| BackgroundSince the USA reported the first case in 1981, acquired immune deficiency syndrome/human immunodeficiency virus (AIDS/HIV) has become a worldwide epidemic. AIDS/HIV epidemic has become a major global public health and social problems in many countries and one of the most serious infectious diseases to human life and health. It increasingly contributes to the erosion of civil order and economic growth. Sexual transmission, blood transmission, and mother-to-child transmission are the dominant modes of HIV transmissions, and about three-quarters of AIDS/HIV were through sexual transmission.Although the AIDS epidemic in China is still in the overall low prevalence, there are significant geographic variations in HIV prevalence in difference Province, some specific groups have emerged high HIV prevalence. Illegal blood and plasma donor was eliminated. Heterosexual contact has become the dominant modes of HIV transmission. About one third infected HIV through heterosexual transmission was through their partners. Heterosexual sexual transmission among cumulative HIV infection increased from 10.7% in 2005 to 47.1% in 2009.Since the 1980s the number of female commercial sex workers (FSWs) has markedly increased in China. The number of women engaging in commercial sex is estimated to be 4 to 10 million. Commercial sex plays a critical role in heterosexual transmission of HIV in China. Sex trade is not accepted by Chinese ethical standards and there is a substantial stigma to FSWs. They are discriminated and marginalized in China. However, some women become FSWs possibly due to being attracted by the relatively high income. According to previous reviews, most FSWs in China are young, mobile, less educated, and some FSWs have also reported substance abuse. However, a recent review reported rates of consistent condom use with their clients among FSWs in China of between 13% and 54%. Recent national comprehensive surveillance data showed that 60% of FSWs in China do not use condoms regularly.FSWs are playing more and more important role in the transmission of HIV infection. Since the majority of FSWs not only have commercial sexual partners but also have one or more noncommercial steady or casual sexual partners at the same time, once FSWs get infected with HIV, their sexual partners are easy to get infected also through unprotected sexual behavior. Approximately 127,000 FSWs and their clients were living with HIV/AIDS, accounting for 19.6% of the total number of estimated HIV cases at the end of 2005. Heterosexual transmission of HIV through contact with FSWs is of particular concern. Data from national sentinel surveillance indicated that the prevalence of HIV among FSWs averaged 1%, with the highest rates at 10% in several sites.10.3% national FSWs sentinel surveillance reported the prevalence of HIV from 1.0% to 5.0% in 2009.Because there is no vaccine or cure, HIV prevention depends on one's ability to modify risky behaviors. The key to containing the spread of HIV is changing individual's HIV risk behaviors. Consistent and correct condom use seems to be the most effective form of HIV prevention among FSWs. It would be imperative to determine predictors of consistent condom use among FSWs to develop effective interventions for the prevention of HIV spread in China.FSWs'HIV risk behaviors are affected by social, psychological and other complicated factors. Most models of HIV sexual transmission risk behavior in HIV are based upon social/health psychology theories to predict whether or not individuals will use condoms when having sex. These models include the Theory of Reasoned Action, with attitudes and intentions as key factors, the AIDS Risk Reduction Model, emphasizing behavior change stages of labeling, commitment, and enactment, the Information-Motivation-Behavior model, and Social Cognitive Theory, with self-efficacy being a central factor. Each of these models, to greater or lesser extents emphasizes the cognitive pathways involved in behavior change. The ARRM model above, however also, allows for a consideration of affective components (condom enjoyment) and sexual communication skills, in addition to purely cognitive constructs to explicate the pathways to sexual risk.The Information-Motivation-Behavioral Skills (IMB) model developed by Fisher and his colleagues was designed to predict HIV preventive behavior and necessary elements HIV prevention intervention. The conceptualization of the IMB model holds that HIV prevention information, motivation, and behavioral skills are the fundamental determinants of HIV preventive behavior. This study was designed to examine the IMB model and to describe the relationships between IMB model constructs.Nearly all these studies among FSWs were based on institution samples or convenience samples. However, institution samples may not be representative of the general FSW population. Furthermore, FSWs are a heterogeneous group and operate in a multiple-layer hierarchy. FSWs working in the entertainment establishments are in the middle of the spectrum and may be the most accessible group. We know little about the FSWs in either the higher ranks or the lower ranks of the hierarchy.Respondent-Driven Sampling (RDS) was used to recruit participants. RDS is an adaptation of chain-referral sampling and a suitable sampling method for hidden populations, which can provide relatively unbiased and representative population-based estimates. One advantage of RDS over other methods of sampling hidden populations, such as time-location sampling, is that it requires little in-depth formative research among study populations. RDS begins with a set number of non-randomly selected seeds (members of the target population). Seeds recruit their peers (other target population members who make up their social network) who in turn recruit their peers into the