Acceptability Of Women-Initiated HIV/STI Prevention Methods And Its Related Factors Among Female Sex Workers In Three Areas Of China

Background and significanceWith the changing of HIV transmission mode,sexual contact has become the most common mode of HIV transmission and the main driver of the epidemic in China.HIV antibody positive rate among FSWs increased year after year,which might increase the risk of HIV transmission to general population.Prevention strategy and measures are sought to adapt to characteristics of HIV epidemic in China.Condom use is affected by knowledge and willingness of men,therefore its protection against HIV is limited in certain degrees.Research and development on HIV prevention methods easier for women to use are needed.Studies on acceptability of women-initiated HIV/STI prevention methods including microbicides and female condom among FSWs will establish important theoretical and practical basis for the future promotion of their use for HIV prevention.ObjectivesTo explore acceptability of women-initiated HIV/STI prevention methods including microbicides and female condom and its related factors among FSWs in three areas of China.MethodsA cross-sectional study was conducted with both quantitative and qualitative methods to collect data in Dehong,Yunnan province,Leshan,Sichuan province and Shenyang,Liaoning province.In the survey,FSWs in accordance with inclusion and exclusion criteria were recruited with convenience sampling.Their risk behaviors and the acceptability scores were measured by self-designed questionnaire and scales;EpiData version 3.1 software was used for data input and management and SPSS version 13.0 software was used for data analysis.In in-depth interviews and group focus discussions, FSWs were recruited by purposive and snowball sampling to gain comprehensive understanding of their acceptability and its related factors;and NVIVO version 8.0 software was used for coding and analysis of qualitative data.Results1.A total of 968 FSWs completed the questionnaires,including 329 in Dehong, 291 in Leshan and 348 in Shenyang.Among the participants,45.4 percent(439) were from medium class sex establishments and 54.6 percent(529) from low class ones. Average age of the participants was 28 years,and they were from 14 ethnics,82.1 percent(791) of whom were Han Chinese.Nearly half of them(43.9%) were single,24.7 percent married,20.5 percent divorced or separated,9.4 percent cohabited,and only 1.5 percent widowed.Majority(72.0%) of them had junior high school education or above, 208(21.8%) had primary school education and only 59(6.2%) never went to school. Their average income during the last month before the survey was about 3200 RMB yuan. Among all the participants,11.5 percent migrated from other provinces.Totally,72 FSWs were recruited in qualitative study,including 29 from Dehong,20 from Leshan and 23 from Shenyang.Thirty-one FSWs participated in in-depth interviews and 41 participated in six group focus discussions.2.Their average age at initiating commercial sex work was 25 years.Totally, 461(47.6%) participants reported to have a primary sexual partner currently,while 133(13.7%) had other sexual partners.In average,each FSW had 27 sexual partners and 32 vaginal sexual encounters,and 503 participants(52.1%) used condom consistently in the past 30 days.Vaginal sexual encounters with paying partners were significantly higher than those with primary and other partners(X~2=402.41,P=0.000).There was statistically significant difference in condom use rate and percentage of consistent condom use among varied types of sexual partners.The percentage of participants who had ever asked their paying,other and primary partners to use condoms was 95.6 percent, 78.9 percent and 62.1 percent,respectively.The main reason for inconsistent condom use with three types of partners was that men do not like using condom.Condom was the most commonly used contraception and HIV prevention methods by the participants. Majority of them reported they could insist on condom use,and the reason why condom was not used in sexual encounter included uncomfortableness of FSWs,poor quality of condom,and less sexual pleasure of their partners.3.Totally,127 of(13.1%) FSWs had ever been diagnosed with an STD;604 (62.5%) had ever had a HIV test;and four(0.7%) were HIV antibody positive.Among 593(61.5%) FSWs who had ever been pregnant,442(74.5%) of them had aborted at least once.A total of 419(43.3%) participants reported experiences with vaginal lubrication,481(50.2%) reported experiences with vaginal pills/suppositories,850(88. 1%) douched their vagina after sex.Nearly half(475) of the FSWs were very worried about contracting STI,and nearly 60 percent(550) were very worried about contracting HIV,with statistically significant difference among study sites(P＜0.001).Score of women's STI internal locus of control averaged 2.88(with full score of four),that of STI locus of control by their partners averaged 2.58,and that of STI locus of control by chance averaged 1.91.The most frequently used contraception methods by interviewees included condom,oral contraceptive pills and IUD.Besides condom,the most frequently used HIV prevention methods included oral anti-inflammation pills,careful choice of partners,physical examinations,vaginal douching,and so on.4.Among the participants,189(19.5%) had ever heard of female condom,of which 22(2.3%) had ever used it.Mean score of female condom acceptability was 2.52 (with full score of four).Univariate analysis indicated that the score of acceptability varied by the study sites,class and features of sex establishments,income,marital status and education level of the participants.Women who worried more about contracting HIV or STI had a higher acceptability score than those worried a little or not at all(x~2=9.69, P=0.008 and x~2=6.06,P=0.048,respectively).Women who had ever been pregnant had higher acceptability score than those had not(Z=-2.38,P=0.017).Logistic regression analysis showed that female condom acceptability in FSWs were associated with the study sites,their experience of being refused to use condom,STI internal locus of control, and STI locus of control by their partners.Majority of interviewees believed that their partners would not accept female condom use.Disadvantages of female condom included inconvenience in its placement,poor appearance,uncomfortableness of its hard inner ring,embarrassment by noise during sex,less sexual pleasure,and so on.Its advantages included women's initiative use without knowledge of their partners,more protection area of the vagina than condom,convenience for ejaculation,and so on.5.Mean score of microbicides acceptability for all FSWs surveyed was 2.88(with full score of four).Microbicides acceptability score of FSWs varied by the study sites, class and features of sex establishments,age and education level of FSWs,their experience of asking partners for condom use and being refused by partners,history of HIV test,pregnancy,abortion and vaginal product use(P＜0.05).Women who very worried about contracting HIV or STI had a significantly higher score than those worried a little or not at all(x~2=39.95,P=0.000 and x~2=32.16,P=0.000,respectively).There was statistically significant difference in participants' willingness to use microbicides (x~2=47.39,P=0.000) and covert use of it(x~2=102.86,P=0.000) among varied types of partners.Logistic regression analysis indicated that microbicides acceptability in FSWs were associated with their experiences of vaginal product use and being refused to use condom by their partners,their STI internal locus of control and worrying about contracting HIV.Interviewees had generally positive response to microbicides use;and they also believed that their partners had a higher acceptability to microbicides.Factors related to their microbicides acceptability included characteristics(forms,placement methods,color and odor,package and storage),function(effectiveness,time of action initiation and persistence,and side effects),price of the products and FSWs' mentality to follow the majority.ConclusionsCondom is the most frequently used prevention method during sexual encounters with FSWs' partners.However,percentage of the participants who use condoms in every sexual encounters and condom use rate are still very low.Main reasons why condom is not used consistently include unwillingness and refusal by their partners.The participants have generally positive response to women-initiated HIV/STI prevention methods, especially microbicides,indicating female condom and microbicides may act as supplements to condom and further,satisfy women's special needs in HIV/STI prevention.Factors related to the acceptability of women-initiated HIV/AIDS prevention methods include characteristics,function and price of the products,FSWs' individual characteristics,and socio-cultural environmental factors,which should be emphasized to bring women's initiation into effects during future promotion and application of these methods in order to make sense to HIV/STI prevention.