Working to prevent HIV/STIs among women in the sex industry in a rural town of Hainan, China

Evidence and gap map report: Social and Behavior Change Communication (SBCC) interventions for strengthening HIV prevention and research among adolescent girls and young women (AGYW) in low- and middle-income countries (LMICs)

Background

Adolescent girls and young women (AGYW), aged 15-24 years, are disproportionately affected by HIV and other sexual and reproductive health (SRH) risks due to varying social, cultural, and economic factors that affect their choices and shape their knowledge, understanding, and practices with regard to their health. Socio-Behavioral Change Communication (SBCC) interventions targeted at strengthening the capabilities of individuals and their networks have supported the demand and uptake of prevention services and participation in biomedical research. However, despite growing global recognition of the domain, high-quality evidence on the effectiveness of SBCC remains scattered. This evidence and gap map (EGM) report characterizes the evidence base on SBCC interventions for strengthening HIV Prevention and Research among AGYW in low- and middle-income countries (LMICs), identifying evidence gaps and outlining the scope of future research and program design.

Objectives

The objectives of the proposed EGM are to: (a) identify and map existing EGMs in the use of diverse SBCC strategies to strengthen the adoption of HIV prevention measures and participation in research among AGYW in LMICs and (b) identify areas where more interventions and evidence are needed to inform the design of future SBCC strategies and programs for AGYW engagement in HIV prevention and research.

Methods

This EGM is based on a comprehensive search of systematic reviews and impact evaluations corresponding to a range of interventions and outcomes-aimed at engaging AGYW in HIV prevention and research - that were published in LMICs from January 2000 to April 2021. Based on guidance for producing a Campbell Collaboration EGM, the intervention and outcome framework was designed in consultation with a group of experts. These interventions were categorized across four broad intervention themes: mass-media, community-based, interpersonal, and Information Communication and Technology (ICT)/Digital Media-based interventions. They were further sub-categorized into 15 intervention categories. Included studies looked at 23 unique behavioral and health outcomes such as knowledge attitude and skills, relationship dynamics, household dynamics, health care services, and health outcomes and research engagement. The EGM is presented as a matrix in which the rows are intervention categories/sub-categories, and the columns are outcome domains/subdomains. Each cell is mapped to an intervention targeted at outcomes. Additional filters like region, country, study design, age group, funding agency, influencers, population group, publication status, study confidence, setting, and year of publication have been added.

Selection Criteria

To be eligible, studies must have tested the effectiveness of SBCC interventions at engaging AGYW in LMICs in HIV prevention and research. The study sample must have consisted of AGYW between the ages of 15-24, as defined by UNAIDS. Both experimental (random assignment) and quasi-experimental studies that included a comparison group were eligible. Relevant outcomes included those at the individual, influencer, and institutional levels, along with those targeting research engagement and prevention-related outcomes.

Results

This EGM comprises 415 impact evaluations and 43 systematic reviews. Interventions like peer-led interactions, counseling, and community dialogues were the most dominant intervention sub-types. Despite increased digital penetration use of media and technology-driven interventions are relatively less studied. Most of the interventions were delivered by peers, health care providers, and educators, largely in school-based settings, and in many cases are part of sex-education curricula. Evidence across geographies was mostly concentrated in Sub-Saharan Africa (70%). Most measured outcomes focused on disease-related knowledge dissemination and enhancing awareness of available prevention options/strategies. These included messaging around consistent condom use, limiting sexual partners, routine testing, and awareness. Very few studies were able to include psychographic, social, and contextual factors influencing AGYW health behaviors and decisions, especially those measuring the impact of social and gender norms, relationship dynamics, and household dynamics-related outcomes. Outcomes related to engagement in the research were least studied.