study. This occurs through successive waves of recruits which become increasingly more representative of the underlying population as the recruitment progresses. Many researchers have assumed that sampling can proceed without detailed prior knowledge about the local target population. RDS has proved feasible and successful in recruiting hidden populations, such as men who have sex with men, sex workers and drug-injecting sex worker. Objects1. Examine the reliability of the questionnaire using the test-retest reliability, Cronbach's alpha coefficient, and the harmonious reliability.2. Explore the feasibility of RDS in the recruitment of female sex workers.3. Understand demographics of FSWs and HIV/STDs prevalence.4. Understand HIV-related high risk behaviors among female sex workers.5. Examine the predictors of condom use with clients during vaginal intercourse among FSWs based on the MB model and to describe the relationships between IMB model constructs.Methods1. Study participantsThe selection criteria for eligible FSW seeds and participants were defined as "a female over the age of 16 who has exchanged sex for money and has lived in Jinan in the past month and is not inebriated at the interview." Each seed or participant had a coded coupon.2. Recruitment of seeds and study participantsRDS was used to recruit female sex workers, and four seeds were initially selected. Each seed or participant was asked to recruit no more than three peers. Each seed was given three uniquely coded coupons to refer their peers. The desired sample size will be gotten by this chain-referral sampling method. Seeds and their recruits were given an incentive package including 50 Yuan, HIV prevention pamphlets and four boxes of condoms for successfully participating, plus an additional 20 Yuan for recruiting a FSW.3. MeasuresA structured questionnaire was used to collect data administered by trained female interviewers. Questionnaire-based interviews provided demographic and social information, sexual behaviors and condom use, drug use and health seeking behavioral information, AIDS/STDs knowledge, the constructs of the IMB model, and etc. Blood samples were collected from all participants to test their status of HIV, HBV, HCV, and syphilis prevalence. We also provide gynecological examination to test cervical and vaginal secretions that interviews voluntarily participated.4. Data analysisSurvey data were recorded with EpiData software. NetDraw software was applied for graphing the recruitment chains, and RDSAT software was used to exaime the equilibrium and representation of Sample. SPSS11.0 software was applied for all statistical analyses, such as mean, variance analysis, chi-square test, stratified analysis. The hypothetical IMB was examined by structural equation model (SEM) using the LISREL.Results1. Test-retest reliability was accepted (r≥0.4); most of Chronbanch's a were over 0.7.2. In total 427 participants, were recruited for the study. The longest recruitment tree had 21 recruitment "waves", the evaluation variables including age, educational level, ethnicity, permanent residence, marital status have reached equilibrium.3. Mean age of the sample was 29.6 years (SD=7.4),66.7% were older than 25 years,99.1% was Han in ethnicity,66.0% received middle school education or less, and 32.6% were divorced or widowed.45.7% had no children. The majority (82.7%) earned more than 2,000 Yuan (or approximately U.S.＄300) per month.40.5% worked in night clubs/dance hall/karaoke bars/bars,13.2% worked in street based entertainment and hair/beauty salons.4. FSWs had low lever in AIDS/STDs knowledge. The AIDS/HIV knowledge score≥13 were 39.6%. Education levels were significant different in AIDS/HIV knowledge score. The major mode for FSWs to access AIDS/HIV knowledge was television, accounting for 75.4%, followed by newspapers/magazine, accounting for 41.0%. A few FSWs access AIDS/HIV knowledge were through health services, and 58.6% have never received free health service.5. The mean age of first lifetime sex was 20.2(SD=2.5), and the age of first lifetime sex was from 13 to 28 years old. The age of first commercial sex was from 13 to 40 years old. Sex work experience was from 1 to 228 months, and the mean of sex work experience was 37.0(SD=40.2) months. More than half had>2 years of sex wok experience. The number of clients was from 0 to 70 in the last week and the number of clients in the last month was 1 to 260. The mean number of clients was 4.5(SD=8.4) in the last week and the mean number of clients in the last month was 14.3(SD=25.1). The FSWs in low-status have and longer sex work experience and more the number of clients compared with the FSWs in middle/high status.6. Using condoms with clients every time during vaginal, oral, and anal intercourse in the last month were 47.1%,48.7%, and 52.2% respectively. Different the number of clients, sex work experience, first sex lifetime and marriage status were have difference condom use rate during vaginal intercourse with clients in the last month(P<0.05).48.0% have commercial sexual partners also have noncommercial steady and causal sexual partners at the same time; 81.5% have noncommercial steady sexual partner(s); 53.4% have noncommercial casual sexual partner(s). FSWs that have noncommercial casual sexual partner(s) were different in condom use when they have sex with clients and noncommercial casual sexual partner(s) (P<0.05).7.79.9% drank alcohol, and 12.6% used drugs.33.3% drug using FSWs reported using condoms with clients every time during vaginal intercourse in the last month. 