CSWs within an establishment had the same value for their intervention status. Goodness of fit of the models was evaluated with the Ventler-Liang likelihood ratio statistic (VLLRS), the comparative fit index (CFI), and the root-mean-square error of approximation.

An initial confirmatory factor analysis tested the factor structure of the hypothesized model and provided correlations among all of the factors and the orthogonal polynomials representing group membership. Once the factor structure was confirmed, a predictive structural model was tested to assess the influence of intervention group membership, perceived risk, knowledge, establishment practices, and condom attitudes on the outcomes of using a condom during the last sexual encounter and incidence of STIs. Of main interest was the between groups model.

To assess possible preexisting differences between the cities (city membership was confounded with intervention status), the investigators conducted a supplementary analysis that contrasted selected behaviors and attitudes measured in the same manner before and after the intervention by city by using multi-sample structural equation modeling and comparisons of latent means at the city level.

Strengths and Weaknesses of the Study Design and Methodology

• □ Cross contamination between intervention and comparison groups

• □ Concurrent interventions occurring in experimental and comparison areas

• □ Historical bias or trend due to historical factors

• ☑ Confounding of city membership with intervention status

City was confounded with intervention, and the selected cities may have differed in significant political, economic, social and cultural factors, which may have affected the outcomes of interest.

Results

Sample Size

Condition	Pre-intervention	Post-intervention
Peer education	Not provided	148
Manager training	Not provided	198
Combined	Not provided	415
Control	Not provided	136
Total	Not provided	897

Retention and Loss to Follow-Up (Cohort Studies Only)

Not applicable to this study.

Sample Demographics

Age

Participants ranged in age from 15 to 41 years (mean 22.5 years).

Race or Ethnicity

Not reported.

Gender

Gender	Pre-intervention (%)	Post-intervention (%)
Male	0	0
Female	100	100

Sexual Orientation

Not reported.

Outcome Measures

The combined peer education and manager training group had the most positive outcomes. Women in that intervention group were more likely to reduce HIV sexual risk—they showed more positive attitudes toward condom use (p < .001) and reported that their establishments were more likely to promote condom use (p < .05). Those women were also significantly more likely to report that they used a condom during their last sexual encounter (p < .001) and were more likely to use condoms consistently than any of the other three groups. The women in the combined group also reported significantly fewer STIs after the intervention (p < .001) compared with pre-intervention levels. The combined group also significantly improved their overall HIV/AIDS-related knowledge (p < .001), and a higher percentage of women in the combined group (93.78 %) had an STI exam in the past 6 months.

The peer-only and manager-only interventions also showed positive improvement over the control group, but the improvements were not consistent in all areas. In both of these intervention conditions, women showed increases in HIV/AIDS knowledge (p < .001) but reported that their establishments were less likely to communicate rules and promote condom use. Women in the peer-only intervention had better condom-use attitudes after the intervention (p < .001) but were not more likely to use a condom during their last sexual encounter. Women in the manager-only intervention did not show an increase in condom-use attitudes but were more likely to use a condom during their last sexual encounter (p < .001). These women also reported significantly fewer STIs at follow-up than at baseline (p < .05).

Conclusions

Overall, the group of women that received peer counseling in addition to having their establishment managers trained had the most positive outcomes. Those participants were much more likely to reduce HIV sexual risk, indicating that the interaction and involvement of various stakeholders, such as managers, peers, health officials, and local officials, was important to the success of the project.

For condom use to become commonplace among Filipino female CSWs, there cannot be a financial penalty for their use (or a financial incentive for nonuse), since a worker’s need for money has the potential to overshadow concerns for her personal health. The solution to this problem lies in the acceptance of condom use by clients, which may be achieved by establishment owners and others educating clients about the benefits of condoms.

Implications and Lessons Learned

Initially, owners and managers of the bars, clubs, and massage parlors did not feel responsible for the sexual health of their employees. Most owners, during the initial needs assessment, reported that they did not counsel employees about safer sexual behaviors and felt this was not part of their role as an owner/manager. Most reported that they would not intervene in situations where an employee was asked to engage in unsafe sexual practices. Since the government requires bars to register employees at social hygiene clinics, attend weekly clinic visits, and be tested for STIs, there is an incentive for managers/owners to help employees stay free of STIs. So although owners/managers did have concern about their employee’s general health, it was up to program developers to convince owners and managers that “health” includes STIs, and it is in their best interest to encourage sexual health among employees. The city health officer, NGO staff, and University of the Philippines faculty all played a role in educating owners/managers about their role in HIV prevention, which helped to convince owners of the program’s importance. In the end, most (>98 %) establishments participated in the intervention’s activities (D. Morisky, personal communication, September 1, 2011).

The greatest gains in HIV prevention and related factors, such as STI reduction, prevention of unwanted pregnancies, and reproductive health, come when many different groups are involved and committed to creating long-term change.

One of the benefits of this intervention was that the effects spread so they were not limited to the original group of people experiencing the intervention.

Supplementary Materials Available

Additional References

Chiao, C., Morisky, D. E., Ksobiech, K., & Malow, R. M. (2009). Promoting HIV testing and condom use among Filipina commercial sex workers: Findings from a quasi-experimental interventions study. AIDS & Behavior, 13(5), 892–901.

Morisky, D. E., Chiao, C., Ksobiech, K., & Malow, R. M. (2010). Reducing alcohol use, sex risk behaviors, and sexually transmitted infections among Filipina female bar workers: Effects of an ecological intervention. Journal of Prevention & Intervention in the Community, 38, 104–117.

Tiglao, T. V., Morisky, D. E., Tempongko, S. B., Baltazar, J. C., & Detels, R. (1996). A community P.A.R. approach to HIV/AIDS prevention among CSWs. Promotion & Education, 3, 25–28.

Case Study 14: The 100 % Condom Program in Thailand: Using Public Policy Change to Increase Condom Use in Brothels

Original Program Developers and Evaluators

David D. Celentano*

Aphichat Chamratrithirong

David C.Sokol

Kenrad E. Nelson

Varachai Thongthai

Prayura Kunasol

Cynthia M. Lyles

Wathinee Boonchalaksi

Robert Hanenberg

Chris Beyrer

Philip Guest

Surinda Kuntolbutra

Sakol Eiumtrakul

Churnrurtai Kanchanachitra

Chirasak Khamboonruang

Vivian F.L. Go

Anchalee Varangrat

Wiwat Rojanapithayakorn

Case Study Contents

• Abstract

• Program at a Glance

• Program Information and Implementation

• Original Program Evaluation

• Implications and Lessons Learned

• Supplementary Materials Available

Bibliography

Celentano, D. D., Nelson, K. E., Lyles, C. M., Beyrer, C., Eiumtrakul, S., Go, V. F. L., Kuntolbutra, S., & Khamboonruang, C. (1998). Decreasing incidence of HIV and sexually transmitted infections in young Thai men: Evidence for success of the HIV/AIDS control and prevention program. AIDS, 12(5), F29–F36.

*Thank you to David Celentano who reviewed an earlier version of this case study.