Conclusion

This EGM highlights that evidence is heavily concentrated within the awareness-intent spectrum of behavior change and gets lean for outcomes situated within the intent-action and the action-habit formation spectrum of the behavior change continuum. Most of the evidence was concentrated on increasing awareness, knowledge, and building risk perception around SRH domains, however, fewer studies focused on strengthening the agency and self-efficacy of individuals. Similarly, evidence on extrinsic factors-such as strengthening social and community norms, relationships, and household dynamics-that determine individual thought and action such as negotiation and life skills were also found to be less populated. Few studies explore the effectiveness of these interventions across diverse AGYW identities, like pregnant women and new mothers, sex workers, and people living with HIV, leading to limited understanding of the use of these interventions across multiple user segments including key influencers such as young men, partners, families, religious leaders, and community elders was relatively low. There is a need for better quality evidence that accounts for the diversity of experiences within these populations to understand what interventions work, for whom, and toward what outcome. Further, the evidence for use of digital and mass-media tools remains poorly populated. Given the increasing penetration of these tools and growing media literacy on one end, with widening gender-based gaps on the other, it is imperative to gather more high-quality evidence on their effectiveness. Timely evidence generation can help leverage these platforms appropriately and enable intervention designs that are responsive to changing communication ecologies of AGYW. SBCC can play a critical role in helping researchers meaningfully engage and collaborate with communities as equal stakeholders, however, this remains poorly evidenced and calls for investigation and investment. A full list of abbreviations and acronyms are available in Supporting Information: Appendix F.

A thematic analysis of experiences of HIV risks among female sex workers in the Yunnan-Vietnam Chinese border region

Background

The Yunnan province is located near the “Golden Triangle” border region between China, Myanmar and Thailand, which has the highest HIV/AIDS prevalence in China. Female sex workers (FSWs) in the Yunnan province are highly vulnerable to HIV infection. The objective of this study was to examine the experiences of FSWs in the Yunnan to better understand the risk of infection and the potential for transmission of HIV.

Methods

Semi-structured interviews were conducted between May 2018 and June 2018 with 20 FSWs recruited in Hekou County, Yunnan Province, China. Thematic analysis was conducted to identify themes that highlighted increased exposure of FSWs to the risk of HIV infection and transmission.

Results

The findings showed that FSWs’ primary source for HIV information was gynecologists, with few visiting the local HIV charity Red Ribbon. FSWs reported infrequent visits for check-ups with some seeing a gynecologist once a year. FSWs felt that the onus was on them to prevent STI/HIV infection by using a condom during sex, regardless of their ability to negotiate use. FSWs were also reluctant to see a gynecologists for treatment. Instead, they resorted to douching as a way of preventing HIV/STIs and treating vaginal health problems, such as leucorrhea. Most FSWs worked without the influence of alcohol and drugs. A small number of FSWs reported heroin addiction and injecting drug use.

Conclusion

The findings suggest a need for innovative HIV prevention strategies among FSWs and their clients in the Chinese border region. Governmental agencies should continue to implement practical strategies in terms of HIV prevention education and condom use through tailored interventions that are localized. Such strategies should include localized tailored interventions that dispel myths about douching as a method of HIV/STI prevention and incorporate a mobile outreach approach, similar to the ‘roadside restaurant’ outreach that has been successful in rural China.

Efficacy of Human Immunodeficiency Virus/Sexually Transmitted Infection Prevention Interventions Targeting Female Entertainment Workers: A Systematic Review and Meta-analysis

Female entertainment workers (FEWs) working in karaoke lounges, bars, pubs, nightclubs, discotheques, dance halls, massage parlours, restaurants (as hostesses or singers) and beer gardens are at high risk for human immunodeficiency virus (HIV)/sexually transmitted infection (STI). The aim of the systematic review and meta-analysis is to evaluate the efficacy of HIV/STI intervention programmes targeting FEWs. Among the 14 included studies, majority were in Asia and targeted native FEWs. Most studies were quasi-experimental and the overall quality was relatively low. While most studies employed only behavioural strategies, structural interventions were the least common. In studies with structural interventions, there was a preference for behavioural and biomedical-based outcome measurements rather than structural-related indicators. FEWs in the intervention group were significantly more likely to report condom use with paying (odds ratio OR 1.7; 95% CI 1.0-2.9, p 0.04), but not with regular (OR 1.0; 95% CI 0.8-1.3, p 0.84) partner than the control/comparison group post-intervention.

