The Effectiveness Of An Intervention Promoting The Female Condom To Female Sex Workers In P City, Guangxi Province

Background and significanceChina’s a drastic change in sexual norms and behaviors over that past three decades has been accompanied by the expansion of sexually transmitted infections (STIs) including HIV/AIDS epidemics which become an important issue of public health. Commercial sex is the one of mainly influential risk behaviors in the STIs epidemics. Female sex workers (hereinafter referred to as FSWs or women) are the key population in that issue.Multipurpose barrier methods have been the most effective preventive devices for STIs to date, which provide the dual protection against unwanted pregnancy and the transmission of sexually transmitted disease. Now the condom includes the male condom (MC) and the female condom (FC). Though male condom (MC) has been promoted efficiently for more than a decade in China, there remains some obstacles to achieve "100%Condom Use" among FSWs only through MC-only intervention. FC is an intravaginal barrier method that is designed for overcoming drawbacks of MC. However, to date there have been very few studies about FC acceptability and use in China, or about the potential effects of integrating FC into the existing MC promotion.ObjectivesThe objectives of this study were to evaluate the effects of FC inclusion in MC promotion efforts through examination of FC acceptability and overall rates of protected sex among FSWs in P city, Guangxi province.MethodsThis study included the design and implementation of an FC intervention and evaluation of outcomes.The FC intervention was implemented mainly through outreach to sex-work establishments, delivering FC knowledge, training the skill and providing free FC1(also including domestic Phoenurse FC at the second year) among women working in sex establishments. The FC intervention was designed as a three-phase program with two6-month phases of introductive intervention and a12-month phrase of routine intervention.Interdisciplinary methods were used to evaluate FC intervention, including:(1)Four serial cross-sectional surveys of FSWs at baseline (pre-intervention), at6months,12months and at24months post-intervention were conducted. Women working in the targeted establishments who were16years or older and sexually active in the prior30days were eligible for the survey at any time point. All cross-sectional surveys were designed to recruit70%to80%of the total estimated women working in the targeted sex establishments.(2)The cohort was consisted of the women who were followed in three post-intervention cross-sectional surveys by matching their unique ID between surveys.(3)Ethnographic observations and interviews were conducted prior to, during and post intervention for collecting the data of the intervention implementation process. The proportions of ever used FC, FC recognition in last6months, FC uptake and overall protected sex in last30days among FSWs in pre-and post-intervention surveys were be compared. The associations between the outcomes and the levels of accepted intervention and other influential factors were also explored.ResultsThere were about152to155women participated in each cross-sectional survey. Aggregately112women’s unique ID codes were matched between at least two surveys. Thirty to forty percentages of women in each cross-sectional survey were matched to the prior surveys. In the fixed cohort based on the pre-intervention survey as the baseline,65participants were followed at least once in the three post-intervention surveys.1. Characteristics of participantsAt the four cross-sectional surveys, the mean age of participants ranged from32.5to34years old. Eighty percentages of women were married and2/3originated from Hunan or Hubei province. Approximately one third of participants worked in the boarding houses, and20-40%of these women worked in hairdresser/massage parlors and hotel-based massage, beauty and sauna parlors, respectively. The median age of first sexual experience and initiating sex work was19to20years old and27to28 years old. Ninety percentages of participants had experienced pregnancy, and2/3had an abortion. However, Twenty to thirty percentages of FSWs had no children.The number of women whose unique personal ID codes were matched among2\3\4surveys was69,28and15. The mean age of these women at "baseline" survey was over33years old, and the mean age of women with non-matched ID codes was30.9years old. The proportion of women from boarding houses among whom with matched ID code and with non-matched ID code were44%and29%.2. Intervention implementation and participationThe staff conducted nearly490outreach encounters to55establishments during the24months of three intervention phrases, and in half of these outreach, FC was delivered. More than2000FC with first generation (FC1),640domestic-made Phoenurse FC and20000MC were delivered in all. The times of outreach in the first year were about320, which was the double times in the second year. Mean times of outreach to the boarding houses during two years (in the first year:10.5; in the second year:5.3) was higher than the hairdresser (in the first year:5.6; in the second year:3.6) and hotel-based massage, beauty and sauna parlors (in the first year:5.8; in the second year:2.8).About70%of FSWs reported having participated in FC intervention