Abstract

In 1991, as part of the national strategy to prevent the spread of HIV in Thailand, the Ministry of Public Health and the National AIDS Committee approved a resolution that required all provinces to implement a “100% Condom Use Program” in sex establishments. The program involved gaining the cooperation of government authorities and owners of sex establishments in the provinces to require commercial sex workers (CSWs) to use condoms in all sexual encounters. If customers refused condom use, the CSWs were urged to withhold services and refund the customers’ money. The program’s goal was to ensure that all sex establishments in the country adopted the measure so that sex seekers would not be able to purchase sex services without condom use, and it enjoyed widespread political support.

The 100 % Condom Use Program relied on three principle strategies. First, a mass communication campaign was employed using television and radio to promote public awareness of the need for reduction of high-risk sexual practices (such as avoiding commercial sex and motivating condom use in commercial sex). Second, a continuous supply of free condoms was provided to commercial sex establishments and female CSWs during periodic sexually transmitted infections (STIs) exams. Third, commercial sex establishments used by men treated for STIs were identified for purposes of condom promotion and enforcing compliance with condom recommendations. The Thai STI control program was based on a strong infrastructure, decentralized to the district level within provinces.

While both administrative data and cross-sectional studies have been used to evaluate the implementation of the public health program, those studies were subject to several sources of bias and may have been less sensitive to the effect of recent behavior change than prospective studies. This evaluation study presents data from two sequential prospective cohorts of young men in Thailand on the effect of recent behavior change on the incidence of STI and HIV during a time when the public health prevention initiatives were underway.

The two cohorts of young men (the majority aged 21 years) were conscripted by lottery for military service in northern Thailand and were enrolled in the longitudinal studies of HIV and STIs in 1991 (n = 2,417) and 1993 (n = 1,669). The young men participated in face-to-face interviews and provided serum samples for HIV antibody testing every 6 months from their induction to their discharge from the military 2 years later. Baseline questionnaires inquired about socioeconomic background, sexual history (lifetime and recent, including condom use), medical history, substance abuse history, and STI history. Follow-up questionnaires at 6-month intervals were used to determine sexual behavior, STI symptoms, sex establishment visits, condom use, and other risk factors for HIV and STIs during the previous 6 months. Sexual practice questions focused on four types of partners: wives, female CSWs, noncommercial female sex partners, and male partners. Incident STIs were determined by physician or medical practitioner diagnosis or by symptom reports.

HIV incidence declined from a rate of 2.48 per 100 person-years during 1991–1993 to 0.55 per 100 person-years during 1993–1995. STI incidence showed an even greater decline, with a tenfold decrease from 1991–1993 to 1993–1995. Behavioral risk factors for new STIs included a history of prior STIs and sex with girlfriends and sex workers. Inconsistent condom use remained a strong predictor of incident STIs among brothel visitors. Other previously reported risk factors in 1991–1993 such as illicit drug use, frequency and cost of brothel visits, and low socioeconomic status were not associated with incident STIs or HIV in 1993–1995.

Program at a Glance

Goal: To increase condom use in sex establishments by implementing a 100 % condom-use policy for all exchanges between clients and CSWs, increasing the availability and accessibility of condoms, building support for the program with key stakeholders, and providing checkups and STI care for CSWs

Target Populations: Female CSWs and their male clients

Geographic Location and Region: Thailand

Establishment and Duration: The policy was established in 1991 and is still in effect.

Resources Required and Goods and Services Provided: Condoms to distribute free of charge to sex establishments; funding to support STI clinics for CSWs

Strategies and Components

• Increased support and visibility of the program by involving local health officials, organizations, and establishment owners in planning and implementation activities

• Increased availability, accessibility, and acceptability of quality condoms

• Ensured appropriate staffing for monitoring and evaluating activities

• Provided checkups and STI care for CSWs

• Facilitated collaboration between health workers, governors, police, establishment owners and managers, and CSWs in every region

Key Partners: Ministry of Public Health, National AIDS Committee, regional offices of Communicable Disease Control, provincial public health offices, Thai Red Cross, Faculty of Medicine at Khon Kaen University, police departments, and provincial governors

Key Evaluation Findings

Statistically Significant

• Decreased STI lifetime history prior to induction and decreased incidence rate during service for the 1993 cohort as compared to the 1991 cohort

• Decreased HIV incidence from 2.48 per 100 person-years to 0.55 per 100 person-years from 1991 to 1995

• Decreased HIV risk behavior such as brothel visits and inconsistent condom use with CSWs

No Effect

• Did not decrease unprotected sex with a noncommercial sex partners

• Did not decrease sex with other men

Program Information and Implementation

Background, History, and Public Health Relevance

Thailand witnessed a rapid rise in the number of new HIV infections from 1988 to 1993, most of which resulted from commercial sex exchanges. Field workers conducting STI and HIV prevention efforts in Thailand noted that the majority of sex workers wanted clients to use condoms, but they were unable to enforce such behavior if the clients refused. In some cases, owners of sex establishments pressured CSWs to yield to customers’ demands in order not to lose establishment business.

Concern over this problem in 1989 led officials in Regional Communicable Disease Control in Ratchaburi Province to institute a policy that all establishments and CSWs in the province use condoms during every sex act. The policy was to assure sex workers, owners, and managers that they would not lose business by requiring condom use, since clients could not go anywhere else to obtain unprotected sex. The disease control officials in the province initiated a collaborative effort among local authorities, public health officers, sex establishment owners, and CSWs to ensure that clients could not purchase sexual services without condom use. When the program was implemented, the rates of STIs dropped quickly and significantly. The policy was soon expanded to the provinces around Ratchaburi (e.g., Samut Sakhon province) and a few other provinces in other parts of the country (e.g., Phitsanulok in the north) with equally positive results. During this early period, the Faculty of Medicine at Khon Kaen University was piloting similar approaches in Khon Kaen, as was the Thai Red Cross Society in Bangkok and Pattaya.

Spurred by strong epidemiological and behavioral data that showed the important role of sex work in fostering the Thai epidemic and the success of the pilot condom efforts, a set of planned steps to formulate a national policy were undertaken in 1991. During the year, the National AIDS Committee, chaired by the prime minister, issued a resolution to implement a 100 % Condom Use Program on a national scale. After the adoption of the resolution, the Prime Minister’s Office and Ministry of the Interior organized presentations at national meetings of all provincial governors, all district officers, and provincial and district chiefs of police. The Ministry of Public Health also organized meetings of all provincial chief medical officers to encourage the implementation of the program as quickly as possible and to provide reports back to the Ministry on a regular basis. By mid-1992, all provinces reported that the 100 % Condom Use Program was in place.

Several other national efforts under the umbrella of the National Condom Promotion Campaign were undertaken in the early 1990s. For example, condoms were added to the Medical Device Act to require quality assurance. Condom use was promoted through mass media, peer education, and outreach programs aimed at specific groups throughout the country. The Ministry of Public Health also began providing approximately 60 million condoms a year free of charge, distributing them mainly to sex establishments.

Theoretical Basis

The diffusion of innovation model helped to guide the program to encourage the adoption of condom use by clients and CSWs. The principles of the theory of harm reduction also helped to shape the 100 % Condom Use Program.

Objectives

The program aimed to decrease the incidence of STIs/HIV/AIDS by increasing condom use in sex establishments; by increasing the availability, accessibility, and acceptability of condoms; by building support for the program with key stakeholders; and by providing checkups and STI care for CSWs.

Class and Type of Outcome or Behavior Change Targeted

• □ Decrease IDU risk

• ☑ Decrease noncommercial sex risk

• ☑ Decrease commercial sex risk

• ☑ Increase health services utilization (exams, testing, and treatment)

Although the policy focused on increasing condom use during commercial sex exchanges, the widespread publicity was intended to encourage condom use with noncommercial partners as well.