Effectiveness of a Peer-Assisted Multicomponent Behavioral Intervention in HIV Risk Reduction Among Female Entertainment Workers in China

This study examined the effectiveness of a behavioral intervention that combined cognitive and social influence approaches. The intervention consisted of small group sessions targeting HIV knowledge, protection motivation, behavioral skills, and social influences of risk reduction. The control was an attention-controlled HIV/STI health education and counseling. Two-group comparisons were conducted to assess the effectiveness of the intervention; risk reduction over time was analyzed to determine the sustainability of the effectiveness. The analyses revealed that the intervention was effective in reducing/increasing HIV risk/protective behaviors and the effect was sustainable. While participants in the control reported a greater reduction/increase in risk/protective behaviors 3-month post-intervention, the initial strong effect quickly faded and completely disappeared 12-month post-intervention. By contrast, the moderate initial effect of the intervention was not only sustained but actually strengthened over time. The intervention was well received by participants and holds promise for HIV risk reduction behavior change among female entertainment workers in China.

Female sex workers and their gatekeepers in China: implications for HIV/STI prevention

Female sex workers (FSWs) play a key role in HIV/AIDS transmission and their gatekeepers play a crucial role in shaping their behaviors. Limited studies are available on the relationship between FSWs and gatekeepers. In the current study we used an ethnographic approach to examine the dynamic and multidimensional relationship of FSWs and their gatekeepers from the perspectives of both parties. We recruited 38 FSWs and 16 gatekeepers from different types of commercial sex venues in Guangxi, China, and conducted in-depth individual interviews. Our data suggest that FSWs and gatekeepers maintain an interdependent and reciprocal relationship during their business practice, but gatekeepers exert significant influence and control over FSWs. Designing culturally appropriate HIV/STI-prevention programs requires us to take advantage of the unique and crucial roles of gatekeepers. We conclude with a call for structural interventions to protect FSWs' occupational health and safety.

Prevalence and factors associated with HIV infection among injection drug users at methadone clinics in Taipei, Taiwan

BACKGROUND

Methadone treatment was introduced in Taiwan in 2006 as a harm-reduction program for injection drug users (IDUs), among whom HIV was endemic. We examined the association of HIV serostatus with demographic characteristics, substance use, and sexual behaviors among IDUs at methadone clinics in Taipei, Taiwan.

METHODS

During 2012-2013, IDUs at methadone clinics in Taipei were recruited to complete a risk assessment interview and undergo serologic testing for HIV infection. Correlates of HIV infection were identified by multivariate logistic regression.

RESULTS

Of the 827 eligible participants, 85.9% were male, median age was 45 years, and mean years of injecting was 18.0 (range 1-56). The prevalence of HIV infection was 17.7%. In multivariate analysis, HIV infection was significantly associated with age ≤ 45 years (adjusted odds ratio [AOR] = 1.62, 95% confidence interval [CI] 1.01-2.62), being divorced (AOR = 1.67, 95% CI 1.06-2.62), deriving the majority of income during the previous 6 months from temporary jobs or other noncriminal sources (AOR = 1.53, 95% CI 1.02-2.30), unstable housing during the previous 6 months (AOR = 1.47, 95% CI 1.003-2.15), higher number of incarcerations (AOR = 1.14, 95% CI 1.03-1.26), and a history of overdose (AOR = 1.51, 95% CI 1.01-2.28).

CONCLUSIONS

Taiwanese IDUs at methadone clinics have a relatively high HIV prevalence, which was associated with younger age and history of overdose. It is imperative to educate IDUs' about HIV transmission, particularly for the younger and overdosed IDUs.

