CIRA Affiliated Project

This 5-year study, entitled "High-risk Establishments and Women's HIV Prevention in Southern China," is a Phase I/Phase II study of HIV risk and social dynamics in sex-work establishments, and the development and evaluation of a multi-level, site-based intervention conducted within those establishments to promote use of the female condom (FC) for HIV/STD prevention among women who work there. Based on a collaboration developed through an AIDS-FIRCA study, U.S. and Chinese investigators will work with Hainan and Guanxi provincial CDCs and local communities to conduct the study in two rural and two mid-sized urban towns in these provinces. The study aims are: 1) to assess the number and nature of sex-work establishments in these towns, and the stability and social dynamics within these establishments that affect delivery and testing of a site-base intervention to promote FC use for HIV prevention; 2) to assess factors associated with HIV risk and use of female and male condoms for HIV prevention among women who work within these establishments; 3) to develop, pilot, conduct a process evaluation, assess short-term efficacy and potential sustainability of, and manualize a site-based, multi-level (individual, site, community) intervention conducted in these establishments to promote the FC for HIV/STD prevention, and 4) to explore factors likely to explain: a) variation in feasibility, acceptability, and fidelity of intervention delivered in different establishments and different towns, and b) variation in short-term efficacy and sustainability of the intervention among women in different establishments and different towns. In each town we will use intensive ethnography to assess the characteristics and dynamics of sex workers and sex-work establishments, as well as the feasibility, process, and outcomes of the intervention conducted in those establishments. We will conduct cross-sectional surveys of sex workers in all 4 towns at three time points (baseline, 6 and 12 months post-baseline) for comparative analyses to assess town-level, sex-work establishment, and individual-level characteristics associated with HIV risk and prevention and outcomes of the intervention. Qualitative and quantitative data will be triangulated to build the strongest assessment of characteristics that affect risk and intervention outcomes and to provide the most comprehensive analysis of factors that enhance or impede use of the FC and other prevention measures by women in these establishments. Development and testing of the FC intervention has significant public health implications because of its potential for reducing sexual HIV transmission in this high-risk population and in the broader population of their sexual networks.

In year 2, the China female condom (FC) intervention study team from ICR, Peking Union Medical College, Hainan CDC HIV Division, and county- and township-level CDC and health care providers/educators, conducted ethnography, pre/post intervention surveys, and ethnographic process and outcome evaluation, and implemented a community-wide multilevel intervention focused on promoting FC in sex work establishments in the first two study sites, FS and YF towns in Hainan Province. Several key findings from this experience include the following:

• Strong peer influence regarding HIV/STI prevention beliefs and practices within sex work establishments: Women in the same establishment engage in similar levels of risk and prevention practices.
• Establishment population stability and mobility: There is almost no migration of women between sex work establishments within a town. The majority of women who return to the sex industry after trips home return to the same establishment in the same town where they first engaged in sex work because of familiarity and comfort with life in the establishment; friendships with other women in the establishment who often come from the same village or region, and good relationship with the establishment owner.
• Establishment response to intervention: Establishments with bosses who exert high control over the women often were more supportive of the intervention and encouraged and helped staff organize the women’s participation (regardless of their own subsequent FC attitudes/use); sites with closer relationships among women and between women and bosses (i.e., greater cohesiveness) also tended to demonstrate more positive response to the FC intervention.
• Strong peer influence over women’s FC initial and subsequent use: In establishments where an initial FC user reported a negative experience, most or all other women in the establishment decided not to try it (including women who initially expressed interest). In establishments where the initial user reported a positive experience, more women decided to try it themselves, even requesting FC from staff if they hadn’t received any.
• Reasons for use/non-use of FC: FC users reported liking FC because: it is more lubrication than MC; it provides better protection over a wider area than MC; their partner liked and/or requested it; they could control its continued use throughout the sex act (as opposed to MC, which some clients remove during sex). FC non-users reported not trying or liking FC because: it is complicated and time-consuming to insert; it looks strange; the inner ring is uncomfortable; their partner didn’t like it or they are concerned about how a partner might react to a new product; they feel it is too big, a product they perceive specifically designed for Western women with (they expect) a different sized anatomy.