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Decreasing STD incidence and increasing condom use among Chinese sex workers following a short-term intervention

Decreasing STD incidence and increasing condom use among Chinese sex workers following a short-term intervention. Ma S, Dukers NHTM, van den Hoek A, et al. Sexually Transmitted Infections , 78(2), April 2002. Amelia Pousson 17 December 2003 Global Health Area of Concentration Journal Club.

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Decreasing STD incidence and increasing condom use among Chinese sex workers following a short-term intervention

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  1. Decreasing STD incidence and increasing condom use among Chinese sex workers following a short-term intervention Ma S, Dukers NHTM, van den Hoek A, et al. Sexually Transmitted Infections, 78(2), April 2002. Amelia Pousson 17 December 2003 Global Health Area of Concentration Journal Club

  2. Background:Commercial Sex Work in China • Commercial sex work is illegal in China, yet industry may, at present, include over 3 million workers. • Prostitution considered to be an element of the Six Evils. • i.e. social problems understood to be ‘pre-revolutionary, influenced by decadent western morality, and incompatible with modernization’ • Convicted commercial sex workers face detention for 6 months to 2 years in order to undergo re-education, which includes legal indoctrination, labor, prevention of sexually transmitted diseases, and involuntary HIV testing, followed by segregation by serostatus.

  3. Background: History of HIV/STDs in China • STDs were common in China prior to the founding of the People’s Republic in 1949. • STDs were eliminated from the country by 1964, but the numbers have begun to rise again in the last decade, concurrent with relaxation of economic strictures. • The total number of reported STD cases in 1998 was 632,512, compared to the mere 13 cases reported in 1977, • Number of STD cases doubled from 1996 to 2000, with especially high rates in Guangdong, Hainan, and Shanghai provinces.

  4. Background:China’s and HIV/AIDS today • As late as mid-2001, China was assessing their own HIV epidemic as under 25,000 cases, all of whom were supposed to be IV drug users from the golden triangle. The existence of transfusion or heterosexual intercourse-infected patients was denied. • As late as mid-2001, China was assessing their own HIV epidemic as under 25,000 cases, all of whom were supposed to be IV drug users from the golden triangle. The existence of transfusion or heterosexual intercourse-infected patients was denied. • In August 2001 China recognized the existence of an HIV epidemic in China. Today, the government suggests that their numbers are approximately 1 million, a number considered by both Chinese and foreign epidemiologists to likely be an underestimate. • At the present, prevention programs are sparse, the political climate hazardous (arrest of Dr. Wan Yahai in August 2002, arrest of Henan province Health Department worker Ma Shiwen), and baseline population knowledge low. • A variety of different organizations, including UNAIDS and the CIA suggest a figure of 10 million Chinese people infected by 2010 if the situation stays as it is now.

  5. Study Goals Study goals were: • To describe baseline status of commercial sex workers in Guangzhou city, [Guandong province, China] with respect to HIV knowledge, sexually transmitted infection status and self-efficacy to use condoms, • To assess how educational interventions provided during medical visit might change these parameters.

  6. Materials & Methods • Female commercial sex workers from Guangzhou were recruited into the study from March 1998 to October 1999. • Study participants were all attendees at clinic who consented to be interviewed by a trained nurse using 3 scales to measure HIV knowledge, condom use and self-efficacy, followed by counseling, a physical exam and treatment for any STDs. • Study design indicated that follow-up visits should be every 2 months through 6 months from intake, e.g. 3 follow-up visits.

  7. Materials & Methods • The scales used to assess knowledge/self-efficacy appear in the paper appendix, and were used with responses dichotomized into binary groupings, • Ex. condom use analyzed as consistent / not consistent, with all scale responses other than “always” considered to be not consistent. • Standard gynecological methods were used to test for gonorrhea, chlamydia, trichomoniasis and syphilis, all infected women were treated with a single return visit.

  8. Results:General Features & Participation • 966 women were participants, and the attrition rate was between 12 and 19 percent between follow up visits, with 53% of intake participants completing 3 follow-up visits. • Participants were compared against themselves as a control for analysis of behavioral studies, and analyzed by characteristics at intake for demographic factors.