Multilevel dynamic systems affecting introduction of HIV/STI prevention innovations among Chinese women in sex work establishments

Social and public health scientists are increasingly interested in applying system dynamics theory to improve understanding and to harness the forces of change within complex, multilevel systems that affect community intervention implementation, effects, and sustainability. Building a system dynamics model based on ethnographic case study has the advantage of using empirically documented contextual factors and processes of change in a real-world and real-time setting that can then be tested in the same and other settings. System dynamics modeling offers great promise for addressing persistent problems like HIV and other sexually transmitted epidemics, particularly in complex rapidly developing countries such as China. We generated a system dynamics model of a multilevel intervention we conducted to promote female condoms for HIV/sexually transmitted infection (STI) prevention among Chinese women in sex work establishments. The model reflects factors and forces affecting the study's intervention, implementation, and effects. To build this conceptual model, we drew on our experiences and findings from this intensive, longitudinal mixed-ethnographic and quantitative four-town comparative case study (2007-2012) of the sex work establishments, the intervention conducted in them, and factors likely to explain variation in process and outcomes in the four towns. Multiple feedback loops in the sex work establishments, women's social networks, and the health organization responsible for implementing HIV/STI interventions in each town and at the town level directly or indirectly influenced the female condom intervention. We present the conceptual system dynamics model and discuss how further testing in this and other settings can inform future community interventions to reduce HIV and STIs.

Promoting female condoms in the sex industry in 4 towns of Southern China: context matters

BACKGROUND

The female condom (FC) is an effective tool for dual protection, but it remains underused. Individual and contextual reasons need to be explored.

OBJECTIVE

The aim of this study was to compare individual and contextual characteristics of FC multitime users, 1-time users, and nonusers among women in the sex industry of 4 study sites in China.

METHODS

A standardized 1-year FC intervention along with male condoms was implemented through outreach to sex establishments. Three serial cross-sectional surveys were conducted at baseline and after each of two 6-month intervention phases.

RESULTS

A total of 445, 437, and 290 eligible women were interviewed at 3 cross-sectional surveys, respectively. At the first and second postintervention surveys, 83.3% and 81.7% of women reported knowing about FC, and 28.8% and 36.6% had used FC at least once. Women who used FC multiple times reported less unprotected sex than nonusers in the last 30 days (3.0% vs. 17.2% at first and 3.2% vs. 16.8% at second postintervention survey, P < 0.01). Polytomous logistic regression showed that both 1-time and multitime users were more likely to come from one particular site (approximately 3 times more than the reference site). Higher intervention scores (adjusted odds ratio, 1.8-4.0) and working in boarding houses (adjusted odds ratio, 3.4) were associated with FC use.

CONCLUSIONS

Adding FC into male-condom-only intervention may reduce unprotected sex among women in sex establishments in rural and small urban areas of China. Adoption of FC may be related not only to intervention exposure but also to contextual factors associated with study site and type of sex establishments.

High HIV prevalence and risk of infection among rural-to-urban migrants in various migration stages in China: a systematic review and meta-analysis

BACKGROUND

Rural-to-urban migrants represent 17% of the total Chinese population and are considered a potential high-risk bridging population of HIV infection between urban and rural China.

METHOD

Based on a systematic review and meta-analysis, this study determined HIV prevalence among rural-to-urban migrants in different stages of migration. This review was conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

We identified 54 studies reporting 59 HIV prevalence levels among rural-to-urban migrants in China. Overall, 53.4% (95% confidence interval, 33.5%-72.4%) of urban patients with HIV have migratory background. The floating-out population showed a higher HIV prevalence (0.15% [0.06%-0.34%]) than did the Chinese population (0.057%; odds ratio, 2.63 [1.35-5.14]). The floating-in population showed a higher HIV prevalence (0.38% [0.29%-0.50%]), corresponding to 6.70 (6.05-7.41) times greater odds of HIV infection. Higher prevalence levels were observed among female migrants (0.69% [0.51%-0.93%]), reflecting a much higher odds of HIV infection (12.18 [11.11-13.35]). Infection risk among returning migrants (0.18% [0.12%-0.29%]) was 3.16 (2.06-4.84) times higher than the overall Chinese population. Chinese internal migrants contribute to a substantial amount of the overall HIV epidemic in China.