Target Population and Venue for HIV Prevention

The program was aimed at all CSWs in sex establishments in Thailand and their clients, a high risk and a “bridge” population, respectively. The venues were all the commercial sex establishments in Thailand.

Pathways for Structural Change

• ☑ Changes in programs

• ☑ Changes in practices

• ☑ Changes in policies and laws

While the directive to implement the 100 % Condom Use Program came from the highest levels of the Thai government (policy change), responsibilities for program management were divided among the Regional Offices of Communicable Diseases Control (RCDCs) and the Provincial Public Health Offices (PPHOs) (program change). Management at these levels made the program more responsive to local needs and helped to increase the relevance of the activities (practice change) to the local situations.

Strategies and Tactics for Structural Change

Each of the 12 RCDCs in Thailand had broad public health responsibilities for five to seven provinces, with the 100 % Condom Use Program being only one of several public health efforts the offices supervised. Within each RCDC, three sections had responsibilities related to the 100 % Condom Use Program in addition to their other public health duties. The Pharmacy Section was responsible for the storage of condoms provided by the Ministry of Public Health, the Implementation Support Section was responsible for estimating the needs for condoms and managing their distribution to the provinces, and the STI and AIDS Center was responsible for providing STI examinations and prevention programs for CSWs. Some RCDCs had two additional units with responsibilities related to the 100 % Condom Use Program. They were the Health Behavior Development Unit to provide HIV/STI prevention and care training for CSWs and the general population and the Epidemiology Unit to assist in monitoring the use of condoms in sex establishments.

While the RCDCs had more responsibility for supervising the program at the regional level in the provinces that they managed, they often were directly involved in the activities. Although the PPHOs collaborated closely with the RCDCs in the program, the former remained responsible for most field activities in their own provinces.

Core Components

There were five core intervention components of the 100 % Condom Use Program:

• 1. Campaigns to Build Program Support and Create Demand for Condoms (i.e., to Improve the Acceptability of Condoms Through Condom Promotion)

  To increase support for the program, health workers regularly visited establishments to discuss prevention alternatives with CSWs and to provide STI testing and treatment. This aspect of the program was widespread, and more than 90 % of owners and managers reported that health workers visited their establishments to discuss health issues, and more than half of owners and managers reported these visits occurred at least once a month. The regular visits to sex establishments by proactive health workers played an essential role in raising awareness, building demand for condom use, and keeping the focus on the issues.

  Other condom promotion events varied by region, since district-level governments managed the program implementation. Some provinces trained peer educators among the CSWs, supplied free condoms in all hotel rooms, and set up projects to improve relationships between CSWs and establishment owners.

• 2. Availability and Accessibility of Quality Condoms (Condom Distribution)

  The central Thai government through the Ministry of Public Health supplied condoms to each RCDC according to the RCDC’s annual plan to ensure a sufficient supply of condoms for the demand anticipated for sex work in each region. The RCDCs then distributed the condoms to the PPHOs upon request, usually about once a month. Most PPHOs reported no supply problems at all, but five provinces reported one instance each of a shortfall in condoms.

  To maintain supplies of quality condoms, RCDC and PPHO staff enacted specific condom storage requirements. When possible, RCDCs stored condoms in air-conditioned warehouses on shelves raised above the floor to avoid humidity. Those with no air conditioning placed condoms in warehouses away from the walls in low, raised stacks. PPHOs took similar steps, with careful attention, avoiding sunlight and humidity, providing good air circulation, and keeping the condoms raised above the floor. The primary measure to ensure quality was a fresh in and fresh out policy, where condoms were not kept long in storage by matching supply and distribution.

  Health workers distributed condoms mainly to CSWs during STI checkups, which were required or strongly encouraged in every province. Sex workers received 100 condoms at a time, with the freedom to ask for more anytime they were needed. One-eighth of the provinces reported that condoms were supplied to establishment owners rather than to CSWs. Some RCDCs also distributed condoms to the military, nongovernmental organizations, private enterprises, and other places believed to benefit from increased condom access.

• 3. Appropriate Staffing, Management Strategies, and Evaluation

  Sufficient staff, appropriate management strategies, and regular monitoring and evaluation were essential to the efficacy of the 100 % Condom Use Program, where the behaviors in question occurred behind closed doors in sites that were not always easily located. The use of condoms could be ascertained only indirectly, through self-reports or condom distribution figures. To address those concerns, the 100 % Condom Use Program staff conducted frequent fieldwork and had specific strategies for locating and managing sites.

  Instead of creating an entirely new program to mount a response to the AIDS epidemic, the 100 % Condom Use Program integrated activity management into a number of already existing departments at the regional, provincial, and district levels. These departments then were able to add staff as needed to support the program and ensure good coverage in their provinces. This strategy helped to contain costs and produced a sustainable, long-lasting program.

  To guide efforts in sex work establishments, the AIDS and STIs Section in each PPHO maintained listings of sex work establishments in the province and updated those listings every 6 months. Health workers were then able to use the listings to direct prevention efforts at sites where STI transmissions were occurring, including informing owners and managers of the problems, expanding treatment and STI testing, and increasing monitoring visits to ensure compliance with the program. The governors and police were available to enforce compliance, although they did not use their power to force closure of establishments very often.

  Most RCDCs and PPHOs set individual goals for condom use and evaluated the program by measuring STI incidence, HIV infection rate, and numbers of condoms used. Even in provinces that did not conduct a formal evaluation, almost all were closely monitoring STI rates. About half of all provinces looked at numbers of condoms distributed and HIV infection levels among CSWs, and about half used the proportion of condom use in sex work, a behavioral indicator.

• 4. Checkups and STI Care for CSWs

  In every province, the RCDC or the PPHO maintained an STI clinic that provided physical exams for CSWs. Many RCDCs and PPHOs required CSWs to obtain checkups between two and four times per month, providing an incentive for workers to avoid infection and allowing the identification of noncompliant sites. Most sex workers used these services, with 91 % reporting regular STI checkups and 90 % getting checkups at least twice a month. Every province also had mobile teams to visit sex establishments to provide HIV and STI education and conduct condom promotion activities.

• 5. Collaboration Between Health Workers, Governors, Police, Sex Establishment Owners and Managers, and CSWs

  The 100 % Condom Use Program involved a number of different actors and agencies. They included the National AIDS Committee, provincial governors, police, regional and provincial health workers, owners of the establishments, CSWs, and clients. Each played a different, but essential, role in the execution of the program, and close collaboration among them was a key factor.

  Because securing the support of the governor ensured the cooperation of others, the program devoted considerable effort to educating and enlisting the support of governors. Almost 60 % of the provinces reported excellent cooperation from the governor, with another third reporting moderate cooperation. In at least one province, the governor investigated sex establishments himself to ensure that condoms were available in every room. In some cases, governors wrote letters to noncooperative owners or managers, insisting on their participation. Only one province reported low levels of cooperation from the governor.

  Most of the sex workers’ awareness and information about the 100 % Condom Use Program appeared to have come from television or health care workers. Health workers and, in some places, NGO workers provided training to CSWs on condom use and negotiation skills. Government clinics and government on-site STI services provided most STI care for sex workers and a substantial part of the care for clients. Health workers were primarily responsible for the core activities of the program, such as condom distribution and evaluation efforts.