35.5% age of drug using FSWs was>30, and 88.9% drug using FSWs were middle/high status.8.89.7% have ever been pregnant, and 80.0% had abortion(s).23.3% had over three abortions.77.7% of FSWs who had gynecological disease in the last fell gynecological disease.44.7% have used antibiotics for preventing HIV.63.9% reported ever appeared STD-related/ gynecological disease symptoms. If FSWs get STDs,77.6% FSW will choose hospital to treatment, and 12.6% will choose to treat by medicine from shopping. Only 19.4% of the women were tested for HIV in the past year.9. Syphilis infection and HBV rate were 6.3% and 4.2%. Mould and Chlamydia infection rate among FSWs who voluntarily received gynecological examination in this study were 8.3% and 6.6%.51.9% infected syphilis FSWs have more than two years sex work experience.63.0% age of infected syphilis FSWs were>30. Different age, education level, martial status, and registered permanent residence have significant different syphilis rates(P<0.05).10. The final traditional model was confirmed as a good fit (x2=143.76,73 df, CFI=0.98, RMSEA=0.08). Condom use among FSWs was predicted by motivation and behavioral skills. Information and motivation had the indirect effects on condom use mediated by behavioral skills.11. The final developed model was accepted x2=405.50,206 df, CFI=0.97, RMSEA=0.05, NNFI=0.95. The explained variances for condom use, health behaviors and condom use skills, and self-efficacy were 38%,57%, and 43%, respectively. Significant predictors of condom use were social referents support, experiences with and attitudes toward condoms, self-efficacy, and health behaviors and condom use skills. Health behaviors and condom use skills was significantly predicted by HIV knowledge, perceived risk, and social referents support. Significant predictors of self-efficacy included HIV knowledge, motivation to comply, social referents support, and substance use.The indirect effects on condom use as reported in the trimmed model were also examined. Variables that indirectly affected condom use through health behaviors and condom use skills or self-efficacy variables included HIV knowledge (p<0.001), social referents support (p≤0.001), and substance use (p≤0.05).Conclusions1. The reliability of the questionnaire was acceptable. However, we recognize that self-reporting bias may exist. The reliability of study participant responses may be questionable due the sensitive nature of responses about sexual practices.2. RDS methods were feasible and effective to attain sufficient samples of FSW. Further research is needed to assess how the practicalities of implementing RDS to abtain more representative FSWs population.3. FSWs reduced mobility in regions and strength mobility in workplaces. FSWs have low AIDS/HIV knowledge level. These misconceptions may result in less compliance in using a condom. These results suggest that more attention is needed toward strengthening education about specific AIDS/HIV knowledge where it is lacking.4. FSWs who were unmarried, low-status, the fist sex lifetime<18, more than two years sex work experience, have steady sexual partner had low condom use rates with clients during vaginal intercourse in the last month. FSWs have low condom use with their stable partners and noncommercial casual sexual partners. The AIDS/HIV intervention should increase their responsibility for safe sex and the awareness of FSWs about AIDS/HIV.5. FSWs in low-status have low STD-related symptom knowledge level, and longer sex work experience, more the number client in the last month, and low condom use rate. In the future intervention should focus on FSWs in low-status.6. Most of FSWs drank alcohol and smoked. Condom use rate of drug using FSWs was lower than no-drug using FSWs; sex worker experience was longer than no-drug using FSWs.7. The specific elements of the IMB model that are critical for condom use among FSWs were identified and confirmed the central proposition that information and motivation works mainly through behavioral skills to influence HIV prevention behaviors. The relationships between constructs of the IMB model were also examined. Our findings have implications for the development of HIV risk reduction interventions for FSWs. Further study should explore effective interventions based on the current study's findings.8. The current study confirmed the role of social referents support and motivation to comply. HIV intervention for FSWs needs to be multilevel, integrating social factors into the intervention. Enhancing social referents support for condom use may be an important strategy to increase condom use.9. AIDS/HIV interventions should increase the awareness of FSWs about HIV and should address assertiveness training to refuse unsafe sex.10. Self-efficacy and health behaviors and condom use skills play an important role in condom use in FSWs. An awareness of the importance of engaging in health-promoting behaviors should be developed in FSWs. Also AIDS interventions should address enhancement of special communication skills so as to successfully negotiate safe sex.11. This study revealed that an indirect effect of substance use on condom use was significant and that lower levels of substance use accompanied positive experiences with and attitudes toward condom.Significance and innovation1. Using three methods examined the reliability of questionnaire. These results may contribute to improve the reliability of questionnaire in this population.2. Our sample is an approximate representative of FSWs using RDS recruit participants. We explored the feasibility of RDS and identified some barriers to successful recruitment among FSWs, which will provide reference for future research in this population and other hidden populations.3. The study based on the IMB model and developed the theory. The developed IMB model is effective to predict the determinant factors of condom use with client among FSWS in China. Further research is warranted to develop preventive interventions on the basis of the IMB model to promote condom use among FSWs in China.
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