CONCLUSION

Migrants are at greater risk for HIV infection than the general Chinese population and likely to facilitate the geographical spread of HIV in China. Targeted strategies for health promotion and HIV prevention for migrants in China should be developed.

A health promotion logic model to review progress in HIV prevention in China

Using the theory and concepts of health promotion, this paper proposes a logic model for HIV/AIDS prevention and control which provides a structure for describing planned actions and predicted impacts/outcomes from comprehensive HIV prevention interventions. The potential usefulness of the model is examined by reviewing the evolution of HIV prevention and management in China, drawing on evidence from interventions reported from a mixture of study designs and formats. It reports that HIV interventions in China can be considered in two distinctive phases, before and after 2003 when China commenced its 'official' response to the HIV epidemic. The logic model was useful in comparing actions taken over these two periods highlighting the importance of political leadership in distinguishing between the two phases, and the continuing importance of systematic and broadly based public education and communication. We conclude that the logic model can not only be used as a planning model, but can also be applied retrospectively to assess successes and failures in national and local responses to HIV in complex social settings.

Systematic review of HIV prevention interventions in China: a health communication perspective

OBJECTIVES

To examine whether communication strategies and principles have been utilized in the HIV prevention intervention programs conducted in China.

METHODS

Comprehensive literature searches were conducted using PsycINFO, Medline, and Academic Search Complete with combinations of a number of keywords. Studies were included if they (1) were conducted in China and published prior to October 2011; (2) tested interventions promoting HIV/sexual risk reduction; and (3) reported empirical outcome evaluations on HIV knowledge, condom use and other condom-related variables. Data on 11 dimensions were extracted and analyzed, including formative research, theory, message targeting, messenger and channels, process evaluation, evaluation design, outcome measures.

RESULTS

The majority of the 45 intervention studies were not theory-based, did not report conducting formative research or process evaluation, used pretest-posttest control group designs, combined nonmedia channels, printed and visual materials, and employed HIV knowledge and condom use as outcome measures.

CONCLUSIONS

Many HIV prevention interventions in China have been successful in reducing HIV risk-related outcomes. This literature has its weaknesses; however, the current review illuminates gaps in the literature and points to important future directions for research.

Outreach with street-involved youth: a quantitative and qualitative review of the literature

Outreach workers meet with street-involved youth in their environment, and attempt to engage them in services vital to their well-being. The goal of this study is to conduct a systematic review of both the quantitative and qualitative research that explores outreach with street-involved youth. Using 16 outreach programs with quantitative information, our meta-analysis found that 63% of youth who are contacted through outreach later participate in the offered service. Our meta-synthesis of 31 qualitative articles on outreach uncovered 13 themes across 4 conceptual domains of interest. Themes pertaining to the therapeutic relationship, flexibility, and youth-centric programming had a large presence among the majority of the articles. Outreach with street-involved youth, when characterized through a strong bond between worker and youth, is an effective strategy for involving youth in agency services.

Understanding the diversity of male clients of sex workers in China and the implications for HIV prevention programmes

Male clients of sex workers have been overlooked in China's HIV prevention efforts. This study aims to examine men's practices and attitudes toward extramarital sexual relationships, motivations for visiting female sex workers (FSWs), perceptions of sexually transmitted infection (STI)/HIV risk and risk prevention strategies used. One hundred and eighty-six clients of FSWs with varying socio-economic statuses were interviewed in different sex work settings. Men described no conflict between their role as a client and a responsible family provider. They described social pressure from peers and business partners to visit FSWs, sexual pleasure and companionship as motivators to seek commercial sex. While some men reported no risks associated with visiting FSWs, others identified risks such as being arrested by the police, robbed by gangs and threatening the health of their families by contracting a STI. This study underscores the diversity of FSW clients and the need to understand the beliefs and behaviours of different client types to develop appropriate HIV prevention programmes. It also demonstrates the feasibility of recruiting different types of male clients, a hard-to-reach population for Chinese HIV prevention efforts.