  Because the provincial governors took the program seriously, police did so as well in most cases. At the beginning of the program, the police took enforcement actions against establishments in at least some provinces to obtain the owners’ cooperation. As the program evolved, however, the role of the police became less visible. The program input survey found that police assisted in organizing meetings of owners in about a third of the provinces. Their primary role appeared to be one of potential enforcement, although most provinces were increasingly operating on a cooperative rather than confrontational basis with owners and managers.

  While all the activities of the program certainly helped to create a supportive environment for condom use and improved STI care, much of the encouragement for using condoms still came from the CSWs. Sex workers reported that about one-fifth of men put on a condom without request and another two-thirds would let the CSW put it on without objection. But there remained a core of about 10 % of clients who had to be convinced to use condoms, although ultimately less than 1 % would totally refuse.

  About two-thirds of young men surveyed who reported visiting sex workers said condom use was their own idea, while about a fifth attributed it to the CSWs. This indicated that most men had learned the importance of using condoms in commercial sex, likely through mass media campaigns (television, radio, and newspapers). These media messages were part of the National AIDS education and condom promotion campaigns and were efforts mounted by government agencies (e.g., the Office of the Prime Minister or the Ministry of Public Health), NGOs, or other organizations. Only about 20 % of the men listed health workers as a substantial source of information.

Resources Required

The program required condoms to distribute free of charge to sex establishments and funding to support STI clinics for CSWs. In addition, it required funding to support the monthly outreach efforts of health workers to sex worker establishments, where they provided HIV prevention education, promoted condom use, and conducted STI testing.

Management Structure

At the level of the province, the governor, chief of police, and provincial health officer were responsible for implementing and directing the activities of the 100 % Condom Program.

Implementation Themes

Building support among government and health officials and mandating 100 % condom use in all sex establishments meant that the program was applied comprehensively and that clients did not have options for unprotected sex in other establishments.

An essential component of the program was to enlist the cooperation of the owners and managers of the sex establishments since they controlled the access of sex workers to prevention programs and STI services. To establish a basis for cooperation with these key individuals, program implementers engaged owners and managers in meetings where they described the local STI and HIV/AIDS situations, discussed prevention, and solicited support from attendees. Better relationships were developed between health officers and establishment owners and managers, allowing program implementers to arrange site visits for prevention programs or STI checks among CSWs.

Only as a last step, threats of police action were used to enlist cooperation from noncompliant owners and managers. The involvement of the police helped to provide legitimacy to the program in the eyes of the establishment owners, even if the police did not participate directly in implementation activities. In about one-third of the provinces, the police helped to invite the owners and managers to meetings. Most provinces used this strategy only sparingly, since the PPHOs recognized that developing cooperative, collaborative relationships with owners and managers was more effective than coercion.

Main Challenges Faced

Owners and managers were not motivated and committed to HIV prevention efforts initially. Most establishments did not have extensive education programs of their own and experienced high turnover in staff. Fewer than half had meetings where they discussed health matters with the workers. Almost two-thirds claimed they had never seen STIs in their establishments or only saw them about once a year. Among the CSWs, less than 2 % reported an establishment employee as a significant source of information about the 100 % Condom Use Program.

Program Continuity and Present-Day Status

The 100 % Condom Program was established in 1991 when the Thai National AIDS Committee and the Prime Minister agreed to implement the program nationwide. The UNGASS Country Report from 2008 to 2009 reported that the 100 % Condom Use Program is still an important strategy used for the prevention of HIV transmission among CSWs in the country. Thailand allocated 15.6 million baht for the program’s activities, including the procurement of 27 million condoms. Nongovernmental organizations also contribute to reducing the cost of quality condoms in Bangkok and Pattaya, and the UNFPA supported the establishment of a national condom committee for comprehensive condom programming.

Other Locations and Regions That Have Implemented Similar Programs

Cambodia piloted the 100 % Condom Use Program in October 1998 in Sihanoukville, a seaside tourist province with a large sex work district. To promote the use of condoms in all sex entertainment establishments and to establish a “no condom–no sex” policy, HIV prevention efforts included involving stakeholders in planning activities, educating CSWs about the program, and supplying them with resources such as condoms and STI services. In October 1999, Prime Minister Hun Sen asked all governors of provinces and municipalities to apply and enforce the 100 % Condom Use Program nationwide. Nationwide implementation occurred in 2001 and has since demonstrated success in increasing condom use and decreasing STI and HIV prevalence among CSWs.

Other countries in Asia, including the Philippines, Vietnam, China, Myanmar, Mongolia, and Lao People’s Democratic Republic, have similarly implemented the 100 % Condom Use Program.

Original Program Evaluation

Study Design

Timeline and Duration

A cohort of military conscripts beginning their 2 years of service in 1991 and a second cohort beginning service in 1993 were each studied for 2 years.

Cohorts

• □ Cross-sectional (snap shots in time)

• ☑ Longitudinal (same people followed over time)

Temporal Direction of Data Collection Relative to Intervention

• ☑ Prospective

• □ Retrospective

Assessment Time Points (Temporal Comparison)

• □ Before and after intervention (baseline and follow-up measures)

• □ After only

• ☑ Serial (more than two measures taken over time)

Implementation Level (Geographic Comparison)

• ☑ Countries

• □ Regions

• □ Counties

• □ Cities

• □ Towns

• □ Villages

• □ Households

• □ Couples, pairs, and dyads

• □ Individuals

The program operated countrywide in Thailand.

Sampling Unit

• □ Countries

• □ Regions

• □ Counties

• □ Cities

• □ Towns

• □ Villages

• □ Households

• □ Couples, pairs and dyads

• ☑ Individuals

Recruitment Techniques

Two entire cohorts of young men who were conscripted by lottery for military service were enrolled in the study.

Randomization

• ☑ No

• □ Yes

  • □ Random assignment

  • □ Random sampling

Study Type

Quasi-experimental

Methods

Data Collection

Data Sources

• ☑ Questionnaire or survey

• □ Chart information or surveillance

• ☑ Record of biological specimen (e.g., urine sample)

Interview

• ☑ Interviewer administered

• □ Self-administered

Instruments

• □ Paper and pencil (data entry after fieldwork)

• □ Computer (ACASI or direct data entry in the field)

Not reported in the original paper.

Modality

• ☑ In-person

• □ Mail

• □ Phone

• □ Internet

Data Analysis

Outcome Variables Measured

• □ Knowledge, attitudes, and beliefs

• ☑ Behaviors and practices

• ☑ Biomarker and clinical data

Other Variables Measured

• ☑ Demographics

• □ Risk groups

• ☑ Behaviors

Baseline questionnaires inquired about socioeconomic background, sexual history, medical history, substance abuse history, and STI history.

Statistical Methods

To evaluate trends in incidence of HIV and other STIs, incidence rates and 95 % confidence intervals were calculated by cohort and by semiannual visit within each cohort using person-time methods. The incidence rates for both STIs and HIV were calculated as the number of incident cases divided by the total person-years at risk. Poisson regression models were used to assess trends in incidence rates over time within a cohort as well as differences between cohorts. The differences between cohorts were evaluated while controlling for any important time trends within cohorts. Significance of covariates was determined by comparing nested models with the likelihood ratio test.

