MinisymposiumInclusion of the female condom in a male condom-only intervention in the sex industry in China: A cross-sectional analysis of pre- and post-intervention surveys in three study sites
Introduction
As the human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) epidemic has entered its third decade in China, recent changes in sexual culture, including attitudes and practice, and a resurgence of the sex industry1, 2, 3 have spawned a rapid increase in sexually transmitted infections (STIs), including HIV/AIDS.4, 5 The ever-expanding sex industry is deeply integrated into China’s developing economy, fed by these changing sexual norms. This is combined with population migration and continuing economic need, particularly in rural areas and among mobile women and men. These forces exacerbate the potential for a major upsurge of HIV through heterosexual contact. It is estimated that 740,000 people are living with HIV/AIDS in China; 48,000 were newly infected in 2009, of whom 42.2% acquired the infection through heterosexual transmission.6
Public health efforts that involve significant collaboration with local health workers to reach populations at the greatest risk are increasingly called for to reduce the rising spread of HIV.7 In particular, the expansion of prevention options through public health education, outreach and promotion has great potential in the fight to prevent a growing epidemic by reducing STIs that facilitate HIV transmission and the rising epidemic in China and other countries.8
Although many recent efforts to curtail the HIV/AIDS epidemic have been made through the Chinese Government and other international organizations, promotion of male condom (MC) use is generally the only tool used for prevention of sexual HIV transmission. Current MC use has increased since the early years of the epidemic. However, different studies have reported huge variation in usage rates, which suggests that so-called ‘100% condom use’ is still far away.9, 10, 11, 12, 13 Much less effort has been invested in prevention in the rapidly growing sex industry in rural and small urban areas of China,14, 15, 16, 17 although this has significant potential to accelerate the national epidemics of STIs and HIV.1, 18, 19 Many migrant sex workers, especially from rural areas, have very low levels of education, are unskilled and have extremely limited knowledge of basic health. Furthermore, the new rural or small urban contexts in which they often find themselves offer few local resources for health and life necessities. Thus, there is increasing need to understand the multiple, complex situations of rural sex workers in different circumstances, and to develop multilevel prevention programmes to target sex work in rural and small urban contexts.14, 20
In general, prevention of STIs and HIV embraces comprehensive strategies. However, only barrier methods (exclusively MCs in the past) are effective for the prevention of multiple diseases and pregnancy. To compensate for the disadvantages of MCs, the female condom (FC) which can be worn by women, has been developed and marketed since the late 1980s.21 Use of the FC still requires negotiation with male sex partners, but gives women more autonomy in its application when MC use is less than 100%. Along with MC promotion, the FC has become increasingly popular and promoted in several countries with high HIV incidence, including in rural contexts, and has been shown to decrease STI incidence and increase protected sex.22, 23, 24, 25
Very limited research on acceptability of the FC has been conducted in China. An early study assessed short-term satisfaction of FC use among married couples in a clinical setting.26 A more recent study tested improvement in FC knowledge and attitudes among female sex workers after introducing the FC for a period of 2 months; however, the study provided few details on how many of the FCs delivered were actually used or the context of FC adoption.27 A very recent publication compared the clinical features of the original prototype FC produced by the Female Health Company and a similar FC produced in China.28 None of these studies have assessed FC use in the context of MC use among sex workers in China.
The China/US Women’s Health Project was designed to develop, implement and test a public health intervention programme to expand HIV prevention with commercial sex workers in four typical southern Chinese towns, including two rural towns and two small cities, by promoting the original prototype FC along with the MC. The study assessed acceptability and adoption of the FC in the context of different levels of MC use after exposure to a community-based educational, skills-enhancement and support intervention conducted in sex work establishments by local health educators and healthcare workers. The international research team worked in partnership with the provincial-level Centres for Disease Prevention and Control (CDCs) in Hainan and Guangxi Provinces, and with county-level and town-level public health educators and healthcare providers to develop and implement the programme and test the intervention model in the study communities.19, 29
This paper reports MC and FC use among sex workers who participated in three cross-sectional surveys: pre-intervention (baseline) and 6-months and 12-months post-intervention. The intervention process and outcomes in the first three study sites of the project in Hainan and Guangxi Provinces are compared.
Section snippets
Settings of the three study sites
In this paper, the three study sites are referred to as FS, YF and PX to protect their identity and that of the study participants. The first two sites (FS, YF) are rural towns located in the same county in Hainan Province. The third site (PX) is a small city in Guangxi Province. At the time of writing, data collection had been initiated at the fourth study site, a larger urban centre in Hainan Province. Only the results from the first three study sites are included in this report.
These three
Characteristics of the study participants
Table 2 indicates the key characteristics of the cross-sectional survey samples in each of the three comparison towns at the baseline, 6-month and 12-month surveys. Some distinctions are evident in the demographic profile and reproductive history of these women. Generally, women in rural FS and YF were more likely to be younger, single, originating from the same province and ethnic minority, while the women in PX were older, more likely to be married and have children, had a longer sexual
Discussion
This paper describes the findings from cross-sectional surveys and process documentation to evaluate the efficacy of an intervention to promote FC use, supplemented with MC use, among Chinese sex workers in rural and small urban towns. The major outcomes in the study are increased FC and MC use and protected sex. Despite no prior knowledge of or experience with FCs before the intervention, approximately one-fifth to one-half of the women in the three study sites had tried the FC by the time of
Ethical approval
Institutional Review Boards at the Institute for Community Research, Hartford, Connecticut, USA; the Peking Union Medical College/China Academy of Medical Sciences, Beijing, China; and the Guangxi Provincial Centres for Disease Prevention and Control in Nanning, Guangxi, China. All study participants provided informed consent.
Funding
United States National Institute of Mental Health, Grant #R01 MH077541.
Competing interests
None declared.
Acknowledgements
The authors wish to thank staff of the Hainan and Guangxi Province Centres for Disease Control and Prevention, and staff of the local county and townships who contributed significantly to this study and made it possible.
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