Understanding the dynamics of condom use among female sex workers in China

OBJECTIVES AND BACKGROUND

Condom use within the context of commercial sex work is a complex issue. Drawing on a hypothesized theoretical model that combines concepts from the health belief model and social cognitive theory, this study examines the complex relationships between multiple levels of determinant factors of condom use with clients among female sex workers in China.

METHODS

Data were collected through the baseline survey of an HIV prevention project among 454 establishment-based female sex workers in a rural county of Guangxi, China in 2004. Path analysis was performed to test the hypothesized model that specifies relationships between all observed variables.

RESULTS

Within the context of this study's model, STD/HIV knowledge and condom use skills were related to self-efficacy which in turn related to condom use. Susceptibility/severity was related to perceived benefits of unprotected sex. Perceived benefits were in turn inversely related to condom use. STD/ HIV knowledge, condom use skills, and susceptibility/severity had no direct effect on condom use. Their effects on condom use were mediated by self-efficacy and perceived benefits. Self-efficacy was not associated with perceived benefits of unprotected sex. Perceived establishment-level support was positively related to condom use.

CONCLUSIONS

Self-efficacy, perceived benefits of unprotected sex, and perceived establishment-level support are proximate determinants of condom use among female sex workers. Future HIV prevention interventions should integrate these factors into conceptual frameworks.

Female condom use in the rural sex industry in China: analysis of users and non-users at post-intervention surveys

Changes in sexual attitudes and behaviors and resurgence of the sex industry in China have increased concerns about HIV/AIDS and sexually transmitted infections (STI) epidemics. Little attention has been paid to the significant and growing sex industry in rural China. Promotion of barrier protection in this context is most effective to prevent STIs and pregnancy. The female condom (FC) is a barrier method that gives women more autonomy in its application, and has other advantages, but has been little promoted and tested in high risk contexts in China. The China/US Women's Health Project was designed to promote FC use in addition to male condoms (MC) through outreach intervention conducted in sex work establishments in rural and small urban towns in southern China, using the original prototype FC1. The study used quantitative and qualitative methods to document the pre-intervention context, intervention delivery process, and post-intervention outcomes of FC use. In this paper we compare post-intervention FC users and non-users in the first study sites, two rural towns in a single county in Hainan Province. Examination of cross-sectional six-month and 12-month surveys indicated that, despite relatively high MC use, about one-third of the women in sex work establishments in these rural towns had adopted FC at each post-intervention survey. Compared with non-users, FC users were more likely to be freelance women in boarding houses, more sexually experienced, married with children, more sexually active in the prior month, and more exposed to the intervention. The rural context hampered intervention implementation, particularly the significant limits in health and human resources available to manage prevention of HIV/STIs among women in the sex industry. These challenges highlight the need to better understand the context of the rural sex industry and capacity of local resources for better prevention efforts and the benefits that new prevention technologies like FC can offer.

The efficacy of a peer-assisted multi-component behavioral intervention among female entertainment workers in China: an initial assessment

Women working in China's entertainment industry are at increased risk of acquiring or transmitting HIV/sexually transmitted infections (STIs). Efforts to develop effective risk-reduction interventions for female entertainment workers (FEWs) remain limited. We conducted a randomized controlled trial of a theory-based risk-reduction intervention among FEWs in Shanghai. The intervention condition consisted of small group, peer-assisted sessions integrating information-motivation-behavioral skills training with social influences of behavior change. The control condition was an attention-matched HIV, health education, and counseling. At three-month post-intervention, participants in the intervention condition reported greater reductions in unprotected sex with a stable partner than participants in the control condition. However, participants in the control condition reported greater reductions in unprotected sex with a non-stable partner than participants in the intervention condition. Some aspects of the study design may have diluted the effects of the intervention. Future intervention studies need to pay more attention to social influences of behavior change and the particular challenges of risk-reduction with stable partner(s).