To evaluate changes in behavioral risks between the 1991 and 1993 cohorts, generalized estimating equations were performed with logistic regression analysis of repeated measures binomial data. This provided estimated odds ratios and 95 % confidence intervals for the association of risk factors with new STI and HIV infections.

Separate regression models analyzed STI and HIV incidence; regression models were constructed based on the covariates found to be significant at the univariate level.

Strengths and Weaknesses of the Study Design and Methodology

• □ Cross contamination between intervention and comparison groups

• ☑ Concurrent interventions occurring in experimental and comparison areas

• ☑ Historical bias or trend due to historical factors

Other programs and events may have played a role in the decrease in STIs and HIV noted by this evaluation. In 1994, the Royal Thai Army began an HIV health education program that reinforced the 100 % Condom Program by providing condoms to conscripts prior to leave and by reinforcing sexual risk reduction messages periodically. In addition, condoms became more widely available to consumers beginning in 1992.

Cohort studies have some limitations that may restrict the conclusions drawn from this analysis. For instance, exposure assessment into “exposed” and “unexposed” groups creates the potential of misclassification since the national AIDS control program was initiated after the 1991 cohort was conscripted and was much more dominant during the period of military service in the 1993 cohort. Individuals in the later cohort may have been more likely to deny risk (e.g., saying that they did use condoms during commercial sex) than individuals in the earlier cohort.

An additional concern and challenge to evaluation are the individuals in each cohort who were lost to follow-up, especially if they represented higher risk for STIs than those who were followed. The losses that occurred in the two cohorts were largely attributed to “away without official leave” (AWOL) or desertion and to early discharge for those with higher education. Therefore, although the 100 % Condom Program was recognized as a significant contributor to the reduction of sexual transmission of HIV in Thailand, causality interpretations must be made cautiously.

Results

Sample Size

	1991 Cohort	1993 Cohort
Baseline	2,417	1,669
6-month follow-up	2,061	1,495
12-month follow-up	1,799	1,381
18-month follow-up	1,676	1,292
24-month follow-up	1,795	672

Retention and Loss to Follow-Up (Cohort Studies Only)

Of the 2,417 and 1,669 conscripts in 1991 and 1993, respectively, 2,191 (91 %) and 1,549 (93 %) had at least one follow-up visit. The follow-up rates or the percent of conscripts at baseline seen at the 6-, 12-, 18-, and 24-month visits were as follows: 85 %, 74 %, 69 %, and 74 %, respectively, among the 1991 conscripts, and 90 %, 83 %, 77 %, and 77 %, respectively, among the 1993 conscripts.

Sample Demographics

Age

Means not reported, although the majority of men were aged 21 years.

Race or Ethnicity

All were Thai nationals.

Gender

The research sample was 100 % male.

Sexual Orientation

Not reported.

Outcome Measures

HIV status in the two military cohorts was detected by enzyme-based immunosorbent assays; STIs were diagnosed via physical exams and confirmatory blood tests; and risk behaviors were assessed with face-to-face interviews.

At induction, the 1991 and 1993 cohorts exhibited the same HIV prevalence (12 %), although the lifetime histories of STIs prior to induction differed (42.2 % among men in the 1991 cohort; 30.1 % among men in 1993 cohort; X ² = 61.5, p < 0.0001). During their 2 years in the military, the 1991 cohort had an overall STI incidence rate of 17.0 per 100 person-years (PY). The 1993 cohort STI incidence rate over a similar time period was nearly 10 times less, at 1.8 per 100 PY (p < 0.0001). The dramatic change in overall STI incidence was seen for specific STIs: gonorrhea incidence declined tenfold, syphilis ninefold, nongonococcal urethritis fivefold, and new cases or chancroids decreased by a factor of 16 between 1991–1993 and 1993–1995.

The 1991 cohort consistently exhibited significantly higher STI infection rates over each follow-up period compared with the 1993 cohort. A significant decline in STI infections over the follow-up period was observed within the 1991 cohort (P < 0.0001), and a borderline trend was observed within the 1993 cohort (P = 0.06). While adjusting for this decline over the period of follow-up, the investigators still observed a significant difference in STI incidence rates between the two cohorts (P < 0.0001). Overall HIV infection rates were 2.48 per 100 person-years (PY) for the 1991 cohort and 0.55 per 100 PY for the 1993 cohort (p < 0.0001), a nearly fivefold difference between cohorts.

The 1993 cohort reported fewer behavioral risks associated with HIV infection than the 1991 cohort, including fewer brothel visits (51 % vs. 34 %, p < 0.0001) and more consistent condom use with sex workers (14 % vs. 2.5 %, p < 0.0001). Three behaviors during the previous 6 months were associated with the acquisition of a new STI: reporting sex with a female CSW, having sex with a girlfriend, and history of an STI prior to induction. Men who reported inconsistent condom use with female CSWs were 3.5 times more likely to acquire an STI than men who reported consistent condom use.

Conclusions

Condom-use practices were clearly important in understanding why men in the Thai military population acquired STIs and HIV. Consistent condom use, particularly with female CSWs, provided protection against acquiring STIs. Prior history of STIs also strongly predicted new STI infections, perhaps because it reflected customary practices of condom use or nonuse. The overall decline in STI incidence between the two cohorts pointed to the success of the Thai 100 % Condom Use Program. Such a rapid decline in HIV/STI incidence among a general young adult population following a reduction in high-risk behaviors is unprecedented. One estimate is that in Thailand between 1989 and 1994, condom use in commercial sex exchange increased from 14 % to over 90 %, while during the same time period, STIs decreased by over 85 %.

Implications and Lessons Learned

There are three main groups that must take responsibility for the 100 % Condom Use Program in order for it to be successful:

• First, health officials and educators must be responsible for condom supply, STI services for sex workers and clients, health education and information for target populations, and reporting noncooperative sex work establishments to authorities.

• Second, the police must be responsible for monitoring and managing noncooperative sex establishments.

• Third, local administrators such as those in the governors’ offices must be responsible for coordinating between all sectors and helping to manage noncooperating sex establishments.

All groups have a hand in managing noncompliant sex work establishments, and this task is an important component of the program. The sex establishments should be aware of the methods that will be used to monitor and verify the use of condoms in sex work, so that management personnel pay close attention to the level of condom use at their site. Noncooperative establishments may receive warnings, temporary or permanent closure, or revocation of business permits. Experiences in Thailand lead one program implementer (Dr. Rojanapithayakorn, 2006) to observe that sanction management was not necessary in most cases.

Considered one of the most significant approaches in preventing the spread of the HIV across an entire nation, researchers have attributed some of its success to country-specific factors which aided the program’s implementation and sustainability. Because the Thai government has had such a long history of tolerating and attempting to control prostitution, rather than attempting to eliminate it, it was possible for the government to work within an existing CSW STI treatment program and infrastructure to deliver condoms directly to CSWs. In addition, researchers have speculated that the nonconfrontational nature of Thai political and cultural life facilitated the ability for the 100 % Condom Program to spread condom promotion messages to the general population, distribute millions of free condoms for an otherwise illegal activity, and for police to work alongside brothel owners and managers.

Supplementary Materials Available

Additional References

Chamratrithirong, A., et al. (1999). The success of the 100% Condom Promotion Program in Thailand: Survey results of the evaluation of the Condom Promotion Program. IPSR Publication No. 238. Institute for Population and Social Research, Mahidol University.