activities, forty eight percentages having recognized the intervention tool (the flip chart as the mark) and24%having practiced FC insertion by herself at6months post-intervention survey. These three proportions were72%,63%,34%and78%,67%,22%at post-intervention12-month and24-month surveys, respectively.3. FC acceptabilityOne third of FSWs had heard of but no one had used FC at baseline. At the6-month,12-month and24-month post-intervention surveys, more than90%of FSWs reported knowing about FC, and30%-40%of FSWs have used FC at least one time, and50%-70%of them had used FC more than once. The proportion of women having used FC during the prior30days remained at about10%at three post-intervention surveys. The mean proportion of protected sex by FC ranges from1%to3%with primary and paying partners in the last30days at each post-intervention cross-sectional survey, which was lower than the proportions using MC (with primary partners:30%-42%; with paying partners:88%-92%).30%-40%FSWs reported they considered FC as an backup protection method or regularly used it in the last6 months at6months,12and24months post-intervention surveys.Seventy five percentages of women’s levels of FC recognition in last6months increased between two surveys that their interval was longest among112women whose ID codes were matched. The levels of FC recognition in last6months in the fixed cohort (N=65) showed a clear growth trend in four serial surveys.4. The level of protected sex before and after interventionAt the baseline survey,42.6%of the participants reported100%protected sex with all types of partners in the last30days. This proportion with clients and the primary partner was77.3%and33.3%, respectively. After intervention, this proportion had increased by (2.4%to6.4%) at the three post-intervention surveys. The proportion of women reported100%protected sex with clients increased by (6.2%to10.2%), but this proportion with the primary partner was stable at each post-intervention surveys.The trend of the level of protected sex in the last30days was not obviously between two surveys that their interval was longest among112women and in the fixed cohort.5. Factors associated with FC acceptability, protected sex and intervention implementation.5.1Quantitative assessmentThe indicators of FC acceptability,"ever having used FC" and "FC recognition in last six months " were associated with age, marriage status, establishment types and participation in intervention in the univariate analysis. Better participation in the intervention was consistently associated with ever having used FC (adjusted OR ranges from3.5to8.0) and recognized FC (adjusted OR ranges from3.4to9.0) in the last6months at three post-intervention surveys, controlling for age, establishment and sex partner and the level of protected sex by MC. Age may be an independent factor associated with FC acceptability, that is older than30years old was associated with recognized FC (adjusted OR=3.3,95%CI:1.1-9.4).As to the level of protected sex,"having100%protected sex in the last30days" was associated with establishment types, age, marriage status, reproductive history, sex partner types and number of sex partners in the univariate analysis. After adjustments for age, establishment and sex partner types, women who better participated in the intervention were more likely to have100%protected sex in the last30days at24month post-intervention survey (adjusted OR=1.9,95%CI:1.1-3.5), however we did not find the association at6month or12month post-intervention survey. Being from boarding house, older than30years old and having primary partner less likely to have100%protected sex in the last30days.5.2Qualitative assessmentMost of women had a negative attitude towards the FC appearance and usage, but some women recognized the FC’s protection and were willing to learn how to use it. Men were pay attention to whether the FC increases sexual joy, but women emphasized the safety of FC. The difference between middle-aged women and youth women on the willingness and ability of using condom, the rule of sex establishments, the chance of accepted intervention in establishment may associate with FC acceptability. In addition, some women were more likely to first try FC with primary partners than with paying partners when they were learning the skill. If they were familiar with FC, they were more likely to sustain FC use with paying partners.On the other hand, good relationship with FSWs was the basic of intervention implementation. The match between FSWs’working time and intervention time, the room in the establishment for intervention, the boss’s attitude towards intervention and the complexity of women in the sex establishments may associated with difficulty of implementing intervention and the chance of accepted intervention.ConclusionsAfter two-year FC intervention along with MC promotion among FSWs in P city, where the MC promotion progress had been made during the last10years, a considerable proportion of women accepted FC as a prevention method.The FC acceptability was not only associated with the level of accepted intervention,but also varied by women’s age and establishments. Moreover, the difficulty of intervention implementation and the chance of women accepted intervention were influenced by the relationship between outreach workers and FSWs and the complexity of the sex establishments.