  9. Results:Demographics

  10. Results:Differences between returned clients and non-returned clients • Clients that returned 3 times for checkups and instruction were different from those that did not by: • Being younger (p <.001) • Entering commercial sex work younger (p<.001) • Less likely to have had a STD checkup w/in 12 months (p=.025) • Less likely to have a history of STD infection (p<.001) • Less likely to have good self-efficacy to use condoms. • Both groups were EQUALLY likely to have poor knowledge of HIV transmission, to have used drugs, to have good knowledge of condoms, and/or to have used condoms consistently in the past 2 months.

  11. Results:Changes in knowledge, attitudes, behavior among clients • Increase in consistent condom use from 30.1% at intake to 81.4% at 3rd followup. • Increase in good knowledge about condom use from 23.6% to 79.3%. • Increase in high condom-use self efficacy from 32.4% to 95.7%. • Decrease in number of women always practicing vaginal sex with their employers from 59.9% to 44%. • LARGE increase in good knowledge of HIV/AIDS from 4.3% to 98.6%.

  12. Results:Changes in knowledge, attitudes, behavior among clients from intake thru 3rd follow up visit

  13. Results:Intervention trends & condom use • Trends after interventions were uniformly significantly upward for knowledge and positive behavior (p <0.001). • Independent predictors of consistent condom use were, by multivariate analysis: • Good self-efficacy (OR 22.9, 95% CI 17.6-29.8) • Later study entry time (OR 1.31, 95% CI 1.07-1.6) • Good condom use knowledge (OR 1.22, 95% CI 1-1.5). • Consistent condom use upward trend with increasing visits remained even after controlling for these independent predictors.

  14. Results:STD Incidence Changes • Incidence rates for all clients showed a clear trend of decreasing incidence rates of Gonorrhea, Trichomoniasis and Chlamydia. • When restricted to patients completing 3 follow up visits, the trend was maintained for Trichomoniasis and Chlamydia, • These numbers reflect a relative risk reduction among those women who attended 3 clinic sessions of nearly 4 times that of those who did not.

  15. Selected StudyLimitations • There is likely to be a certain degree of selection bias among those sex workers willing to participate in the study, as the cohort was selected by convenience sampling & self-selection. The attrition to the inception cohort is also a matter of concern. • Reliance on self-reported behavioral data may introduce an element of weakness to the evidence of major behavioral change. Yet, the decreases in STD incidence support the truth of the self-reported behavioral changes. • It appears that no STD diagnoses were made at the intake visit, which makes it challenging to compare the follow-up results to a baseline. • There is no discussion of the specific type of counseling provided to clients nor whether it was standardized, thus the ‘exposure’ may not have been equivalent for all study subjects.

  16. Selected Analyses and Possible Implications • Chlamydial infection is extremely high among the population studied, with infection rates comparable to those found in re-education centers. • This is worrying with respect to the fact that HIV may be being co-transmitted with Chlamydia. • Knowledge of HIV pre-intervention was very low. • However, the short intervention achieved major increases in HIV/AIDS knowledge, suggesting a possible direction for future interventions. • Sex workers seemed to be able to exercise a measure over their own autonomy with respect to choice of sexual act and use of condoms, which may be very important to restricting HIV transmission.

  17. Conclusions • China is on the verge of an enormous HIV epidemic, which seems likely to spread exponentially from several foci, one being likely to be commercial sex workers and their clients. • Brief educational interventions targeting commercial sex workers can have major impacts on STD incidence as well as knowledge, attitudes and risky behaviors of client sex workers, potentially reducing risk of spread of HIV both within this subpopulation and between this population and the general population.

  18. References • All photos from Associated Press • China STD map from US embassy in China website. • Background and Statistics from: • China and AIDS--the time to act is now.Science. 2002 Jun 28;296(5577):2339-40. • Portsmouth S, Stebbing J, Keyi Z, Jianping Z, Guohua P. HIV and AIDS in the People’s Republic of China: a collaborative review. International Journal of STD & AIDS. 2003 Nov; 14(11):757-761. • Xinha S, Junhua N, Qili G. AIDS and HIV infection in China. AIDS 1994; 8(S2):S55-59.

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