Inclusion of the female condom in a male condom-only intervention in the sex industry in China: a cross-sectional analysis of pre- and post-intervention surveys in three study sites

OBJECTIVES

To describe female condom (FC) use, male condom (MC) use and overall levels of protected sex before, during and after FC education and promotion (using the original prototype FC) combined with MC promotion among female sex workers in three rural or small urban settings in southern China.

STUDY DESIGN

The 1-year FC intervention was conducted by local health workers through outreach to establishments where sex work is conducted. Three serial cross-sectional surveys were conducted in each study town before, during and after the intervention along with process documentation throughout the intervention period.

METHODS

Cross-sectional data from pre-intervention (baseline) and 6-month and 12-month post-intervention surveys from three study sites are used in a descriptive comparison of the context of the sex industry, outreach in two phases of intervention, and FC adoption after the intensive intervention phase in each site.

RESULTS

Approximately 75-80% of eligible women working in sex establishments, varying from 74 to 155 participants for each survey, were recruited from three study sites. After introduction and promotion of the FC along with the MC during the community public health intervention, between one-fifth and one-half of the study participants had tried the FC in the three study sites by the time of the 6-month and 12-month cross-sectional surveys. Among them, 10-30% had used the FC more than once. FC awareness increased following the intervention with much less variation across the three study sites. At baseline, 31-54% of participants across the three sites reported 100% protected sex in the last 30 days with all types of partners. At one of the sites with relatively low MC use before the intervention, the proportion of women reporting 100% protected sex in the last 30 days increased by 15%, and the proportion reporting nil protected sex in the last 30 days decreased by 13% between baseline and 12-month post-intervention surveys. More complex profiles of FC and MC use and protected sex were shown at the other two study sites, where a higher level of protection had been reached before the project started.

CONCLUSIONS

Different levels of FC adoption were identified after the 1-year FC promotion intervention through outreach to sex establishments. The input, output and outcomes of the intervention may be associated with women's demographic and risk characteristics, the local capacities of intervention staff, and other contextual factors. Further analysis of these factors will help establish the role of the FC in increasing protected sex, and provide insight into how to achieve greater FC use.

Internet use among female sex workers in China: implications for HIV/STI prevention

Based on a cross-sectional survey with 1,022 female sex workers (FSWs) recruited from different types of commercial sex venues in Southwest China, we examined their Internet-using behaviors and explored the feasibility of Internet-based HIV/STI intervention in this population. About 75% of FSWs were Internet users; among them 57% were frequent users, and 40% had searched HIV/STI information online. Internet use was significantly associated with younger age, more schooling, higher income, and engagement in a social network of Internet users. Frequent use of the Internet was associated only with factors of the social environment, such as peers' Internet use. Two thirds of Internet-using FSWs were willing to participate in an online HIV/STI prevention program. Multivariate analyses showed that willingness to participate in an online HIV/STI prevention intervention was significantly associated with higher Internet use and younger age. Our data suggest that Internet may offer a promising strategy to deliver low-cost HIV/STI prevention programs for FSWs in China.

A life-skills-based HIV/AIDS prevention education for rural students of primary schools in China: what changed? What have we learned?

OBJECTIVE

To evaluate a four-hour life-skills-based HIV/AIDS prevention curriculum among 5th grade students in rural primary schools of Hainan province.

METHODS

The study included two stages. Stage one (September 2006-May 2007) was a pre-post-quasi experimental design; a total of 2,413 students aged 9 to 14 years from fifth grade classes of nine primary schools completed a baseline survey (1,720 students were in the intervention group, 693 in the control group), and over 98% of them took part in a short survey. The experimental curriculum was provided to the intervention group. At stage two (September 2008), a cross-sectional questionnaire was administered to 6,923 students in 7th grade classes of eight middle schools in the same study sites. There were 1,437 students in the intervention group when the curriculum was conducted.