Hanenberg, R. S., Rojanapithayakorn, W., Kunasol, P., & Sokal, D. C. (1994). Impact of Thailand’s HIV-control program as indicated by the decline sexually transmitted infections. Lancet, 344(8917), 243–245.

Joint United Nations Program on AIDS (UNAIDS). (2000). Evaluation of the 100% Condom Use Program in Thailand. Geneva: Joint United Nations Program on AIDS.

Rojanapithayakom, W., & Hanenberg, R. (1996). The 100% condom use program in Thailand. AIDS, 10(1), 1–7.

Rojanapithayakorn, W. (2006). The 100% condom use programme in Asia. Reproductive Health Matters, 14(28), 41–52.

UNAIDS: Evaluation of the 100% Condom Programme in Thailand. Retrieved from www.unaids.org/publications/jc275-100pcondom_en.pdf

WHO: 100% Condom Use Programme in Entertainment Establishments. Retrieved from www.wpro.who.int/publications/docs/condom.pdf

WHO: Responding to Questions About the 100% Condom Use Program. Retrieved from http://www.wpro.who.int/publications/pub_9290610867/en/index.html

WHO: STI/HIV: Training course for the 100% condom use programme. Retrieved from http://www.wpro.who.int/publications/pub_9290610166/en/index.html.

Case Study 15: The Sonagachi Project: Empowering Sex Workers in the Songagchi District of Calcutta, India

Original Program Developers and Evaluators

I. Basu  

M.J. Rotheram-Borus 

D.Swendeman 

S.Lee

P.A.Newman

R.Weiss

S.Das

S.Jana

T.Ghose

S.George

D.Chowdhury

D.N.Gangopadhyay

M.Chanda

K.Sarkar

S.K.Niyogi

S.Chakraborty

M.K.Saha

B.Mana

P.Ray

K.Bhattacharya

R.Detels

Case Study Contents

• Abstract

• Program at a Glance

• Program Information and Implementation

• Original Program Evaluation

• Implications and Lessons Learned

• Supplementary Materials Available

Bibliography

Basu, I., Jana, S., Rotheram-Borus, M. J., Swendeman, D., Lee, S., Newman, P., & Weiss, R. (2004). HIV prevention among CSWs in India. Journal of Acquired Immune Deficiency Syndromes, 36(3), 845–852.

Swendeman, D., Basu, I., Das, S., Jana, S., & Rotheram-Borus, M. J. (2009). Empowering CSWs in India to reduce vulnerability to HIV and sexually transmitted diseases. Social Science & Medicine, 69(8), 1157–1166.

Abstract

Sonagachi is one of the oldest and largest red light districts in Calcutta. In 1992, the All India Institute of Hygiene and Public Health conducted a survey in Sonagachi to assess the prevalence of Sexually Transmitted Infections (STIs) and HIV among commercial sex workers (CSWs). Due to concern about increasing HIV and STI transmission from CSWs to clients, the institute initiated the sexually transmitted disease/HIV intervention project—eventually becoming the Sonagachi Project—in order to organize CSWs and promote behavioral change to decrease the spread of STIs and HIV between CSWs and clients. The project included health services, such as STI treatment, condom promotion, and information about STIs and HIV transmission. It employed CSWs as peer educators to share information about behavior change, to distribute condoms, and to refer CSWs to health clinics. The project also aimed to empower CSWs to improve their social, political, and economic conditions and to improve their lives through education and self-reliance. The CSWs formed the Durbar Mahila Samanwaya Committee, a quasi-trade union, which functioned to promote dignity and betterment of working conditions for CSWs.

The program in Sonagachi did not have a thorough evaluation in its early period, although a reported 90 % condom-use rate among CSWs indicated its success. To evaluate the overall program approach, researchers implemented it in another community in West Bengal and compared the condom-use behaviors of that population to another demographically similar control community. Between the baseline and three follow-up time points over 15 months, significantly more CSWs adopted 100 % condom use with their clients than those who relapsed to less than 100 % condom use in the intervention community. There were also significantly more CSWs who remained consistent adopters of 100 % condom use from baseline through all three assessments than those who relapsed across all time points. Additionally, there were significantly more adopters than relapsers at each assessment. In the control community, there were no significant differences between the numbers of adopters and relapsers. Condom use increased among CSWs in both the control and intervention communities, but condom use increased significantly more among those in the intervention community across the three follow-up periods.

Program at a Glance

Goal: To decrease HIV-risky sexual behaviors among CSWs in the West Bengal red light districts by increasing condom use, STI treatment, and HIV testing and to empower CSWs and help them develop skills to improve their lives by increasing literacy and economic opportunities and forming a collective trade union of united CSWs (i.e., to replicate the Sonagachi Project)

Target Populations: CSWs

Geographic Location and Region: West Bengal, India

Establishment and Duration: The Sonagachi Project was initiated in 1992 and is ongoing. An evaluation of the Sonagachi Project model was conducted in two communities in West Bengal from 2000 to 2001 over a period of 15 months.

Resources Required and Goods and Services Provided: Health services such as a central clinic where CSWs and family members can undergo HIV and STI testing and treatment and treatment for other health problems; resources and means to distribute HIV and STI information and prevention messages; condoms to distribute for a small fee; pay for CSWs who work as peer educators, both full and part time; and funding to establish schools for children of CSWs.

Strategies and Components

• Targeted commercial CSWs employed in brothels

• Employed peer educators to disseminate HIV and STI prevention information and to encourage condom and health facility use

• Increased availability, accessibility, and acceptability of condoms

• Increased the acceptability of the sex trade as a legitimate profession

• Empowered CSWs to unite and negotiate for good health by establishing a sex worker trade union

• Evolved to meet continually changing community needs

Key Partners: Dr. Smarajit Jana of the All India Institute of Hygiene and Public Health founded the Sonagachi Project program. The NIH Fogarty AIDS International Training and Research Program supported the evaluation research.

Key Evaluation Findings

Statistically Significant

• Increased adoption of 100 % condom use overall

• Increased any condom use at three follow-up time points in the intervention community

• Increased any condom use in the intervention community compared to the control community at two follow-up time points

Program Information and Implementation

Background, History, and Public Health Relevance

In the regions of Mumbai, Delhi, and Chennai, India, HIV rates among CSWs had reached levels as high as 90 % in the 1990s. In Mumbai, the largest city in India, HIV rates among CSWs rose from 1 % to 51 % in the 1991 to 1996 period. Rates of about 10 % had been observed among CSWs in Calcutta, a city on the drug route into the heart of India and one of the more impoverished areas of the world. In response to concern about the rampant spread of HIV infection across India, the Sonagachi Project was implemented in 1992 in the red light district of Sonagachi, Calcutta, India, to try to keep the HIV rate low among CSWs.

The Sonagachi Project may have been responsible for the low incidence of HIV among CSWs in the region as well as the dramatic increase in condom use by CSWs—from 3 % in 1992 to 90 % in 1999. There was little evidence from controlled studies that the Sonagachi Project was responsible for the results, however. Several studies had examined the Sonagachi Project or the CSWs participating in the project, but none had been published to demonstrate the efficacy of the Sonagachi model. In 2000–2001, researchers designed a two-community study, replicating the Sonagachi Project in another area of India, to examine the efficacy of the program.

Theoretical Basis

The Sonagachi Project used an empowerment approach to STI and HIV prevention by focusing on increasing the status and power of marginalized women. Factors such as extreme poverty, class/caste/ethnicity-based discrimination and few opportunities for education may limit the economic opportunities women have in India and may force them into the sex work profession. The empowerment approach brings together advocacy, community organizing and mobilization, rights-based messages, and microfinance to link individual self-efficacy (person-level empowerment) with organizations that can influence risk environments relevant to HIV transmission.

Objectives

The Sonagachi Project aimed to decrease HIV-risky sexual behaviors among CSWs in the Sonagachi red light district in Calcutta by increasing condom use, STI treatment, and HIV testing and to empower CSWs and help them develop skills to improve their lives by increasing literacy and economic opportunities and forming a collective trade union of united CSWs.

Class and Type of Outcome or Behavior Change Targeted

• □ Decrease IDU risk

• □ Decrease noncommercial sex risk

• ☑ Decrease commercial sex risk

• ☑ Increase health services utilization (exams, testing, and treatment)

Target Population and Venue for HIV Prevention

The target population of the Sonagachi Project was commercial CSWs in brothels in the Sonagachi area and the clients of the CSWs. Likewise, this replication study targeted the CSWs and their clients in two areas of West Bengal.

Pathways for Structural Change

• ☑ Changes in programs

• ☑ Changes in practices

• □ Changes in policies and laws

Strategies and Tactics for Structural Change

The Sonagachi Project employed peer educators who were also CSWs to disseminate HIV and STI prevention information and to encourage use of condoms and health facilities to other CSWs. The model continually evolved during the program and aimed to better the lives of CSWs through advocacy and empowerment.

Core Components

By providing easy access to screening and treatment for STIs and HIV, the program aimed to increase use of the services by CSWs. The program sought to disseminate information about safer sex and to increase condom use by CSWs in brothels. The program used an empowerment approach to STI and HIV prevention. Peer educators were trained to work as leaders within their communities and to empower other CSWs to take control of their own health and well-being. Peer educators engaged in advocacy missions to promote the interests of the CSWs and campaign for their rights.

Resources Required

The Sonagachi Program required health services such as a central clinic, where CSWs and family members could undergo HIV and STI testing and treatment and treatment for other health problems as well. Resources and means to distribute HIV and STI information and prevention messages were needed, along with condoms to distribute for a small fee. Pay for CSWs to work as peer educators, both full and part time, and funding to establish schools for children of CSWs were required.

Management Structure

Two teams from the Sonagachi Program worked together for the evaluation project. An assessment team conducted the project’s rapid assessment and evaluation activities, and an intervention team included sex worker peer educators and community organizers, and professional project staff involved in advocacy work. A team from the University of California, Los Angeles, consulted on the design of assessment measures, data analysis, and assurance of fidelity in implementation of assessment and intervention. The original Sonagachi developers trained the peer educators involved in the project. During the project’s implementation, three to six peer educators worked under a more experienced peer supervisor. Peer supervisors and professionally trained social workers acted together under the supervision of a project coordinator and director (D. Swendeman, personal communication, March 29, 2011).

Implementation Themes

The theme of the Sonagachi Program was to empower CSWs and help them develop skills to improve their lives by using condoms to prevent STIs and HIV, by increasing literacy and economic opportunities, and by forming a collective trade union.

Main Challenges Faced

The assessment of the Sonagachi Program was conducted in two communities only, which limited the generalizability of the study results. The researchers noted that while they took steps to reduce contamination, there was some back-and-forth movement between the two communities. STI rates during the evaluation project were too low for the researchers to use them as an outcome of interest, even though a demonstration of the Sonagachi Program influencing STI prevalence would have been most useful.

The evaluation project implementers faced an ethical challenge when designing the study, since the control site did not receive an enhanced intervention against STIs and HIV. The researchers did provide the control site with a free, accessible health clinic for CSWs, which was an improvement over the normal level of care in the community. In addition, the researchers employed a crossover design so that the control community received the intervention after the evaluation period.

Program Continuity and Present-Day Status

The Sonagachi Program began in one district of Calcutta, continues at the time of this publication, and has been replicated in at least 60 sites throughout West Bengal, India.

Other Locations and Regions That Have Implemented Similar Programs

A similar program in the South African gold mining district of Summertown was designed to address HIV transmission among CSWs and migrant mineworkers by managing STIs, peer education, and stakeholder management. An outreach coordinator started the peer education program, to mobilize women to form a peer education group and engage others in health promotion activities. Stakeholders formed management committees, which included members of the health department, the gold mining industry, trade unions, and funders/academics. Unfortunately, the program ran into substantial barriers and challenges as it was implemented, and the project had little effect on STI incidence overall.

Original Program Evaluation

Study Design

Timeline and Duration

The Sonagachi Program was initiated in 1992 and is ongoing at the time of this publication. An evaluation of the Sonagachi Program model in two communities in West Bengal lasted for 15 months in 2000 and 2001.

Cohorts

• □ Cross-sectional (snap shots in time)

• ☑ Longitudinal (same people followed over time)

Temporal Direction of Data Collection Relative to Intervention

• ☑ Prospective

• □ Retrospective

Assessment Time Points (Temporal Comparison)

• ☑ Before and during intervention (baseline and follow-up measures)

• □ After only

• □ Serial (more than two measures taken over time)

Implementation Level (Geographic Comparison)

• □ Countries

• □ Regions

• □ Counties

• ☑ Cities

• □ Towns

• □ Villages

• □ Households

• □ Couples, pairs, and dyads

• □ Individuals

Sampling Unit

• □ Countries

• □ Regions

• □ Counties

• □ Cities

• □ Towns

• □ Villages

• □ Households

• □ Couples, pairs, and dyads

• ☑ Individuals

Recruitment Techniques

Not provided.

Randomization

• □ No

• ☑ Yes

  • □ Random assignment

  • ☑ Random sampling

The researchers used two communities in the Cooch Behar district of West Bengal in Northeastern India (Cooch Behar and Dinhata) in their evaluation, since they were matched on size, socioeconomic status, and number of CSWs. The researchers randomly assigned each community to either the intervention or control condition. They then identified a population of about 350 CSWs in each community and randomly selected 100 CSWs from each area using a two-stage randomization process. First, brothel rooms in each red light district were numbered and randomly selected using a random number table. The CSWs living in these rooms were then numbered and randomly selected using a random number table. The researchers recruited study participants with informed consent to participate in the longitudinal study.

Study Type

Quasi-experimental

Methods

Data Collection

Data Sources

• ☑ Questionnaire or survey

• □ Chart information or surveillance

• □ Record of biological specimen (e.g., urine sample)

Interview

• ☑ Interviewer administered

• □ Self-administered

Instruments

• □ Paper and pencil (data entry after fieldwork)

• □ Computer (ACASI or direct data entry in the field)

Not provided.

Modality

• ☑ In-person

• □ Mail

• □ Phone

• □ Internet

Data Analysis

Exposure Variables Measured

CSWs in the intervention community were exposed to the full Sonagachi Program model, while those in the control community were not.

Outcome Variables Measured

• □ Knowledge, attitudes, and beliefs

• ☑ Behaviors and practices

• □ Biomarker and clinical data

  Primary outcome measures included condom use and changes in condom use.