RESULTS

Students tended to score higher in areas of HIV/AIDS related knowledge and attitudes, if they were younger than average, lived in the county seat, had access to the internet, and their parents had completed higher levels of education. Path analysis showed that, after controlling for characteristics such as family and community factors, the total effects of curriculum on knowledge in the short-term model increased remarkably compared with the baseline, and maintained major contributions to knowledge in the mid-term model. The positive effect of knowledge on attitudes was significantly improved in the short-term model as well.

CONCLUSION

A life-skills based curriculum can improve HIV/AIDS related knowledge and self-perceived level of life-skills among primary school students in rural areas in a short time, and these positive effects can still be observed at least 2 years post participation in the curriculum.

Challenges, strategies, and lessons learned from a participatory community intervention study to promote female condoms among rural sex workers in Southern China

China faces a rapidly emerging HIV epidemic and nationwide resurgence of sexually transmitted infections associated with a growing sex industry. Community empowerment and capacity building through community-based participatory research partnerships show promise for developing, testing, and refining multilevel interventions suited to the local context that are effective and appropriate to address these concerns. However, such efforts are fraught with challenges, both for community collaborators and for researchers. We have built an international team of scientists from Beijing and the United States and collaborating health policy makers, health educators, and care providers from Hainan and Guangxi Province Centers for Disease Prevention and Control and the local counties and towns where we are conducting our study. This team is in the process of testing a community-wide, multilevel intervention to promote female condoms and other HIV prevention within sex-work establishments. This article presents lessons learned from our experiences in the first two study sites of this intervention trial.

HIV/AIDS behavioral interventions in China: a literature review and recommendation for future research

In the past two decades, China has witnessed an alarming increase of HIV/AIDS epidemic. Meanwhile, a number of HIV prevention interventions have been conducted. This study reviews existing studies in literature on behavioral interventions on HIV/AIDS in China. Of 25 studies we identified, most have been concentrated in South and South-West China, mainly targeting injection drug users and female sex workers. The most commonly used intervention strategy was individual-oriented HIV-related knowledge education and behavioral skill training. All studies reported positive intervention effects including improved HIV-related knowledge, increased condom use, reduced needle sharing, and reduced STI. Literature also suggests a lack of intervention among other at-risk populations such as MSM, migrant workers, and non-injecting drug users, lack of studies with rigorous evaluation design, inadequate follow-up, limited outcome measurement, and lack of multi-faceted structural interventions. The existing intervention studies document strong evidence of controlling HIV/AIDS epidemic through effective behavioral intervention. More efforts are needed to control the growing HIV/AIDS epidemic in China. Future studies need to employ more rigorous methodology and incorporate environmental or structural factors for different populations at risk of HIV infection in China.

Acceptability of hypothetical microbicides among women in sex establishments in rural areas in Southern China

OBJECTIVES AND GOAL

The objectives of this study were to measure the potential acceptability of a hypothetical microbicide among women in sex establishments in rural areas of Southern China and demographic, behavioral, and social context factors likely to affect microbicide acceptability.

STUDY DESIGN

This was a cross-sectional survey, using a quota sampling, among 300 women from sex establishments in 3 rural towns. An interviewer-administered standardized questionnaire was used to measure the acceptability score of hypothetical microbicides' characteristics, as well as sexual relationships and behaviors and other contextual factors.

RESULTS

Findings showed a generally positive response to microbicides, indicated by an acceptability index score of 2.89 (SD, 0.56, scale of 1-4) in the overall sample. Multivariate analysis shows that the acceptability score varied significantly by study sites, type of sex-work establishments, marital status, sex partner type, vaginal product experience, locus of control by partners, and locus of control by chance.

CONCLUSIONS

Microbicides may be acceptable among sex workers in rural settings in China; however, contextual factors should be carefully considered in education and promotion of microbicides in the future.