Other Variables Measured

• ☑ Demographics

• □ Risk groups

• ☑ Behaviors

Age, gender, marital status, regular sexual partner, years working in the sex industry, earnings, alcohol use, drug use, HIV/AIDS knowledge, and condom use were assessed at baseline.

Statistical Methods

The researchers assessed differences in baseline characteristics with chi-square tests for categorical variables and t-tests for continuous variables. To assess change in condom use from baseline to follow-up assessments, they used the McNemar test, stratified on intervention condition. They assessed change in any condom use, including changes to or from 100 % condom use over time, by using a random effects regression model. They calculated the intervention effect by comparing slopes between the conditions over time.

Strengths and Weaknesses of the Study Design and Methodology

• ☑ Cross contamination between intervention and comparison groups

• ☑ Concurrent interventions occurring in experimental and comparison areas

• □ Historical bias or trend due to historical factors

The assessment of the Sonagachi Program was conducted in two communities only, which limited the generalizability of the study results. The researchers noted that while they took steps to reduce contamination, there was some back-and-forth movement between the two communities in the evaluation study.

Results

Sample Size

	Baseline	Follow-up rates (%)
Intervention area	100	84
Comparison area	100	75

Retention and Loss to Follow-Up (Cohort Studies Only)

Follow-up rates were similar in the intervention and the control communities at each wave from the baseline interviews (n = 100 each condition). In the intervention community, 84 % were interviewed at every follow-up time point; 75 % were assessed at every follow-up assessment in the control community.

Sample Demographics

Age

	Intervention	Control	Overall
Mean age in years	26	27	27

Race or Ethnicity

Not reported.

Gender

Gender	Baseline (%)
Male	0
Female	100

Sexual Orientation

Not reported.

Outcome Measures

The percentage of condom use increased significantly more among CSWs in the intervention community than among those in the control community in a linear fashion over three follow-up periods (β = 0.3447, P = 0.002).

In both the intervention and control groups, researchers identified adopters, defined as individuals who increased their condom use to 100 %. They then compared the number of adopters to the number of relapsers (who switched from 100 % condom use to less than 100 % condom use) at each time point in both the intervention and control communities. At the first follow-up in the intervention group, 35 CSWs (39 %) were adopters, and only 4 (4 %) were relapsers. This difference was statistically significant (McNemar test = 26.64, P < 0.0001). The difference between the number of adopters in the control group (17 adopters, 18 %) and the number of relapsers (11, 12 %) was not significant.

At the second and third follow-up assessments, there were significantly more adopters (35 [41 %] at the second follow-up and 37 [40 %] at the third follow-up) than relapsers (6 [7 %] at the second and third follow-ups) in the intervention community (McNemar test = 20.51, P < 0.0001, McNemar test = 22.32, P < 0.0001). There were no significant differences between the number of adopters and relapsers at either follow-up in the control community.

In the intervention community, the research team observed 27 adopters (32 %) between the baseline to first follow-up who maintained 100 % condom use in second and third follow-up assessments. Only six relapsers were observed (7 %) (McNemar test = 13.36, P = 0.0003). In the control community, only 7 CSWs (9 %) maintained 100 % condom use, whereas 19 CSWs (25 %) failed to maintain 100 % condom use. This difference was statistically significant (McNemar test = 5.54, P = 0.0186). Changes in condom use from baseline to follow-up assessments followed similar patterns.

The results of an additional study conducted by the same researchers at the same time and in the same locations compared the standard care of STI clinic, condom promotion, and peer education to the Sonagachi intervention. That study found that the Sonagachi Program’s empowerment intervention strategies, which included community organizing and advocacy, were responsible for:

• Improving knowledge of STIs and condom protection from STIs and HIV and maintaining STI and HIV risk perceptions despite treatment

• Motivating change based on reframing sex work as valid work, as measured by greater disclosure of profession to non-CSWs by self-employed CSWs, and instilling hope for the future reflected as desire for more education and training

• Improving cognitive, affective, and behavioral skills in sexual and workplace negotiations, shown by increasing awareness that CSWs were the most important condom use decision-maker (over madams and clients), increased refusal abilities, and ability to change work contract

• Building social support among CSWs by increasing social interactions outside work, social function participation, and helping other CSWs when harassed

• Addressing environmental barriers such as economic vulnerability and insecurity, by increasing savings and alternative income sources for older CSWs

Conclusions

Although the effects of the original Sonagachi Program were not thoroughly evaluated, the results of two studies in other communities showed the benefit and sustainability of the condom promotion and empowerment strategy of the program. In addition to increasing consistent condom use among brothel CSWs, the program model effectively engaged members of the target population to promote behavior change and empower other women to take control of their lives and situations. The widespread recognition of Sonagachi Program’s success has helped it expand to more than 60 communities throughout West Bengal, India.

Implications and Lessons Learned

Changing the acceptability of sex work to that of a legitimate profession was a major component of the Sonagachi Program. The following set of rights for CSWs was articulated:

• Sex work is work.

• CSWs have the right to speak out.

• CSWs and their children deserve an education.

• CSWs deserve good health.

• CSWs can have freedom of movement.

• CSWs deserve fulfillment in a sexual relationship.

In Indian society, the rights of CSWs were difficult to assert and to have others accept. Because the intervention worked at first by demonstrating the positive economic benefit CSWs’ sexual health conferred on stakeholders and gatekeepers (i.e., the community power brokers), the rights seeped into society and redefined the role of CSWs in society (D. Swendeman, personal communication, March 29, 2011).

The evaluators outlined five key components that were important to the continued success of the Sonagachi Program. It was (1) cost-effective, (2) useful, (3) realistic, (4) evolving, and (5) sustainable.

While some aspects of the cultural context in India (and specifically West Bengal) allowed the original Sonagachi Program to develop and expand naturally, the evaluation project demonstrated that the intervention could be set up in another location quickly and effectively. The key is to find the right frames that will resonate and motivate the target population and power brokers. For the Sonagachi Program, the developers framed the project as a human rights and social justice issue, which motivated high-status doctors and high-status officials in their networks to support the project. They framed the issue of HIV prevention to power brokers (landlords and brothel owners) as an economic issue and were able to convince that population that it was in their best interest to support the goals of the program (D. Swendeman, personal communication, March 29, 2011).

Supplementary Materials Available

Additional References

Cornish, F., & Campbell, C. (2009). The social conditions for successful peer education: A comparison of two HIV prevention programs run by CSWs in India and South Africa. American Journal of Community Psychology, 44(1–2), 123–135.

Gangopadhyay, D. N., Chanda, M., Sarkar, K., Niyogi, S. K., Chakraborty, S., Saha, M. K., Manna, B., Jana, S., Ray, P., Bhattacharya, K., & Detels, R. (2005). Evaluation of sexually transmitted diseases/human immunodeficiency virus intervention programs for CSWs in Calcutta, India. Sexually Transmitted Diseases, 32(11), 680–684.

Ghose, T., Swendeman, D., George, S., & Chowdhury, D. (2008). Mobilizing collective identity to reduce HIV risk among CSWs in Sonagachi, India: The boundaries, consciousness, negotiation framework. Social Science & Medicine, 67(2), 311–320.

Jana, S., Basu, I., Rotheram-Borus, M. J., & Newman, P. A. (2004). The Sonagachi project: A sustainable community intervention program. AIDS Education and Prevention, 16(5), 405–414.